Preoperative Anxiety and Depression Increases the Incidence of Delirium After Coronary Artery Bypass Graft Surgery

PurposeTo address the effect of anxiety and depression before coronary artery bypass graft surgery on the postoperative delirium and the length of hospitalization.DesignProspective cohort study.MethodsThe anxiety and depression before surgery was measured using the 14-item Hospital Anxiety and Depression Scale. The main outcome of interest was delirium, which was assessed at baseline and then on the second, third, fourth, and fifth days after surgery, using the nine-item Neecham Confusion Scale. The incidence of delirium was compared in the positive group (153 patients with anxiety and depression at baseline) versus the negative group (153 patients without anxiety and depression at baseline).FindingsThere was a significant difference between the mean score of delirium in the two groups on the second, third, fourth, and fifth days after surgery (P = .001). The incidence of mild and moderate/severe delirium was significantly higher in the positive group than in the negative group for the entire length of follow-up (P = .001). The average length of hospitalization was nearly the same in the two groups (P = .156).ConclusionsThis study indicated that anxiety and depression before coronary artery bypass graft surgery can significantly increase the incidence of postoperative delirium, but it has no significant effect on the length of hospitalization.     

Long-term Intellectual Dysfunction Following Coronary Artery Bypass Graft Surgery: A Six Month Follow-up Study

As part of a prospective study of neurological and neuropsychologicalcomplications of coronary bypass surgery, 259 patients underwentpsychometric assessment before operation and at seven days andsix months after operation using a battery of 10 standard testsof intellectual function. This report describes the naturalhistory of intellectual dysfunction soon after surgery and theincidence and functional impact of late neuropsychological impairment. The mean neuropsychological scores for the whole group remainedunchanged or improved compared with levels before operationfor the majority of the 10 tests. Analysis of the test scoresfor individuals showed that 147 of 259 (57 per cent) patientsshowed deterioration on at least one test score at six months.The degree of impairment was usually mild. One hundred and thirtyof the 147 patients showed mild cognitive dysfunction (scoredeterioration on one or two tests) and only 17 patients hadmoderate or severe impairment (score deterioration on threeor more tests). Detectable neuropsychological deteriorationat six months often did not matter to the patient in functionalterms. Seventy-one per cent of these patients had no significantsymptoms; 27 per cent had minor symptoms and only 2 per centwere seriously disabled. Of the patients unemployed at six months,in only one case was intellectual impairment the factor preventingreturn to work. A search for possible predisposing factors for long-term intellectualdysfunction was made using a multivariate analysis of 91 variablesfor each patient. Cardiac failure before surgery and globalimpairment of left ventricular function were the only factorsshowing significant correlation.     

不同血管活性药物在冠状动脉旁路移植手术中的实验研究

目的 比较米力农、酚苄明和硝酸甘油对人桡动脉痉挛的防治作用.方法 收集20例冠状动脉旁路移植手术(CABG)者的桡动脉标本,制成3 mm宽的血管环.利用Organ-Bath技术比较米力农(米力农组)、酚苄明(酚苄明组)、硝酸甘油(硝酸甘油组)对离体痉挛桡动脉的治疗作用,并观察经药物预处理后桡动脉对致痉挛因素刺激的反应情况.结果 痉挛缓解实验中,硝酸甘油在痉挛桡动脉完全舒张时间上最迅速有效,与米力农和酚苄明比较差异有统计学意义(P＜0.01);酚苄明与米力农比较差异亦有统计学意义(P＜0.01);3组药物组均较空白对照组有效(P＜0.01).痉挛预防实验中,酚苄明组产生静息张力的平均药物剂量明显低于硝酸甘油组与米力农组(P＜0.05);硝酸甘油组与米力农组比较无统计学意义(P＞0.05);3组药物组与空白对照组比较均有统计学意义(P＜0.05).结论 米力农、酚苄明、硝酸甘油都能不同程度地预防和缓解桡动脉痉挛,硝酸甘油对缓解已痉挛的桡动脉最有效,而经酚苄明预处理的桡动脉最不易产生新的痉挛.     

Patients' Responses to Postponement of Coronary Artery Bypass Graft Surgery

The purpose of this study was to determine the thoughts and feelings of patients (n=241 awaiting coronary artery bypass graft (CA5G) surgery and, in particular, the thoughts and feeling of those patients (n=77) whose surgical procedure was postponed. On average these patients waited four additional days before the surgery could be performed. Patients reported that the most difficult part of CABG surgery was the wait itself. Those whose CABG surgery was postponed expressed anger and disappointment, had additional tests, procedures and medication, extended hospital stays and increased costs.     

