Psychiatric complications following cardiac surgery

Correlation between serum melatonin circadian rhythm and intensive care unit psychosis after thoracic esophagectomy

BACKGROUND

Intensive care unit (ICU) psychosis is still a relatively frequent complication after esophageal surgery. We investigated the correlation between ICU psychosis and serum melatonin concentration during the period after esophagectomy.

METHODS

The study group comprised 41 patients who underwent esophagectomy for treatment of esophageal cancer between 1999 and 2001. The cohort included 36 men and 5 women, aged 36 to 78 years. After surgery, blood samples were collected 4 times a day for 4 days. Serum levels of melatonin were determined with a melatonin radioimmunoassay kit. The regularity of the melatonin circadian rhythm pattern, as defined by the frequency of occurrence of the peak level of melatonin secretion, was determined (the pattern was described as irregular at less than 3 times in the measurement period).

RESULTS

Of the 41 patients who met the inclusion criteria, 11 (26.8%) had ICU psychosis develop. These patients were older than those patients in whom ICU psychosis did not develop (P =.01). No significant differences were seen in the duration of surgery, volume of blood loss, term in the ICU, term of intubation, tumor location, disturbances of organ function, and postoperative complications between patients in whom ICU psychosis developed, and those patients in whom it did not. Patients with ICU psychosis tended to have abnormally low serum levels of melatonin. Of the 41 patients studied, 9 (22%) had an irregular pattern of melatonin circadian rhythm. A significant correlation was seen between ICU psychosis and an irregular melatonin circadian rhythm (P =.0001).

CONCLUSION

Irregular patterns of melatonin circadian rhythm may be associated with ICU psychosis. Supplementation with melatonin, or acceleration of melatonin secretion, may protect patients from development of ICU psychosis and may promote recovery to a normal mental state.

The relationship of anxiety to development of postoperative delirium

1. Although patients who experience unplanned, unanticipated surgery were not more anxiety prone than patients undergoing planned surgery, they did experience higher levels of state anxiety and a higher incidence of delirium postoperatively. 2. Nurses should be alert to an increased risk of negative outcomes among patients with little or no opportunity for psychological preparation prior to surgery, and especially among patients undergoing unanticipated orthopedic surgery. 3. State anxiety scores among patients undergoing unplanned surgery declined postoperatively rather than rose. This indicates that the critical period for nursing intervention may be in the preoperative period. 4. Delirium is not associated with anxiety in a direct or linear way. Patients who experience delirium postoperatively do not experience greater state anxiety, nor are they more anxiety prone than patients who do not exhibit delirium.

Psychosomatic aspects of coronary artery bypass graft surgery. A prospective study of 101 male patients

101 consecutive male patients were examined by means of clinical interviews and depression, anxiety, personality, psychometric and life stress tests. The examinations took place preoperatively, on the 9th postoperative day (average) and 7.5 months after surgery. The mean age of the patients was 52.2 years and the mean duration of CHD was 6.7 years. Prior to surgery 77% had experienced myocardial infarction and 85% belonged to NYHA class III or IV. 74% had a 3-vessel disease. When the NYHA classification was used as criterion for rehabilitation the result was excellent. Postoperatively 80% belonged to NYHA class I or II. Hospital mortality rate was 4% and one patient died from myocardial infarction prior to the final follow-up. Preoperatively 17% of the study group were working. 87% of the patients experienced negative effects on work life, caused by CHD. Postoperatively 33% worked regularly. The postoperative work situation correlated with the duration of preoperative unemployment (p less than 0.0001), the patient's own opinion about work return (willingness/unwillingness to return to work) (p less than 0.01), as well as with the amount of negative life stress experienced preoperatively (p less than 0.01). Only 13% of the series experienced positive effects on work life, caused by CABG surgery. The majority of the patients had experienced negative effects on social and economic life (51%), as well as on sexual life (70%), caused by CHD. After surgery improvements were noted by 36% on social life and by 27% on sexual life. 15% experienced impairment of sexual life postoperatively. According to the Beck Depression Inventory 29% showed depression preoperatively, and 10% postoperatively. The difference is significant (p less than 0.0001). Clinically the figures tended to be higher. The same tendency holds for anxiety scores as measured by the Hamilton anxiety scale. The incidence of postoperative psychoses was 35%. Higher age (p less than 0.01) and/or absence of psychosomatic diseases (p less than 0.05) correlated with higher frequency of psychoses. Even though cardiological rehabilitation according to the NYHA classification was excellent, 22% of the series did not think their expectations were fulfilled. Psychic and social rehabilitation was in several aspects unsatisfactory, and the patients did not seem prepared for this. The importance to consider rehabilitation from a psychosomatic standpoint is clearly shown. To predict the result of rehabilitation preoperatively is not possible.

Postoperative hospital course of patients with history of severe psychiatric illness

The postoperative hospital course of 54 patients with a past history of psychiatric illness was studied through chart review. Both chronic schizophrenics and chronic depressives tolerated surgical procedures well, without any unusual difficulties or exacerbation of psychiatric illness. They represented no management problems. Patients with acute, severe upset in the preoperative period (regardless of diagnosis) presented most of the management problems postoperatively.

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.