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

Risk Factors for Delirium After Spine Surgery in Extremely Elderly Patients Aged 80 Years or Older and Review of the Literature: Japan Association of Spine Surgeons with Ambition Multicenter Study

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

Spine surgeries in elderly patients have increased in recent years due to aging of society and recent advances in surgical techniques, and postoperative complications have become more of a concern. Postoperative delirium is a common complication in elderly patients that impairs recovery and increases morbidity and mortality. The objective of the study was to analyze postoperative delirium associated with spine surgery in patients aged 80 years or older with cervical, thoracic, and lumbar lesions.

METHODS

A retrospective multicenter study was performed in 262 patients 80 years of age or older who underwent spine surgeries at 35 facilities. Postoperative complications, incidence of postoperative delirium, and hazard ratios of patient-specific and surgical risk factors were examined.

RESULTS

Postoperative complications occurred in 59 of the 262 spine surgeries (23%). Postoperative delirium was the most frequent complication, occurring in 15 of 262 patients (5.7%), and was significantly associated with hypertension, cerebrovascular disease, cervical lesion surgery, and greater estimated blood loss (P < .05). In multivariate logistic regression using perioperative factors, cervical lesion surgery (odds ratio = 4.27, P < .05) and estimated blood loss ≥300 mL (odds ratio = 4.52, P < .05) were significantly associated with postoperative delirium.

CONCLUSIONS

Cervical lesion surgery and greater blood loss were perioperative risk factors for delirium in extremely elderly patients after spine surgery. Hypertension and cerebrovascular disease were significant risk factors for postoperative delirium, and careful management is required for patients with such risk factors.

Postoperative delirium following transcatheter aortic valve implantation: a historical cohort study

PURPOSE

Transcatheter aortic valve implantation (TAVI) techniques show favourable survival outcomes in high-risk patients, but the incidence of postoperative delirium is unknown. We conducted a historical cohort study to compare postoperative delirium in retrograde transfemoral (TF) versus anterograde transapical (TA) TAVI procedures. We also sought to identify independent predictors of delirium following TAVI.

METHODS

We performed a retrospective chart review on all patients who underwent TF (n = 77) or TA (n = 45) TAVI during 2008 and 2009 at St. Paul's Hospital (Vancouver, BC, Canada), the pioneering centre for these procedures. The primary outcome was a documented physician diagnosis of delirium. Abstracted data included information on demographics, medical history, surgical procedure, anesthesia, and postoperative care. We employed a multivariable logistic regression to identify independent predictors of delirium.

RESULTS

Delirium occurred in 12% of TF patients vs 53% of TA patients (P < 0.001). Preoperatively, the groups differed significantly in the rates of hypertension, pulmonary hypertension, dyslipidemia, peripheral vascular disease, congestive heart failure, previous myocardial infarction, and memory impairment. Differences in anesthetic management were also observed between the TF vs TA groups regarding inhalational anesthetics, opioids, neuromuscular blockers, antihemorrhagic drugs, and antibiotics. Independent predictors for delirium after TAVI included coronary artery disease (odds ratio [OR] 12.7; 95% confidence interval [CI] 1.0 to 154.9), cognitive impairment (OR 6.5; 95% CI 1.8 to 23.2), and cardiac arrhythmia (OR 3.5; 95% CI 1.1 to 11.6). Compared to the TF approach, TA-TAVI independently increased the risk of delirium (OR 13.8; 95% CI 3.3 to 59.0).

CONCLUSIONS

Patients undergoing TA-TAVI had a markedly increased incidence of postoperative delirium compared with patients undergoing TF-TAVI.

Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients?

PURPOSE

Sleep is commonly altered in critically ill patients. Ventilatory mode may impact on quality of sleep. The aim of our study was to evaluate the effect on sleep of pressure-controlled ventilation (PCV) to spontaneous ventilation with 6 cm H2O inspiratory pressure (low-PSV).

