[Undesired awareness phenomena during general anesthesia: Evidence-based state of knowledge, current discussions and strategies for prevention and management]. / Unerwünschte Wachphänomene ("Awareness") während Allgemeinanästhesie: Evidenzbasierter Kenntnisstand, aktuelle Diskussionen und Strategien zu Prävention und Management.

Patient awareness during general anesthesia and the later recall of what happened during surgery can be experienced by patients as horrifying events that leave lasting mental trauma in the form of posttraumatic stress syndrome (PTSS). Awareness is related to a temporary insufficient depth of anesthesia. This phenomenon has been discussed for more than 20 years. According to randomized controlled studies, in the absence of risk factors awareness phenomena occur in 1-2 per 1000 operations involving general anesthesia (0.1-0.2%) and are classified as occasionally occurring critical events. An astonishing twist occurred elicited by the recent data from the 5th National Audit Project from Great Britain (NAP5) published in the British Journal of Anaesthesia and in Anaesthesia. The NAP5 evaluated patient reports of accidental awareness during general anesthesia (AAGA) in a multicenter manner in more than 2.7 million cases and indicated incidences of awareness of only 1:19,600, a frequency 20 times less than previously reported. These results gave rise to some controversy. It seems likely that, due to the absence of structured interviews, the NAP5 data only demonstrated the tip of the iceberg and may have vastly underestimated the real incidence of intraoperative awareness. The present overview summarizes the current knowledge about awareness. Furthermore, it addresses the question whether the awareness problem has been overestimated by evidence-based criteria or underestimated by the results of the NAP5. The responsibility for sufficient anesthesia in the clinical routine requires knowledge of awareness risks and potential sequelae. A formal recommendation from the German Society of Anesthesia and Intensive Care Medicine (DGAI) concerning awareness is not yet available; however, the recognition of evidence-based strategies in the management of anesthesia may minimize the occurrence of awareness and its sequelae.

[Pain, agitation and delirium. Amended 2013 guidelines of the American College of Critical Care Medicine]. / Schmerz, Agitation und Delirium. Neufassung der Leitlinie des American College of Critical Care Medicine 2013.

BACKGROUND: Intensive care patients regularly feel pain, not only during intensive care therapeutic measures but also when resting. The associated negative physiological and psychological sequelae can be serious and protracted in intensive care patients. Acute pain is predestined for the development of persistant neuropathic pain. AIM: This study informs the readership on the contents of the amended 2013 guidelines of the American College of Critical Care Medicine (ACCCM) on pain, agitation and delirium and presents strategies for implementation of the guidelines. MATERIAL AND METHODS: The focus of the amended recommendations is to give recommendations for treatment, in particular with respect to practical implementation of evidence-based scientific knowledge in the daily routine of intensive care wards. RESULTS: The fundamental principles which are summarized in these guidelines are: the regular collation of pain, measurement of depth of sedation and delirium with valid and reliable measurement instruments, an adequate and preemptive analgesia, administration of sedatives only when necessary and titration of sedatives so that patients remain responsive and are able to react. CONCLUSION: The amended version of the guidelines is intended to achieve a high acceptance and clinical implementation in intensive care medical teams and therefore to improve the outcome of intensive care patients by optimized therapy.

Nervus medianus evoked potentials and bispectral index during repeated transitions from consciousness to unconsciousness.

BACKGROUND: We investigated the relationship between median nerve somatosensory evoked potentials (SSEPs) and the bispectral index (BIS) during alternating periods of consciousness and propofol-induced unconsciousness. METHODS: Loss of consciousness (LOC) was repetitively induced by bolus injections of propofol in 24 patients undergoing elective surgery in spinal anaesthesia. SSEP and the BIS were recorded during LOC and recovery of consciousness (ROC). The level of consciousness was clinically assessed by the observer's assessment of alertness/sedation scale. Propofol venous plasma concentrations were measured simultaneously. RESULTS: At LOC, all SSEPs latency components were prolonged (P<0.001), whereas amplitudes of the components > or = 45 ms were smaller (P=0.008) and the BIS values were lower (P<0.001). None of the EEG variables regained baseline levels during ROC. Regression analyses revealed that the SSEP components (five latencies and five amplitudes) explained 33% of the variance when predicting ROC; the BIS explained 12%. The combination of SSEP and BIS explained 37% of variance in this patient sample. Propofol venous plasma concentration was 1.2 (0.8) microg ml(-1) during LOC and 0.4 (0.5) microg ml(-1) during ROC. CONCLUSIONS: The present results indicate the usefulness of combining variables of the evoked and spontaneous EEG to measure different levels of consciousness, because the SSEP provide additional information beyond the BIS. Inter-individual variability of all the EEG variables limits their predictive potency of ROC after propofol infusion.

