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Robert E. Levey*,
PhD, MPH; Raymond A. Dieter III**, MD;
Jan C. Preston***, BSN, RN; Pamela M. Smithª, BSN, RN;
Teresa L. Leveyªª, BSN, RN
Department of Medicine*,
Department of Surgery, Cardiothoracic Section**,
Intensive Care Unit***, Comprehensive Cardiovascular Unitª, Heart, Lung Vascular Instituteªª,
The University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
More than 598,000 coronary artery bypass procedures (CABGs) are performed in the U.S each year (1).
While cardiac surgery is known to improve physiological status, 7% to 35% of patients do not resume former levels of physical activity (2).
This failure is not necessarily due to physical status, rather, it may reflect psychological influences (3,4). In fact, 52% of CABG patients, and 49% of CABG patients who also suffered an MI, reported having emotional reactions (5).
COMMON PSYCHOSOCIAL REACTIONS
Anxiety and depression are reactions to (6):
- Injury to self-esteem.
- Feelings of powerlessness and vulnerability.
- Helplessness to face adaptive challenges of the illness.
- Actual or anticipated losses of independence, financial security, or social support systems.
- Family discord.
Psychosomatic (Cardiac) Invalidism (7)
- This refers to patients' manifesting such symptoms as anxiety, somatization, dysphoria, and functional impairment, which are exaggerated beyond the actual cardiac condition (hypochondriasis). They over-interpret bodily sensations and misinterpret them as indicative of cardiac disorder.
Sleep Disturbances (8-9)
- Difficulty sleeping, particularly in the initial postoperative period, has been reported.
Heightened Sense of Anger and Irritability has also been
- Patients and their spouses have reported high levels of marital conflict, dissatisfaction, and discord during the first six months following surgery.(11-13)
- Spouses have been reported to have higher levels of stress than the patients had while in the hospital (14).
Fears about resumption of sexual activity have been reported to occur in cardiac patients (15,16) and their partners.(17)
- Some authorities believe this defense mechanism is predictive of a good outcome, as it shields the patient from extreme fear.
- Moderate levels in the short term may be a helpful coping mechanism.
- If denial leads to medical noncompliance, it may present a problem.
TREATMENT AND RECOVERY PHASES
- Adjustment waiting for surgery is often characterized by high levels of anxiety and anticipation (19).
- Additional concerns may include: helplessness, fears of impairment, seriousness of the surgery, fears of dying, future plans, postoperative pain, and the appearance of incisions (20-22).
In Hospital Post-Surgery Period
- This is a complicated and critical period of recovery characterized by preoccupation with: bodily state and functions, requirements to ambulate, and facing the implications of heart surgery (23).
- Anxiety experienced tends to be a reaction to: physical care procedures, such as intubation, and one's tolerance for them, concerns about family members' anxieties, having to depend on others, sleeping in an unfamiliar and uncomfortable bed, and things not being in easy reach (24).
Early Recovery Period
- It has been acknowledged that for most patients with coronary artery disease, CABG surgery is an effective treatment that leads to improved quality of life, not only in physical functioning 12 months postoperatively, but also in social functioning and role limitations caused by emotional status (25).
- Jaarsma et al (1995) (5) found 56% of their 82 study patients reported emotional reactions (i.e. anxiety, depression, feeling resigned, emotional and unstable feelings, and mutinous thoughts) during the first six months of recovery.
- Anxiety has commonly been reported to occur upon discharge ("homecoming depression") (26) and declines in most patients, but may reemerge when a return to work date approaches.
- Return to work following bypass is influenced by amount of time off work preoperatively. Patients off longer than six months had a 50% chance of permanent invalidism. Expectation of returning to work preoperatively is the best predictor of success (17).
- Post-bypass patients suffer cognitive dysfunction ranging from 79% after surgery to 57% at six months. Only 30% of these cases are symptomatic.(18) Forty-one percent of spouses or next of kin observed short-term memory problems even though the patient might not have noticed it (25).
A number of physiological effects of cardiopulmonary bypass surgery (CPB) have been cited to effect both psychological and neurological responses: (27,28)
- Catecholamines, especially epinephrine and norepinephrine,
reach very high levels during CPB. They may remain elevated post-op, especially
in hypertensive patients.
- Cortisol levels rise some during CPB and peak after discontinuation.
- Total T3 and free T3 fall during CPB.
Kallikrein-Bradykinin cascade is activated
· Bradykinin increases vascular permeability, dilates arterioles, and moderates pain.
· Kallikrein activates Hageman factor and plasma.
Compliment system is activated (29)
· C3a and C5a increase causing vasoconstriction and increased vascular permeability.
· C4a increases after protamine administration.
Arachadonic Acid Cascade is activated.
- Prostaglandins and leukotrienes increase secondary to cyclo-oxygenase and lipoxygenase pathways.
· Interleukin 1 increases, which plays a major role in the inflammatory response.
· Both the coagulation and fibromolytic cascades are activated.
- Microemboli occur.
· gaseous, thrombotic, atherosclerotic
· effect on CNS
Metabolic acidosis probably 2° to
regionally underperfused areas despite "adequate flow rates."
