Pre-Surgical Benzodiazepine Use for Surgical Phobia

Age-Based Approach to Benzodiazepine Selection

For patients under 60 years old with significant surgical phobia, the American College of Emergency Physicians recommends using a short-acting benzodiazepine, such as midazolam or lorazepam, at the lowest effective dose, prioritizing non-pharmacologic anxiolysis first 1, 2
The ERAS Society guidelines recommend that benzodiazepines should be avoided entirely in patients over 60 years old due to increased sensitivity, risk of cognitive impairment, delirium, and falls 1, 2, 3, 4, 6

The American College of Medical Toxicology recommends avoiding combination of benzodiazepines with other CNS depressants due to significantly increased respiratory depression risk 5
The American Geriatrics Society Beers Criteria provide a strong recommendation with moderate quality evidence that benzodiazepines should be avoided in patients ≥65 years due to increased sensitivity, risk of cognitive impairment, delirium, and falls 1, 6

The ERAS guidelines emphasize that preoperative educational sessions with information on the surgical pathway successfully reduce patient anxiety and improve perioperative experience 1, 6
Effective communication strategies are imperative since high anxiety levels occur days prior to admission, not just on surgery day 1, 6

The ERAS Society guidelines specifically state that long-acting benzodiazepines are not indicated in the elderly (age >60 years) because they are associated with cognitive dysfunction and delirium after surgery 2, 3, 4
No advantages exist for using long-acting benzodiazepines (e.g., diazepam, clonazepam) due to psychomotor impairment during the postoperative period 2, 3, 4

The British Journal of Anaesthesia recommends creating a perioperative pain and anxiety management plan with the patient and communicating it to surgical and anesthetic teams 7
Document prior benzodiazepine tolerance and any history of paradoxical reactions 5