Narcotrend-assisted propofol/remifentanil anaesthesia vs clinical practice: does it make a difference?

BACKGROUND: The Narcotrend is a computer-based EEG monitor designed to measure the depth of anaesthesia. The aim of the present study is to test the hypothesis that the intraoperative level of anaesthetic depth differs if decision-making is guided by Narcotrend monitoring or not. METHODS: Forty-eight patients undergoing elective surgery were randomized to receive a Narcotrend-controlled propofol/remifentanil anaesthetic regimen or standard clinical practice. In the EEG group, anaesthesia was adjusted to achieve a Narcotrend level of D2-E0, which is recommended for moderate to deep anaesthetic depth for surgery. EEG values were recorded continuously every 20 s in both groups. Depending on data distribution, group comparisons of the EEG parameters, propofol plasma concentration, and recovery characteristics were performed by analysis of variance for repeated measurements or non-parametric statistics. RESULTS: About 62 (sd 29)% of the Narcotrend values were within the target level in the EEG group during maintenance of anaesthesia; this was true for 64 (26)% of the data in the non-EEG group. The variance of the Narcotrend data was significantly lower in the EEG group compared with the non-EEG group [median: 0.4 (range: 3.5) vs 0.6 (2.5); P = 0.048]. There was no difference in propofol or remifentanil dosage, propofol plasma concentrations, and time for extubation. Ten minutes after extubation, visual analogue scores for nausea indicated a lower incidence in the Narcotrend group [7 (15) vs 24 (34); P = 0.005]. CONCLUSIONS: Guidance of anaesthesia with the Narcotrend-monitor leads to fewer deviations from a defined target than clinical assessment of anaesthetic depth only. This results in lower scores of nausea in the immediate period after anaesthesia.

[Sleep disturbances in critically ill patients]. / Schlafstörungen bei kritisch kranken Patienten.

Sleep is an essential part of life with many important roles which include immunologic, cognitive and muscular functions. Of the working population 20% report sleep disturbances and in critically ill patients an incidence of more than 50% has been shown. However, sleep disturbances in the intensive care unit (ICU) population have not been investigated in detail. Sleep disturbances in ICU patients have a variety of reasons: e.g. patient-related pathologies like sepsis, acute or chronic pulmonary diseases, cardiac insufficiency, stroke or epilepsy, surgery, therapeutical interventions like mechanical ventilation, noise of monitors, pain or medication. Numerous scales and questionnaires are used to quantify sleep and the polysomnogramm is used to objectify sleep architecture. To improve sleep in ICU patients concepts are needed which include in addition to pharmacological treatment (pain reduction and sedation) synchronization of ICU activities with daylight, noise reduction and music for relaxation. In order to establish evidence-based guidelines, research activities about sleep and critical illness should be intensified. Questions to be answered are: 1) Which part of sleep disturbances in critically ill patients is directly related to the illness or trauma? 2) Is the grade of sleep disturbance correlated with the severity of the illness or trauma? 3) Which part is related to the medical treatment and can be modified or controlled? In order to define non-pharmacological and pharmacological concepts to improve sleep quality, studies need to be randomized and to include different ICU populations. The rate of nosocomial infections, cognitive function and respiratory muscle function should be considered in these studies as well. This will help to answer the question, whether it is useful to monitor sleep in ICU patients as a parameter to indicate therapeutical success and short-term quality of life. Follow-up needs to be long enough to detect adverse effects of withdrawal symptoms after termination of analgesia and sedation or delirium.

Psychomotor dysfunction after remifentanil/propofol anaesthesia.

