Nuevos actores

Subjective Questionnaires'. Immediately after consent, patients completed the following:-

~ Trait Anxiety (Speilberg,1970)

~ Type 'A' personality scale (Bortner, 1969), This scale measures fourteen behaviours consistent with Type ‘A’ personalities. A seven point scale is

anchored by two extremes of behaviour e.g.’Never late for appointments/ Casual about appointments’ subjects rate their behaviour on the scale.

~ Response to Surgery Questionnaire (RSQ) this questionnaire assesses subjective responses to surgery, see developing the RSQ (chapter, 4).

~ Zung Anxiety and Depression Scale (Zung,1974). This questioimaire consists o f two scales, anxiety/ depression of six items each and a four part response scale. Subjects respond to each item according to how they feel ‘right now’. ~ The Cognitive Failures Questioimaire (Broadbent, 1982), this questioimaire assesses minor cognitive errors in perception, memory and motor function e.g. ‘ how often do you enter a room and forget what you came in for’. A second part, to be completed by spouse or close other is an objective measure of minor cognitive failings.

~ A 'Confidence Scale', a ten point scale (anchored; I no help at all -1 0 very helpful) to indicate their confidence in the pre-surgical preparation. This scale served to identify those patients who achieved 'perception o f control'. Those with no confidence in the psychological treatment were unlikely to enhance their sense

of involvement in their recovery. In the case of the "no treatment" controls patients were asked to indicate whether setting down their feelings by answering the questionnaires was helpful.

~ Pain VAS scales. On the first occasion that the patients reported pain post- operatively they completed visual analogue scales to record the intensity of the pain and the distress it was causing them. The pain VAS was repeated four days post-operatively. At the same time subjects were asked to recall their first instance of pain mark a separate VAS (recalled pain is reported in chapter 7). ~ Anxiety and depression were measured on days one and four post-operatively. ~ A recovery inventory (Wolfer & Davis, 1970) was added to each post-operative assessment.

~ Fatigue scale to measure mental and physical fatigue (Wessely,1989) was added to each post-operative assessment. This asks patients to evaluate their fatigue in relation to 'how they felt before' providing ratings in relation to their state before surgery.

~ The Pain Response Questionnaire was added on the first post-operative day . ~ The RSQ on the fourth post-operative day.

One month following surgery approximately 21 days after discharge (for completion

at 30 days) each subject was sent the anxiety and depression questionnaire and cognitive failure questionnaire (self and other).

Objective questionnaire'. On the first occasion post-operatively that the subjects indicated pain the investigator or nurse completed a visual analogue scale assessing the pain intensity and distress. On the first and fourth post-operative days the nursing staff completed the nurse recovery assessment.

Neuro-psychological assessment: Following major surgery patients often complain of failure of cognitive function, loss o f concentration, short attention span and an

increase in occurrence o f minor mistakes. Two simple tasks were devised to assess loss o f cognitive ability in the early post-operative period.

1) Digit span; subjects are asked to recall a short sequence o f numbers to assess short term memory function. The patient's base line digit span was established pre-operatively and assessed immediately post-operatively, when the patient was able to communicate and in early recovery.

2) Perceptual motor ability was measured by placing different shapes into holes against the clock. This test was repeated on the same schedule as the digit span.

The pre-operative and first post-operative questionnaires were completed by all patients. All but one patient completed the questionnaires on the forth post-operative day and 58 (79%) returned completed questionnaires 30 days post-operatively.

Catecholamines and cortisoh Blood samples were drawn (A) at 18.30 hours on the pre-operative day (B) immediately before induction o f anaesthesia (C) immediately after median sternotomy (D) when the patient was rewarmed following

cardiopulmonary bypass (B) 2 hours after removal to the intensive care unit (F) 2 hours after disconnection from the ventilator (which normally occurred at 08:00 hours on the post-operative day) (G-I) at 18:30 on the first, second and third post-operative days. All samples were taken from resting patients and drawn into heparinized tubes. Samples A, B and I were normally taken from a peripheral vein through a cannula inserted at least 30 minutes prior to sampling. All other samples were drawn from a central line and frozen at -70°C until assay by HPLC for epinephrine (adrenaline) and norepinephrine (noradrenaline).

Figure 9:1 Sample Time for Plasma Levels of Catecholamines and Cortisol

pre-op. per-cp. post-op.

A B c D E F G H I

18.30 prior to post median on 2 hrs 2hrs after 18.30 18.30 18.30

1 day anaesthesia sternotomy rewarm after removal 1 day 2 days 3 days

pre­ arrival from post­ post­ post­

Figure 9:2 Overview of the Psychological Procedure

Intervention groups

1 day pre-op. pre-op. day of op.

post-op. day of op.

1 day post-op. 4 days post-op 1 month post-op.

perception of control

relaxation training + tape Type A, trait anx Anxiety/ depression, RSQ, confidence scale. Base line Cognitive failure, digit span and sensory motor. relaxation with tape. postop relaxatio ntape. pain vas anxiety/ depression, fatigue, recovery inventory, PRQ, digit span, sensory motor. anxiety/ depression, fatigue, recovery inventory, RSQ, digit span, sensory motor. Pain vas and recall vas

anxiety/depression, cognitive failure self and others

social support emotional support + tape Type A, trait anx. Anxiety/ depression, RSQ, confidence scale Base line Cognitive failure, digit span and sensory motor emotional support postop support tape, pain vas anxiety/ depression, fatigue, recovery inventory, PRQ, digit span, sensory motor. anxiety/ depression, fatigue, recovery inventoryT^SQ , digit span, sensory motor. Pain vas and recall vas

anxiety/depression, cognitive failure self and others

No Treatment Type A,trait anx. Anxiety/ depression, RSQ, confidence scale. Base line Cognitive failure, digit span and sensory motor

no visit pam vas anxiety/ anxiety/ depression. depression. fatigue. fatigue. recovery recovery inventory. inventory JISQ PRQ, digit digit span. span, sensory sensory motor. motor. Pain vas and

recall vas

anxiety/depression, cognitive failure self and others

objective measures. Nurses.

Pain vas nurse recovery inventory

nurse recover inventory

STATISTICAL ANALYSIS

Catecholamines were log-transformed ( logjo X+1) to normalise distributions. Groups were compared first by one-way analyses o f variance on age, start time and duration o f surgery, trait anxiety and baseline measures of anxiety, depression,