Term Paper: Cardiac Stress Response

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[. . .] al, 1994) or at the "level of the spinal cord" (Koltun, et. al, 1996) significantly reduce "neuroendocrine or immune responses affected by surgery" (Glaser, et. al, 1998). Significantly lower pain scores have been noted among patients who experienced advantages in surgery such as epidural anesthesia, which is typically associated with " a significant reduction in the incidence of postoperative pain and immune outcome, including infections" (Glaser, et. al, 1998; Cuschieri, et. al, 1985). Epidurals have in fact been associated with lower overall pre and post operative pain scores among patients enduring Cardiac surgery, which suggests that use of such anesthesia will ultimately result in a reduced stress response, eliciting a more positive pre and post operative outcome.

The reduction in stress induction during cardiac surgery will also likely result in a significantly better immune outcome post operative for cardiac patients (Glaser, et. al, 1998; Cuschieri, Morran, Howie McArdle, 1985). Important to note here also is that narcotic based anesthesia has also been shown to "suppress the hormonal response to surgery" (Lacoumenta et. al, 1987; from Glaser, 1998). Effective pain management has been associated with epidural anesthesia in many instances, and also in response to infusion of systemic opioids which have the effect of reducing the overall plasma cortisol levels (Moller, et. al 1988; from Glaser, 1998).

Research also indicates that administering "analgesic doses of morphine" may significantly attenuate "surgery induced increases in the metastasis of a tumor cell line" which indicates that a negative immune consequence as a result of apin induction may be halted based on the delivery of appropriate systems (Page Ben-Flivahu, 1994; from Glaser, 1998).

Pain often results from an activation of the inflammatory response, which is commonly associated as a mechanism for pain, immunity and "initiation of wound healing" (Glaser, 1998). Tissue damage is often a residual side effect from cardiac surgical procedures, commonly caused by the release of "factors including substance P, bradykinin, prostaglandins, and histamine" (Glaser, 1998). Cytokines are generally released from tissue cells in the body, such as the neutrophil (Hubner et. al, 1996; from Glasner, 1998). Working together, these factors generally initiate an "inflammatory response" which is traditionally characterized by the following: vasodilatation, increased capillary permeability and "local hyerpalgesia" (Schweizer, et. al, 1988; from Glasner, 1998).

Clearly, pain suppresses the overall immune function; thus anesthesiologists working with cardiovascular patients should focus on reducing the pain response commonly associated with cardiovascular surgery in an attempt to limit the overall immune system response and failure that might otherwise result. Immune function has been noted to typically decline with advanced age; cardio bypass surgery and similar surgical endeavors are commonly affiliated and associated with an elderly population; thus it is critical that anesthetists reduce the potential for surgical mortality by taking into consideration the age distress relation and factor (Herbert & Cohen, 1993; from Glasner, 1998).

There do exist some risk factors that may increase the overall stress response in surgery; these include the following: smoking, alcohol, drug abuse and poor nutrition (Kehlet, 1987; from Glasner, 1998). Thus anesthetists have an obligation to asses all patients undergoing cardiac surgery to determine whether or not they fit into these high risk categories.

Wound healing" may also be affected by a variety of other factors, including heightened stress that is associated with a poor life style (Glaser, 1998). Anesthesiologists must make choices that may alter the levels of stress hormones that correspond to the natural state of life including these factors.

IMPLICATIONS FOR PRACTICE

Early assessment of "psychological predictors of outcome" provides physicians and anesthetists the opportunity to identify which patients are at increased likelihood for poor outcome (Glaser, 1998). Additionally, technological advances have made it possible for cardiac procedures to be less invasive, thus resulting in a decreased overall stress response, which ultimately might result in an increased likelihood for a positive post operative outcome. Anesthesiologists have an obligation to evaluate new technologies and procedures to provide cardiac patients with optimal anesthetic mechanisms. By investigating new research and technology, anesthesiologists might better learn how to mitigate the stress response naturally elicited by surgery, and subsequently facilitate a positive outcome for patients undergoing cardiac surgery.

Surgery in and of itself is a natural psychological and physiological stressor to the body; Anesthetists have the ability to mitigate the potential stress factors inherent in cardiovascular surgery and thus affect the likelihood for an increased positive outcome. Some techniques that have been proven to reduce the stress response during cardiac bypass surgery include utilization of opioids and other narcotics, and administration of an epidural during cardiac surgery. Mitigating the stress response is critical to managing potential immunological reactions from surgery and the likelihood for a positive response.

Physicians and anesthetists have an obligation to investigate any and all mechanisms that might further the likelihood for success in surgery; this paper suggests avenues through which they might do so.

Bibliography

Cook, Richard I. "Adapting to New Technology in the Operating Room." Human Factors, Vol. 38, 1996.

Cook, R.I., Woods, D.D., Howie, M.B., Horrow, J.C. & Gaba, D.M. (1992). "Unintentional delivery of vasoactive drugs with an electromechanical infusion device." Journal of Cardiothoracic and Vascular Anesthesia, 6, 238-244.

Cuschieri, R.J., Morran, C.G., Howie, J.C., & McArdle, C.S. (1985). "Postoperative pain a dpulmonary complications: comparison of three analgesic regimens." British Journal of Surgery, 72, 495-499.

Glaser, J., Kiecolt-Glaser, MacCallum P., Marucha, P., & Page, G. "Psychological Influences on Surgical Recovery: Perspectives from Psychoneuroimmunology." American Psychologists, Vol. 53, 1998.

Glaser, R., & Kiecolt-Glaser, J.K. (Eds.). (1994). "Handbook of human stress and immunity." San Diego, CA: Academic Press.

Herbert, T.B., & Cohen, S. (1993). "Biological commonalities of stress and substance abuse." In S. Shiffman & T.A. Wills (Eds.)., "Coping and substance use." San Diego: CA: Academic Press.

Hubner, G., Brauchle, M. Smola, H., Madlener, M., Fassler, R., & Werner, S. (1996). "Differential regulation of pro-inflammatory cytokines during wound healing in normal and glucocorticoid-treated mice." Cytokine, 8, 548-556.

Johnston, M, & Vogele, C. (1993). "Benefits of psychological preparation for surgery: A meta-analysis." Annals of Behavioral Medicine, 15, 245-256.

Johnston, M. & Wallace, L. (Eds.). (1990). "Stress and medial procedures." Oxford, England: Oxford University Press.

Kiecolt-Glaser, J.K.,l & Glaser, R. (1988). "Methodological issues in behavioral immunology research with humans." Brain, Behavior, and Immunity, 2, 67-78

Liebeskind, J.C. (1991).… [END OF PREVIEW]

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