PSYCHOLOGICAL DISTURBANCES ASSOCIATED WITH OPEN HEART SURGERY

Risk factors of postoperative delirium after cardiac surgery: a meta-analysis

Background

Postoperative delirium is a frequent event after cardiac surgery. This meta-analysis aimed to identify relevant risk factors.

Method

In this meta-analysis, all original researches regarding patients undergoing mixed types of cardiac surgery (excluding transcatheter procedures) and postoperative delirium were evaluated for inclusion. On July 28th 2020, we searched PubMed, Embase, Web of Science and Scopus. Data about name of first author, year of publication, inclusion and exclusion criteria, research design, setting, method of delirium assessment, incidence of delirium, odds ratio (OR) and corresponding 95% confidence interval (CI) of risk factors, and other information relevant was collected. OR and 95% CI were used as metrics for summarized results. Random effects model was applied.

Results

Fourteen reports were included with a total sample size of 13,286. The incidence of delirium ranged from 4.1 to 54.9%. Eight risk factors were identified including aging, diabetes, preoperative depression, mild cognitive impairment, carotid artery stenosis, NYHA functional class III or IV, time of mechanical ventilation and length of intensive care unit stay.

Conclusion

In this study several risk factors associated with postoperative delirium after cardiac surgery were identified. Utilizing the information may allow us to identifying patients at high risk of developing postoperative delirium prior to delirium onset.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01496-w.

Neurocognitive Status after Aortic Valve Replacement: Differences between TAVI and Surgery

Over the past decade, indications for transcatheter aortic valve implantation (TAVI) have progressed rapidly—procedural numbers now exceed those of surgical aortic valve replacement (SAVR) in many countries, and TAVI is now a realistic and attractive alternative to SAVR in low-risk patients. Neurocognitive outcomes after TAVI and SAVR remain an issue and sit firmly under the spotlight as TAVI moves into low-risk cohorts. Cognitive decline and stroke carry a significant burden and predict future functional decline, reduced mobility, poor quality of life and increased mortality. Early TAVI trials used varying neurocognitive definitions, and outcomes differed significantly as a result. Recent international consensus statements defining endpoints following TAVI and SAVR have standardised neurological outcomes and facilitate interpretation and comparison between trials. The latest TAVI and SAVR trials have demonstrated more consistent and favourable neurocognitive outcomes for TAVI patients, and cerebral embolic protection devices offer the prospect of further refinement and improvement.

Study protocol for a prospective randomised double-blind placebo-controlled clinical trial investigating a Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium: the Basel BOMP-AID study

INTRODUCTION

Delirium is frequently observed in the intensive care unit (ICU) population, in particular. Until today, there is no evidence for any reliable pharmacological intervention to treat delirium. The Basel BOMP-AID (Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium) randomised trial targets improvement of hypoactive delirium therapy in critically ill patients and will be conducted as a counterpart to the Basel ProDex Study (Study Protocol, BMJ Open, July 2017) on hyperactive and mixed delirium. The aim of the BOMP-AID trial is to assess the superiority of melatonin to placebo for the treatment of hypoactive delirium in the ICU. The study hypothesis is based on the assumption that melatonin administered at night restores a normal circadian rhythm, and that restoration of a normal circadian rhythm will cure delirium.

METHODS AND ANALYSIS

The Basel BOMP-AID study is an investigator-initiated, single-centre, randomised controlled clinical trial for the treatment of hypoactive delirium with the once daily oral administration of melatonin 4 mg versus placebo in 190 critically ill patients. The primary outcome measure is delirium duration in 8-hour shifts. Secondary outcome measures include delirium-free days and death at 28 days after study inclusion, number of ventilator days, length of ICU and hospital stay, and sleep quality. Patients will be followed after 3 and 12 months for activities of daily living and mortality assessment. Sample size was calculated to demonstrate superiority of melatonin compared with placebo regarding the duration of delirium. Results will be presented using an intention-to-treat approach.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Northwestern and Central Switzerland and will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, the International Conference on Harmonisation (ICH) of technical requirements for registration of pharmaceuticals for human use; Good Clinical Practice (GCP) or ISO EN 14155 (as far as applicable), as well as all national legal and regulatory requirements. Study results will be presented in international conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03438526.

PROTOCOL VERSION

Clinical Study Protocol Version 3, 10.03.2019.

Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms

For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.

Baden Prevention and Reduction of Incidence of Postoperative Delirium Trial (PRIDe): a phase IV multicenter, randomized, placebo-controlled, double-blind clinical trial of ketamine versus haloperidol for prevention of postoperative delirium

Background

Delirium is a neurobehavioural syndrome that frequently develops in the postoperative setting. The incidence of elderly patients who develop delirium during hospital stay ranges from 10-80%. Delirium was first described more than half a century ago in the cardiac surgery population, where it was already discovered as a state that might be accompanied by serious complications such as prolonged ICU and hospital stay, reduced quality of life and increased mortality. Furthermore, the duration of delirium is associated with worse long-term cognitive function in the general ICU population. This long-term experience with delirium suggests a high socioeconomic burden and has been a focus of many studies. Due to the multifactorial origin of delirium, we have several but no incontestable options for prevention and symptomatic treatment. Overall, delirium represents a high burden not only for patient and family members, but also for the medical care team that aims to prevent postoperative delirium to avoid serious consequences associated with it.

The purpose of this study is to determine whether postoperative delirium can be prevented by the combination of established preventive agents. In addition, measured levels of pre- and postoperative cortisol, neuron specific enolase (NSE) and S-100β will be used to investigate dynamics of these parameters in delirious and non-delirious patients after surgery.

Methods/design

The Baden PRIDe Trial is an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial for the prevention of delirium with haloperidol, ketamine, and the combination of both vs. placebo in 200 patients scheduled for surgery. We would like to investigate superiority of one of the three treatment arms (i.e., haloperidol, ketamine, combined treatment) to placebo.

Discussion

There is limited but promising evidence that haloperidol and ketamine can be used to prevent delirium. Clinical care for patients might improve as the results of this study may lead to better algorithms for the prevention of delirium.

Trial registration

ClinicalTrials.gov, NCT02433041. Registered on 7 April 2015.

Swiss National Clinical Trial Portal, SNCTP000001628. Registered on 9 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2498-6) contains supplementary material, which is available to authorized users.

Depressive Symptoms Before, During, and After Delirium: A Literature Review

BACKGROUND

Delirium and depression are often thought of as mutually exclusive conditions. However, several studies cite depression as a risk factor for delirium whereas others note that patients with delirium often manifest depressive symptoms. Whether these depressive symptoms persist after delirium resolves remains unclear.

OBJECTIVES

This article reviews published studies that have investigated the relationship between depression and delirium.

METHODS

Literature searches on PubMed, CINAHL, Cochrane Library, and PsycInfo were conducted using search criteria "delirium" AND "depress⁎" as keywords or MeSH terms.

RESULTS

Of 722 search results, 10 prospective cohort studies were identified for inclusion. These studies were categorized regarding the time of assessment for depressive symptoms. Included studies varied greatly (regarding their index population, their methods of assessment, and their timing of assessments). Of the studies, 3 involved patients undergoing hip fracture repair. They demonstrated more severe depressive symptoms both during delirium and after delirium ended. Conversely, the other studies did not find any statistically significant correlations between the 2 conditions.

CONCLUSIONS

The literature suggests a correlation between depression and delirium in patients with hip fracture. Whether other specific populations have higher comorbidity is unclear. Unfortunately, studies varied widely in their methods, precluding a meta-analysis. Nonetheless, our review provides a foundation for future research.

Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery

BACKGROUND

Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery.

METHODS

The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness).

RESULTS

Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy.

CONCLUSION

Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.

Does ‘Hospital in the Home’ treatment prevent delirium?

Delirium is a common problem, mostly affecting older patients in hospital, which results in greater mortality, nursing-home placement and cognitive and functional impairment. Delirium can be triggered by a wide range of conditions, treatments and procedures, as well as by certain environments. Some hospital environments have been causally implicated, but until it was possible to compare treatment in-hospital with treatment in other places, the observation remained at the level of an association. However, the development of ‘Hospital in the Home’ services has allowed clinicians to explore this question scientifically. Recently, a number of studies comparing treatment of acute conditions, both medical and surgical, and rehabilitation in hospital with treatment at home, have found a lower incidence of delirium with home treatment, as well as lower rates of the sequelae of delirium. Since delirium is an indicator of a wide range of subsequent poor outcomes, this information has broad implications for the delivery of hospital-level services to older patients, and means that health services should seek to provide Hospital in the Home services wherever older patients are treated.

Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial)

BACKGROUND

delirium is a frequent adverse consequence of hospitalisation for older patients, but there has been little research into its prevention. A recent study of Hospital in the Home (admission substitution) noted less delirium in the home-treated group.

SETTING

a tertiary referral teaching hospital in Sydney, Australia.

METHODS

we randomised 104 consecutive patients referred for geriatric rehabilitation to be treated in one of two ways, either in Hospital in the Home (early discharge) or in hospital, in a rehabilitation ward. We compared the occurrence of delirium measured by the confusion assessment method. Secondary outcome measures were length of stay, hospital bed days, cost of acute care and rehabilitation, functional independence measure (FIM), Mini-Mental State Examination (MMSE) and geriatric depression score (GDS) assessed on discharge and at 1- and 6-month follow-up and patient satisfaction.

RESULTS

the home group had lower odds of developing delirium during rehabilitation [odds ratio (OR) = 0.17; 95% confidence interval 0.03-0.65], shorter duration of rehabilitation (15.97 versus 23.09 days; P = 0.0164) and used less hospital bed days (20.31 versus 40.09, P < or = 0.0001). The cost was lower for the acute plus rehabilitation phases (7,680 pounds versus 10,598 pounds; P = 0.0109) and the rehabilitation phase alone (2,523 pounds versus 6,100 pounds; P < or = 0.0001). There was no difference in FIM, MMSE or GDS scores. the home group was more satisfied (P = 0.0057).

CONCLUSIONS

home rehabilitation for frail elderly after acute hospitalisation is a viable option for selected patients and is associated with a lower risk of delirium, greater patient satisfaction, lower cost and more efficient hospital bed use.

Alterations to haemostasis following cardiopulmonary bypass and the relationship of these changes to neurocognitive morbidity

Cardiopulmonary bypass (CPB) is routinely utilized to provide circulatory support during cardiac surgical procedures. The morbidity of CPB has been significantly reduced since its introduction 50 years ago; however, cerebral injury remains a potentially serious consequence of otherwise successful surgery. The risk of stroke postoperatively is approximately 1-5%. Incidence rates for neurocognitive deficit, however, vary markedly depending on the detection method, although typically it is reported in at least 50% of patients. The aetiology of this cerebral injury remains open to debate, although evidence shows that ischaemia secondary to microembolism may be the principal factor. Emboli originate from bubbles of air, atheroemboli released on aortic manipulation and thromboemboli generated as a result of haemostatic activation. Significant generation of thrombin occurs during CPB resulting in fibrin formation, although the trigger of this activation is not fully understood. Rather than originating from contact activation as previously thought, the primary trigger may be via the activated factor VII/tissue factor pathway of coagulation, with an additional role of contact activation in amplification of coagulation as well as the fibrinolytic response to CPB. Haemostatic activation is inhibited with systemic heparin therapy. The relationship between haemostatic activation and emboli formation during CPB is not known. Interventions to reduce cerebral injury in the context of cardiac surgery depend, in large part, on the minimization of emboli. This review investigates cerebral injury after cardiac surgery and evidence showing that microembolism is the principal causative agent. Fibrin emboli are postulated to be an important source of cerebral embolism. The mechanism of haemostatic activation during CPB is therefore also discussed.

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.

Acute confusion and unreal experiences in intensive care patients in relation to the ICU syndrome. Part II

The intensive care unit syndrome (ICU syndrome) is defined as an altered emotional state occurring in a highly stressful environment, which may manifest itself in various forms such as delirium, confusion, crazy dreams or unreal experiences. The purpose of this part of a study of patients' experiences is to describe and illuminate patients' experiences of acute confusion, disorientation, wakefulness, dreams and nightmares during and after their stay in the ICU. The data were obtained from 19 ventilated patients, who were interviewed twice and had stayed at least 36 hours in the ICU, the first interview being about one week after discharge from the ICU, and the second 4-8 weeks later. The hermeneutic approach used when interpreting and analysing the text from the interviews revealed that patients' experiences of unreal experiences were often associated with intense fear. Intense or continuous unbearable fear seems to result in frightening unreal experiences, which further increase the level of fear. Care actions or caring relationships with relatives or nurses can reduce this fear, which can help to prevent the occurrence and/or duration and intensity of the unreal experiences. Trust and confidence in nurses or significant others and feelings of self-control or trust in self-control seemed to reduce the risk of unreal experiences so that adverse stimuli might only trigger a mild confusion.

