Intensity and discomfort of thirst in the immediate postoperative period of oncological surgeries: a cross-sectional studyABSTRACT
Objective: To investigate thirst intensity and demographic and clinical factors associated with this outcome among cancer patients in the immediate postoperative period.
Method: A cross-sectional study conducted in the Post-Anesthesia Recovery Room of a philanthropic hospital in Paraíba, Brazil, with 87 patients undergoing oncological surgeries. Data were collected in July and August 2022 using the Visual Analogue Scale, Numerical Verbal Scale, and Perioperative Thirst Discomfort Scale, which were subjected to descriptive and inferential statistical analysis. The Mann-Whitney U test, Kruskal-Wallis test, and Spearman's correlation (p ≤ 0.05) were used to compare thirst intensity, sociodemographic variables, and clinical variables
Results: Thirst assessment using the Visual Analogue Scale, Numerical Visual Scale, and Perioperative Thirst Discomfort Scale resulted in medians of 3, 4, and 5, respectively, and thirst intensity showed a statistically significant inverse correlation with age (p = 0.046).
Conclusion: Thirst in the immediate postoperative period was frequent and inversely correlated with age, being more intense in younger patients. The findings reinforce the need to systematically assess and manage thirst during this period.
Descriptors:
Thirst; Postoperative Period; Surgical Oncology
RESUMO
Objetivo: Verificar a intensidade da sede e os fatores demográficos e clínicos associados a esse desfecho entre pacientes oncológicos em pós-operatório imediato.
Método: Estudo transversal, realizado na Sala de Recuperação Pós-Anestésica de um hospital filantrópico na Paraíba, Brasil, com 87 pacientes submetidos a cirurgias oncológicas. Os dados foram coletados nos meses de julho e agosto de 2022, por meio da Escala Visual Analógica, Escala Verbal Numérica e Escala de Desconforto da Sede Perioperatória, os quais foram submetidos à análise estatística descritiva e inferencial. Utilizaram-se o teste U de Mann-Whitney, teste de Kruskal-Wallis e a correlação de Spearman (p ≤ 0,05) para comparação entre a intensidade de sede, variáveis sociodemográficas e clínicas.
Resultados: A avaliação da sede por meio da Escala Visual Analógica, Escala Visual Numérica e Escala de Desconforto da Sede Perioperatória resultou em medianas de 3, 4 e 5, respectivamente, e a intensidade da sede demonstrou uma correlação inversa estatisticamente significativa com a idade (p = 0,046).
Conclusão: A sede no pós-operatório imediato foi frequente e apresentou correlação inversa com a idade, sendo mais intensa em pacientes mais jovens. Os achados reforçam a necessidade de avaliar e manejar a sede de forma sistemática nesse período.
Descritores:
Sede; Período Pós-Operatório; Oncologia Cirúrgica
RESUMEN
Objetivo: Investigar la intensidad de la sed y los factores demográficos y clínicos asociados con este desenlace entre pacientes con cáncer en el período postoperatorio inmediato.
Método: Este estudio transversal se realizó en la Sala de Recuperación Postanestésica de un hospital filantrópico en Paraíba, Brasil, con 87 pacientes sometidos a cirugías oncológicas. Los datos se recopilaron en julio y agosto de 2022 utilizando la Escala Visual Analógica, la Escala Verbal Numérica y la Escala de Malestar de Sed Perioperatoria, las cuales se sometieron a análisis estadístico descriptivo e inferencial. Se utilizaron la prueba U de Mann-Whitney, prueba Kruskal-Wallis y la correlación de Spearman (p ≤ 0,05) para comparar la intensidad de la sed, las variables sociodemográficas y las variables clínicas.
Resultados: La evaluación de la sed mediante la Escala Visual Analógica, la Escala Visual Numérica y la Escala de Malestar de Sed Perioperatoria arrojó medianas de 3, 4 y 5, respectivamente, y la intensidad de la sed mostró una correlación inversa estadísticamente significativa con la edad (p = 0,046).