METHODS

Thirty-five patients intubated and mechanically ventilated for acute-on-chronic respiratory failure were included in this prospective randomized cross-over study. Nine were discarded, 13 received PCV first (10 p.m.-2 a.m.) and then low-PSV (2-6 a.m.) and 13 patients received low-PSV first and then PCV.

RESULTS

Sleep architecture was altered (50.4% of the night was spent in wakefulness). PCV was associated with significantly improved sleep quality and quantity compared to low-PSV: sleep efficiency (total sleep time/total recording time) was 63% (range: 9-100) vs. 37% (0-96; p = 0.0002), stage 2 NREM sleep was 33% vs. 13% (p = 0.0005), stages 3 and 4 NREM sleep were 9% vs. 3.5% (p = 0.003) and REM sleep was 6.5% vs. 0% (p = 0.003).

CONCLUSIONS

Sleep quantity and quality were significantly improved with PCV compared to low-PSV. Nocturnal respiratory muscles rest through PCV is recommended to improve sleep in ICU patients with acute-on-chronic respiratory failure.

Delirium after spinal surgery in Korean population

STUDY DESIGN

The incidence and risk factors of postoperative delirium were retrospectively examined in patients who had spine surgery for degenerative lumbar disease.

OBJECTIVE

The aim of this study is to examine the incidence, pre- and postoperative risk factors and clinical results of postoperative delirium after spine surgery.

SUMMARY OF BACKGROUND DATA

Postoperative delirium is of great concern in older patients. Patients with postoperative delirium tend to have delay in functional restoration and difficulty in postoperative care. But to author's knowledge this is the first report to postoperative delirium after spine surgery in South Korean population.

METHODS

Eighty-one patients over 70 years of age, who underwent spinal fusion for degenerative lumbar disease from November 2000 and March 2007 were selected. We analyzed the relation between postoperative delirium and such variables as operation time, intraoperative blood loss and transfusion, fusion level, comorbidity and laboratory data checked before surgery and at 1 day after surgery.

RESULTS

Postoperative delirium was found in 11 patients (13.6%). There were significant relationships between postoperative delirium and comorbidity such as cerebral vascular disease and gastric ulcer. Hemoglobin and hematocrit levels at 1 day after surgery and albumin level before surgery was significantly lower than in control group. Oswestry disability index was improved from 50.4% to 27.6% in delirium group and from 48.5% to 24.9% in control group. Hospitalization period was significantly longer in delirium group.

CONCLUSION

History of cerebral vascular disease, low hemoglobin and hematocrit levels at 1 day after surgery, and bad nutritional status were risk factors for delirium. As it is of great concern in older patients, careful observation is necessary for the management of patients with risk factors for delirium.

Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment

Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.

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.

Sleep in acute care units

Patients in the acute care units (ACU) are usually critically ill, making them more susceptible to the unfavorable atmosphere in the hospital. One of these unfavorable factors is sleep disruption and deprivation. Many factors may affect sleep in the ACU, including therapeutic interventions, diagnostic procedures, medications, the underlying disease process, and noise generated in the ACU environment. Many detrimental physiological effects can occur secondary to noise and sleep deprivation, including cardiovascular stimulation, increased gastric secretion, pituitary and adrenal stimulation, suppression of the immune system and wound healing, and possible contribution to delirium. Over the past few years, many studies have endeavored to objectively assess sleep in the ACUs, as well as the effect of mechanical ventilation and circadian rhythm changes critically ill patients. At this time, therefore, it is important to review published data regarding sleep in ACUs, in order to improve the knowledge and recognition of this problem by health care professionals. We have therefore reviewed the methods used to assess sleep in ACUs, factors that may affect sleep in the ACU environment, and the clinical implications of sleep disruption in the ACU.

Postoperative delirium in spine surgery

BACKGROUND CONTEXT

Postoperative delirium is a great concern in the treatment of hip fracture. However, there have been no reports regarding the postoperative delirium in spine surgery.

