Influence of preoperative emotional state on postoperative pain following orthopedic and trauma surgery

OBJECTIVES: to analyze the relationship between preoperative emotional state and the prevalence and intensity of postoperative pain and to explore predictors of postoperative pain. METHOD: observational retrospective study undertaken among 127 adult patients of orthopedic and trauma surgery. Postoperative pain was assessed with the verbal numeric scale and with five variables of emotional state: anxiety, sweating, stress, fear, and crying. The Chi-squared test, Student's t test or ANOVA and a multivariate logistic regression analysis were used for the statistical analysis. RESULTS: the prevalence of immediate postoperative pain was 28%. Anxiety was the most common emotional factor (72%) and a predictive risk factor for moderate to severe postoperative pain (OR: 4.60, 95% CI 1.38 to 15.3, p<0.05, AUC: 0.72, 95% CI: 0.62 to 0.83). Age exerted a protective effect (OR 0.96, 95% CI: 0.94-0.99, p<0.01). CONCLUSION: preoperative anxiety and age are predictors of postoperative pain in patients undergoing orthopedic and trauma surgery.


Introduction
Orthopedic and trauma surgeries are often associated with severe postoperative pain for two main reasons. First, the surgery often causes intense nociceptive stimulation of the musculoskeletal tissue (1)(2) . Second, postoperative analgesia remains inadequate and exposes patients to severe postoperative pain (3) . This situation can lead to significant patient discomfort and negative physical and psychological effects as well as a major socioeconomic impact by increasing the postoperative morbidity and hospital stay (4) . Timely prevention, detection and treatment may help reduce health problems associated with the high prevalence and intensity of postoperative pain.
Although postoperative pain is predictable and there are various ways to prevent and treat it, the correct approach widely varies from one patient to another in similar surgical procedures (5) . In this regard, knowing the emotional factors that influence the occurrence of postoperative pain would be an important contribution to a more appropriate treatment for each patient. It has been shown that certain emotional states such as anxiety and fear can influence individual responses to surgical intervention and to the need for analgesia (6)(7) .
In the last decade, there has been increasing interest in analyzing the influence of preoperative anxiety on postoperative pain and recovery, but the data come from heterogeneous studies that vary in their sociodemographic characteristics and the type of surgery (7)(8) . Furthermore, studies on patients undergoing orthopedic surgery, one of the most painful procedures, are even scarcer (9) . Confirming the relationship between preoperative anxiety and postoperative pain is significant because if one exists, patients with high anxiety should be identified before surgery and should expect individualized strategies for pain treatment after surgery (7,10) . Patient expectations regarding surgery have changed, and the lack of postoperative pain is an important indicator of satisfaction with hospital care (11,12) . min, ≥90 min); surgical indication (thighbone fracture or knee, hip or shoulder prosthesis); type of anesthesia (regional, general, or combined); and pain treatment (analgesic consumption and rescue analgesia).
Pain intensity was assessed using the Numeric Rating Scale (NRS) (14) . This validated scale ranges from 0 (no pain) to 10 (maximum pain). For this study, two standardized pain intensities were established: mild pain (NRS≤3) and moderate-to-severe pain (NRS≥4).

Results
The general characteristics are summarized in

No statistically significant difference was observed in
pain intensity by gender, number of comorbidities or duration of surgery.
In Figure 1,   The data for the association of immediate pain with emotional state are listed in Table 3. showed no significant differences.

Discussion
The main outcomes of this study reveal that nearly one out of three patients undergoing trauma or prosthetic surgery have pain during the immediate postoperative period and that more than half of these patients have moderate-to-severe pain within the first 24 hours of the postoperative period. The multivariate regression analysis also shows that there is an association between preoperative anxiety and postoperative pain.
In the last fifteen years, various clinical guidelines have been published with recommendations for treating postoperative pain (11,(15)(16) . Nevertheless, several authors agree on the need to improve pain therapy (3,17) . These shortcomings have been mentioned in this study, which reveals a prevalence of postoperative pain in trauma and prosthetic surgery ranging between 28% and 61%, with episodes of moderate-to-severe pain in 45% of patients during their PCU stay and 66% within the first 24 hours of the postoperative period. These findings are consistent with those of other studies where between 22% and 67% of patients of trauma surgery had pain within the first 24 hours of the postoperative period (3,18) and 64% on the previous day. However, the authors did not report whether it was immediate postoperative pain (3) . Although the studies have reported a high prevalence of postoperative pain, comparing their results is difficult, hence the need to determine the influence of socio-demographic, clinical and psychological factors as predictors of postoperative pain (7,9,(19)(20)(21)(22)(23) .
Patient characteristics such as age, gender, type of patient, previous experiences or type of surgery may help explain the large variability in the prevalence of postoperative pain. However, the literature is rather contradictory in these respects. In a systematic review of 23,000 patients, the authors highlighted preoperative pain, anxiety, age and type of surgery as the most significant predictors of postoperative pain and analgesic consumption (7) , but they disregarded gender as a consistent predictor. In another study, with a cohort of 1,990 patients, anxiety and depression were predictors of pain, but neither age nor gender were associated with pain (19) . Some authors have described a higher prevalence of pain among young people (23) , while others report a higher prevalence in older patients (20,22) .
There are also mismatches in the prevalence of pain among men and women. Some authors observed more pain in women and younger patients while others found a higher prevalence in men (20,23) . Our results are consistent with some studies and differ from others.
Young patients experienced more pain during the immediate postoperative period, but no differences according to gender or other factors such as operating time or comorbidities were observed. Another factor associated with a greater prevalence of pain is the type of surgery (18) (11,17) . Morphine was used as rescue analgesia in almost a quarter of patients, similar to other studies (3) . These data support the conclusion that pain remains inadequately treated with the current guidelines and that there is significant room for improvement. and trauma surgeries (8)(9)19,(24)(25) . Some authors have analyzed anxiety/depression or preoperative anxiety as predictors of postoperative pain (19,24) . Others have reported on the association between anxiety and pain (8)(9)25) ; although all of the investigators agree there is an association between these factors, it is unclear whether anxiety causes pain or pain causes anxiety. Our Finally, the retrospective nature of the study may limit the interpretation of the results, but in our opinion, the present findings are a good first approximation to the issue.

Conclusion
In conclusion, the present investigation identified two predictors of immediate pain during the postoperative period: age and preoperative anxiety.
Consequently, we recommend that young and anxious