Coronary Artery Bypass Graft (CABG) Surgery and Nursing Care

Afza.Malik GDA

Nursing Care for CABG Surgery

Coronary Artery Bypass Graft (CABG) Surgery and Nursing Care

Coronary Artery Bypass Graft (CABG) Surgery,Risk Factors By Research Outcomes ,Evidence of Pathogenic Effect of Anxiety and Depression,Demand of CABG Surgery,Psychological Impact of Studies ,Depression Is The Timing of The Evaluation,Impact of Depression on Mortality,Post Operative Care,Preoperative Care.

Coronary Artery Bypass Graft (CABG) Surgery

    Coronary artery bypass graft surgery, a common treatment for coronary artery disease (CAD), provides significant improvement in symptoms in 76%-90% of the patients (Rahimtola, 1982). 

    An estimated 800,000 surgeries are performed worldwide each year (Borowicz et al., 2002) with 519,000 performed in the United States in 2000 (American Heart Association, 2001). 

    Although CABG surgery succeeds in treating physiological problems, a significant number of patients report feelings of anxiety and depression pre- and/or postoperatively and depression has been linked to morbidity and mortality (Borowicz et al.).

Risk Factors By Research Outcomes 

    Research findings support the relationship of depression, anxiety, or a combination of the two with risk for cardiovascular disease CVD), independent of classic risk factors, in patients with established CAD and in previously healthy individuals. 

    Prevalence rates for patients with CVD range from 16%- 23%, for clinical depression, and 31.5% and 60% for depressive symptoms (Pignay-De- maria, Lesperance, Demaria, Frasure- Smith, & Perrault, 2003).

Evidence of Pathogenic Effect of Anxiety and Depression

    Evidence that depression and anxiety have prognostic importance in determining CABG surgery outcomes supports the development of pre-and-post operative nursing assessment strategies to identify patients at risk for adverse events. 

    Nurses can play pivotal roles in identifying patients who need further evaluation, providing education about the effects of depression and anxiety on CABG surgery outcomes, and developing and evaluating interventions aimed at ameliorating the effects of these risk factors on postoperative morbidity and mortality.

Demand of CABG Surgery

    Demand for CABG surgery exceeds resources in many developed countries, leading to waiting lists. The experience of waiting for surgery has been studied from quantitative as well as qualitative perspectives. 

    Patients on waiting lists experienced anxiety, depression, and negative impacts on quality of life (Screeche Powell & Owens, 2003; Fitzsimmons, Parahoo, & Stringer, 2000; Teo et al., 1998; Jonsdottir & Baldursdottir, 1998). 

    Levels of anxiety and depression in patients awaiting CABG surgery were significantly reduced in a randomized controlled trial of a nurse-led shared care intervention (McHugh et al., 2001).

Psychological Impact of Studies 

    Longitudinal studies of the impact of psychological variables on outcomes of CABG surgery demonstrate that recovery is neither simple nor experienced consistently in all patients. Although some studies included the measurement of both anxiety and depression, most examined the impact of depression on recovery. 

    Researchers have found that anxiety levels significantly decreased over time and remained linear. Relationships between anxiety and depression over time were relatively weak while those relationships, at the same points in time, were relatively strong (Duits, Boeke, Taams, Passchier, & Erdman, 1997; Duits et al., 1999). 

    Postoperative anxiety was directly related to perception of pain with the strongest relationship on postoperative day two. In a study of 38 males, 80% scored in the moderate range of anxiety preoperatively with anxiety-prone reactivity persisting in 38.9% of the patients postoperatively. 

    These patients exhibited significantly more sleep disturbances, energy deficits, tiredness, immobility, and a lower quality of life (Edell Gustafsson & Hetta, 1999).

    Recently reported longitudinal studies evaluating depression pre-and-post operatively report prevalence ranging from 16- 50% pre-operatively and 19-61% post-operatively. Almost all studies used self-report questionnaires for measuring depression. Subjects (#50 to 336) mean ages ranged from 54 to 65 years, represented a 3:1 male- to-female ratio, and ranged from 85%- 100% Caucasian.

Depression Is The Timing of The Evaluation

    An issue in evaluating patients for depression is the timing of the evaluation. Poston, Haddock, Conard, Jones, and Spiritus (2003) found depression 1 month after surgery to be a better predictor of depression at 6 months than the preoperative score. 

    Piragliatin, Peterson, Williams-Russo, Gorkin, and Charleston (1999) identified other predictors of post- operative depression: poor social support, at least one stressful life event in the last year, low level of education, and moderate to severe dyspnea. 

    Hypothermia during CABG has been associated with higher levels of post- operative emotional distress (Khatri et al., 2001), and early extubating has been associated with fewer patients with depressive symptoms on day three postoperatively (Silbert et al., 2001).