PURPOSE

To determine the incidence and risk factors for postoperative delirium in the patients who have had spine surgery.

STUDY DESIGN/SETTING

The incidence and intraoperative risk factors of postoperative delirium were retrospectively examined in patients who had spine surgery during a 3-year period.

PATIENT SAMPLE

Three hundred forty-one patients who underwent spine surgery from 2000 to 2002 were included.

METHODS

The presence of delirium was determened by the Confusion Assessment Method. Laboratory data were checked preoperatively, at 1 day and 1 week postoperatively. The prognosis of postoperative delirium was evaluated.

RESULTS

Postoperative delirium was found in 13 patients; all of them were in their 70's or 80's. The incidence of delirium was 12.5% in the patients over 70 years old. Hemoglobin and hematocrit levels at 1 day after surgery in the delirium group were significantly lower than those in the control group. One patient had persistent cognitive dysfunction after surgery. Two patients who developed postoperative delirium died during the follow-up period.

CONCLUSION

Low concentrations of hemoglobin and hematocrit 1 day after surgery were risk factors for postoperative delirium. As delirium is thought to represent not only brain dysfunction, but also impaired general physical condition, careful observation is necessary for the management of patients with postoperative delirium.

Pharmacodynamics and pharmacokinetics of high-dose oxycodone infusion during and after coronary artery bypass grafting

OBJECTIVE

In small to moderate doses, oxycodone has similar analgesic efficacy to morphine with fewer side effects. The present study evaluated the pharmacokinetics and dynamics of high doses of oxycodone during anesthesia for primary coronary artery bypass grafting.

DESIGN

A randomized, prospective clinical evaluation.

SETTING

A major Scandinavian university clinic.

PARTICIPANTS

Two groups with 10 patients each were studied.

INTERVENTIONS

Invasive hemodynamics, echocardiograms, and electrocardiograms were monitored. Oxycodone kinetics, histamine liberation, and plasma cortisol levels were measured. Anesthesia was induced with 1.0 mg/kg of oxycodone and, thereafter, in a random order, maintained with a continuous infusion of oxycodone at a rate of either 0.5 mg/kg/h (group OX 0.5, 10 patients) or 1.0 mg/kg/h (group OX 1.0, 10 patients). An additional bolus dose of 0.5 mg/kg (OX 0.5) or 1.0 mg/kg (OX 1.0) of oxycodone was given before the incision. Enflurane was administered according to hemodynamic criteria.

MEASUREMENTS AND MAIN RESULTS

The induction of and the course of anesthesia were hemodynamically stable in all patients. Enflurane was given to every patient. The mean total doses of oxycodone were 3.5 mg/kg (OX 0.5) and 6.2 mg/kg (OX 1.0). The median t(1/2) of oxycodone varied from 5.1 to 5.9 hours. No hemodynamic differences were found between the groups. No histamine liberation was detected. During anesthesia, the predominant waves in the EEG were theta;- and delta-waves. The mean times to awakening were 3.8 hours and 7.0 hours in the groups OX 0.5 and 1.0, respectively. All patients were intubated until the first postoperative morning. No recall of awareness was reported.

CONCLUSION

A combination of oxycodone and enflurane provides hemodynamically stable anesthesia. No advantages were gained with the higher dose. Elimination of oxycodone was slower than reported previously.

Predictors of delirium after cardiac surgery delirium: Effect of beating-heart (off-pump) surgery

BACKGROUND

Despite improved outcomes after cardiac operations, postoperative delirium remains a common complication that is associated with increased morbidity and prolonged hospital stay.

METHODS

Univariate and multivariate predictors of postoperative delirium were determined from prospectively gathered data on 16,184 patients undergoing cardiac operations with cardiopulmonary bypass (conventional, n = 14,342) and without cardiopulmonary bypass (beating-heart surgery, n = 1847) between April 1996 and August 2001. Delirium was defined as a transient mental syndrome of acute onset characterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity, and a disordered sleep-wake cycle.