Conclusión: La sed en el postoperatorio inmediato fue frecuente y presentó una correlación inversa con la edad, siendo más intensa en los pacientes más jóvenes. Los hallazgos refuerzan la necesidad de evaluar y gestionar sistemáticamente la sed durante este período.
Descriptores:
Sed; Periodo Posoperatorio; Oncologia Quirúrgica
INTRODUCTION
Thirst is defined as a subjective symptom characterized by discomfort that induces an intense need to drink water. The regulation of this symptom involves mechanisms such as cellular tonicity and decreased extracellular fluid, signaled by the neuro-hormonal system, being one of the most recurrent sensations of discomfort in the immediate postoperative period (IPO)1.
It can be identified and classified through signs and symptoms such as dry lips, dry mouth, unpleasant taste, thick tongue and saliva, as well as the conscious urge to drink water. It is recommended that its identification be carried out considering the evaluation criteria, such as the perception of intensity and frequency, and the discomfort caused by thirst, integrating clinical practice1, and that special attention be given to patients undergoing oncological surgeries, already exposed to greater metabolic risks2.
Several external and internal factors influence the complex sensation of thirst, including body fluid homeostasis, changes in salivary production of the sympathetic and parasympathetic nervous system, psychological stress and visceral sensations3. These factors are markedly affected in the surgical context, and studies that have evaluated postoperative thirst have identified sex, anesthetic medication used and type of surgery as contributing factors4.
Due to its subjective and multifactorial nature, it is imperative to assess thirst in its entirety, encompassing dimensions such as incidence, frequency, and discomfort. Prevalence can be assessed and measured using instruments such as the Visual Analogue Scale (VAS), the Verbal Numerical Scale (VNS), and the Perioperative Thirst Discomfort Scale (PEDS)5,6.
Assessing thirst dimensions aims to enable healthcare professionals to take actions directed at managing and relieving it, such as using chewing gum, cold oral stimuli, room temperature water, and oral rehydration solutions7-10. However, limited care for this phenomenon represents a challenge for the clinical team, especially for nurses, who accompany the patient at each stage of the perioperative period. This highlights the importance of accurate assessment and the search for interventions that meet patients' needs 11.
Measuring thirst in the postoperative period of patients undergoing surgery, especially oncological surgery, is of great importance, as it can guide interventions in care during surgical recovery. Patients report having perceived improved quality of care and relief of symptoms9,10. Other determinants of thirst sensation in oncological patients may be dehydration, hyperosmolarity, opioid use, mouth breathing, vomiting, and stomatitis12.
Factors associated with thirst in the postoperative period need to be understood for better planning of nursing care, especially in oncology patients, whose expectation of continued life may already have been affected, generating feelings of negative care outcome, fear, death, and spiritual distress13. Understanding the physiological, emotional, and environmental aspects that influence the manifestation of thirst enables the nurse to develop a targeted care plan, with relief strategies appropriate to each patient. This broader perspective favors a humanized and proactive approach, contributing to improved comfort, satisfaction, and postoperative recovery5.
The prevalence of thirst is considered a challenge for the multidisciplinary team and an indicator of the quality of post-surgical care. Given this scenario, the study aimed to answer the following research question: What is the intensity of thirst, and what demographic and clinical factors are associated with this outcome in cancer patients in the immediate postoperative period (IPO)? Thus, the objective was to verify the intensity of thirst and the demographic and clinical factors associated with this outcome among cancer patients in the IPO.
METHOD
This is a cross-sectional study with a quantitative approach, conducted from July to August 2022 in a Post-Anesthesia Care Unit (PACU) of a healthcare institution located in Campina Grande, a municipality in the state of Paraíba, Brazil.
The sample size calculation was based on the number of oncological surgical procedures performed at the study site (152 surgeries/quarter). The Epi Info® calculator was used. A 95% confidence level and a 7% margin of error were adopted, and in order to obtain a representative sample 87 patients had to be evaluated.
