Circadian distribution of sleep phases after major abdominal surgery
01 Jan 2008-BJA: British Journal of Anaesthesia (Oxford University Press)-Vol. 100, Iss: 1, pp 45-49
TL;DR: Patients have significantly increased REM sleep, LS, and reduced time awake during the daytime period after surgery compared with before surgery, suggesting disturbances in the circadian regulation of the sleep-wake cycle may be involved in the development of postoperative sleep disturbances.
Abstract: Background It is believed that the severely disturbed night-time sleep architecture after surgery is associated with increased cardiovascular morbidity with rebound of rapid eye movement (REM). The daytime sleep pattern of patients after major general surgery has not been investigated before. We decided to study the circadian distribution of sleep phases before and after surgery. Methods Eleven patients undergoing elective major abdominal surgery were included in the study. Continuous ambulatory polysomnographic monitoring was made 24 h before surgery and 36 h after surgery, thus including two nights after operation. Sleep was scored independently by two blinded observers and the recordings were reported as awake, light sleep (LS, stages I and II), slow wave sleep (SWS, stages III and IV), and REM sleep. Results There was significantly increased REM sleep ( P =0.046), LS ( P =0.020), and reduced time awake ( P =0.016) in the postoperative daytime period compared with the preoperative daytime period. Five patients had REM sleep during the daytime after surgery. Three of these patients did not have REM sleep during the preceding postoperative night. There was significantly reduced night-time REM sleep for two nights after surgery compared with before surgery ( P =0.001). Conclusions Patients have significantly increased REM sleep, LS, and reduced time awake during the daytime period after surgery compared with before surgery. Disturbances in the circadian regulation of the sleep–wake cycle may be involved in the development of postoperative sleep disturbances.
Citations
More filters
TL;DR: A review of recent advances in the role of neurotransmitters and neuromodulators in anesthetic emergence discusses recent advances, focusing mainly on methylphenidate, an inhibitor of dopamine and norepinephrine transporters.
Abstract: Historically, emergence from anesthesia was believed to progress only through the passive elimination of pharmacologic agents from the brain. However, recent studies indicate that anesthetic emergence may not simply be a process mirroring the induction of anesthesia. Several substances reduce the duration of anesthesia but not its induction time. Their action is not the result of a passive process, because they actively affect the kinetics of neurotransmitters or the endogenous sleep circuit to shorten anesthesia. The latest notable substance among this group of agents is methylphenidate, an inhibitor of dopamine and norepinephrine transporters. Studies on emergence from anesthesia aim not only to stimulate scientific interest but also to improve the clinical course following general anesthesia, when patients sometimes experience life-threatening complications such as myocardial infarction, bronchial asthma, and cerebral hemorrhage. This review discusses recent advances in this field, focusing mainly on the role of neurotransmitters and neuromodulators in anesthetic emergence.
18 citations
TL;DR: Perioperative frustration levels were different among inexperienced and experienced surgeons and perioperative sleep quality may influence postoperative mental strain and should be considered in studies examining surgeons’ stress.
Abstract: Purpose Surgical procedures are mentally and physically demanding, and stress during surgery may compromise patient safety. We investigated the impact of surgical experience on surgeons' stress levels and how perioperative sleep quality may influence surgical performance. Methods Eight experienced and 8 inexperienced surgeons each performed 1 laparoscopic cholecystectomy. Questionnaires measuring perioperative mental and physical strain using validated visual analog scale and Borg scales were completed. Preoperative and postoperative sleep quality of the surgeon was registered and correlated to perioperative strain parameters. Results Preoperative to postoperative frustration among experienced surgeons was significantly reduced and this was not found in the inexperienced surgeons (visual analog scale: preoperative 13 (2-65) mm, postoperative 4 (0-51) mm vs. preoperative 5(0-10) mm, postoperative 5(1-46) mm; P=0.04). Physical strain was significantly induced in both groups in the upper extremities. Preoperative and postoperative sleep quality was significantly correlated to postoperative mental strain parameters. Conclusions Perioperative frustration levels were different among inexperienced and experienced surgeons. Perioperative sleep quality may influence postoperative mental strain and should be considered in studies examining surgeons' stress.