Inspiratory Muscle Strength as a Determinant of Functional Capacity Early After Coronary Artery Bypass Graft Surgery

Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery.

Objective

To evaluate the effects of a 6-day postoperative in-hospital cardiopulmonary rehabilitation program on inspiratory muscle strength and its potential association with improved functional capacity after coronary artery bypass graft (CABG) surgery.

Design

Prospective, randomized controlled trial.

Setting

Tertiary public hospital in Brazil.

Participants

Men (N=20) after CABG were randomized to cardiopulmonary rehabilitation (n=10; age, 64±8y) or to usual care (n=10; age, 63±7y).

Interventions

Ten subjects underwent a 6-day postoperative in-hospital program, which included the use of expiratory positive airway pressure mask and bronchial hygiene techniques, coupled with progressive distance walking and calisthenics as well as cardiopulmonary training. Ten controls were followed by their own physicians and received routine nursing assistance but were not exposed to any specific respiratory or motor physical intervention.

Main Outcome Measures

Maximal inspiratory and expiratory pressure were measured by a pressure transducer, and the highest pressure obtained in 6 measurements was used for analysis (before surgery, and 7 and 30d after surgery). The six-minute walk test (6MWT) was performed 7 days after surgery, and maximal cardiopulmonary exercise testing was performed 30 days after CABG.

Results

After randomization, clinical and functional characteristics were similar in the 2 groups. Rehabilitation resulted in maintenance of maximal inspiratory pressure (PImax) measured at 7 and 30 days postoperatively, respectively (from 68±19% at baseline to 58±22% and to 61±22% predicted), while it was significantly reduced in the control group. 6MWT distance was longer 7 days after CABG in rehabilitation subjects (416±78m) than controls (323±67m). Peak oxygen uptake (Vo₂peak) at day 30 was also higher (28%) in the rehabilitation group and was correlated with PImax (r=.90).

Conclusions

A 6-day rehabilitation program attenuated the postoperative reduction in respiratory muscle strength and also improved the recovery of functional capacity after CABG. The correlation between PImax and Vo₂peak during the late postoperative period suggests that inspiratory muscle strength is an important determinant of functional capacity after CABG.     

Effect of Enhanced Recovery After Surgery Protocol on Patients Who Underwent Off-Pump Coronary Artery Bypass Graft

PurposeEnhanced recovery after surgery (ERAS) is an evidence-based perioperative measure to improve outcomes. Although the benefits of ERAS are well proven for other surgeries, little is known about its effect on off-pump coronary artery bypass graft (OPCABG) surgery. Thus, this study aimed to explore the effect of an ERAS protocol in patients who underwent OPCABG surgery.MethodsThis quasi-experimental study included 94 participants (traditional care group = 47 vs ERAS group = 47). An ERAS protocol was established by a multidisciplinary team. Knowledge of coronary artery disease, fasting time, water deprivation time, extubation time of the tracheal tube and pericardial and mediastinal drainage tube, off-bed activity participation rate, length of hospital stay, hours of intensive care unit (ICU) stay, expenses in ICU, incidence rates of ICU delirium and postoperative nausea and vomiting, and the 6-Minute Walk Test on postoperative day 7 were recorded and calculated between the groups.ResultsDemographics, lifestyle, and disease severity showed no significant difference between the two groups (p > .05). The ERAS group patients had improved understanding of coronary artery disease (t = −3.89, p < .01), shorter fasting time (t = 7.98, p < .01), shorter water deprivation time (t = 9.29, p < .01), increased off-bed activity participation (t = 17.67, p < .01), and the improved 6-Minute Walk Test on postoperative day 7 (t = −3.23, p < .01).ConclusionsThe ERAS protocol is safe and effective for patients undergoing OPCABG surgery.     