The decision was made to use the number of oncological surgical procedures performed in the first quarter of 2022, instead of the total for 2021, due to the impact of the COVID-19 pandemic on surgical production, to more accurately reflect the resumption of the surgical flow and, therefore, offer a more robust and appropriate basis for the sample size calculation. In 2021 there was a significant reduction in the volume of surgeries due to the suspension and rescheduling of elective procedures, which would make the estimate unrepresentative of the service's routine care.
Patients aged 18 years or older, of both sexes, in the IPO of oncological surgeries (the first 24 hours after the procedure), who were conscious, awake, and cooperative were included. Patients on non-spontaneous mechanical ventilation and those with severe cognitive or visual sequelae were excluded because they did not have the clinical conditions to guarantee effective communication, adequate understanding of instructions, or a reliable response to the thirst assessment instruments used. The application of the scales requires conscious interaction, subjective judgment, and the ability to express themselves verbally or visually, which would be unfeasible and potentially generate discomfort or misinterpretation in these groups.
The data collection procedures were guided by validated instruments. The EVN and EVA record the presence of thirst and its intensity in numerical values from 0 to 10, where 0 indicates absence of thirst, and 10 corresponds to the highest level of thirst5,6.
The EDESP contains items evaluated using a three-point Likert-type rating, resulting in a total score from 0 to 14, where 14 points correspond to the highest intensity of thirst. The EDESP analyzes thirst discomfort by assessing dry mouth and throat, chapped lips, thick tongue and saliva, bad taste in the mouth, and the urge to drink water5,14.
Data was collected in two different and subsequent stages. In the first stage, a pre-operative visit was conducted with the patients, during which a semi-structured questionnaire was applied, which included information for the sociodemographic and clinical profile of the participants. During the pre-operative visit stage, the participants' consent was obtained through presentation and assisted reading of the Informed Consent Form (ICF), written in accessible language compatible with the level of understanding of the research subjects.
To characterize the profile of the respondents the following sociodemographic variables were evaluated: skin color (classified as white and non-white); age (in years); biological sex (male or female); education level (primary, secondary and higher education); marital status (with or without a partner); and place of residence (city of origin).
Clinical variables were collected from information in the department's surgical procedure logbook, analyzing the presence of comorbidities (yes/no), the type of surgery performed (head, neck and soft tissues/gastrointestinal and genitourinary systems/breasts/adnexa), and the procedure time (in minutes).
The second stage consisted of applying the EVN, EVA, and EDESP, with data collection at the SRPA in the IPO. Prior to applying the data collection instruments, participants received detailed guidance on the objectives, procedures, risks, and benefits of the research, ensuring full understanding of the aspects involved in the study. Participants were guaranteed the freedom not to participate in the research or to withdraw from it, as well as privacy, confidentiality, and anonymity.
In order to reduce confounding factors for assessing headquarters related to the environment, it was ensured that data collection took place in the same location for all participants, with temperatures ranging between 20 and 24º, in accordance with Collegiate Board Resolution No. 5015.
The Statistical Package for the Social Sciences® (SPSS) was used. Initially, a descriptive analysis of the sample was performed using mean, median, interquartile range, standard deviation, and minimum and maximum values for quantitative variables. For qualitative variables, absolute and relative frequencies were calculated. The comparison between thirst levels measured by the VAS, AVN, and EDESP and categorical variables was performed with the Mann-Whitney U test and the Kruskal-Wallis test. To verify the correlation between thirst levels and continuous variables, Spearman's correlation test was applied. The choice of the Mann-Whitney U test, the Kruskal-Wallis test, and Spearman's correlation was due to the evidence of a non-normal distribution of thirst scores obtained by the VAS, AVN, and EDESP. For all tests, a p-value of 0.05 was adopted.
The study followed the guidelines of Resolution No. 466/2012 of the National Health Council16 on research involving human beings, and was submitted to and approved by the Research Ethics Committee, under Protocol No. 5,478,930. All patients were invited and, after accepting to participate, signed the Informed Consent Form.