Recall in the sedated ICU patient

The effect of sedation on ICU patient recall is uncertain. Ensuring suppression of awareness and, particularly, recall, may prevent post-ICU psychological problems. Development of ICU sedation pathways and improved neurophysiologic monitoring techniques may help clinicians provide good levels of recall suppression and sedation when they are most needed by ICU patients.

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.

Intensive care syndrome: a literature review

The aim in this literature review is to describe the definitions, denominations, clinical signs and symptoms, explanations, causative factors and interrelationships of the intensive care syndrome discussed since 1950. It was found that there is no agreement about which symptoms should be included in the syndrome, when the syndrome may appear and how many patients may be affected. Furthermore, it is unclear what causes the development of the syndrome; most authors conclude that there are many reasons for it. The syndrome has generally been examined by using a medical or psychological approach, but during the last few years it has also been described and analysed from a nursing care perspective. From this nursing perspective the syndrome may be seen as an individual pattern developed by patients during their stay in an intensive care unit (ICU) and sometimes this pattern of clinical signs and symptoms lasts for a shorter or longer period even after discharge from the unit. From a wider viewpoint the development of the syndrome can be seen as an increase by degrees or as a vicious circle. finally, most authors agree that the ICU syndrome consists of, and is caused by, a complex interaction between many factors.

Preventing the ITU syndrome or how not to torture an ITU patient! Part 2

Admission to an intensive therapy unit (ITU) has been described as a 'necessary evil' (Barrie-Shevlin 1987), and some of the 'tortures' described in Part I of this article (Dyer 1995) may be an inevitable result of ITU care. This does not mean that the development of the ITU syndrome should be regarded as inevitable. Many potential causes of the syndrome can be avoided or at least ameliorated. Some suggested means of preventing the syndrome include designing ITUs with windows (Keep et al 1980), use of noise reducing materials when building ITUs (Hopkinson 1994, Topf & Davis 1993), using noise level as a criterion when purchasing equipment (Dracup 1988) or using remote telemetry for monitoring (Fisher & Moxham 1984). These would undoubtedly be beneficial but they are not practical propositions for nurses who wish to improve psychological care in the short term. For this reason, this article, concentrates mainly on immediately applicable, relatively cost-free interventions. Methods of preventing the syndrome should begin, whenever possible, before admission and should continue throughout the patients' stay. The main emphasis should be placed on prevention, but early detection and treatment of problems should also be given high priority. If a patient exhibits symptoms of psychological disturbance physical causes should be considered, but at the same time the ITU syndrome should be suspected and attempts made to alleviate possible causes of this. Nurses play a vital role in any attempts to alleviate problems and in 'humanising' the technical ITU environment (Ashworth 1987, Mackellaig 1990).(ABSTRACT TRUNCATED AT 250 WORDS)

Preventing the ITU syndrome or how not to torture an ITU patient! Part I

Staff working in intensive therapy units (ITUs) have known about the 'ITU syndrome' for many years. In spite of this the syndrome continues to occur. It is suggested that one of the reasons for this continued occurrence is that ITU staff place a lower priority on psychological care than they do on physical care. In this paper the potential seriousness of the ITU syndrome is emphasised by describing it as a form of torture. Publications from Amnesty International which describe methods of psychological torture are provided to support this suggestion. The analogies between psychological torture and ITU care are explored, and this is followed by consideration of ways of reducing the incidence of the syndrome and a suggested method of auditing an ITU in order to identify potential problem areas.

Psychosocial interventions in adult patients with coronary heart disease and cancer. A literature review

A growing body of evidence suggests that chronic medical illness is associated with an increased prevalence and incidence of psychiatric and psychological disturbances. The present literature review is based on two theses: first, that chronic illness is viewed as a stressor and is associated with increased psychological distress, and secondly, that interventions can minimize the distress. A review of the studies conducted with adult patients diagnosed either with coronary heart disease or cancer suggests that psychosocial interventions are, in general, efficacious in relieving self-reported psychological distress. The review also recommends psychosocial interventions for high-risk patients rather than all patients, and that researchers need to identify other outcomes such as health care costs, disability, days in hospital, morbidity, and mortality in order to convince policy makers that these interventions are worthwhile. Recommendations for future research are also discussed.