RESULTS

The overall prevalence of postoperative delirium was 8.4%. Of 49 selected patient-related risk factors and treatment variables, 35 were highly associated with postoperative delirium by univariate analysis. Stepwise logistic regression revealed the following variables as independent predictors of delirium: history of cerebrovascular disease, peripheral vascular disease, atrial fibrillation, diabetes mellitus, left ventricular ejection fraction of 30% or less, preoperative cardiogenic shock, urgent operation, intraoperative hemofiltration, operation time of 3 hours or more, and a high perioperative transfusion requirement. Two variables were identified as having a significant protective effect against postoperative delirium: beating-heart surgery and younger patient age.

CONCLUSIONS

Postoperative delirium is a common complication in cardiac operations. The increased use of beating-heart surgery without cardiopulmonary bypass may lead to a lower prevalence of this complication and thus improve patient outcomes.

Postcardiotomy delirium: an overview

Any one of a number of psychologic patterns may appear cardiotomy: (1) Some patients may be elated and confident after awakening from anesthesis and have no severe changes of affect or neurologic deficit. Denial seems to be for them an adequate defense against anxiety. (2) Others are disoriented and manifest neurologic disturbance immediately after awakening, without a lucid interval. The sensorium begins to clear five days after surgery. (3) Some patients go into delirium after being lucid for as long as a week and have hallucinations, illusions, and motor excitation for a few days-or over several weeks. Pathologic brain changes that are apparently anatomical correlates of neurologic deficits in delirium include anoxic lesions of the hippocampus, and infarcted foci. Physiologic factors that contribute to this reaction include: long periods of extracorporeal circulation, arterial hypotension during surgery, emboli, and low postoperative cardiac output. Age, and the type and severity of heart impairment are also factors. Psychologic factors to be taken into account include preexisting psychopathology and the failure of denial under the stress of physical symptoms or hospitalization. Delirium is fostered by sensory overload (or deprivation) in the recovery room and intensive care unit, and by staff tension. Modification of the intensive care unit environment, the administration of antipsychotic drugs, and metabolic correctives are recommended. Preoperative psychologic evaluation, with therapy as needed, preliminary familiarization with perioperative procedures, as well as collaboration between psychiatrist and surgeon, can do much to prevent post-cardiotomy delirium.

Hospital noise pollution: an environmental stress model to guide research and clinical interventions

Hospital noise pollution: an environmental stress model to guide research and clinical interventions This commentary provides an expanded environmental stress model. Conceptual relationships between ambient stressors, ambient stress, and health are detailed. A three-part intervention, enhancement of person-environment compatibility, is specified. Details are provided on how this approach to reducing environmental pollution/hazards and sustaining these changes may be influenced by sociopolitical values, technological advances, and motivation for control over hazards. Personal variables thought to mediate the impact of environmental stress on health, including intrinsic sensitivity to specific hazards, personality, restricted capacities, other stress, culture, personal preferences, stage of life, gender, and perceived social support, are highlighted. Research results on the stress and health effects of hospital noise on patients and nurses are summarized to provide support for the model. Future directions for research are recommended. Implications of the model for nursing, including an environmental activist role in an interdisciplinary effort to plan and implement noise abatement interventions, are described.

Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators

BACKGROUND

Acute changes in cerebral function after elective coronary bypass surgery is a difficult clinical problem. We carried out a multicenter study to determine the incidence and predictors of -- and the use of resources associated with -- perioperative adverse neurologic events, including cerebral injury.

METHODS

In a prospective study, we evaluated 2108 patients from 24 U.S. institutions for two general categories of neurologic outcome: type I (focal injury, or stupor or coma at discharge) and type II (deterioration in intellectual function, memory deficit, or seizures).

