Psychiatric complications of open-heart surgery. A re-examination

Primary prevention: fact or fiction

This paper is a review of studies oriented to the primary prevention of psychiatric disorder. Difficulties in this field are noted, including current aetiological concepts, outcome measures, techniques and processes, methodological problems, humanitarian and ethical issues and the role of social processes. Studies in several different areas of primary prevention are described. These include projects directed towards parenting processes, vulnerable children, crisis intervention, psychosomatic variables, biological factors, mental health education and community processes. Resistances to preventive work are outlined. It is concluded that much work in this field represents a "call" for prevention; that diffuse interventions for diffuse population groups to achieve diffuse outcomes may not lead to demonstrable effects in prevention. Specific interventions directed towards high risk populations to achieve specific prevention goals have shown that primary prevention may be accomplished in some areas.

Propranolol: an unrecognized cause of central nervous system dysfunction in patients undergoing cardiopulmonary bypass

An organic mental syndrome developed in a patient soon after he underwent repair of a dissecting thoracic aortic aneurysm. The operation was accomplished with cardiopulmonary bypass. Initially, the mental changes were thought to be related to the operation. However, they subsequently were shown to be associated with propranolol. The potential role of propranolol in inducing central nervous system disturbances is emphasized, and the literature on the subject is reviewed.

Sleep disturbances after open heart surgery

This study was designed to document quantitatively the sleep disturbances that occur after open heart surgery and to investigate a group of patients who underwent a thoracic surgical procedure not involving cardiopulmonary bypass. Nine patients were studied, six after open heart surgery and three after partial or complete pneumonectomy. In each patient, sleep patterns were recorded with use of all night polygraphy before and after operation and for up to 5 weeks on follow-up studies. After open heart surgery, patients manifested considerable suppression of both rapid eye movement and slow wave sleep patterns. In the three patients subjected to thoracotomy these sleep indexes returned to preoperative levels much earlier. Evidence of stage 2 sleep was present in one of the three patients with thoracotomy on the first postoperative night, and in two of the three both rapid eye movement and slow wave sleep returned to preoperative levels by the time of hospital discharge. It is concluded that patients undergoining open heart surgery experience both acute and chronic disruptions of sleep that last well beyond the hospital period of convalescence. These sleep disturbances have considerable relevance for postoperative management.

Stress, cardiac activity and sleep

An overview is presented of the relationship between cardiovascular activity and sleep, emphasizing the interrelations between stage of sleep and cardiovascular dysfunction. Possible implications of the data are discussed, especially in relation to stress-related factors and possible treatment regimens.

The psychiatric aspects of cardiac intensive therapy: a review

The post cardiotomy state is typically delirious and although organic factors are important it is multi-determined. Cerebral ischaemia has been implicated in the development of psychological disorder after resuscitation but longer term neurotic disorders also occur. Affective disturbances, particularly depression, are associated with the coronary care experience. The following conditions are directly related to an increased incidence of psychological disorder: age, loss of sleep, sensory deprivation, stressful experiences, pre-operative morbidity (both physical and mental), the severity of both surgical trauma and the post-operative medical state. For both the staff who administer intensive therapy and the patient who receives it there are unique psychological hazards, the management of which depends largely on mutual understanding and support.

Hypotension-induced changes in cerebral function during cardiac surgery

In a series of 75 patients undergoing cardiac operations with the assistance of cardiopulmonary bypass (CPB), 15 patients were subjected to relatively large hypotensive stresses during CPB as measured by the depth and duration of the fall in cerebral perfusion pressure. Of these 15 patients, eight manifested cerebral dysfunction postoperatively ranging from temporary exacerbation of pre-existing focal neurological deficits to irreversible coma. In each of these eight cases, EEG disturbances which first appeared at the time of hypotensive episodes during CPB persisted postoperatively and correlated with the nature and evolution of the clinical deficit. In two of the patients who did not regain consciousness postoperatively, neuropathological studies revealed bilateral laminar cortical necrosis, primarily involving cerebral cortex in one case and cerebellar cortex in the other, with accentuation in arterial border zones. Of seven other patients who suffered comparable exposures to hypotension during CPB, none evidenced cerebral dysfunction postoperatively. The most important determinants of this selective vulnerability to low extracorporeal perfusion pressure appeared to be the "reperfusion" pressure established after the hypotensive episode, postoperative blood pressure and cardiac output, and brain temperature at the time of the hypotension. Advanced age and history of cerebrovascular insufficiency were the greatest risk factors among patient variables.

Sleep and delirium after open heart surgery

The quantity and quality of sleep have been measured objectively in 4 patients before and after open heart surgery; 2 of these became delirious on the third postoperative day. A fifth patient was studied in relation to major abdominal surgery. The degree of sleep disturbance in the early postoperative period was greater after cardiac than abdominal surgery but was not consistently related to the ensuing delirium. Although patients were woken frequently by the necessity for nursing and other care, they were unable to remain asleep when left undisturbed during the period of delirium, which lasted for several days. Rapid eye movement (REM) sleep was absent and delta wave sleep markedly reduced after cardiac surgery and with delirium although the patients described frequent ‘dream-like’ experiences in their drowsy state. Delirium after cardiac surgery difsers from that which sometimes occurs after withdrawal of addictive drugs, when a high proportion of REM sleep is observed.

The ICU syndrome: fact or fancy

Thirty-two patients admitted to a general medical intensive care unit were compared to twenty patients, matched for age, sex, type and severity of illness, treated in a conventional medical ward. No meaningful difference in incidence of delirium was noted. Neither sensory monotony nor sleep deprivation could be correlated with occurrence of delirium. An organic base was present in all four cases of delirium which occurred in the ICU. By use of a specially devised scale to measure levels of anxiety or depression in medically ill patients, no higher levels of anxiety or depression were found in ICU patients than in comparably ill patients treated in a ward. This comparative study fails to support the proposition that the intensive care unit environment per se causes psychological disturbance.

Ego-supportive care in open-heart surgery

Open heart surgery has been shown to have a rate of occurrence of postoperative psychopathological phenomena (9 percent-57 percent) many times greater than that of general surgery (1/1500). These phenomena result from an interplay of organic, environmental, psychological, and social factors which act on the integrative and coping capacity of the ego.

Treatment is accomplished through support of the ego by: 1) establishment of a relationship, 2) reassurance, 3) environmental support, 4) consultative relationships with staff, 5) ventilation of feelings, 6) medical measures in support of somatic function, and 7) anti-anxiety drugs. Such supportive measures are usually effective in bringing about a rapid remission of these psychopathological phenomena.

Psychological adjustment and response to open-heart surgery: some methodological considerations

Psychological factors have long been posited as having a role in determining a person's response to open-heart surgery. As early as 1956 Bolton and Bailey reported a high correlation between a history of psychiatric problems and psychiatric complications following cardiac surgery.

Postcardiotomy psychosis in non-English-speaking patients

This paper presents another causative or additive factor in the production of post-cardiotomy delirium. Comparison of two matched groups of patients from the National Heart Institute reveals a marked difference in the incidence of psychosis between the group that is from the United States and speaks English and the group that is foreign and has no ability to communicate in English. The United States group had two patients with psychosis (3.9 percent), while the foreign group had fifteen (29.4 percent) (p<0.001). A higher incidence of delirium occurred in men than women, and there was suggestive evidence that the group with psychoses had more medical complications, with resulting delays in discharge. The importance of language and culture in the determination of this delirium are considered and methods of mitigating this reaction are presented.