Effeets of Guided Imagery on PostoperativeOutcomes in Patients Undergoing Same-DaySurgical Procedures: A Randomized, Single-Blind Study

Maj Eric A. Gomales, CRNA, MS, USAF, NCCapt Rachel JA. Ledesma, CRNA, MS, USAF, NCCapt Danielle J. McAllister, CRNA, MS, USAF, NCLt Col Susan M. Perry, CRNA, MS, USAF, NCLt Col Christopher A. Dyer, CRNA, MS, USAF, NCCOR John P. Maye, CRNA, PhD, NC, USN

The purpose of this investigation was to evaluate theeffects of guided imagery on postoperative outcomes inpatients undergoing same-day surgical procedures.Forty-four adults scheduled for head and neck proce-dures were randomly assigned into 2 groups for thissingle-blind investigation. Anxiety and baseline painlevels were documented preoperatively. Both groupsreceived 28 minutes of privacy, during which subjects inthe experimental group listened to a guided imagerycompact disk (CD), but control group patients receivedno intervention. Data were collected on pain and nar-cotic consumption at 7- and 2-hour postoperative inter-vals. In addition, discharge times from the postoperativeanesthesia care unit (PACU) and the ambulatory proce-

dure unit and patient satisfaction scores were collected.The change in anxiety levels decreased significantly

in the guided imagery group (P = .002). At 2 hours, theguided imagery group reported significantly less pain(P = .041). In addition, length of stay in PACU in theguided imagery group was an average of 9 minutesless than in the control group (P = .055).

The use of guided imagery in the ambulatory sur-gery setting can significantly reduce preoperative anx-iety, which can result in less postoperative pain andearlier PACU discharge times.

; Alternative therapies, guided imagery, post-operative outcomes, same-day surgery.

As the cost of healthcare continues to escalate,providers search for alternative therapies toalleviate this financial btirden, while contin-uing lo improve panent care. Any interven-tion intended to heal or treat a disease that is

"nol included in the iratiilional medical curticula tanglii inihc United States or Britain" Is considetcd alternaUve med-icine.' Guided imagery is an alternative therapy that hasbeen used as an adjunciive treatment, in combination wiihgeneral aticsihcsia tor orthopedic, cardiovascular, and col-orectal cases.^"'' Guided imagery has been defined as adirected, deliberate daydream (hat uses all senses to createa focused state of relaxation and a sense oí physical andemotional well-being."* Multiple investigations suggest thaiwhen guided imagery- is administered before a surgical pro-cedure, it can diminish a patients preoperative anxiety andreduce postoperative sut;gical pain, use of narcotics, andlengiii of postoperative hospital stay"^^^ However, thevalue and feasibility of this intervention has not been ade-quately explored in the ambulatory care setting.

Surgery is a stressful event that can increase anxietylevels. There has been a focus in recent literature regard-

ing the impact of high levels ol anxiety observed in thepreoperative period and the potential impact on postop-erative outcomes. The fear of the unknown, loss ofcontrol, and pain or discomfort after surgery have a neg-ative impact on anxiety and ean potentially influence anindividual's ability to cope with events postoperative-

Anxiety is a perpetuating factor that influences an in-dividual's abihty lo cope with pain.'*^ In the perioperativearena, using techniques to decrease anxiety may provebeneficial in reducing narcotic requirements, postopera-tive pain, and discharge times. In addition, it may be ad-vantageous to identify patients in the preoperativeholding area with substantial anxiety, who may be at riskfor developing severe postoperative pain." These pa-tients in particular, may benefit from alternative therapiesto alleviate preoperative anxiety.

Postoperative pain can result in prolonged lengths ofstay, increased medication requirements, and lowerpatient satisfactioti levels.'" When guided imagery is usedas a coping strategy before surgery; it can lessen a patientspreoperative anxiety and reduce postoperative surgical

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pain, narcotic use, and length of hospital stay for inpa-tient surgical procedures.^

A study by Laurion and Fetzer'^ investigated theeffects of guided imagery and music on female patientsundergoing laparoscopic gynecologic surgery The re-searchers reported that the control group had a signifi-cantly higher pain score upon discharge than did theguided imagery and music groups. Tusek et al" examinedthe use of guided imagery in both men and womenduring the perioperative period to decrease patients'anxiety, pain, narcotic medication use, postoperative sideeffects, sleep quality, and length of stay. The guidedimagery groups' median narcotic requirement was 36%less than that of the control group. Differences in pa-tients' pain and anxiety were also markedly lower in theguided imagery group on all postoperative days.