RESULTS

Adverse cerebral outcomes occurred in 129 patients (6.1 percent). A total of 3.1 percent had type I neurologic outcomes (8 died of cerebral injury, 55 had nonfatal strokes, 2 had transient ischemic attacks, and 1 had stupor), and 3.0 percent had type II outcomes (55 had deterioration of intellectual function and 8 had seizures). Patients with adverse cerebral outcomes had higher in-hospital mortality (21 percent of patients with type I outcomes died, vs. 10 percent of those with type II and 2 percent of those with no adverse cerebral outcome; P<0.001 for all comparisons), longer hospitalization (25 days with type I outcomes, 21 days with type II, and 10 days with no adverse outcome; P<0.001), and a higher rate of discharge to facilities for intermediate- or long-term care (69 percent, 39 percent, and 10 percent ; P<0.001). Predictors of type I outcomes were proximal aortic atherosclerosis, a history of neurologic disease, and older age; predictors of type II outcomes were older age, systolic hypertension on admission, pulmonary disease, and excessive consumption of alcohol.

CONCLUSIONS

Adverse cerebral outcomes after coronary bypass surgery are relatively common and serious; they are associated with substantial increases in mortality, length of hospitalization, and use of intermediate- or long-term care facilities. New diagnostic and therapeutic strategies must be developed to lessen such injury.

Early diagnosis of delirium after cardiac surgery

In order to detect patients who become delirious after cardiac surgery in an early postoperative stage, an observational checklist was used. Fifteen patients were constantly observed during their 48-hour stay at the intensive care unit for postoperative care. Two (13%) male patients developed postoperative delirium according to DSM-III-R criteria. It was possible to detect these patients in an early postoperative stage (within 48 hours) by means of systematic observations of their behavior.

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.

Sleep in the intensive care unit

The most critically ill patients in the hospital are located in the ICU. Due to intensive individualized care and monitoring, these patients often suffer from severe sleep deprivation. The amount and continuity of sleep as well as normal sleep architecture are all affected. Moreover, by impairing protein synthesis, cell division, and cellular immunity, sleep deprivation can affect the healing process and thus contribute to an increased morbidity and mortality. Reasons for sleep deprivation appear to be multifactorial and include the following: the patient's chronic underlying illness, an acute superimposed illness or surgical procedure, medications used in treatment of the primary illness, and the ICU environment itself. Therapeutic interventions need to address each of these potential causes, with an emphasis placed on providing an environment that is both diurnal and focused on the importance of uninterrupted sleep.

Aspects of psychological and social morbidity in patients awaiting coronary artery bypass grafting

OBJECTIVES

To assess anxiety, depression, and social adjustment in patients awaiting coronary artery bypass surgery.

DESIGN

Patient completed questionnaire study.

SETTING

Regional cardiothoracic centre.

PATIENTS

109 questionnaires were sent to patients on the waiting list of two cardiothoracic surgeons. Sixty eight (62%) were returned and 15 (22%) of the respondents were women. There was no difference in the response rates for men (53/84) 63% and women (15/25) 60%.

MAIN OUTCOME MEASURES

Anxiety and depression were assessed by the hospital anxiety and depression (HAD) scale. Social functioning was assessed by several nine point rating scales on which patients indicated how their work, family relationships, social activities, private leisure activities, and home management were impaired. Patients also indicated the severity of their cardiac symptoms on a questionnaire based on the New York Heart Association classification for the assessment of the functional state of patients with heart disease.

RESULTS

On the HAD scale 19 (28%) patients scored in the clinically significant range for anxiety. Time spent on the waiting list was positively and significantly related to anxiety (p = 0.05). Thirty two (47%) patients scored in the clinically significant range for depression. Time spent on the waiting list was positively and significantly related to depression (p = 0.005). Positive and significant relations were found between time spent on the waiting list and impairment of work (p = < 0.0001), family relationships (p = < 0.0001), private leisure activities (p = < 0.0001), and social activities (p = 0.004). No correlation was found between any of the above variables and the indicated level of clinical symptoms.