BACKGROUND AND OBJECTIVES: Early recovery after anaesthesia is gaining importance in fast track management. The aim of this study was to quantify psychomotor recovery within the first 24 h after propofol/remifentanil anaesthesia using the Short Performance Test (Syndrom Kurztest (SKT)), consisting of nine subtests. The hypothesis was that psychomotor performance remains reduced 24 h after anaesthesia. METHODS: Thirty-seven patients scheduled for elective surgery took part in the study. The SKT was performed on the day before general anaesthesia (T0), 10, 30, 90 min and 24 h after extubation (T1). Parallel versions were used to minimize learning effects. Anaesthesia was introduced and maintained with remifentanil/propofol as a target controlled infusion. Propofol plasma concentration was measured 10 and 90 min after extubation. Perioperative pain management included novaminsulfon and piritramide. RESULTS: Up till 90 min after surgery and anaesthesia, psychomotor performances were significantly reduced as the lower test results in all SKT subtests indicated (P < or = 0.007 vs. baseline T0). In the three memory subtests (ST 2, ST 8 and ST 9), psychomotor performance was still reduced on the first postoperative day (P < or = 0.005; T1 vs. T0). There was no correlation between propofol plasma concentration and the psychometric test results. CONCLUSIONS: Propofol/remifentanil-based target controlled general anaesthesia for surgery is associated with a reduced psychomotor function up to the first postoperative day. Further studies are needed to confirm the usefulness of the SKT in the perioperative period and to clarify which components in the perioperative period are responsible for a lower performance in the SKT.

[Topographic electroencephalography: endotracheal intubation during anaesthesia with propofol/fentanyl]. / Topographie des Elektroenzephalogramms: Endotracheale Intubation unter Narkose mit Propofol und Fentanyl -- EEG-Mapping während Intubation unter Propofol-/Fentanyl-Narkose.

OBJECTIVE: We used quantitative analysis of the electroencephalogram (EEG) during routine clinical practice to assess the effect of tracheal intubation following induction of anesthesia with propofol and fentanyl. METHODS: The topographic EEG was recorded from eight bipolar electrode derivations in 25 patients. Z-scores relative to age expected normative data were computed for relative power in the delta, theta, alpha and beta frequency bands. Multivariate statistics (Hotellings' t-sqare) were used to evaluate changes in regional brain electrical activity. RESULTS: Tracheal intubation induced an increase in alpha and beta frequencies, while delta power was reduced (F-values: Delta: 7.68, p = 0.011; Alpha 31.93; p < 0.001; Beta 12.85, p = 0.001). The most pronounced regional effect was seen for the alpha frequency band with the largest increase in both fronto-temporal regions (F-value 33.89, p < 0.001). During clinical practice the patients received propofol 2.7 (+/- 1.2; minimum: 0.5, maximum 6.9) mg kg (- 1) and fentanyl 2 (+/- 1; minimum 1, maximum 4) microg kg (- 1). Vital parameters did not change during intubation. CONCLUSION: Individual titration of the dose of propofol and fentanyl as done during routine clinical practice is not sufficient to block the strong noxious stimulation of intubation. Tracheal intubation resulted in "classical" cortical arousal. It remains open whether this cortical wake-up phenomenon has a clinical impact.

Changes in cortical electrical activity during induction of anaesthesia with thiopental/fentanyl and tracheal intubation: a quantitative electroencephalographic analysis.

BACKGROUND: There are regional differences in the effects of anaesthetics agents and perioperative stimuli on the EEG. We studied the topography of the EEG during induction of anaesthesia and intubation in patients receiving thiopental and fentanyl to document regional electrical brain activity. METHODS: EEG was recorded in 25 patients in the awake state, after pre-medication, during induction, at loss of consciousness and after intubation. Eight bipolar recordings were made and the relative power of the frequency bands delta, theta, alpha, and beta were used (after z-score transformation for age) to measure changes in regional EEG activity. RESULTS: Noxious stimulation during tracheal intubation partially reversed the slowing of the EEG caused by anaesthesia. During induction of anaesthesia alpha activity was most reduced in temporal and occipital regions. The most prominent EEG changes after intubation were an increase in alpha and a decrease in delta power (P<0.001). The largest changes were in the frontal and temporal leads for alpha and in the frontal and central leads for delta. Heart rate and arterial pressure remained constant during intubation. CONCLUSIONS: Changes in alpha and delta power were identified as the most sensitive EEG measures of regional changes in electrical brain activity during anaesthesia and noxious stimulation.

Impaired explicit memory after recovery from propofol/sufentanil anaesthesia is related to changes in the midlatency auditory evoked response.

