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Divisions of *Cardiac Surgery and Physiology, Karl-Franzens University Hospital, Graz, Austria
Address correspondence and reprint requests to Dr. Peter Bergmann, and Karl-Franzens University Clinic, Division of Cardiac Surgery, Auenbruggerplatz 29, A-8036 Graz, Austria. Address e-mail to peter.bergmann{at}kfunigraz.ac.at
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Abstract |
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IMPLICATIONS: The quantity of stress during transport to the operating room and the perioperative psychoendocrinologic course of stress in combination with two different methods of preoperative medical information are described in 60 consecutive patients awaiting cardiac surgery.
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Introduction |
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Previous studies have demonstrated that open-heart surgery is associated with high levels of psychoendocrine stress (8–10). Our primary interest was to detect when perioperative stress is highest. In addition, we questioned whether extensive medical information in combination with more personal attention by the surgeon before surgery has any effect on patients’ perioperative psychoendocrinologic responses as compared with a control group receiving the information pamphlet alone. The aim of the study was to evaluate the quantity of perioperative stress from hospital admission until discharge and the possibility of perioperative psychoendocrinologic stress reduction through provision of extensive medical information in combination with more personal attention by the surgeon before surgery.
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Methods |
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Group II (n = 30) received medical information through the same informative pamphlet as well as extensive oral medical information by one of our surgeons (PB). Oral information covered the same four-point checklist (preoperative course and preparation for the operation, surgical technique, postoperative course, and possibility of intra- and postoperative complications). The oral method put more emphasis on perioperative problems, and individual patients’ concerns were considered in more detail. In addition, in Group II one of our surgeons (PB) visited the patient two times per day to give the patients an opportunity to talk about perioperative concerns or personal problems. All patients in Group II took advantage of this opportunity, and the conversation lasted at least 20 min. The individual surgeon (PB), like most heart surgeons, had no training in psychotherapy, but a graduate psychotherapist (EL) supervised PB in conversations with patients before the study. No other health care professionals (e.g., nurses) supplied similar information to the patients.
Subjects were randomly assigned to one of the groups before being given one or the other kind of preoperative medical information. Patient characteristics are shown in Table 1. Points of psychoendocrinologic measurements were I (immediately after hospital admission, 3 days before surgery), II (after receiving medical information, 3 days before surgery), III (2 days before surgery), IV (day before surgery), V (on the way to the operating room [OR]), VI (after the induction of anesthesia), VII (first day after surgery), and VIII (sixth day after surgery). Patients with acute or recent myocardial infarction (within the last 6 wk), as well as those undergoing percutaneous transluminal coronary angioplasty, patients with angina unresponsive to medical therapy and therefore scheduled for urgent operation, patients taking psychopharmaceuticals or thyroid hormones before surgery, and those who had to wait for more than 3 days for their operation were excluded. Two patients in Group I who asked for additional information were excluded from the study. Blood pressure and heart rate were taken at all points of measurement.
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All patients received 300 µg/kg etomidate and 10 µg/kg fentanyl for the induction of anesthesia and 0.08 mg/kg pancuronium for paralysis IV. Clinical monitoring included seven-lead electrocardiography, systemic arterial pressure, central venous pressure, pulmonary arterial pressure, pulse oximetry, and capnography. Anesthesia was supplemented with isoflurane to 0.5% inspired and bolus doses of 50–100 µg fentanyl IV as indicated. Cardiopulmonary bypass was performed with a membrane oxygenator by using hemodilution and systemic hypothermia of 31°C. St. Thomas Hospital solution was used for cardioplegia.
Saliva was collected with a small cotton swab (Salivette®; Sarstedt, Rommelsdorf, Germany). Patients were asked to retain the cotton swab in their mouth for at least 2 min and then insert it into a special plastic tube, which was stored at -20°C until assay (at most 20 days later) (5). Samples at measuring Point I and II were collected to assess stress reactions to the medical information (in the morning between 8:00 AM and 9:30 AM), and the fifth sample was collected on the way to the OR (in the morning between 8:00 AM and 9:30 AM); at all other times, salivary cortisol was collected in the evening at 8:00 PM, when patients were unaffected by routine therapeutic interventions.
Samples of 5 mL of blood were drawn from all patients to measure plasma cortisol levels. All plasma cortisol samples were collected in the morning between 8:00 AM and 9:30 AM. At measuring Points III and IV, samples were drawn from a peripheral vein in addition to the routine sampling. At Points VI, VII, and VIII, samples were drawn from the superior vena cava via a central venous catheter. Samples were placed in chilled tubes and centrifuged at 3000g for 10 min at 4°C; the separated plasma was stored at -20°C until assay (at most 20 days later).
Plasma and salivary cortisol were determined in duplicate with a commercial radioimmunoassay kit (CORT-CT2 kit®; CIS Bio International-ORIS Group, Yvette Cedec, France). Intraassay coefficients of variation for plasma and salivary cortisol were 5.6% and 2.1%, respectively.