Population-Based Study of the Use of Cardiac Stress Imaging and Referral for Coronary Angiography and Repeated Revascularization After Coronary Artery Bypass Graft Surgery

ObjectiveTo assess stress single-photon emission computed tomography (SPECT) and stress echocardiography use after coronary artery bypass grafting (CABG) and their effect on referral for coronary angiography and revascularization.Patients and MethodsThe referral, timing, and results of stress imaging after CABG; referral for coronary angiography and revascularization; and all-cause mortality were assessed in this longitudinal, population-based, retrospective study of 1138 Olmsted County, Minnesota, patients undergoing CABG between January 1, 1993, and December 31, 2003.ResultsA total of 570 patients (50.1%) underwent a stress imaging study (341 SPECT and 229 echocardiography) during the study period. Of the 1138 patients, 372 (32.7%) were referred for coronary angiography, and 144 of those patients (12.7%) underwent repeated revascularization (132 percutaneous revascularization and 12 CABG). The median interval between CABG and the index stress imaging study was 3.0 years (25th-75th percentile, 1.2-5.7 years). The results of 75.7% (258 of 341) of the stress SPECT studies and 70.7% (162 of 229) of the stress echocardiograms were abnormal. Seventy-six of 570 patients (13.3%) referred for stress imaging underwent coronary angiography within 180 days after the stress test. Repeated coronary revascularization was performed in 25 patients (4.4%) who underwent a stress imaging study within the preceding 180 days. The 5- and 10-year survival rates in the entire study cohort (83.5% and 65.1%, respectively) were not significantly different than predicted for the age- and sex-matched Minnesota population.ConclusionHalf of this community-based population of patients with CABG underwent stress SPECT or echocardiography during median follow-up of 8.9 years. Despite that approximately 75% of the results of stress imaging studies were abnormal, subsequent referral for coronary angiography within 180 days was low (13.3%), and the yield for repeated revascularization was very low (4.4%).     

A Retrospective Review of Leg Wound Complications After Coronary Artery Bypass Surgery

Little research or attention has been paid to finding out whether wound closure with sutures or staples attains the best outcomes after saphenous vein harvest for coronary artery bypass grafting. We undertook a quality improvement project to compare the prevalence of leg wound complications (eg, infection, seroma, hematoma, dehiscence) between two types of skin closure (ie, staples, subcuticular sutures) after conventional open surgery with bridging between incisions and vein harvesting during coronary revascularization to determine the need for practice changes. We found no significant differences between patients with wound complications and those without. However, in this project, the risk for infections was greater for patients with diabetes whose wounds were closed by using subcuticular sutures. These findings have led to practice changes for reducing leg wound complications within our institution: clinicians now assess patients for increased risk of leg wound complications preoperatively and opt to close wounds with staples for patients who have diabetes.     

Intravenous 3-Methoxy-O-Desmethyl-Encainide in Reentrant Supraventricular Tachycardia: A Randomized Double-Blind Placebo-Controlled Trial in Patients Undergoing EP Study

Encainide is an agent effective in atrioventricular and atrioventricular nodal reentrant tachycardia. The metabolites O-desmethyl encainide and 3-methoxy-O-desmethyl encainide (MODE) are responsible for the clinical effects of encainide in most patients. In this study, intravenous MODE was evaluated in eight patients with reentrant supraventricular tachycardia undergoing electrophysiological testing. After tachycardia was induced at least twice to ensure reproducibility, MODE (30 micrograms/kg/min x 15 min, then 7.5 micrograms/kg/min) or placebo was administered in a double-blind fashion. If tachycardia remained inducible, the infusion was unblinded; in nonresponding subjects who received placebo, MODE was then administered. Placebo was ineffective in 3/3 patients. MODE prevented tachycardia induction in 5/8 patients and increased the tachycardia cycle length from 302 +/- 38 to 413 +/- 67 msec in the other three. At a mean concentration of 774 +/- 229 ng/ml, MODE prolonged PR, AH, HV, QRS, and QT intervals, right ventricular and accessory pathway effective refractory periods, and slowed or blocked antegrade accessory pathway conduction. Changes in intracardiac conduction were rate independent between cycle lengths 400 to 600 msec, while changes in ventricular effective refractory periods were most pronounced at rapid pacing rates. No adverse effects, hemodynamic changes, or conduction disturbances occurred. Thus, MODE can modify or suppress induction of reentrant atrioventricular or atrioventricular nodal tachycardia. The study design used here is well suited for the evaluation of newer antiarrhythmic agents by electrophysiological testing.     