    Depression has consistently been associated with adverse outcomes after CABG surgery. Investigators (Perski et al., 1998; Scheier et al., 1999; Saur et al., 2001) have found depressive symptoms, pre- or postoperatively to predict postoperative cardiac events (unstable angina, myocardial infarction (MI), repeat CABG, or angioplasty) and were positively correlated with the rate of readmission for cardiac events. 

    Connerney, Shapiro, McLaughlin, Bagiella, and Sloan(2001) determined that patients meeting criteria for major depressive disorder at discharge were significantly more likely to experience a cardiac related event than were those who failed to meet the criteria (including those with depressive symptoms). Further- more, depression was a predictor independent of classic cardiovascular risk factors.

Impact of Depression on Mortality

    In a study investigating the impact of depression on mortality, Baker, Andrew, Schrader, and Knight (2001) found mortality rates to be six times higher among the patients with preoperative symptoms of depression. 

    Blumenthal et al. (2003) also identified higher mortality rates for patients with moderate to severe depression at baseline and mild or moderate to severe depression that persisted from baseline to 6 months. 

    Limitations of these reviewed studies include low enrollment of women, racial homogeneity, high rates of refusal to participate, high attrition, and use of self-report measures to evaluate anxiety and depression.

    Several studies have addressed gender differences in recovery from CABG surgery. Vaccarin o et al. (2003) found that women. were older and more often had unstable angina, congestive heart failure, lower physical function, and more depressive symptoms in the month before surgery. 

    Younger women were at a higher risk of in-hospital death than men, a difference decreasing with age (Vac carino, Abramson, Veledar, & Weintraub, 2002). 

    Postoperatively, for women but not men only, pain was correlated with depressive symptomatology and functional impairment (Con, Linden, Thompson, & Ignaszewski, 1999) and women had a more difficult recovery, unexplained by illness severity, presurgery health status, or other patient characteristics.     

Post Operative Care

    Postoperative neuropsychological deficits are a common complication of cardiac surgery, with incidence ranging from 25%-80% (Borowicz, Goldsborough, Selnes, & Mc-Khann, 1996). 

    Although investigators have found that changes in anxiety and depression did not influence changes in neuropsychological performance (Andrew, Baker, Knee- bone, & Knight, 2000), multiple investigators have found that anxiety and depression impact perception of cognitive functioning (Vingerhoets, De Soete, & Jannes, 1995; Khatri et al., 1999). 

    Factors predictive of post-CABG cognitive deficits were preexisting cognitive deficits, greater age, lower premorbid intelligence, and, at 3 months. Post-surgery, patients who received their first CABG surgery without cardiopulmonary by- pass (Millar, Asbury, & Murray, 2001; Van Dijk et al., 2002).

    Based upon several reviews of recent data, symptoms of depression and, to some extent, anxiety may be associated with cardiac events and mortality through multiple pathophysiological pathways. 

    These include exerting a direct influence on health related lifestyle behaviors (smoking, poor diet, low activity levels, poor adherence to treatment), effects on of hyper activation of the hypothalamic pituitary-adrenal and/or sympathy medullary axes, diminished heart rate variability, myocardial and ventricular instability in reaction to mental stress, alteration in platelet receptors and/or reactivity, and the inflammatory processes. 

    To date, no one mechanism has been identified as the causal link between psychological states and cardiac events.

Preoperative Care 

    Although the benefits of short term preoperative interventions have been examined in only one randomized controlled study of patients awaiting CABG surgery (McHugh et al., 2001), clinical experience suggests that routine screening and effective treatment preoperatively may decrease postoperative anxiety and depression and facilitate recovery. 

    There is general agreement that early postoperative intervention should be offered to patients experiencing depression and/or anxiety. 

    Some studies have shown that early psychological intervention may be associated with reduction in length of hospital stay, analgesic use, less subjective tension, and post surgical morbidity (Mumford, Schlesinger, & Glass, 1982; Ashton et al., 1997; Perski et al., 1999; Karlsson, Berglin, & Larsson, 2000). 

    A stress-management program, based upon relaxation techniques, offered 3 months after the MI or CABG surgery improved emotional well being, daily activities, and several social parameters (Trzcieniecka Green & Steptoe, 1996). 

    Data is also accumulating about the efficacy of selective serotonin reuptake inhibitors on the treatment of depression (specifically sertraline and fluoxetine) in patients with cardiovascular disease (CVD). To date, no studies investigating the effect of antidepressants after CABG surgery have been published. 

    Clearly, there is a need for large, randomized trials of both antidepressants and psychosocial interventions post CABG surgery to determine their efficacy, especially since depression has clearly been linked to increased morbidity and mortality.

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