In a pilot study examining the effects of guidedimagery in elderly patients undergoing hip surgery, re-searchers reviewed the outcomes of pain relief, anxiety,and length of stay^ The results of the study revealed thatpatients who listened to guided imagery at least twiceeach day beginning in the preoperative period and con-tinuing into the postoperative recuperation had a shorterlength of stay, lower average pain ratings on a verbalnumeric scaie, and lower use of pain medication.Although anxiety levels at baseline and on day 3 werehigher in the intervention group, the researchers foundthat when compared with the baseline measurements, theguided imagery group had a greater overall decrease inlevel of anxiety.

In a research study by Halpin et al,' guided imagerywas used on patients undergoing cardiac surgery. Thepurpose was to determine if a guided imagery programreduced anxiety, pain, and length of stay at a decreasedcost to the consumer while maintaining a high level ofpatient satisfaction. There were no statistically significantdifferences between the guided imagery and nonguidedimagery groups for "overall care and treatment provided";however, patient satisfaction scores were higher in theguided imagery group.^ Patients' anxiety improved by anaverage of 41% from before to after listening to the lapes,but only a small percentage (17.9%) reported that theirpain was better after guided imagery. The average hospitalstay was 1.5 days shorter in the guided imagery group (P= .000), and direct hospital cost was $1,982 less in theguided imagery group (P = .001). Mean pharmacy directcosts were $288 less for the guided imagery (P = .002);however, no statistically significant differences were notedin narcotic pain medication cost in either group.

Most of the sLudies performed to date use guidedimagery by having the subjects listen to the tapes days orweeks before their surgeries. '' • ' ' ^ ' Due to the increasingtrend of same-day surgeries and varying processes for pre-operative evaluations, it may no longer be feasible tobegin guided imagery therapy days in advance. The out-

Maxlllary procedures, 2

FESS, b

er (eye. gland, neck,other soft lissue}, 8

Figure 1. Types of ProceduresUPPP indicates uvulopalatopharyngoplasty; T&A, tonsillectomyand adenoidectomy, FESS, functional endoscopie sinus surgery.

comes related to the use of guided imagery may be affect-ed by when and how often it is applied. In reality, mostanesthesia providers meet their patients on ihc morning ofsurgery. Therefore, this study queried whether positiveoutcomes could still be obtained when guided imagerywas implemented only on the day ol surgery.

There is limited evidence available on the feasibilityand effectiveness of guided imagery for outpatient surgi-cal procedures. The objectives of this study were to de-termine the effects of guided imagery on postoperativeoutcomes for patients undergoing sanic-day surgical pro-cedures of the head and neck, to include ear/nosc/lhroat(ENT), oral-maxillofacial (OMF), and plastic surgeries(Figure 1). Specifically, preoperative anxiety levels, anal-gesic consumption, postoperative pain, length of stay,and patient satisfaction were measured.

Materials and MethodsA randomized, single-blinded, quasi-experimental studywas conducted at Wright-Patterson Medical Center atWrigbt-Patterson Air Force Base in Ohio to investigatethe effects of guided imagery as an adjunct for postoper-ative outcomes in patients undergoing same-day surgicalprocedures of the head and neck. Approval was obtainedfrom the Institutional Review Boards at the UniformedServices University of the Heallh Sciences in Bethesda,Maryland, and at Wright-Patterson Air Force Base.

• Inclusion and Exclusion Criteria. Inclusion criteriawere age 18 years and older; scheduled for outpatientsurgery of the head or neck to be performed undergeneral anesthesia; ASA physical staius I. II, or III; abilityto read and understand directions in English; andconsent to participate in the study Exclusion criteria in-cluded hearing loss severe enough to preclude listeningto the compact disk (CD), vision loss too severe to com-plete data collection instruments without glasses, docu-

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iiientcd alfective disorders, documented chronic pain dis-orders, and use of guided imagery before enrollment.