全机器人不开胸心脏冠状动脉旁路移植术的围术期护理

全机器人不开胸心脏微创手术具有创伤小、痛苦轻、恢复快和不影响美观等优势,是一种高度精密和复杂的技术。此术式的开展极大程度地依赖于术者丰富的心血管外科知识和熟练的手术技巧。     

冠状动脉旁路移植术患者术前焦虑状况的调查

目的了解冠状动脉旁路移植术患者术前的焦虑状况,为制订针对性的干预措施提供依据。方法采用一般资料调查表及焦虑自评量表(self-rating anxiety scale,SAS)对2012年1月至2013年12月南京大学医学院附属鼓楼医院心胸外科收治的行冠状动脉旁路移植术的128例患者进行调查。结果 128例患者中,50例患者存在焦虑症状,其中轻度焦虑16例、中度焦虑32例、重度焦虑2例;不同性别、年龄、文化程度、病程、家庭人均月收入及医疗费用支付方式、患者术前焦虑情况的差异有统计学意义(P0.05或P0.01);不同婚姻状况患者术前焦虑情况的差异无统计学意义(P0.05)。结论年龄大、病程长、文化程度低、家庭人均月收入低、医疗费用自付、女性患者在冠状动脉旁路移植术术前易出现焦虑症状,护理人员应加强对这部分患者的观察和心理护理,针对性地采取护理干预,以减轻患者的心理负担,从而有利于手术的顺利进行和术后的康复。     

冠状动脉搭桥术前超声检测颈动脉狭窄的临床意义

目的 评价血管超声技术应用于冠状动脉搭桥术(CABG)前的临床价值及意义.方法 随机抽取拟行CABG的住院患者共104例,年龄(68.9±6.09)岁,于CABG前1周之内进行颈动脉超声检查,判断颈动脉狭窄程度,对颈动脉超声提示重度狭窄和/或闭塞的患者进行颈动脉造影检查并依据检查结果进行干预治疗.结果 颈动脉重度狭窄和/或闭塞患者超声和造影检查结果具有很好的相关性(相关系数r=0.92,P<0.001).对颈动脉超声和造影均显示重度狭窄和/或闭塞的10例患者在CABG前进行了颈动脉内膜剥脱术(CEA)或颈动脉支架置入术(CAS),这些患者在CABG围术期无1例脑血管并发症发生.结论 应用血管超声技术可准确检测颈动脉狭窄程度,其结果与颈动脉造影具有很好的相关性,依据颈动脉超声及造影结果,对严重狭窄和/或闭塞的颈动脉进行介入治疗或手术治疗可明显降低CABG围术期脑卒中的发生率.     

Preliminary Trial of Rebamipide for Prevention of Low-Dose Aspirin-Induced Gastric Injury in Healthy Subjects: A Randomized,Double-Blind,Placebo-Controlled,Cross-Over Study

Although low-dose aspirin is widely used, since it is a cheap and effective means of prevention of cardiovascular events, it can cause hemorrhagic gastrointestinal complications. The aim of this study was to evaluate the efficacy of rebamipide in preventing low-dose aspirin-induced gastric injury. A randomized, double-blind, placebo-controlled, crossover trial was performed in twenty healthy volunteers. Aspirin 81 mg was administered with placebo or rebamipide 300 mg three times daily for 7 consecutive days. The rebamipide group exhibited significant prevention of erythema in the antrum compared with the placebo group (p = 0.0393, respectively). Results for the body and fornix did not differ significantly between the placebo and rebamipide groups. In conclusion, short-term administration of low-dose aspirin induced slight gastric mucosal injury in the antrum, but not in the body or fornix. Rebamipide may be useful for preventing low-dose aspirin-induced gastric mucosal injury, especially which confined to the antrum.     

Randomized Controlled Trial of Intensive Versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery: GLUCO-CABG Trial

OBJECTIVE

The optimal level of glycemic control needed to improve outcomes in cardiac surgery patients remains controversial.

RESEARCH DESIGN AND METHODS

We randomized patients with diabetes (n = 152) and without diabetes (n = 150) with hyperglycemia to an intensive glucose target of 100–140 mg/dL (n = 151) or to a conservative target of 141–180 mg/dL (n = 151) after coronary artery bypass surgery (CABG) surgery. After the intensive care unit (ICU), patients received a single treatment regimen in the hospital and 90 days postdischarge. Primary outcome was differences in a composite of complications, including mortality, wound infection, pneumonia, bacteremia, respiratory failure, acute kidney injury, and major cardiovascular events.

