Recovery after coronary artery bypass grafting: Patients’ and health professionals’ views of the hospital experience

The Effects of Dexmedetomidine on Perioperative Neurocognitive Outcomes After Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The purpose of this systematic review and meta-analysis is to examine the effect of DEX on delayed dNCR (cognitive dysfunction ≥ 1 week postoperative) after cardiac surgery.

BACKGROUND

DEX has salutary effects on cognitive outcomes following cardiac surgery, however, studies are limited by inconsistent assessment tools, timing, and definitions of dysfunction. It is imperative to identify accurate point estimates of effect of DEX on clinically relevant changes in cognitive function.

METHODS

Randomized trials of adults undergoing cardiac surgery comparing perioperative DEX to placebo or alternate sedation and assessing cognitive function ≥ 1 week postoperative were included. Data was abstracted by three reviewers independently and in parallel according to PRISMA guidelines. The primary outcome is dNCR. To classify as dNCR, cognitive function must decrease by at least the minimal clinically important difference or accepted alternate measure (eg, Reliable Change Index ≥1.96). Bias was assessed with the Cochrane Collaboration tool. Data was pooled using a random effects model.

RESULTS

Nine trials (942 participants) were included in qualitative analysis, of which seven were included in the meta-analysis of dNCR. DEX reduced the incidence of dNCR (OR 0.39, 95% CI 0.25-0.61, P < 0.0001) compared to placebo/no DEX. There was no difference in the incidence of delirium (OR 0.69, 95% CI 0.35-1.34, P = 0.27) or incidence of hemodynamic instability (OR 1.14, 95% CI 0.59-2.18, P = 0.70) associated with perioperative DEX.

CONCLUSIONS

DEX reduced the incidence of dNCR 1 week after cardiac surgery. Although this meta-analysis demonstrates short term cognitive outcomes are improved after cardiac surgery with perioperative DEX, future trials examining long term cognitive outcomes, using robust cognitive assessments, and new perioperative neurocognitive disorders nomenclature with objective diagnostic criteria are necessary.

Modifying a generic postoperative recovery profile instrument to an instrument specifically targeting coronary artery bypass grafting

Patients may suffer from a wide range of postoperative symptoms after coronary artery bypass grafting. In-depth knowledge of the recovery process is a prerequisite for nursing interventions. However, we found no specific instrument covering the entire range and duration of postoperative symptoms related to this procedure. We therefore modified and extended the 19 items, generic Postoperative Recovery Profile questionnaire for the specific evaluation of the recovery after coronary artery bypass grafting. We here report on the development process of the new questionnaire. Procedure-specific symptoms were identified by a literature review and by experts. The content validity was assessed by healthcare professionals (n = 15), inpatients (n = 12) and outpatients (n = 4). A test run was done with inpatients (n = 10), which was followed by a test-retest reliability evaluation with inpatients (n = 24). We identified 15 new symptoms in the literature review and six in the content validity assessment. Only three of the 35 items had an acceptable content validity index, but all 35 items in the test run were reported by at least two patients. The questionnaire took 4-9 minutes to complete and was considered easy to use. The final instrument used in the reliability test included 22 new items, and 25 of the 35 items were satisfactory stable. To conclude, we developed a 35 items, procedure-specific questionnaire that was easy to use and may aid systematic assessment of the recovery after coronary artery bypass grafting.

Experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium: one year follow-up

Background

Cardiovascular disease is common among old people and many undergo cardiac surgery. Scientific knowledge is available on cardiac surgery from several perspectives. However, we found few studies focusing on older patients’ experiences of cardiac surgery. The aim of this study was to illuminate experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium, a one year follow-up.

Methods

Qualitative interviews were conducted with 49 participants (aged ≥70 years) diagnosed with delirium after cardiac surgery. Data were collected in Sweden during 2010 through individual, semi-structured interviews in participants’ homes one year after surgery. The interviews were analyzed using qualitative content analysis.