The psychological variables included the State-Trait Anxiety Inventory and patients’ well-being. The completion of the psychological test sheets was supervised by the medical psychologist (EL). The psychologist and the person administering the psychological tests were the same individual, who was strictly blinded with reference to group assignment.
Patients’ state and trait anxiety were measured by the State-Trait Anxiety Inventory, which records state and trait anxiety separately. Subjects rated their levels of state and trait anxiety on a four-point scale ranging from "not at all" (1 point) to "almost always" (4 points). A total score of 20 to 80 points increased in proportion to anxiety (12). Patients’ well-being was evaluated by the well-being scale (13), a list of 28 pairs of opposite adjectives, one relating to enhanced (0 points) and the other to impaired (2 points) well-being. An indifferent decision rated 1 point. A small total of points reflects a rather positive condition, and a large total a rather negative one. The intra- and intervariabilities of the state anxiety test vary in the range between 6% and 10% (12).
The main objective of our study was to detect differences in patients’ state anxiety between Measurements I and II in both groups. Spielberger et al. (12) presented a detailed statistical preparation of the State-Trait Anxiety Inventory; furthermore, a significant correlation between anxiety and salivary cortisol is described in the literature (14). On the basis of these data, we performed a power analysis of patients’ state anxiety at measurement points I and II: we found that in a number of the 30 patients in each group, a difference of 10% from the primary level was detectable with a reliability of 80%. Because our data did not show normal distribution, they were subjected to log transformation before analysis and are now presented as the geometric mean (95% confidence interval [CI]).
The Student’s t-test was used to compare the groups. There was no significant difference between Groups I and II at measuring Point I (P = 0.61) and measuring Point II (P = 0.60). Related to the primary level, Group I showed a reduction in state anxiety of 7.4% (CI, 3.2%–11.3%) at measurement Point II, and Group II showed a reduction of 7.2% (CI, 1.0%–13.0%). The difference between measuring Points I and II for the two groups was 0.2% (CI, -7.6%–6.6%). A three-way analysis of variance for repeated measurements with the main effects group, points of measurement, and sex was performed. There were no significant interactions between groups and between groups and points of measurement. Comparisons between groups for pre- and intraoperative patient characteristics (Table 1) were performed with the equal variance t-test, Fisher’s exact test, and 
2 statistics. P values of <0.05 were considered significant.
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Results |
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There was no significant difference in state anxiety between groups (P = 0.43) and between female and male patients (P = 0.82) in any point of measurement. State anxiety was higher before medical information at measuring Point I (Group I, 40.6 points [36.8–44.9]; Group II, 39.2 points [35.3–43.5]) than afterward at Point II (Group I, 37.7 points [34.5–41.1]; Group II, 36.4 points [32.8–40.3]). The day before surgery, at Point IV (Group I, 37.7 points [34.7–41.0]; Group II, 37.2 points [34.3–40.2]), state anxiety remained almost unchanged compared with Point II (Fig. 3).
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Again for salivary cortisol, neither between groups (P = 0.32) nor between sexes (P = 0.19) was a significant difference seen in any point of measurement after surgery. Peak salivary cortisol concentration was reached after surgery at measuring Point VII (Group I, 29.7 nmol/L [20.5–43.0]; Group II, 36.3 nmol/L [25.7–51.3]). This value was significantly higher (P < 0.001) versus measuring points I, II, III, IV, and VIII (Group I, 13.1 nmol/L [9.6–18.1]; Group II, 12.0 nmol/L [9.0–16.1]) (Fig. 2).
There was no significant difference in patients’ well-being between groups (P = 0.96) or between sexes (P = 0.94) after surgery. Patient well-being was better (P = 0.003) before surgery at measuring Points II and IV than afterward at measuring Point VIII (Group I, 14.6 points [10.7–19.8]; Group II, 14.4 points [10.9–18.9]) (Fig. 4). However, state anxiety decreased in both groups (P = 0.001) after surgery at Point VIII (Group I, 33.1 points [30.1–36.6]; Group II, 32.1 points [29.4–34.9]) versus Point I (Fig. 3).
All patients survived surgery. Blood pressures and heart rates were in the physiologic range at all points of measurement. One patient (Patient 44, Group II) with preoperatively diagnosed high-grade reduced left ventricular function and chronic obstructive pulmonary disease developed a low cardiac output syndrome after surgery. Preoperative cortisol levels and psychological scores did not differ from the rest of the group. After surgery, this patient’s cortisol levels were high, as was state anxiety, whereas well-being decreased after surgery. Otherwise, none of the patients developed pre-, intra-, or postoperative complications.