RESULTS
In total, 87 patients underwent oncological surgical procedures, and 56.3% were male. Table 1 presents the variables characterizing the sample. Regarding the anesthetic procedure, general anesthesia predominated (78.2%).
The median surgical procedure time was 53.5, ranging from 15 to 200 minutes, and the VAS, VNS, and EDESP scores were 3, 4, and 5, respectively (Table 2).
Regarding the EDESP, attributes related to the perception of thirst were evaluated, such as dry mouth, chapped lips, thick tongue, thick saliva, dry throat, bad taste in the mouth, and the urge to drink water. The urge to drink water was the symptom that caused the most discomfort, with 24.1% (n = 21) of participants reporting significant discomfort (Table 3).
Analysis of the correlation between thirst levels assessed by VAS, VAS, and EDESP, age, and duration of the surgical procedure revealed a significant inverse correlation between age and VAS scores. This indicates that the lower the VAS score (reflecting lower thirst intensity), the older the participants, and vice versa (r = -0.215; p = 0.046) (Table 4).
In the comparison between thirst levels and the sociodemographic and categorical clinical variables evaluated, no statistically significant relationships were identified (Table 5).
DISCUSSION
Thirst represents a multifactorial and complex phenomenon, influenced by physiological and neuroendocrine mechanisms1. The identification of this prevalence reinforces the need to understand thirst not only as a manifestation of dehydration, but as a symptom that directly affects the patient's comfort and recovery experience4.
Studies on general and orthopedic surgeries have shown prevalence rates of thirst in the postoperative period exceeding 80%17. Among patients undergoing oncological surgery, thirst tends to manifest as a frequent symptom, influenced both by the clinical impairment resulting from the disease and by invasive procedures and exposure to prolonged periods of fasting. In addition, factors such as dehydration, hyperosmolarity, opioid use, mouth breathing, episodes of vomiting, and stomatitis can also act as determinants of the sensation of thirst in this group9,10.
The use of different scales (VAS, VNS and EDESP) to measure thirst, encompassing different perceptions, demonstrates a growing trend in the assessment of this symptom, being a practical and widely used method1,8.
Methods based on the neurophysiology of thirst allow for its identification; however, they are not the only ones, since thirst is a symptom that can be an intense and uncomfortable experience, characterized by subjectivity and individuality, making its assessment a challenge. In this context, self-reporting serves as a benchmark for measurement.
Underestimation and inadequate management of thirst in clinical practice represent a challenge in perioperative care, extending beyond the specific context of this study. Thirst assessment is rarely conducted intentionally and systematically, with scarce or nonexistent records. When thirst is assessed, attention is predominantly focused on its intensity, neglecting other crucial dimensions such as prevalence, incidence, frequency, duration, and discomfort.
This gap is corroborated by national and international evidence, such as the lack of recognition and systematic care of thirst among nurses in Japan, revealing a global trend of deprioritizing this symptom18. Similarly, national studies point to the lack of a standardized routine for measuring thirst in the Post-Anesthesia Care Unit (PACU), often as a result of the perception that thirst is a “common” and “expected” suffering in the postoperative period17.
Regarding the use of EDESP in clinical practice, it is possible to measure the intensity and discomfort of thirst, which can facilitate the identification of the symptom and the implementation of interventions to promote patient comfort14.
The most prevalent discomforts were dry lips and dry mouth, indicating the relevance of these attributes in the experience of thirst. The perception of thirst, therefore, is not restricted to the patient's verbal response, but encompasses attributes such as dry mouth, dry lips, thick tongue, thick saliva, dry throat, bad taste in the mouth and the desire to drink water, which make up the scale adopted14.
The high prevalence of dry mouth observed in this study is consistent with findings in the literature1, which point to this symptom as one of the most expressive in the dimensionality of thirst. The attributes evaluated in the EDESP demonstrate usefulness in expanding the measurement of thirst and in determining its intensity, being a useful tool, due to its comprehensiveness and ease of use14, allowing the objective evaluation of subjective symptoms.