BACKGROUND: Midlatency auditory evoked responses (MLAER) can distinguish different stages of anaesthesia. We studied MLAER during emergence from propofol/sufentanil anaesthesia in relation to recovery of explicit memory. METHODS: MLAER were recorded in 29 healthy patients before and during anaesthesia and during emergence until the patients opened their eyes spontaneously. After a structured interview the next day, patients were classified into those with and without explicit memory of the recovery period. Latencies Na, Pa and Nb and the peak-to-peak amplitudes NaPa and PaNb were compared between the groups by multivariate analysis of variance. Results are mean (SD). RESULTS: At eye opening (37 (12) min after the end of anaesthesia) the latency Nb (47 (5) compared with 41 (5) ms; P < 0.001) was prolonged and the amplitude PaNb (1.3 (0.8) compared with I (0.5) ms; P = 0.012) was greater than the baseline value, respectively. The Nb latency was significantly shorter in patients with explicit memory (49 (2) ms compared with 45 (I); P = 0.041). CONCLUSIONS: Large intra- and inter-individual variability in the MLAER values limited their ability to predict memory responses in individual patients during emergence from propofol/sufentanil anaesthesia.

Recovery of memory after general anaesthesia: clinical findings and somatosensory evoked responses.

BACKGROUND: Mid-latency somatosensory evoked responses are used to monitor the integrity of the sensory pathways intra-operatively. They can quantify the effects of anaesthetics on the central nervous system. Mid-latency auditory evoked responses have been related to cognition during anaesthesia, but there are no detailed studies using median nerve somatosensory evoked responses (MnSSER). METHODS: We studied 49 patients during recovery from general anaesthesia (isoflurane/nitrous oxide or propofol) to assess implicit and explicit memory function in relation to mid-latency MnSSER. The MnSSER recordings were made before anaesthesia, during steady-state anaesthesia, and at the end of the recovery period. The patients were interviewed 24 h later about their memory for the immediate wake up phase. Statistical analysis was by multivariate analysis of variance. RESULTS: Out of 49 patients, 23 recalled the recovery period, 11 had implicit memory for an object shown to them during the recovery period, and 15 did not have any memory for the recovery period. At RECOVERY the patients with recall had significantly shorter MnSSER latencies N45 and P50 and inter-wave conduction times LatN35-LatP45 than patients without memory (P<0.05). CONCLUSIONS: We conclude that MnSSER components warrant further investigation for studying the effects of anaesthetic drugs on cognitive function.

Incidence of recall, nightmares, and hallucinations during analgosedation in intensive care.

OBJECTIVE: To define the incidence of recall and dreams during analgosedation in critically ill patients. DESIGN: Prospective clinical study. SETTING: Anaesthesiological intensive care unit (ICU) in a university hospital. PATIENTS AND PARTICIPANTS: Two hundred and eighty-nine critically ill patients, who either arrived intubated and sedated at the ICU or required intubation, mechanical ventilation, and sedation during their ICU stay. INTERVENTIONS: none. MEASUREMENTS AND RESULTS: The patients were interviewed 48-72 h after discharge from the ICU. By a structured interview they were asked whether they recalled any event before they had regained consciousness at the ICU. Moreover they were asked for dreams. Descriptive statistics: 64.7% of all patients did not recall any event, before they regained consciousness. However, 17% ( n=49) of all patients indicated that they remembered the tracheal tube or being on the ventilator, before they woke up. Some patients (21.1%) reported dreams or dreamlike sensations. Some patients (9.3%) recalled nightmares, while 6.6% reported hallucinations. CONCLUSIONS: Critically ill patients reported a high incidence of recall for unpleasant events, which they thought to have taken place before they regained consciousness. The patients, who stayed longer than 24 h at the ICU, indicated vivid memory for nightmares and hallucinations. Further studies are suggested to evaluate: 1) whether there is an impact of the present findings on outcome; and 2) whether clinical scores for sedation or neurophysiological monitoring help to define the exact time, when recall happens, in order to guide therapeutic intervention.

Median nerve evoked responses: stimulation modalities for midlatency cortical components.