After consent for anesthesia was obtained, patientsmeeting inclusion criteria were approached regardingpossible involvement in the study. Forty-four subjectsconsented to participate during the preoperative process.With the use of cotnputerized random number genera-tion, the patients were assigned to either the guidedimager)' or control group,

• Anxiety Meas u remen is. On arrival to the preoperativeliolding area, each participant was isolated from other pa-licnts by a privacy curtain. Bclore receiving sedation, theresearch participant's baseline anxiety was measured usingthe Amsterdam Preoperative Anxiety and InformationScale (APAIS) and a vertical visual analog scale (vVAS).The APAIS is a self-report tool used to assess level of pre-operative anxiety.'^ The vVAS was used by having thesubject mark the point on a 100-mm vertical line, whichreflected what he or she was experiencing. The distancewas measured in millimeters from zero to the pointmarked to obtain a numerical data point. Baseline pain wasalso measured using a vVAS. Reliability of measurement ofthe vVAS was established by using the same ruler for allmeasurements, and a second researcher performed repeatmeasurements lo confirm accuracy and consistency.

After the itiitial measurements were obtained, subjectsin the guided imagery group were provided with a CDplayer, headphones, and a guided imagery CD, This CDled the patient through a progressive relaxation andguided imagery exercise. While in the preoperativeholding area, the subjects in the guided imagery grouplistened to the 28-minute CD, whereas the control groupwas provided 28 tninutes of privacy but no CD. Shortlybefore transfer to the operative suite, and before receivingmidazolam, all participants' anxiety levels were re-assessed wiih the vVAS,

Before induction, the anesthesia provider ensured thatthe headphones were placed on the guided imagerysubject and that a second guided imagery CD was initiat-ed. This CD consisted of soothing biorhythmic musiccombined with positive, encouraging statements. Thestihject was directed to set the volume to a level ofcomfort and the CD was permitted to play throughout in-duction. Before incision, the CD player was stopped andI he ear buds were retnoved frotn the subject's ears toensure no potential harm to the participant. For prolec-lion of the single-blinded nature of the study, the CD wasnot restarted in the postoperative period.

• Anesthesia, A standardized anesthetic protocol wasdesigned incorporating the most common medicationsand anesthetic agents currently used at this facility. Basedon subject requirements and the anesthesia providers' as-sessment, all patients were administered midazolam, 0 to5 mg intravenously (IV), preoperatively. For postopera-tive nausea and votniting prophylaxis, patients received

IV ondansetron, 4 mg, and dexamethasone, 4 to 8 mg. Aconsistent induction sequence of fentanyl, 1 to 3 Hg/kg;lidocaine, up to 1.5 mg/kg; propofol, L to 2 mg/kg; andeither rocuronium, 0.6 to 1.2 mg/kg, or succinylcholine,1 to 1,5 mg/kg, was administered. Sevofluranc was usedand titrated at the provider's discretion. Maintenance ofanesthesia was supplemented with fentanyl IV, up to 8|jg/kg. On emergence, morphine, I to 10 mg; hydromor-phone (Dilaudid), 0.2 to 2 mg; or fentanyl, up to 150 pg,was used based on provider preference, if required, neu-romuscular blockade was reversed using neostigmine,0.05 mg/kg IV, and giycopyrrolate, 0.01 mg/kg IV,

• Posloperalive Data Collection. All postoperative datawas collected in the postoperative anesthesia care unit(PACU) and the ambulatory procedure unit (APU) by ablinded investigator. The postoperative data collectionperiod began with arrival to PACU and terminated whenAPU discharge criteria were met. One hour after depar-ture from the operating room, the investigator had sub-jects rate their pain over the first hour using the vVAS. Atthe second hour, subjects were again asked to rate theirpain over the previous hour on the vVAS, At the 2-hourdata collection point, patient satisfaction was assessedusing a 5-point Likert scale.

Discharge time from PACU and APU were based onthe time the patient actually met discharge criteria. Thiswas to control for multiple factors that could delay actualdischarge time, such as arrival of transportation, staffavailability, lack of discharge orders, and bed availability.Time in APU began immediately after PACU dischargecriteria were met and terminated when patient met APUdischarge criteria.

Analgesics were administered postoperatively in PACUand APU by the staff nurses in accordance with postoper-ative orders and were documented on the standard medicalrecord. The blinded investigator reviewed the charts after-ward to obtain this data. Analgesics administered wereconverted into morphine equivalents for analysis.