Thirst is a symptom that is generally neglected in care, seen as expected and less serious. In contrast, it generates significant discomfort and additional impact in cancer patients, whose multidimensional context is weakened by the cancer diagnosis. Measuring thirst in these patients enables the development of specific nursing actions to alleviate the discomfort associated with the symptom.
In this study, it was observed that older patients tend to have lower levels of thirst measured by the VAS. This is an expected finding given the physiological changes of aging, when changes in thirst perception can occur mainly due to increased basal blood osmolality and reduced osmoreceptor response to osmolality changes. In addition, behavioral and cognitive changes, changes in taste buds and hyposalivation, reduced capacity to excrete water load, and neuroendocrine changes may occur. For these patients, a thorough assessment of physical findings related to thirst is essential, preventing, among other things, the risk of events associated with dehydration19,20.
Although our study found an inverse correlation between thirst and age (p=0.046), with no significant associations with other sociodemographic or clinical characteristics, other studies indicate that sex, anesthetic medications, and type of surgery are also factors statistically associated with postoperative thirst in a broader perspective4.
Even though the results of this study did not demonstrate a statistical association when comparing thirst levels and surgery time, it appears that longer surgical times may be associated with a higher risk of complications and prolonged fasting time in the postoperative period, which may contribute to the occurrence of thirst21. It is believed that factors such as inadequate bleeding control, fluid infusion, and medication use may also impact thirst22.
No statistically significant association was found between the type of surgery and thirst levels. However, it is observed that surgical types can determine the necessary fasting periods, which may be reflected in postoperative thirst. The average fasting time in surgeries of the digestive system or abdominal wall has been reported as longer than that prescribed in the literature, which may lead to implications for thirst in the IPO2. In a randomized clinical trial conducted in the south of the country, the average fasting time obtained was 12.80 for solids and 11.35 for liquids, a period much longer than the hours for residue-free liquids recommended by the American Society of Anesthesiologists23.
Prolonged fasting has been associated with the occurrence of thirst in the postoperative period. Studies have shown that the average fasting time frequently exceeds the prescribed period21,23. Surgical delays are common in institutions, and afternoon appointments are generally the most impacted by unforeseen events. An institutional protocol guiding preoperative fasting will be the basis for minimizing avoidable patient suffering, with longer periods of restricted fluid intake and greater discomfort. Protocols with a longer window, beyond that physiologically indicated according to the type of surgery, do not promote safety, additionally exposing the patient to a greater risk of thirst.
In view of this finding, it is important to standardize the prescribed fasting time, avoiding its prolongation, as well as seeking strategies to reduce this period, such as the administration of supplements. The use of supplements has shown potential to promote satiety and patient comfort, minimizing stress during the perioperative period3.
The nursing team's perception of thirst and its management is also relevant. This management can be aided by the application of the Nursing Process and the use of international taxonomies, such as the North American Nursing Diagnosis Association - International (2024-2026), which assesses the phenomenon of thirst through the nursing diagnosis (ND) "Ineffective self-management of dry mouth", defined as the unsatisfactory management of therapeutic regimen, consequences and lifestyle changes associated with reduced salivary secretion24.
Despite highlighting the nursing diagnosis as a crucial element for the implementation of specialized care and the clinical relevance of postoperative thirst, it is observed that people undergoing surgical procedures do not constitute a risk population for the presence of nursing diagnosis, and their clinical indicators do not contemplate specific situations of the phenomenon of postoperative thirst, so that its revision may be necessary based on content and clinical validation in this population. In this scenario, some research is already moving towards the elaboration of a new concept of perioperative thirst to be worked on among nursing diagnoses22.
Another important taxonomy that can guide the prescription of nursing activities directed to the diagnoses evidenced by nurses is the Nursing Interventions Classification. However, despite its contribution to clinical care, there is a lack of nursing interventions with a specific focus on thirst management25. Therefore, studies are suggested that evaluate the impact of activities to monitor and mitigate thirst on effective management.