CONCLUSIONS

This study documents previously unreported associations between the time patients wait for coronary artery surgery and levels of anxiety, depression, and social functioning. Conclusions regarding the causes of these symptoms cannot be made from this small population of patients but these results do suggest that these associations should be studied further.

Delirium after elective orthopedic surgery: risk factors and natural history

Forty-six orthopedic patients were studied to determine the incidence, natural history, and risk factors associated with post-operative delirium. Pre-operatively, patients were given a neuropsychological screening evaluation, the Mood Adjective Checklist (MACL), the Zung Depression Scale, the Anxiety Inventory Scale, and the Health Assessment Questionnaire (HAQ). A psychiatrist interviewed each patient on post-op day four for evidence of delirium as defined by DSM III criteria. Of the patients studied, thirteen (26%) were possibly or definitely delirious following surgery. Treatment with propranolol, scopolamine, or flurazepam (Dalmane) conferred a relative risk for delirium of 11.7 (p = 0.0028). Delirium was associated with increased post-operative complications (p = 0.01), poorer post-operative mood (p = 0.06), and an increase of about 1.5 days in length of stay (not significant). Delirious patients were significantly less likely than matched controls to improve in function at six months compared with a pre-operative baseline HAQ (t = 6.43, p less than 0.001).

Research links between psychiatry and cardiology. Hypertension, type A behavior, sudden death, and the physiology of emotional arousal

Psychiatrists and cardiologists have collaborated in clinical care and research for decades. This article reviews some of the current areas of mutual interest, with special attention focused on research on behavior and hypertension, type A behavior pattern, sudden death, and the physiology of emotional arousal. In clinical care and epidemiologic and physiologic research, there are numerous issues at the cutting edge of knowledge that will be clarified by continued collaboration.

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.

Brain oedema and blood-brain barrier permeability in pulsatile and nonpulsatile cardiopulmonary bypass

In pigs subjected to pulsatile or nonpulsatile cardiopulmonary bypass (CPB) at normothermia for 3 hours, evaluation was made of water content in brain tissue (specific gravity measurements), blood-brain permeability to serum proteins (immunocytochemical demonstration of extravasated proteins, using peroxidase-antiperoxidase technique) and histopathology (paraffin sections). The specific gravity in parietal cortex was higher after pulsatile than after nonpulsatile CPB or in control pigs, the change corresponding to a 6.3% water increase. The tissue water content was unchanged in the internal capsule, basal ganglia and nucleus accumbens after CPB. The vascular permeability to serum proteins was unchanged after nonpulsatile CPB, but after pulsatile CPB minute foci of extravasated serum proteins appeared. All the animals showed dark neurons in cortical and subcortical regions, but these could have been artefacts in immersion-fixed tissue. There were no other signs of ischaemic tissue damage. The study indicated that cortical oedema may follow pulsatile CPB, the cause being altered permeability of the blood-brain barrier to serum proteins.

Acute cerebral dysfunction after open-heart surgery. A reaction-time study

A sensitive measure of subtle CNS dysfunction, the continuous reaction time (CRT), was used in 19 patients to quantify the immediate effects of open-heart surgery and extracorporeal circulation (ECC) on the CNS. The control group comprised 17 patients undergoing thoracic surgical procedures without ECC. The reaction time was significantly prolonged after surgery both in the ECC patients and in the controls. CRT was unrelated to the duration of anaesthesia in both groups, but in the ECC group deterioration of CRT showed positive correlation with (a) the duration of ECC, (b) the duration of perfusion pressure below 50 mmHg during ECC and (c) the PCO2 during ECC. These three factors may be of pathogenetic significance in the development of CNS dysfunction following open-heart surgery. The acute changes in reaction time resolved within a week of surgery, but on questioning two months later half of the ECC patients reported intellectual disturbance, primarily impairment of memory and lability of mood.