PURPOSE: Median nerve somatosensory evoked responses (MnSSER) are frequently used clinically and scientifically. However, the stimulus-response interrelationship has not been documented for the midlatency components. Therefore we investigated the spinal and cortical midlatency MnSSER, to document the effect of different stimulus intensities. METHODS: Spinal and midlatency MnSSER were recorded following percutaneous electrical stimulation of the median nerve at the wrist in 32 neurological healthy females. Three different stimulation intensities were applied: threefold sensory threshold (INT 1), motor plus sensory threshold (INT 2), individual level of tolerance (INT 3). STATISTICS: Multivariate analyses of variance (independent variable: stimulation intensity). RESULTS: Three negative and two positive midlatency components were identified after median nerve stimulation. At INT 1 the early waves N20, P25 and N35 were identified in all of the patients. In contrast, the component P45 was identifiable in 23% of the sample at the lowest intensity level and N55, respectively, in 32%. At INT 2 the spinal and the midlatency cortical amplitudes (except amplitude N35P45) were significantly increased (p < 0.014). At INT 3 the amplitudes of the primary cortical complex did not increase further, but the components > 35 ms became identifiable in the whole sample except in one subject. In contrast, there was no change in the MnSSER latencies. The intensity was comfortable for all subjects. CONCLUSION: For monitoring the midlatency MnSSER components > 35 ms the authors suggest a stimulation intensity close to individual tolerance level for optimal cortical responses.

Cortical arousal in critically ill patients: an evoked response study.

OBJECTIVE: Assessing the level of sedation in critically ill patients remains a challenge for the intensivist in order to avoid over or under-sedation. Clinical scoring systems may fail in patients with concomitant neurological disorders or requiring muscle relaxants. We evaluated auditory (AER) and median nerve somatosensory evoked responses (MnSSER) in critically ill patients sedated with sufentanil and propofol, in order to quantify the level of sedation during therapeutic interventions. DESIGN: Prospective clinical study. SETTING: Anaesthesiological intensive care unit (ICU) in a university hospital. PATIENTS AND PARTICIPANTS: Thirty-two patients following major abdominal or thoracic surgery requiring sedation during their stay on the ICU. INTERVENTIONS: During physiotherapy and following nursing care (tracheal suctioning) AER and MnSSER were recorded. The level of sedation was evaluated clinically in relation to vital parameters. Data were analysed by multivariate analyses of variance (Hotellings T2), Friedman test. MEASUREMENTS AND RESULTS: In comparison to baseline levels the AER latency Nb decreased, while the amplitude NaPa increased during physiotherapy and after tracheal suctioning (p < 0.001). In contrast, the MnSSER latency P25 decreased and the amplitude P25N35 increased after tracheal suctioning only (p < or = 0.001). Clinical sedation scores decreased and mean arterial blood pressure increased during physiotherapy and nursing care. CONCLUSIONS: Changes of AER or MnSSER waves indicated cortical arousal in ICU patients during nursing care and physiotherapy. Further studies with evoked responses are recommended to evaluate whether bolus injections of sedatives and/or analgesics reduce cortical arousal and thereby minimise the patient's stress during nursing care.

Median nerve evoked responses and explicit memory during recovery from isoflurane/nitrous oxide anesthesia.

PURPOSE: To evaluate median nerve somatosensory evoked responses during recovery from anesthesia in relation to clinical findings. METHODS: Twenty-two gynecologic patients received isoflurane in nitrous oxide for anesthesia. Midlatency somatosensory evoked responses (N20, P25, N35, P45, N50) were recorded the day before surgery (AWAKE), during steady state anesthesia (STABLE), and every five minutes after discontinuation of anesthesia until the patients were able to name a shown object correctly (RECOVERY). Next day the patients were questioned with a structured interview about their explicit memory of the immediate recovery period and classified into groups: No-MEM (no memory) and MEM (memory). Multivariate analysis of variance compared electrophysiological parameters at the different time points and between the two memory groups. RESULTS: During STABLE isoflurane/N2O anesthesia, all cortical amplitudes were reduced (P< or =0.003) and all latencies were prolonged compared with AWAKE (P<0.001). At RECOVERY the latencies N35, P45, N50 remained prolonged (P< or =0.001), while the amplitudes N20P25 and P45N50 were reduced in comparison to AWAKE (P< or =0.02). The latencies P45 (48+/-8 vs. 61+/-9 msec) and N50 (67+/-12 vs. 81+/-10 msec) were shorter in the patients of the group MEM (P< or =0.03) at RECOVERY. CONCLUSION: The reversibility of anesthetic induced changes in amplitudes and latencies of median nerve somatosensory evoked responses reflected clinical awakening during emergence from isoflurane/nitrous oxide anesthesia. In the patients who had recall for the immediate recovery period, the reversibility of anesthetic induced changes of components P45 and N50 was faster than in patients without recall.