The lack of a routine for measuring thirst in post-anesthesia recovery rooms, the difficulty in identifying related signs and symptoms, the belief that thirst is a common suffering, and the lack of documented records of thirst relief measures can interfere with the quality of care provided18. The inclusion of protocols for thirst management, with well-defined evaluation criteria, can change the nurse's daily attitude of not advising on fluid intake for fear of other complications such as aspiration, facilitating the administration of relief strategies18. However, its development still represents a challenge for the teams, especially regarding the identification of factors that hinder its consolidation.
Implementing measures to alleviate this symptom, such as using ice popsicles, has shown potential to reduce patient discomfort in the postoperative period. Administering small doses of room temperature water or ice chips has also shown satisfactory results in mitigating thirst7,18,20.
In short, the nursing team's role in identifying and measuring thirst, clinically assessing the patient, and promoting comfort measures is fundamental to ensuring qualified and humane care, addressing a vital priority need.
Nevertheless, the study has limitations related to the sample used, which came from a single institution, restricting the generalization of the findings to other populations and contexts.
The results of the present study indicated a greater representation among patients who underwent head, neck and soft tissue surgeries. Soft tissue neoplasms are a heterogeneous group of rare mesenchymal tumors, the most common being liposarcomas and synovial sarcomas, representing one of the malignant neoplasms in adults26. Most of these sarcomas occur in people over 65 years of age, as in the study in question, with the majority of patients being over 60 years old27. Furthermore, the prevalence of head and neck and digestive system neoplasms reflects the vulnerability of these systems to risks and metabolic alterations 28.
Regarding the anesthetic procedure, general anesthesia predominated (n = 68; 78.2%). This result is consistent with other studies, which indicate general anesthesia as a procedure frequently associated with postoperative complications29. General anesthesia, by inducing unconsciousness and blocking painful stimuli, can lead to longer fasting times and signs and symptoms related to thirst, such as throat irritation and dry mouth30.
Regarding the presence of comorbidities, most participants did not present this condition, in contrast to data from the literature, which indicate a higher prevalence of surgical patients with comorbidities, which can increase the risk of complications and prolong surgical time30.
Therefore, identifying postoperative thirst becomes imperative in order to plan the implementation of relief measures and strategies, such as the use of mentholated chewing gum, ice cubes, room temperature water, and oral rehydration solution to mitigate discomfort and prevent thirst in oncological surgical patients. Implementing thirst assessment and management protocols in clinical practice can substantially improve the quality of care provided to these patients by the multidisciplinary team, resulting in a better patient experience.
The development of validation studies of the "Self-Management of Dry Mouth" nursing diagnosis in cancer patients undergoing surgical procedures may allow for an accurate diagnosis of this phenomenon among these individuals. Considering environmental factors as potential confounders is fundamental for a more precise understanding. This study highlights the control of these variables, ensuring that all samples were collected in the same location, at the same ambient temperature, and after the same fasting period.
It should also be emphasized that this study is an initial investigation into the assessment of thirst intensity. Future research, especially experimental and longitudinal studies, is necessary to identify predictive factors through multifactorial analyses, establish possible causal relationships, detect other confounding factors, and evaluate the effectiveness of different interventions aimed at managing thirst. Furthermore, investigations focused on specific subgroups of patients, stratified by cancer type, comorbidities, or therapeutic regimens, may contribute to the development of personalized and optimized interventions.
CONCLUSION
Thirst during the immediate postoperative period (IPO) was a frequent symptom among participants, showing an inverse correlation with age. This means that the lower the score on the scale (indicating less intense thirst), the older the individuals were.
The use of different instruments in measuring thirst has made it possible to evaluate it from different perspectives, encompassing subjective variables and a wide range of possibilities for identifying the symptom, which presents itself as complex and individual in nature.
Clinical factors such as fasting, anesthesia, and type of surgical procedure are relevant to consider in clinical practice, and nursing care should focus on the early identification of thirst, implementation of relief interventions, and promotion of comfort.
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Access to the dataset may be granted upon request to the corresponding author.