18 citations
Additional excerpts
...Sleep quality (mm) 40 (1-69) 21 (9-61) 32 (1-82) 20 (8-88) General well-being (mm) 31 (1-69) 17 (2-64) 27 (0-52) 29 (5-91) Fatigue (1-10) 4 (1-6) 3 (1-5) 4 (1-7) 4....
[...]
...General well-being (VAS) 14 (2-33) 15 (1-32) 14 (2-50) 12 (3-66) Time pressure (VAS) 9 (0-60) 14 (1-35) 9 (1-99) 4 (1-63) Effort (VAS) 24 (1-100) 41 (0-88) 52 (0-99) 88 (16-100) Performance (VAS) 13 (0-28) 26 (2-52) 31 (1-45) 20 (2-53) Frustration (VAS) 13 (2-65)*w 5 (0-10)w 4 (0-51)*w 5 (1-46)w Satisfaction (VAS) 15 (1-51) 15 (0-62) 23 (0-46) 17 (0-51)...
[...]
...preoperative 5(0-10)mm, postoperative 5(1-46)mm; P=0....
[...]
TL;DR: The development and validation of a Score for Prediction of Postoperative Respiratory Complications (SPORC) focusing on the early postoperative period of 3 days after surgery, a simple way to identify high-risk patients in future studies and prospectively evaluate the effectiveness of interventions in preventing or reducing the incidence of postoperative respiratory failure.
Abstract: 1247 June 2013 C LINICAL research in Anesthesiology increasingly focuses on prediction of myriad perioperative complications. This research has been driven by development of databases that capture various measures of patient health, anesthetic care, surgical procedure, and outcomes. One of the strengths of this approach is that it allows analysis of outcomes that were previously understudied due to their rarity or complexity. Postoperative respiratory failure is a perfect target for such researches because it is relatively rare and has a significant impact on healthcare costs1 and patient mortality.2,3 Previous investigators have developed several screening tools for the prediction of postoperative respiratory failure,2–4 but most have focused on 30-day outcomes, a period that may well exceed the immediate influence of anesthesia technique and perioperative respiratory management. For example, the first 24 h after surgery represent the highest risk of unanticipated respiratory failure due to opioids,5,6 whereas postoperative hypoxemia has been shown to peak by the third night after major surgery.7–10 In this issue of the Journal, Eikermann et al. report the development and validation of a Score for Prediction of Postoperative Respiratory Complications (SPORC) focusing on the early postoperative period of 3 days after surgery.11 The investigators identified several independent predictors for reintubation such as planned postoperative hospital admission, preoperative history of congestive heart failure, chronic pulmonary or cerebrovascular disease, emergency surgery, American Society of Anesthesiologists score of 3 or more, and high-risk surgical service. By using a weighted point system, the SPORC yielded a calculated area under the receiver operating characteristics curve of 0.84–0.87, with a step-wise increase in the odds for reintubation with increasing number of risk factors. As previously reported, the development of respiratory failure was associated with a large increase in 30-day mortality.2 The SPORC tool is, thus, a simple way to identify high-risk patients in future studies and prospectively evaluate the effectiveness of interventions in preventing or reducing the incidence and severity of postoperative respiratory failure. For example, success of continuous positive airway pressure therapy in patients recovering from major abdominal surgery suggests that screening tool such as SPORC may have a role in identifying the patients who are likely to benefit from this therapy.12 There are, however, several limitations to the authors’ approach to screening. Bayes Theorem describes the relation between the prevalence of a disease and the accuracy of prediction tools.13–15 For rare events, even highly accurate tests will generate many false positives, with the potential consequences of excess resource utilization and complications from unnecessary treatment. Most prediction models derived from outcomes databases have positive predictive