• Vertical Visual Analog Scale. A review of studies con-sistently demonstrates that VAS and verbal rating scaleshave high construct validity.'''^Jensen et al^^ cotiiparedthe sensitivity of a VAS, a verbal rating score for pain in-tensity, and a verbal rating score for pain relief. Theresults concluded that all 3 tools had a high validity, butthe sensitivity in measuring changes in pain varied."^ TheVAS difference score was found to be the most sensitiveto changes in pain. Compared with horizontal scales,vVASs have been rated as easier for patients to use.'^

• Amsterdam Pieoperalive A}ixiely and Infotmation Scale.The APAIS is a self-report anxiety tool used to assess levelof anxiety and information-seeking behaviors specific tosurgery,'** This measure is easily administered and can becompleted in less than 2 minutes.'^ The APAIS consists of6 items: 4 relating specifically to anxiety and 2 relating toa need for information.'"* Subjects use a 5-point Likert

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Demographic variable

Age (yl

Height (cmi

Weight (kg)

Length of surgical case (min)

GenderFemaleMale

RaceWhiteAfrican American

Table 1. DemographicVar iablesData are given as mean ± SD or number of cases.

Anxiety score

APAIS

vVAS baseline (mm)

vVAS repeat (mm)

Control (n = 22)

33.32 ± 10.76

176.30 ±8.76

82.26 ±21.00

67.50 ± 52.33

913

166

Control (n = 22)

8.77 ± 3.96

24.14 ±25.91

21.50 + 26.70

Guided ¡magery (n = 22)

35.91 ±15.13

172.85± 11.10

82.51 ± 16.45

54.95 ±41.92

913

184

Guided imagery (n = 22)

8.05 ± 3 302

25.32 ± 27.80

11.86± 16.18

P

.516

.257

.965

.445

1.00

472

P

628

.266

002

Table 2. Anxiety ScoresData are given as mean ± SD.APAtS indicates Amsterdam Preoperative Anxiety and Information Scale; vVAS, vertical visual analog scale.

scale to rate their level of agreement with each ilem (1, notat all; 5, extremely).'"^ In a study by Moerman et al, ^ theanxiety subscale, which was the portion used in this in-vestigation, was found to have good internal consistencyreliability, with Cronbach a equaling 0.86. Correlation ofthe anxiety subscale of the APAIS with the State-TraitAnxiety Inventory (STAI)-State revealed a high concurrentvalidity (0.74).'' Boker et al'" compared 3 anxiety scales,the VAS. the STAI-State, and the anxiety subscale of theAPAIS for assessment of preoperative anxiety in patientsundergoing same-day surgery. The researchers concludedthat both the anxiety component of the APAIS and the VASshowed a statistically significant correlation to the STAl (P< .001) in surgical populations.'" The VAS and APAIS areuseful measurement tools that can provide the anesthesiaprovider wiih brief, valid, and reliable methods of assess-ing patients' anxiety in the preoperative [>eriod.' "''

• Guided Imagery CD. Michael R. "Ron" Eslinger,CRNA, MA, APN, BCH, CMI. FNCH, CAPT(ret), USN, ofHealthy Visions, Oak Ridge, Tennessee, designed theguided imagery products used for this investigation. TheCDs used were "Preparing for Your Surgery" and the CDspecific to general anesthesia in "Ceneral Anesthesia andConscious Sedation: 2 CD Set of Music and Suggestions."Both products consist of positive suggestions and bio-rhyihmic music. Although many anesthesia providers usethese types of CDs in their clinical practice and reportpositive outcomes in their patients, minimal data has beenpublished to evaluate their use in outpatient surgeries.

• Statistical Analysis. Demographic data analysis wasperformed using descriptive and inferential statistics.

Normality was determined mathemaiically, and in caseswhere variables did not meet strict normality assump-tions, nonparametric procedures were used for statisticalanalysis. The Wilcoxon signed rank test was used to eval-uate differences in anxiety vviihin ihe groups. Narcotic useand patient's age, height, and weight were analyzed usingthe independent-samples / tests. Pain measurements,length of Slay, satisfaction, and APAIS scores were ana-lyzed using the Mann-Whitney U test. For all statisticaltests, a P value of less than .05 was considered significant.