Cultural care: the missing link in severe sensory alteration

The phenomenon of severe sensory alteration has been studied for some twenty-five years. Sensory overload, sensory deprivation, and sleep deprivation have been identified as contributing factors in its cause. Yet, the incidence of severe sensory alteration remains high. In this paper the author suggests that Leininger's theory of cultural care advocating the use of culturally assistive, supportive, or facilitative acts in nursing care, may provide important new insights into this phenomenon.

A comparison of nurses' and patients' perceptions of intensive care unit stressors

This study was designed to compare intensive care unit (ICU) nurses' and patients' perceptions of the stressfulness of items in the environment for patients in an ICU. The sample consisted of 20 ICU patients and 23 registered nurses employed in the medical and surgical ICUs at a large midwestern university hospital. The patients were contacted 1 to 2 days after transfer from an ICU and asked to complete the Intensive Care Unit Environmental Stressor Scale (ICUESS), a Likert-type questionnaire designed to measure the stressfulness of commonly occurring items in the ICU environment. The nurses were asked to complete the same questionnaire as they believed an ICU patient would complete it. They were asked to complete the questionnaire after the completion of a shift worked in an ICU. A series of one-way ANOVAs were done to compare the patients' and nurses' responses. In every comparison, nurses rated the items as being significantly more stressful than did the patients. Items with the highest mean ratings by patients were: (1) having tubes in your nose or mouth; (2) being stuck with needles; (3) being in pain; (4) not being able to sleep; and (5) being thirsty. Patients and nurses also were asked to list the three most stressful items from the ICUESS. These responses were compared using chi-square tests for homogeneity. Nurses mentioned 'being tied down by tubes' and 'not being in control of oneself' significantly more times than did patients. The items 'being in pain', 'having tubes in your nose or mouth', and 'not being able to sleep' were listed most often by both nurses and patients.

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.

Long-term cerebral outcome after open-heart surgery. A five-year neuropsychological follow-up study

A prospective 5 years' neuropsychological, neurological, cardiological and electroencephalographical follow-up study was carried out in 44 patients who had undergone open-heart surgery for valve replacement. A distinct interrelationship was found between the clinical outcome immediately after operation and the neuropsychological long-term course despite the rapid recovery of occasional clinical disorders related to operative procedures. In fact, the psychometric performance scores of those who did not develop clinical signs of cerebral dysfunction induced in operation showed a significant difference only years after operation. Similarly, the harmful effects of long perfusion time (extracorporeal circulation) in operation were reflected in the long-term neuropsychological performance. Some evidence seemed to suggest that the correction of the prolonged circulatory disorder might possibly afford real enhancement of higher cerebral functions. The long-term results not only emphasize the importance of a careful clinical evaluation but also emphasize the necessity of considering the subclinical level of events both before and after operation when assessing the overall outcome and cerebral safety of cardiac surgery patients.

Behavioral disturbance, embolism, and mitral stenosis

The hypothesized equivalence of behavioral disturbances (BD) and embolic (E) events in predicting subsequent events in mitral stenosis patients was tested by a retrospective comparison of clinical courses. Behavioral disturbances, presenting in twenty patients, were followed by 9.6 BD, 13.8 E, and 5.3 fatal events per 100 patient years. Embolic events, presenting in thirty-three patients, were followed by 1.9 BD, 8.4 E, and 3.4 fatal events per 100 patient years. Forty-six patients presenting with neither event subsequently had 2.7 BD, 7.3 E, and 3.6 fatal events per 100 patient years. It is concluded that a behavioral disturbance in the setting of mitral stenosis is a predictive of an embolic event as is an embolic event itself.

Does prostacyclin prevent cognitive deficits after open heart surgery?

Two groups of open heart surgery patients, one receiving prostacyclin and one placebo, were assessed one week pre-operatively and 3 months post-operatively, using a battery of clinical tests measuring a variety of cognitive functions. No significant differences between the groups were detected, apart from a visual retention deficit at 3 months in the prostacyclin group. The results cast doubt on previous findings suggesting that prostacyclin reduces cognitive deficits following open heart surgery.