values less than 10% (low clinical precision) as the outcomes of interest are typically rare (0.1–4%).2,16 As most patients who underwent surgery have low risk and will not develop the complication in question, high specificity is given; but, because only a small fraction of patients will screen positively as high-risk, the sensitivity typically tends to be low. A tool with sensitivity of less than 50% will, by definition, fail to identify the majority of patients who will develop the complication. This is the case with the majority of prediction models derived from outcomes databases for perioperative complications (low sensitivity and low technical precision). A consequence is that policies or care processes that preferentially allocate treatments to high-risk patients, based on these screening tools, may potentially place more patients at harm due to misdiagnoses (i.e., patients who should be given treatment do not receive it). Furthermore, heterogeneity in patient populations is high in most prediction models, resulting in significant variability Clinical Prediction of Postoperative Respiratory Failure
17 citations
01 Jan 2009
TL;DR: Cares for patients who are obese or have metabolic syndrome are unfortunately becoming increasingly common perioperative issues and the ultimate aim of caring for such patients is to find ways to minimize the untoward effects of surgery.
Abstract: Contemporary life, with its sedentary lifestyles, fast foods, processed foodstuff, and desk-bound service employment, is beset by an epidemic of overweight and obese individuals. The World Health Organization reported that worldwide a billion adults are overweight and at least 30% of them are obese. Moreover, increasing numbers of children are obese. In the United States, two National Health and Nutrition Examination Surveys of adults aged 20 to 74 years showed that the prevalence of obesity increased from 15% in the 1976 to 1980 survey to 34% in the 2003 to 2004 survey. This epidemic has been associated with significant increases in the prevalence of glucose intolerance and/or type 2 diabetes mellitus, hypertension, dyslipidemia, and cardiovascular diseases. This constellation of conditions has piqued the interest of the medical community, which has dubbed it the metabolic syndrome and developed formal definitions (Box 1). Patients with the metabolic syndrome have increased risks for developing coronary artery disease, stroke, peripheral vascular disease, and type 2 diabetes mellitus, and greater mortality from coronary disease and other causes. 1 Furthermore, such patients have a proinflammatory and prothrombotic state. Whether this syndrome is a disease in and of itself, is merely a list of obesity-induced complications, or is composed of discrete disorders is the subject of much investigation and controversy. 2 For example, although individuals with the metabolic syndrome have a cardiovascular risk 50% to 60% higher than others, the absolute cardiovascular risk of the metabolic syndrome is not higher than those of its individual components. 3 The reason that abdominal or central obesity is associated with the development of hypertension, hypercholesterolemia, and insulin resistance is partially attributed to abdominal (or visceral) fat being more metabolically active than subcutaneous fat.
17 citations
Cites background from "Circadian distribution of sleep pha..."
...Surgery disrupts sleep patterns with a decrease in REM sleep during the first postoperative nights, and a subsequent rebound increase.(38) As airway obstruction in OSA occurs particularly during REM sleep, the finding that hypoxia is more common in OSA patients on the second and third postoperative nights(39,40) is not surprising, and parallels an increase in cardiovascular events during this period....
[...]
TL;DR: Both anesthetics increased brain MCH content in the postanesthetic period, with the degree of increase being greater with propofol, but the modulation pattern may depend on the type of anesthetic.