Central nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients

A prospective analysis of 421 patients undergoing coronary artery bypass graft (CABG) surgery as the sole cardiac procedure was carried out to assess the frequency of central nervous system (CNS) complications. In all, 451 variables were assessed in each patient. Stroke occurred in 5.2% but was severe in only 2%. Prolonged encephalopathy occurred in 11.6% but usually resolved before discharge. No statistically significant pre- or intraoperative risk variables for CNS complications were found; specifically, age or pump times in excess of two hours were not significant factors. Postoperative use of an intraaortic balloon pump and pressor agents were significantly correlated with prolonged encephalopathy. The frequency of CNS injury in CABG surgery is similar to that in other forms of open heart surgery, and there has been little change in the frequency of CNS complications over the past seven years. Possible mechanisms of CNS damage during CABG surgery are discussed.

Psychopatho-ophthalmology, gnostic disorders, and psychosis in cardiac surgery. Visual disturbances after open heart surgery

The visual disturbances of 45 patients following open heart surgery could be divided into disturbances of (1) visual acuity, (2) visual accuracy, and (3) visual reality testing. The non-hallucinatory phenomena consisted mainly of loss of colour vision, metamorphopsias, visual gnostic disorders and cortical blindness. The hallucinatory phenomena could be divided into the delirium type of hallucinations with clouding of consciousness and the spectator type of hallucinations with a clear sensorium. The causes of the visual symptomatology and cardiac psychoses are seen in microembolization and/or ischemic hypoxia. The basal ganglia and the occipital lobe are areas of predilection for embolic and hypoxic changes. Identical psychoses also occur in cerebral malaria and polycythemia vera which show the same embolic and anoxic neuropathological changes of vascular occlusion as do many patients who die following open heart surgery with extracorporal circulation.

Adverse psychological sequelae associated with total joint replacement surgery

Although total joint replacement surgery is generally successful in pain relief and improved joint function, adverse psychological sequelae sometimes do occur. This report highlights potential problems associated with total joint replacement surgery and illustrates with brief cases from a referral hospital for arthritis patients. An appreciation of psychological factors can ensure patients' motivation to participate in the rehabilitative efforts after surgery, and thus enhance optimal results from the surgery.

Effect of open heart surgery on intellectual performance

The interrelationship between postoperative psychosis, neurologic symptoms, and changes in tests of cognitive performance have been studied in a series of 60 cardiac valvular patients who underwent open heart surgery. The effects of preoperative psychological, psychiatric, and cardiologic factors on postoperative cognitive changes were analyzed. The investigation period was from five months before up to five months after the operation. There was a general trend towards improvement in intellectual performances. The psychotic group, however, still showed a persisting impairment in some visual and psychomotor tests several months after the surgery. The group with neurologic symptoms showed impairment in one visual test. Of the preoperative variables, mitral valve disease, a high level of hypochondriasis and anxiety, and poor performance in some visual and psychomotor tests predicted postoperative intellectual impairment. The results suggest two types of cerebral complications of open heart surgery. Postoperative psychosis reflects diffuse brain dysfunction manifesting itself in psychological tests long after the clinical symptoms have resolved. The presence of neurologic symptoms refers to a focal or lateralized injury. Both the neurologic and neuropsychologic findings indicate that the right hemisphere may be prone to dysfunction than the left hemisphere.

Psychiatric morbidity in elderly surgical patients

One hundred patients aged 65 and over were psychiatrically assessed before and in the first week after elective surgery. Thirteen were psychiatrically ill before operation and 21 developed post-operative illness. Post-operative confusional states (14 patients) were associated with physical complications but not with environmental or pre-operative psychiatric variables. Affective disorders either improved following successful surgery (5 patients) persisted or developed after operation in association with continuing physical illness (6 patients).