Based on results of a research investigation evaluatingthe effects of guided imageiy on length of stay on cardiacsurgical patients, where the mean difference (and standarddeviation) in hospital stay for the guided imagery groupwas 5.6 days (± 1.2) compared with 7.5 days (± 3.2). apower analysis was performed. Wilh use of an fi of CO"! anda ß ol 0.20, a total of 19 subjects per group were reqtured toachieve significance. Factoring in a 15% attrition ratebrought the total sample size to 44 subjects (22 per group).

ResultsA convenience sample of 44 ASA classification I, II, and IIIadults was enrolled. The sample consisted of 26 men and18 women, ranging in age from 18 to 71 years (mean ±SD, 34.6 ± 13 years), x analysis and independent-.samplesÍ tests were used to identify any significant differences inthe demographic composition of the groups, and no sta-tistically significant differences were found (Table 1).

The Wilcoxon signed rank test was used to compareinitial anxiety levels with immediate preoperative anxietylevels for both groups (Table 2). The control group had a

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30 n

Baseline Repeated tasting

Figure 2. Mean Preoperative Anxiety Scores (mm) atBaseline and RepeatedTesting, Using Vertical VisualAnalog ScaleControl, P= .266; guided imagery. P^ 002.

50-

45-

40-

35 -

Mill

i met

ers

M

M C

O

1 1

1

15-

10-

5 -

0 -Baseline, P=.228 '

B Control

^ vjuidBii imagery

1 Hour

Z3.6B

1•• jP=.O57 ' 2 Hours

•••P= .041 '

Figure 3. Baseline and Postoperative Pain Scores(mm), Using Vertical Visual Analog Scale

Variable

vVAS pain scores (mm)

Baseline1 hour2 hours

Narcotic use (mg)^

IntraoperativelyPACUAPU

Total

Control (n = 22)

2.23 ± 3.9841.18 ±24.8234.72 ± 27.54

20.35 ± 10.422.38 ± 4.465.41 ±4.14

28.03 ± 11.64

Guided imagery (n = 22}

5.95 ± 10.1928.68 ±27,1620.00 ± 28.92

17.40 ± 8.241.77 ±3.375.05 ± 5.40

24.55 ± 11.75

P

.228

.057

.041

.308964.569

,335

Table 3. Postoperative Pain Scores and Analgesic UseDala are given as mean ± SD. Measured in morphine equivalents.^ vVAS indicates vertical visual analog scale; PACU, postoperative anesthesia care unit; and APU, ambulatory procedure unit.

mean initial anxiety level of 24.14 mm and a mean repeatlevel of 21,50 mm (P = .266). The guided imagery groupreported a significant decrease in mean anxiety levelsInini an initial 25.32 mm to a mean repeat level of 11.86mm (P = .002; I igure 2). As no intervention occurredwithin the control group between the initial and repeatanxiety measurements, no change in anxiety would heexpected. However, a significant decrease in anxiety didoccur within the guided imagery group after listening tothe ( 0 preoperatively.

lo determine total narcotic consumption, we reviewedsuhjects' records for intraoperative and postoperativeanalgesic use. These data were converted into morphineequivalents and compared between tlie 2 groups using anindependent-samples í test. No significant difference wasfound (P = .335), The total narcotic use ranged from 7.5lo 57.0 mg (SD. 11,68 mg), with the mean for ihe controlgroup at 28.02 mg and the guided imagery group at 24.55mg. At each individual data collection point (intraop-erative, PACU, and APU), the narcotic consumption

between the 2 groups was compared and no significantdifference was found (Table 3).

Doses of midazolam were compared between groupsto identify any differences that may have contributed topostoperative outcomes. The assumption of normalitywas not met for the independent-samples / test, so theMann-Whitney t. test was used. No statistieally signifi-cant difference was found (P = 1,00), with mean doses ofmidazolam for the control and guided imagery groups of2.30 and 2.32 mg, respectively.

One- and 2-hour pain measurements helween the 2groups were compared using the Mann-Whitney V test(see Table 3). The mean level of pain for the controlgroupât 1 hour was41.18 mm compared with the guidedimagery group at 28.68 mm, which approaches statisticalsignificance (P = .057). The pain levels for the guidedimagery group at 2 hours were significantly lower (P =.041) than the control group, with means of 20,00 and34.72 mm, respectively (Figure 3),

The control group had a mean length of stay in the

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Variable

Length of stay in PACU (min)

Length of stay in APU (min)

Patient satisfaction (1-5 scale!