RESULTS

Mean glucose in the ICU was 132 ± 14 mg/dL (interquartile range [IQR] 124–139) in the intensive and 154 ± 17 mg/dL (IQR 142–164) in the conservative group (P < 0.001). There were no significant differences in the composite of complications between intensive and conservative groups (42 vs. 52%, P = 0.08). We observed heterogeneity in treatment effect according to diabetes status, with no differences in complications among patients with diabetes treated with intensive or conservative regimens (49 vs. 48%, P = 0.87), but a significant lower rate of complications in patients without diabetes treated with intensive compared with conservative treatment regimen (34 vs. 55%, P = 0.008).

CONCLUSIONS

Intensive insulin therapy to target glucose of 100 and 140 mg/dL in the ICU did not significantly reduce perioperative complications compared with target glucose of 141 and 180 mg/dL after CABG surgery. Subgroup analysis showed a lower number of complications in patients without diabetes, but not in patients with diabetes treated with the intensive regimen. Large prospective randomized studies are needed to confirm these findings.     

Cerebral Hemodynamics during Coronary Artery Bypass Graft Surgery: The Effect of Carotid Stenosis

Carotid stenosis is a frequent coexisting condition in patients undergoing coronary artery bypass graft (CABG) surgery. The impact of carotid stenosis on cerebral perfusion is not fully understood. The purpose of this study was to determine the impact of carotid stenosis on cerebral blood flow velocity in patients undergoing CABG. Seventy-three patients undergoing CABG were prospectively recruited and underwent preoperative Duplex carotid ultrasound to evaluate the degree of carotid stenosis. Intraoperatively, transcranial Doppler ultrasound was used to record the mean flow velocity (MFV) within the bilateral middle cerebral arteries. In addition, during the period of cardiopulmonary bypass, regulators of cerebral hemodynamics such as hematocrit, partial pressure of carbon dioxide and temperature were recorded. The ipsilateral middle cerebral artery mean flow velocity was compared in arteries with and without carotid stenosis using a repeated measures analysis. Seventy-three patients underwent intraoperative monitoring during CABG and 30% (n = 22) had carotid stenosis. Overall, MFV rose throughout the duration of CABG including when the patient was on cardiopulmonary bypass. However, there was no significant MFV difference between those arteries with and without stenosis (F = 1.2, p = .21). Further analysis during cardiopulmonary bypass, demonstrated that hemodilution and partial pressure of carbon dioxide may play a role in cerebral autoregulation during CABG. Carotid stenosis did not impact mean cerebral blood flow velocity during CABG. The cerebrovascular regulatory process appears to be largely intact during CABG.     

体重指数对冠脉搭桥手术预后的影响

目的:分析冠脉搭桥术(CABG)患者体重指数(BMI)对手术预后影响。方法:采用回顾性方法入选2007-01/2008-12在中国医科大学附属第一医院接受CABG术治疗的123例患者,按BMI分为:BMI25组和BMI≥25组。比较两组之间的临床和预后情况。结果:术后常见并发症的发生两组无统计学差异。结论:行冠脉搭桥手术患者,BMI增加并不增加术后合并症发生的危险。     

Effects of Music and Preoperative Education on Coronary Artery Bypass Graft Surgery Patients' Anxiety

PurposeThe aim of this study was to evaluate the effectiveness of music and preoperative education on anxiety, physiological responses, length of hospital stay, and quality of life in Coronary Artery Bypass Graft Surgery (CABG) patients.DesignThis was a non–randomized quasi-experimental study.MethodsFor this study, 214 patients were separated into an experimental and control group. A dual intervention using preoperative education and a CD with classical Turkish music was applied to the experimental group. The control group was provided with an uninterrupted rest period at the same time. The primary outcome was the difference in anxiety of the patients. Other outcomes included differences in the physiological responses, length of hospital stay, and quality of life.FindingsAnxiety decreased in the preoperative and postoperative periods in both groups (P = .000), and patients’ anxiety level in the experimental group was lower than the control group (P = .000). The experimental group patients had a decrease in systolic blood pressure, diastolic blood pressure, and heart rate in the preoperative period (P = .000), and all physiological responses in the postoperative period were lower than the control group (P = .000). Furthermore, the experimental group's length of hospital stay was shorter (5.8 ± 1 days), and their quality of life was better (P = .000).ConclusionsThe dual integrative nursing intervention (music and preoperative education) was effective in reducing anxiety in CABG patients. The results of the study will contribute to nonpharmacological approaches in the management of anxiety in CABG patients.