PSYCHOLOGICAL DISTURBANCES ASSOCIATED WITH OPEN HEART SURGERY

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.

The meaning of heart-valve surgery to the patient

Observations are presented about patients' psychological reactions to the experience of having a heart valve replaced or repaired. The importance of the patient's conceptualization of the cardiac valve and the surgical procedure is discussed. By understanding what such a procedure may mean to the patient, the medical staff can help make a terrifying experience more bearable.

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.

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.

Subjective follow-up of patients from a surgical intensive therapy ward

One-hundred consecutive patients who had been treated in the surgical intensive therapy ward completed a form recording their impressions of their stay. Most patients had a reasonable idea of how long they had spent in the ward and few remembered being in pain or excessively worried by any of the procedures carried out. Those who had been artificially ventilated had little recollection of this period; most either did not realize that their breathing had been artificially maintained or had no idea of the duration of ventilatory support. Very few of the patients who had tracheal suction via endotracheal or tracheostomy tubes were unduly worried by this, but 60% of the patients who needed nasopharyngeal suction to help sputum clearance had been considerably worried by this.Most of the patients were very pleased with the medical and nursing attention they had received and did not find the "intensive" nature of their care unduly disturbing.

Psychological reactions to cardiac operations: an historical perspective

The impact of heart surgery has many ramifications for the patient. With studies of mitral commissurotomies in the early 1950's, we begin to learn of man's response to newer surgical and medical procedures which radically change the course of life. In the area of heart surgery, the dramatic and prevalent postoperative psychoses occurring in intensive care units have been discussed, along with the intimate relationship existing between preoperative emotional slate and postoperative outcome. The symbolism of the heart, as the life-sustaining organ, the meaning of death, and the importance of the motivation to live are three interrelated facets representative of man's response to having his heart operated on. New technology in physical medicine leads to new insights in psychological medicine and thereby underscores the pressing need for greater collaboration amongst all specialists concerned with patient care.

Psychiatric view of the intensive care unit

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