Control (n = 22)

43.82 ± 20.49

103.41 ±44.27

4.90 ± 0.30

Guided imagerv (n = 22) P

34.82 ± 9.87 .055

103.41 ± 55.47 .265

5.00 ±0.00 ,143

Table 4. Length of Stay and Patient Satisfaction VariablesData are given as mean ± SD.PACU indicates postoperative anesthesia care unit; APU, ambulatory procedure unit.

PACU of 43.82 minutes, and the guided imagery group'smean stay was 34.82 minutes (Table 4 and Figure 4). Thisdifference of 9 minutes approached statistical significance(P = .055). The duration of APU stay, however, was notsignificantly different between the 2 groups (P = .265).

The patients were very satisfied with their anesthesiaexperience, regardless of their group assignment. Two pa-tients in the control group rated their satisfaction as "satis-fied (4)," 1 guided imagery subject was discharged heforecompleting the survey, and all other patients gave ratingsof "completely satisfied (5)." No significant difference inpatient satisfaction was found (P = .143; see Table 4).

DiscussionThe concept of pain today has expanded beyond the tra-ditional views of interpretation and modulation of noci-ceptive impulses.^'' The pain experience encompasses notonly the nociceptive stimulus but also metabolic activity,stress, and emotional responses that exacerbate pain per-ception. The emotional motor system is composed ofthe autonomie nervous systetn, the greater limbic system,the hypothalamic-pituitary-adrenal (HPA) axis, and thecranial nerve system. ' The brain processes input fromthe central and peripheral nervous system, including af-ferent signals, thoughts, and emotions; this informationis passed to numerous areas of the brain for interpreta-tion and processing.

The limbic system is an integral part of the interpreta-tion of pain, and includes the stimulation of the auto-nomie nervous system and the HPA axis in response tonociceptive stimuli.^'^ Accumulating evidence currentlypoints to the amygdala as a neural substrate of the inter-action between pain and emotion.^^ It modulates pain be-havior and experience; it is linked to both facilitatory andinhibitory pathways, where pain enhances its activity.^^These connections hetween emotions and the modula-tion of pain support the theory that higher anxiety mayaffect an individual's perception and coping vnth the painexperience."'

The overall purpose of this research was to investigatethe effects of guided imagery on preoperative anxiety andpostoperative outcomes. Many studies performed to date,follow the advocated method of using guided imageryCDs or tapes days or weeks before surgery.^''*''''^'^^ Asmentioned previously, the increase in same-day surgeries

Control Guided imagery

Figure 4. Length of Stay in Postanesthesia Care UnitP = .055

makes implementation of guided imagery weeks inadvance more challenging. Therefore, this investigationfocused on using guided imagery on the day of surgery.

The reduction in preoperative anxiety for the guidedimagery group was statistically greater than in the controlgroup. Previous studies, such as by Antall and Kresevic,^Halpin et al,' and Tusek et al," also found statistically sig-nificant decreases in anxiety after implementation ofguided imagery, although they applied it for longer times.The results of this investigation suggest that when imple-mented only on the day of surgery, guided imagery maystill aid in decreasing anxiety in patients undergoing sur-gical procedures.

No differences were found in narcotic consumption,time to discharge, or patient satisfaction. Despite statisti-cally similar narcotic administration, the guided imagerygroup had statistically significantly lower pain levels atthe 2-hour measurement, compared with the controlgroup. This decrease in pain is cotisistent with previousfindings by Tusek et al"* and Laurion and Fetzer.'^Although not statistically significant, 1-hour pain levelsand PACU discharge times were lower in the guidedimagery groups, suggesting potential clinical significancein these areas as well.

A limitation in the study is the trend of preemptiveanalgesia. Many providers at this facility provide loadingdoses of narcotics early in cases to reduce the amount of

186 AANA Journal - June 2010 • Vol. 78, No. 3 wwvy.aana.com/aanajournalonllne.aspx

narcotics required long-term. Additionally, many APUnurses dosed patients with oral analgesics as soon as theytolerated oral intake. These factors make it more chal-lenging to assess differences in narcotic consumption.This investigation did not intend to manipulate anesthe-sia practice as it occurs on a daily basis. Instead, this in-vestigation simply provided an additional benefit ofguided imagery in the preoperativo period and evaluatedoutcomes as they would occur in a normal daily routineat our institution.