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.

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.

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.

The effect of the intensive therapy ward environment on patients' subjective impression: a follow-up study

One hundred consecutive patients who had been treated in a new purpose-built surgical intensive therapy ward (ITU) completed a questionary recording their impressions of their stay. Their replies were then compared with the results of a similar survey done in the same hospital ten years previously when the ITU was part of a converted open-plan ward. Most patients still found the ward pleasant but difficulty in sleeping and resting was still the commonest complaint (27%), despite the patients being nursed in individual rooms. The subjective impressions reported did not reflect any advantage to the patients from being nursed in individual rooms.

Comparison of two non-intellective scales of intelligence and their relationship to intellectual changes following surgery

Two MMPI scales of intelligence measuring intellectual efficiency ( Ie and Iq) were significantly correlated with WAIS IQ, Wechsler Memory Scale memory, and Bender-Gestalt errors for a sample of 102 patients undergoing coronary artery surgery ( rs = .54 to .36). Pre-operative intellectual efficiency was not predictive of changes in intelligence, memory, and perceptual-motor ability assessed six days post-operatively. The intellectual efficiency scales were also positively correlated with adjustment as measured by MMPI basic scales and Dependency ( Dy), Ego Strength ( Es) and Manifest Anxiety ( At) scales.

Stimulus deprivation in windowless rooms

Enough evidence now exists to suggest that windowless environments in hospitals increase the risk to the patient for a number of reasons. These include a direct influence on his own physiological and psychological state, a lowering of the standard of care by an effect on hospital staff, and increased vulnerability to physical hazards. The psychological ill effects of the intensive therapy unit (ITU) environment on its occupants are well recognised. The aggravation of these effects by the construction of any further windowless units can no longer be regarded as acceptable.

Sleep disturbances after open heart surgery

This study was designed to document quantitatively the sleep disturbances that occur after open heart surgery and to investigate a group of patients who underwent a thoracic surgical procedure not involving cardiopulmonary bypass. Nine patients were studied, six after open heart surgery and three after partial or complete pneumonectomy. In each patient, sleep patterns were recorded with use of all night polygraphy before and after operation and for up to 5 weeks on follow-up studies. After open heart surgery, patients manifested considerable suppression of both rapid eye movement and slow wave sleep patterns. In the three patients subjected to thoracotomy these sleep indexes returned to preoperative levels much earlier. Evidence of stage 2 sleep was present in one of the three patients with thoracotomy on the first postoperative night, and in two of the three both rapid eye movement and slow wave sleep returned to preoperative levels by the time of hospital discharge. It is concluded that patients undergoining open heart surgery experience both acute and chronic disruptions of sleep that last well beyond the hospital period of convalescence. These sleep disturbances have considerable relevance for postoperative management.

Stress, cardiac activity and sleep

An overview is presented of the relationship between cardiovascular activity and sleep, emphasizing the interrelations between stage of sleep and cardiovascular dysfunction. Possible implications of the data are discussed, especially in relation to stress-related factors and possible treatment regimens.

MMPI profile predictors for successful and expired open heart surgery patients

A total of 31 patients (17 females, 14 males) who were scheduled for open heart surgery were administered an MMPI within 1 week prior to surgery. Of the 31 patients, 20 (13 females, 7 males) survived and 11 (4 females and 7 males) did not survive the operation. MMPI scale T-score comparisons were made within sex between survivors and nonsurvivors. Surviving and expired males did not differ on any MMPI scales, while expired females had much higher average scale 1 and 3 elevations than did their surviving counterparts (p less than .05). Subsequent comparisons of expired and surviving female patients with 1-3 profiles revealed that females with 1-3 profiles who expired had a higher average L scale T-score and a lower average scale 6 T-score (p less than .05). Cutting scores established to divide 1-3 female profiles into success and expired groups yielded two results: (1) an L scale T-score of 50 or above identified 100% of the expired females while it generated 40% false positives and no false negatives; and (2) a scale 6 T-score of 57 and below identified 100% of the expired females while it generated no false negatives and no false positives. These results are consistent with previous research and may be used to predict mortality for prospective female open heart surgery patients with implications for psychotherapeutic assistance prior to surgery to increase prospects for success.

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.