Results

Four themes with sub-themes were formulated: Feeling drained of viability includes having a body under attack, losing strength and being close to death. Feeling trapped in a weird world describes participants having hallucinations, being in a nightmare and being remorseful for their behavior. Being met with disrespect includes feeling disappointed, being forced, and feeling like cargo. On the other hand, Feeling safe, including being in supportive hands and feeling grateful, points to participants’ experiences of good care and the gift of getting a second chance in life.

Conclusions

Even one year after cardiac surgery, participants described in detail feelings of extreme vulnerability and frailty. They also had felt completely in the hands of the health care professionals. Participants described experiences of hallucinations and nightmares during hospitalization. Cardiac surgery was a unique, fearful, traumatic and unpleasant experience yet could also include pleasant or rewarding aspects. It seems that health care professionals need deeper knowledge on postoperative delirium in order to prevent, detect and treat delirium to avoid and relieve the suffering these experiences might cause.

Approach and avoidance coping and regulatory focus in patients having coronary artery bypass graft surgery

Coronary artery bypass graft (CABG) surgery is stressful, and the patient's coping affects recovery and outcome. The aim of the study was to identify patients' thoughts and concerns, and explore the relevance of approach/avoidant coping and Regulatory Focus Theory (RFT). Nine patients were interviewed, using an interpretative phenomenological approach. The patients made use of various avoidant (e.g. neglecting symptoms, delaying help-seeking, avoiding thoughts) and approach strategies (e.g. persistent search for the diagnosis, mental preparation for surgery). RFT versus approach/avoidant coping is discussed. RFT may contribute to our understanding of motivational cognitions in patients' coping with illness and treatment.

Patients' narrative accounts of open-heart surgery and recovery: authorial voice of technology

In this narrative inquiry, we examined patients' experiential accounts of technology in open-heart surgery and recovery. A convenience sample of sixteen individuals was recruited from a preoperative clinic at a regional centre for cardiac services in Canada. Each participated in two interviews following transfer from cardiovascular intensive care and 4-6 weeks post discharge from the hospital. Participants also documented their experiences in journals during the first 3-4 weeks following discharge. The focal point of the study's theoretical foundations was narrative emplotment, which directs attention to the active processes of plot construction and shaping forces of stories. In our narrative analysis, we used narrative mapping to document the temporal flow of events. We found that technology acted as the authorial voice, or controlling influence, over how participants' narratives were shaped and unfolded. Key were the ways in which technology as the authorial voice was linked with participants becoming background characters and surrendering agency. Problematic and important to health care professionals is ensuring that authorial voice shifts back to patients so that they become active in shaping their own course of recovery. This study underscores the benefits of using literary techniques such as narrative analysis in health science research. Examining the narrative structures and forces that shape patients' stories sheds light on how health care professionals and their technologically-driven practices of care strongly affect the stories' content and how they unfold. By focusing on how stories unfolded, we revealed ways in which cardiac surgery practices and patients' course of recovery could be enhanced.

Nurse training of a patient-centered information procedure for CABG patients

OBJECTIVE

At the study hospital, all elective coronary artery bypass graft (CABG) surgery patients were given similar, standardized information by the nurses. The nurses reported problems in establishing contact and interacting with patients when using this approach. To help remedy communication problems between nurses and CABG patients, a programme training nurses in a patient-centred information procedure was developed and implemented. This article describes how challenging interactions were recorded and analysed for training nurses in the patient-centred approach.

METHOD

In group training for patient-centeredness, nurses presented audio-recordings of nurse-patient interactions they found problematic. These were used as a basis for discussions and training in the patient-centered approach. A set of cases was developed using a qualitative phenomenological approach, illustrating how the patient-centered approach could be applied to the difficult situations.

RESULTS

The nurses found the patient-centered approach particularly useful in situations when patients frequently asked questions, seemed to have difficulties expressing their worries, frequently complained, or when spouses expressed worries.

CONCLUSION

Nurses found the patient-centered approach and the training procedure used in this study useful in their clinical work with CABG patients.

PRACTICE IMPLICATIONS

This training which requires minimal resources and can be easily implemented, may guide the nurses in their interaction with patients. Providing a patient-centered approach to the CABG patients may enhance the nurse-patient contact and improve patients' hospital experience and subjective health.