Additional limitalions of this study include a single-hiinded approach and differences in types of surgeries.Although double-blind studies are usually desired, it isdifficuli to blind the patient owing to the nature of thestudy. Additionally, there are significant differences in thedegree of pain and lenglh of surgical time between themany types of head and neck procedures. Ideally, a studycould focus on only one specific surgery, such as tonsil-leciomies; however, this was not feasible because of thevolume of cases performed at this facility relative to thenuniber of study subjects required.

Levels of operating room noise and variations in pre-operative holding area limes were not controlled for inthis study. The volume and type of music played duringsurgery, as well as extraneous noise from staff andmedical equipment can vary drastically. Other issues,such as surgical delays, staff availability, and roomturnover times, can cause prolonged stays in the preop-erative holding area. These are real-world conditions thatoccur daily; to avoid creating a fictitious surgical envi-ronment, no attempt was made to control them.

ConclusionsCuiiilcd imagery appears to show promise in the areas ofdecreased preoperative anxiety, length of slay in PACU,and postoperative pain. One advantage of this interven-tion is its ability to be used by a patient without the directinvolvement of trained specialists. Patients can learn thisrelaxation technique on their own via tapes, CDs, orbooks. While it may be preferable to implement thisihcrapy in advance of scheduled surgery, this studydemonstrates the potential benefits of guided imageryeven when used immediately before a procedure. Futureresearch on ihe use of guided imagery with tighter con-trols in the same-day surgical settings is needed beforeany definite recommendations can be made.

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AUTHORSMaj tiic A. Gonzales, CRNA, MS. USAR NC,* is a staff nurse anesthetistat Wilford Hall Medical Center, Lackland Air Force Base. San Amonio,Texas. Email: eric gonzales@us.af.mil.

Capt Rachel J.A. Ledesma, CRNA, MS, USAF. NC,* is a staff nurseanesthetist at Eglin Hospital, Eglin Air Force Base. Florida.

Capt Danielle J. McAllister. CRNA. MS. USAF, NC.* is a staff nurseanesthetist al Wnght-Patterson Medical Cenier, Wright-Patterson AirForce Base, Ohio.

Lt Col Susan M. Perry. CRNA. MS, USAF, NC, adjunct professor. Uni-formed Services University of the Health Sciences, Graduate School ofNursing, and associate clinical site director. Nurse Anesthesia Program,Wright-Pauerson Air Force Base, Ohio.

www.aana.com/aanajournalonline.aspx AANA Journal • June 2010 • Vol. 78, No. 3 187

u Col ChrisiophíT A. Dyer, CRNA, MS, USAi; NC, is an adjunct pro-fessor, Uniformed S<.T\'ices University of ihe Health Sciences, GraduateSchool of Nursing, Ciinical Siie Direcior, Nurse Anesthesia Program,Wnghi-Patterson Air Force Base.

CDR John P Maye, CRNA, PhD, NC, USN. is a director of research.Nurse Anesthesia Program, Unifotmed Services University of ihe HealthSciences, Graduate School of Nursing, Belhesda, Maryland.

• Studeritsat Unifurmed Services University of the Health Science.s, Graduu[f Schuciof Nursing, Wrighi-Pailersiin Air Force Base, ai tht lime this paper was wntteti.

ACKNOWLEDGMENTSA special thanks to Michael R. "Ron" Eslinger, CRNA, MA. APN, BCH.

CMl, FNCH, CAPT(rei), USN, for his assistance with our investigation.We thank Dorraitie Waits, PhD, for her invaluahle suppon with statisticalanalysis. We also gratefully acknowledge Capt Bartley Holmes, CRNA, MS,USAF, NC. and Maj Matthew über, CRNA, MS, USAF, NC, ior iheir helpduring data collection.

DISCLAIMERThe views expresed in this article are those of the authors and do notreflect ihe official policy or position of the Uniformed Services Universityof the Health Sciences Graduate School of Nursing, Depanmeni of the AirForce, Departtncnt of Defense, or the Ihiilcd States Government.

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