Neuro-psychiatric problems of cardiac surgery

Delirium in the postoperative cardiac patient: a review

BACKGROUND AND AIM OF REVIEW: Cardiac surgery is increasingly common and relatively safe, but there are frequent reports of neuropsychiatric sequelae occurring in the postoperative period. One of the most common neuropsychiatric presentations of cardiac surgery is delirium, also called postcardiotomy delirium (PCD). Despite the vast numbers of cardiac surgeries performed today, there is a paucity of data on risk factors and management options of PCD available to the clinician. This review aims to summarize available information, increase clinicians' awareness of PCD and suggest effective management of this illness.

METHODS

Our literature search was completed using the databases Medline and CINAHL; it was limited to human and English language studies from 1964 to the present. Search terms included "delirium," "agitation," "postoperative," "cardiac," "neuropsychiatric," "neuroleptics," "psychosis," "surgery," "treatment," "postcardiotomy," and "pharmacotherapy."

RESULTS

Our review of the literature revealed several risk factors for PCD, as well as various options for its pharmacological management.

CONCLUSIONS

A multifactorial model should be applied when considering risk stratification for and prevention of delirium postoperatively. Pharmacologically, conventional antipsychotic agents, such as haloperidol, have long been used to manage delirium. In light of haloperidol's side effects, particularly those applicable to the cardiac patient, further research is required into the role of second generation antipsychotics. These agents are common in clinical use, and may be the preferred medications.

The incidence of gastrointestinal symptoms in cardiac surgery patients through six weeks after discharge

OBJECTIVE

To determine the incidence and the effect of intraoperative and discharge variables on gastrointestinal (GI) symptoms after cardiac surgery during hospitalization and 2 and 6 weeks after discharge.

DESIGN

Prospective and descriptive.

SETTING

Two university-affiliated medical centers.

PATIENTS

One hundred twenty-two adult patients undergoing cardiac surgery.

OUTCOME MEASURES

Frequency of GI symptoms and level of distress caused by GI symptoms during hospitalization and 2 and 6 weeks after hospital discharge.

INSTRUMENTS

GI symptoms were measured by The Gastrointestinal Symptom Frequency and Symptom Distress Scale. Depression was measured by The Center for Epidemiologic Studies Depression Scale.

INTERVENTION

Demographic and physiologic variables were collected by chart review. Patients completed the Gastrointestinal Symptom Frequency and Symptom Distress Scale and The Center for Epidemiologic Studies Depression Scale in the hospital. Telephone interviews were used to collect 2- and 6-week data.

RESULTS

Fifty-seven percent of patients after surgery reported poor appetite, 37% lack of taste, and 34% nausea during hospitalization. The frequency of all GI symptoms decreased with time; 19% of subjects reported poor appetite, 19% lack of taste, and 10% nausea at 6 weeks after discharge. Although poor appetite occurred with the greatest frequency, patients reported the greatest distress with lack of taste. When analyzed with a logistic regression model, use of antihypertensive agents was associated with lack of taste; use of diuretic and antiarrhythmic agents was associated with nausea; and level of depression was associated with all three GI symptoms. Length of cardiopulmonary bypass time mean arterial blood pressure during surgery, mixed venous oxygen saturation during surgery, and subject age did not significantly affect the frequency of GI symptoms at any data collection point.

CONCLUSIONS

The incidence of GI symptoms after cardiac surgery is significant, but their etiology has yet to be determined.

Delirium after cardiac surgery: a critical review

Numerous articles have been published investigating the incidence of and risk factors for delirium after cardiac surgery. Smith and Dimsdale reviewed the literature on postcardiotomy delirium in 1987 using a meta-analysis of 44 research studies. However, doubts about their methods and results caused the authors to re-examine the literature using these 44 references as well as computerized literature searches to gather research and review papers from medical journals. Delirium after cardiac surgery appeared to be ill-defined in most of these studies. The methods and instruments used to assess delirium proved to be very different, and the patient samples were rather heterogeneous. Therefore, in most cases, the results are not comparable. Only a small number of the studies that were examined fit the criteria for statistical meta-analysis. On the basis of our analysis, a tentative conclusion may be drawn that the incidence of postcardiotomy delirium has declined slightly and that no strong risk factors have yet been identified.

Fostering hope in terminally-ill people

This study explored the meaning of hope and identified strategies that are used to foster hope in a convenience sample of 30 terminally-ill adults using the technique of methodological triangulation (interview, Herth Hope Index and Background Data Form). Cross-sectional data were collected on 20 of the subjects, and longitudinal data were collected on 10 of the subjects in order to provide a clearer understanding of the hoping process during the dying trajectory. Hope was defined as an inner power directed toward enrichment of 'being'. With the exception of those diagnosed with AIDS, overall hope levels among subjects were high and were found to remain stable over time and across the background variables. Seven hope-fostering categories and three hope-hindering categories were identified based on the interview responses. The findings could serve as a guide for the development of interventions to foster hope in terminally-ill people.

Current management of patients after cardiopulmonary bypass

The postoperative management of cardiac surgical patients is reviewed with particular reference to some of the recent advances and current controversies. It is emphasised that there has been a marked decrease in the incidence of many of the major problems associated with cardiopulmonary bypass and that, in the majority of cases, cardiac surgery is now a routine procedure associated with a very low morbidity and mortality.

Psychological factors and recovery from cardiac surgery

21 Subjects awaiting open-heart surgery were given personality and attitude questionnaires. They were re-tested six months after the operation, when they were divided into "completely recovered" (I) and "not completely recovered" (II) groups, according to the New York Heart Association classification. Results showed that Group I was significantly less depressed, more optimistic about the future and had a more positive attitude towards others. Group II realised they had been very ill and had a more negative attitude towards their spouses. Group I was found to be much better adjusted, vocationally and psychosexually, than Group II.