Midlatency median nerve evoked responses during recovery from propofol/sufentanil total intravenous anaesthesia.

BACKGROUND: Median nerve somatosensory evoked responses (MnSSER) are frequently used to monitor the integrity of the somatosensory pathway during surgery. We investigated MnSSER components during the wakeup phase from anaesthesia with propofol/sufentanil, because detailed information is lacking about the reversibility of anaesthetic induced changes of MnSSER. The aim of the study was to document precisely the MnSSER waves in relation to the clinical awakening. The hypothesis was that anaesthetic induced MnSSER changes are reversed when the patient becomes responsive after anaesthesia. METHODS: In 20 gynaecological patients anaesthesia was maintained with propofol 8 mg kg(-1) h(-1) supplemented by bolus injections of sufentanil. MnSSER were recorded at C4' (N20, P25, N35, P45, N50) following electrical median nerve stimulation on the day before surgery, after the end of surgery during anaesthesia and every 5 min during recovery, till the patients were responsive again and able to identify a shown object. RESULTS: While the primary cortical MnSSER complex N20P25 regained baseline values, the cortical latencies > or =35 ms remained prolonged (P<0.001) and the amplitudes P45N50 were suppressed (P< or =0.013), when the patients were responsive after 26+/-7 min following anaesthesia. However, the amplitudes P25N35 exceeded their corresponding baseline value (P<0.01) CONCLUSION: Persistent changes of MnSSER waves > or =35 ms reflect impaired signal processing along the somatosensory pathway following propofol/sufentanil anaesthesia when the patients are responsive again. Further studies combining MnSSER recording with distinct neuro-psychological tests are needed to define the clinical relevance of these findings.

[Median nerve evoked potentials and explicit memory function during recovery from propofol-sufentanil anesthesia]. / Nervus medianus evozierte Potentiale und explizite Gedächtnisfunktion während der Aufwachphase aus der Propofol/Sufentanil-Anästhesie.

OBJECTIVE: In a prospective study rnidlatency somatosensory evoked Potentials (SEP) were investigated in relation to explicit memory function during recovery from propofol/sufentanil anaesthesia. METHODS: Anaesthesia was maintained in 20 patients with 8 mg kg-1 h-1 propofol and supplemented with sufentanil. SEPs (N20, P25, N35, P45 N50) elicited by median nerve stimulation were recorded at the day before surgery (AWAKE) and during recovery from anaesthesia, when patients were able to identify a shown object (RECOVERY). The day after surgery patients were interviewed about their memory of the recovery period. STATISTICS: Hotellings' T2. RESULTS: One day after anaesthesia 9 patients could remember events during the recovery period. At RECOVERY SEP-latencies P45 and N50 were significantly shorter in the patients with recall for the wakeup-phase (p < 0.05). CONCLUSION: SEP latencies P45 and N50 indicated impaired explicit memory function during recovery from propofol/sufentanil anaesthesia.

Patients' vs nurses' assessments of postoperative pain and anxiety during patient- or nurse-controlled analgesia.

We have compared patients' and nurses' assessments of postoperative pain and anxiety after different analgesic treatments. Sixty orthopaedic patients were allocated randomly to receive i.v. piritramide (either nurse-controlled or patient-controlled) or subarachnoid bupivacaine (nurse-controlled or patient-controlled). Patients and nurses assessed pain and anxiety using a visual analogue scale (VAS; 1-100 mm). Pain and anxiety ratings of patients and nurses were significantly correlated (Spearman's r > or = 0.69; P < 0.001). In general, patients' pain scores were higher than nurses' scores (patients' median VAS = 34 (range 1-76) mm; nurses VAS 21 (1-59) mm) and for all groups except the patient-controlled subarachnoid bupivacaine group, where they were significantly higher (P < 0.01). Discrepancy in pain estimates between patients and nurses increased with the level of pain. The relationship between patients' and nurses' anxiety scores was less clearly defined and did not depend on the level of anxiety.