Abstract: Anesthesia and surgery disturb sleep. Disturbed sleep adversely affects postoperative complications involving the cardiovascular system, diabetes, and infection. General anesthetics share neuronal mechanisms involving endogenous sleep–wakefulness-related substances, such as orexin (OX) and melanin-concentrating hormone (MCH). We evaluated changes in sleep architecture and the concentration of OX and MCH during the peri-anesthetic period. To examine sleep architecture, male Sprague–Dawley rats weighing 350–450 g received ketamine 100 mg/kg (n = 9) or propofol 80 mg/kg (n = 6) by intraperitoneal injection. Electroencephalography was recorded from 2 days pre- to 5 days postanesthesia. To quantify levels of OX and MCH, 144 similar rats received the same doses of ketamine (n = 80) or propofol (n = 64). Brain concentrations of these substances were determined at 0, 20, 60, and 120 min after anesthetic administration. Ketamine decreased OX content in the hypothalamus during the anesthesia period. OX content was restored to pre-anesthesia levels in the hypothalamus and pons. Both anesthetics increased brain MCH content in the postanesthetic period, with the degree of increase being greater with propofol. Ketamine enhanced wakefulness and inhibited non-rapid eye movement sleep (NREMS) immediately after anesthesia. Conversely, propofol inhibited wakefulness and enhanced NREMS in that period. Ketamine inhibited wakefulness and enhanced NREMS during the dark phase on the first postanesthesia day. Anesthetics affect various endogenous sleep–wakefulness-related substances; however, the modulation pattern may depend on the type of anesthetic. The process of postanesthetic sleep disturbance was agent specific. Our results provide fundamental evidence to treat anesthetic-related sleep disturbance.
17 citations
Cites background from "Circadian distribution of sleep pha..."
...The time spent in rapid eye movement sleep (REMS) is also decreased on the first postoperative day, increasing as a rebound reaction from the second postoperative day [1, 2]....
[...]
...For example, lack of deep non-rapid eye movement sleep (NREMS) and frequent awareness are commonly observed in postoperative sleep architecture [1]....
[...]
References
More filters
Book•
01 Jan 1968
11,993 citations
TL;DR: Techniques of recording, scoring, and doubtful records are carefully considered, and Recommendations for abbreviations, types of pictorial representation, order of polygraphic tracings are suggested.
Abstract: With the vast research interest in sleep and dreams that has developed in the past 15 years, there is increasing evidence of noncomparibility of scoring of nocturnal electroencephalograph-electroculograph records from different laboratories. In 1967 a special session on scoring criteria was held at the seventh annual meeting of the Association for the Psychophysiological Study of Sleep. Under the auspices of the UCLA Brain Information, an ad hoc committee composed of some of the most active current researchers was formed in 1967 to develop a terminology and scoring system for universal use. It is the results of the labors of this group that is now published under the imprimatur of the National Institutes of Health. The presentation is beautifully clear. Techniques of recording, scoring, and doubtful records are carefully considered. Recommendations for abbreviations, types of pictorial representation, order of polygraphic tracings are suggested.
8,001 citations
01 Jan 1968
3,002 citations
01 Jan 1968
2,439 citations
TL;DR: REM sleep is associated with profound sympathetic activation in normal subjects, possibly linked to changes in muscle tone and the hemodynamic and sympathetic changes during REM sleep could play a part in triggering ischemic events in patients with vascular disease.
Abstract: Background The early hours of the morning after awakening are associated with an increased frequency of events such as myocardial infarction and ischemic stroke. The triggering mechanisms for these events are not clear. We investigated whether autonomic changes occurring during sleep, particularly rapid-eye-movement (REM) sleep, contribute to the initiation of such events. Methods We measured blood pressure, heart rate, and sympathetic-nerve activity (using microneurography, which provides direct measurements of efferent sympathetic-nerve activity related to muscle blood vessels) in eight normal subjects while they were awake and while in the five stages of sleep. Results The mean (±SE) amplitude of bursts of sympathetic-nerve activity and levels of blood pressure and heart rate declined significantly (P<0.001), from 100 ±9 percent, 90 ±4 mm Hg, and 64 ±2 beats per minute, respectively, during wakefulness to 41 ±9 percent, 80 ±4 mm Hg, and 59 ±2 beats per minute, respectively, during stage 4 of non-REM sl...
1,378 citations