It was not possible to perform salivary and plasma cortisol determinations in the course of all measurements. However, in previous studies, measurements of salivary cortisol reflected the plasma levels (15,16), and the comparability between salivary and plasma cortisol was not the goal of our study. At measuring Points I and II, no plasma cortisol measurements were performed to avoid any stress response caused by consecutive venous sampling (17). For the same reason, we did not perform plasma measurements during transport to the OR. After the induction of anesthesia, immediately before skin incision, when the patient was intubated, the secretion of saliva was reduced and sufficient salivary extraction therefore impossible. On grounds of different times of salivary cortisol collection during the day, diurnal changes confounded the correlation between salivary measurement Points II and III, IV and V, and V and VII. However, the comparability between groups is valid (same measurement points for all samples in both groups), which was the goal of our study. The number of psychological tests was limited to four. At Point V the patient was sedated, at Point VI the patient was intubated, and at Point VII the patient was in the intensive care unit; this precluded completion of psychological test sheets.
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Discussion |
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We share the experience presented by other authors, who relate the absence of significant differences between different methods of preoperative information to the increased level of patients’ medical information (18). Anderson (1) described a lower level of state anxiety and a better emotional state after surgery, as well as better physical and psychological convalescence, in a group of better informed heart-surgery patients. However, he used different informative techniques (sensorial and procedural techniques and techniques of controlling and modeling) that are not suitable for our routine clinical use.
Other authors have suggested that increased cortisol secretion was seen only when an individual’s psychological defenses were inadequate to cope with a situation (5,19). Despite premedication with meprobamate 200 mg three times per day, from admission until the evening before surgery, our patients’ levels of salivary and plasma cortisol remained almost unchanged. The possibility of minimizing differences between the groups because of preoperative tranquilizer application in all our patients was present. Retrospectively and in view of the results of our study, we believe that withholding meprobamate would be inadvisable in view of the increased stress level en route to the OR. Sex did not influence our results, supporting some previous observations (20,21) but opposing others that describe a larger cortisol response to stress in male than in female patients (22,23).
Episodic 24-hour measurements of plasma cortisol on the day before major surgery in patients awaiting elective cardiac surgery are reported by Czeisler et al. (8), but no data in the literature describe patients’ cortisol reaction during transport to the OR. Although all our patients received pentobarbital 100 mg and diazepam 5–10 mg on the evening before surgery and were sedated during the transport to the OR, levels of salivary cortisol were approximately two to three times higher during the transport than immediately after admission to the hospital (Fig. 2). The lack of stress reduction in these patients who received extraordinary extensive preoperative medical information and more personal attention by the surgeon was unexpected. This situation—the transport into the OR—seems to be more than their coping mechanisms were prepared to handle. Indeed, it is a high-stress situation, considering that previous studies by Chatterton et al. (24) demonstrated a similar amount of stress in skydivers immediately after their first jump from an airplane (24). There was no increase in cortisol levels three days before the jump, on the morning of the jump, or just before boarding the plane. However, the jump itself—the sensation of falling and the loss of coping mechanism—leads to a significant increase of salivary and plasma cortisol that is similar to that of our patients during the transport into the OR. Forthcoming studies will show whether more generous preoperative sedation can reduce patient stress on the way to the OR.
After the induction of anesthesia, cortisol levels decreased considerably in our patients (Fig. 1). After surgery, however, salivary and plasma cortisol increased again to finally return to high-normal values until the sixth postoperative day (Fig. 1 and 2). These results are confirmed by other studies that describe a decreasing plasma cortisol concentration during anesthesia and surgery before cardiopulmonary bypass, a significant increase during cardiopulmonary bypass, and a gradual normalization after surgery (9,10,25). State anxiety decreased significantly six days after surgery, whereas well-being worsened after surgery (Fig. 3 and 4). Burker et al. (26) describe anxiety as a significant predictor of pre- and postoperative depression and suggest that methods to reduce anxiety are indicated. This supports psychological care given to these patients perioperatively.
In summary, extensive detailed oral medical information in addition to an informative pamphlet and more personal attention by the surgeon does not seem to have any effect on patients’ perioperative stress indicators, anxiety, and well-being.
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Acknowledgments |
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This article has been cited by other articles:
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  D. Hohener, S. Blumenthal, and A. Borgeat Sedation and regional anaesthesia in the adult patient Br. J. Anaesth., January 1, 2008; 100(1): 8 - 16. [Abstract] [Full Text] [PDF]
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 M. Good, S. Wotman, G. C. Anderson, S. Ahn, and X. Cong Obtaining Parotid Saliva Specimens after Major Surgery Biol Res Nurs, October 1, 2004; 6(2): 110 - 116. [Abstract] [PDF]
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 A. Lee, P. T. Chui, and T. Gin Educating Patients About Anesthesia: A Systematic Review of Randomized Controlled Trials of Media-Based Interventions Anesth. Analg., May 1, 2003; 96(5): 1424 - 1431. [Abstract] [Full Text] [PDF]
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