· increased pCO2 causes increased cerebral blood flow
· decreased pCO2, decreased cerebral blood flow
· may be argument against pH stat acid base management
- Increased SVR during CPB may cause regional low flow areas
Nonpulsatile blood flow
· cerebral blood flow especially below arterial pressure of 40 mm Hg
Alteration of Temperature (31,32)
· Degree and rate of cooling and warming
· Cooling thought to be CNS protective but unclear
Increase in extravascular fluid-edema
Effect of anesthesia and other meds
- All of the above play a role in neurological and psychological changes after CABG. Some directly effect O2 consumption, availability, and cerebral blood flow. Whether off-pump CABGs will help improve psychological function is still not known.
- Long term sexual problems that are psychogenic in nature have been reported in 20% to 58% of cardiac patients.(33) Partners often share the same fears, which plays a factor in reduced activity and enjoyment.(27)
PREDICTORS OF NEGATIVE REHABILITATION OUTCOMES (18)
History of anxiety and depression pre-event.
Misinformation about heart condition (i.e. fear that "strain" could "dislodge the graft" and that angina is a "mini-heart attack").
Poor communication with clinical staff (i.e. overguarded statements, vague advice).
Lower socioeconomic status (i.e. due to higher correlation with anxiety, depression, misinformation problems, poor communications with clinical staff, and greater threat to employment).(34)
Perceived stress and social isolation.
Personality factors (i.e. hypochondriasis, "passive fearful coping style", etc.).
Pre-event history of emotional problems.
Presence of emotional problems (i.e. anxiety, depression, hypochondriasis, personality disorder, etc.) and need for referral for psychiatric medication evaluation and/or counseling.
Levels of denial. (Will this interfere with medical compliance and healthy lifestyle behaviors?).
Presence of misinformation concepts and lack of knowledge and understanding of the disease and treatment issues, as these factors can contribute greatly to stress.
Cognitive dysfunction (may require neuropsychological assessment).
Marital discord/unmet spousal needs.
Problems with/questions about sexual activity.
Return to work questions/ fears.
Socialization and support networks (to assure withdrawal and isolation do not occur).
Pre-operative education for the patient and family is important for post-operative recovery. The cardiothoracic surgeon should provide specific information on the deleterious effects of the treatment, changes in physical condition, risk factors, convalescence, and knowledge of the disease.
Nursing must reinforce this information to the patient and family. A variety of teaching methods have been utilized including videos that outline the surgery and recovery period, group instruction classes for non-urgent cases, and written educational materials.
Vicarious experience through peer support may help surgery patients cope better with the experience. One-on-one support given by former surgery patients to current surgery patients may be effective in lowering anxiety, raising efficacy expectation, and increasing self-reported activity.
Important concerns to discuss pre-operatively include:
- Approximate schedule for the day of surgery, including expected length of the surgery, communication sources and post-operative visitation schedule.
- What the patient should expect- IV's, endotracheal tube (inability to talk, etc.), incisions and dressings. Also, their role in post-op recovery, i.e. deep breathing and coughing.
- What the family should expect- physical appearance of the patient, equipment, monitors, staff and unfamiliar noises.
If possible, allowing the patient and family to tour the unit and meet staff pre-operatively will provide some familiarity with procedure. Establishing a relationship with the nurse pre-operatively allows the patient and family to develop a sense of trust in the intensive care phase.
Consistent communication throughout the patient's stay in the critical care unit is essential. An individualized care plan, specific to needs of the patient and family, (35) is reported to produce greater satisfaction and lower anxiety levels, thus enabling the spouse to provide greater support for the surgery patient.
Post-operatively, the patient and family may be overwhelmed with role changes and fear of discharge. Teaching should be carefully timed, as pain, anxiety and sleep deprivation may also interfere with the receptiveness to the information provided. It is important to normalize these feelings for the patient.
Discharge planning should begin early
and reinforced frequently. Included in the education must be information regarding:
- Ongoing pulmonary hygiene
- New medications
- Dietary restrictions or changes
- Activity levels
- Signs/symptoms to report to the physician
Nurse Case Managers should carefully coordinate a formal plan of follow-up with the cardiothoracic surgeon, cardiologist and primary care physician to ensure that the patient and family does not get "lost in the cracks". Clear instructions regarding who to contact for questions or problems must be addressed. Appreciation of the psychological factors is critical in order to assure these issues do not go unaddressed.
Continuing telephone contact for the immediate post-discharge days may help alleviate anxiety and uncertainty for both patient and family. This provides an opportunity to reinforce education related to home care and again normalize the patient's experiences.
Psychiatric medications for anxiety and depression may be indicated.
Individual and/or marital counseling when indicated.
Cardiac rehabilitation and a long-term maintenance exercise program should be strongly encouraged. These programs address psychological, family and social factors and attempt to ensure long-term healthy lifestyles are maintained.
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2nd Virtual Congress of Cardiology
Dr. Florencio Garófalo
Dr. Raúl Bretal
Dr. Armando Pacher
Technical Committee - CETIFAC
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