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.
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TL;DR: It is concluded that the pathogenesis of POCD is multifactorial and future studies should focus on evaluating the role of postoperative sleep disturbances, inflammatory stress responses, pain and environmental factors.
Abstract: There is evidence that postoperative cognitive dysfunction (POCD) is a significant problem after major surgery, but the pathophysiology has not been fully elucidated. The interpretation of available studies is difficult due to differences in neuropsychological test batteries as well as the lack of appropriate controls. Furthermore, there are no internationally accepted criteria for defining POCD. This article aims to provide an update of current knowledge of the pathogenesis of POCD with a focus on perioperative pathophysiology and possible benefits achieved from an enhanced postoperative recovery using a fast-track methodology. It is concluded that the pathogenesis of POCD is multifactorial and future studies should focus on evaluating the role of postoperative sleep disturbances, inflammatory stress responses, pain and environmental factors. Potential prophylactic intervention may include minimal invasive surgery, multi-modal non-opioid pain management and pharmacological manipulation of the inflammatory response and sleep architecture.
267 citations
Cites background from "Circadian distribution of sleep pha..."
...The rebound REM sleep leads to labile haemodynamics and ventilatory changes with a decrease in hypoxic drive with implications for cardiovascular morbidity.(33,35,36) Acetylcholine and adenosine play an important role in mediating alertness and wakefulness, and the elderly are more susceptible to unwanted...
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...A substantial decrease in REM sleep occurs on the first postoperative night,(35,36) followed by a profound rebound phenomenon on the second to fourth postoperative night, where REM sleep increases in both intensity and amount.(33,35,36) The rebound REM sleep leads to labile haemodynamics and ventilatory changes with a decrease in hypoxic drive with implications for cardiovascular morbidity....
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TL;DR: Combination of an obstructive sleep apnea screening tool preoperatively (SACS) and recurrent PACU respiratory events was associated with a higher oxygen desaturation index and postoperative respiratory complications.
Abstract: Background: Patients with obstructive sleep apnea are at risk for perioperative morbidity. The authors used a screening prediction model for obstructive sleep apnea to generate a sleep apnea clinical score (SACS) that identified patients at high or low risk for obstructive sleep apnea. This was combined with postanesthesia care unit (PACU) monitoring with the aim of identifying patients at high risk of postoperative oxygen desaturation and respiratory complications. Methods: In this prospective cohort study, surgical patients with a hospital stay longer than 48 h who consented were enrolled. The SACS (high or low risk) was calculated; all patients were monitored in the PACU for recurrent episodes of bradypnea, apnea, desaturations, and pain‐sedation mismatch. All patients underwent pulse oximetry postoperatively; complications were documented. Chi-square, two-sample t test, and logistic regression were used for analysis. The oxygen desaturation index (number of desaturations per hour) was calculated. Oxygen desaturation index and incidence of postoperative cardiorespiratory complications were primary endpoints. Results: Six hundred ninety-three patients were enrolled. From multivariable logistic regression analysis, the likelihood of a postoperative oxygen desaturation index greater than 10 was increased with a high SACS (odds ratio 1.9, P < 0.001) and recurrent PACU events (odds ratio 1.5, P 0.036). Postoperative respiratory events were also associated with a high SACS (odds ratio 3.5, P < 0.001) and recurrent PACU events (odds ratio 21.0, P < 0.001). Conclusions: Combination of an obstructive sleep apnea screening tool preoperatively (SACS) and recurrent PACU respiratory events was associated with a higher oxygen desaturation index and postoperative respiratory complications. A two-phase process to identify patients at higher risk for perioperative respiratory desaturations and complications may be useful to stratify and manage surgical patients postoperatively. PATIENTS with obstructive sleep apnea (OSA) are at risk for perioperative morbidity, and many patients who present for surgical procedures may have undiagnosed OSA. 1–5 In 1993, approximately 4% of men and 2% of
236 citations
TL;DR: One half of unanticipated tracheal intubations in a period of 30 days occurred within the first 3 days after nonemergent, noncardiac surgery and were independently associated with a 9-fold increase in mortality.
Abstract: Background Although the risk of hypoxemia is greatest during the first 72 h after surgery, little is known of the incidence of respiratory failure during this period. The authors studied the incidence and predictors of unanticipated early postoperative intubation (within 3 days) and its role in mortality. Methods A total of 222,094 adult patients undergoing nonemergent, noncardiac surgery in the American College of Surgeons-National Surgical Quality Improvement Program database were studied to determine the incidence and independent predictors of unanticipated early postoperative intubation. A risk-class model was developed and subsequently validated in 109,636 patients. Results Overall, 2,828 of 5,725 (49.4%) unanticipated tracheal intubations in a period of 30 days occurred within the first 3 days after surgery. The incidence of unanticipated early postoperative intubation was 0.83-0.9% in the derivation and validation cohorts. Independent predictors of unanticipated early postoperative intubation included current ethanol use, current smoker, dyspnea, chronic obstructive pulmonary disease, diabetes mellitus needing insulin therapy, active congestive heart failure, hypertension requiring medication, abnormal liver function, cancer, prolonged hospitalization, recent weight loss, body mass index less than 18.5 or ≥ 40 kg/m, medium-risk surgery, high-risk surgery, very-high-risk surgery, and sepsis. Unanticipated early postoperative intubation was an independent predictor of 30-day mortality, with an adjusted odds ratio of 9.2. Higher risk classes were associated with increasing incidence of unanticipated early postoperative intubation and death. Conclusions One half of unanticipated tracheal intubations in a period of 30 days occurred within the first 3 days after nonemergent, noncardiac surgery and were independently associated with a 9-fold increase in mortality. The authors present a validated perioperative risk class index for determining risk of unanticipated early postoperative intubation.
164 citations
TL;DR: Postoperatively, sleep architecture was disturbed and AHI was increased in both OSA and non-OSA patients and breathing disturbances during sleep were greatest on postoperative N3.
Abstract: Background:Anesthetics, analgesics, and surgery may profoundly affect sleep architecture and aggravate sleep-related breathing disturbances. The authors hypothesized that patients with preoperative polysomnographic evidence of obstructive sleep apnea (OSA) would experience greater changes in these p
141 citations
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...OSA 38 34 (23, 55)† 3 (0, 39)* 45 (20, 66)† 37 (15, 58)† 33 (20, 46)†...
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TL;DR: Patients with a higher preoperative AHI were predicted to have a higher postoperatively AHI and slow wave sleep percentage was inversely associated with postoperative A HI and central apnea index.
Abstract: Introduction:The knowledge on the mechanism of the postoperative exacerbation of sleep-disordered breathing may direct the perioperative management of patients with obstructive sleep apnea The objective of this study is to investigate the factors associated with postoperative severity of sleep-diso
132 citations
References
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TL;DR: There is a need for further studies of sleep‐and respiration‐related effects on postoperative nocturnal cardiac function and the efficacy of monitoring during this apparent high‐risk period should be evaluated.
Abstract: Unexpected deaths still occur following major surgical procedures. The cause is often unknown but may be cardiac or thromboembolic in nature. Postoperative ischaemia, infarction and sudden cardiac death may be triggered by episodic or constant arterial hypoxaemia, which increases during the night. This study examined the circadian variation of sudden unexpected death following abdominal surgery between 1985 and 1989 inclusive. Deaths were divided into those occurring during the day (08.00-16.00 hours), evening (16.00-24.00 hours) and night (24.00-08.00 hours). Twenty-three deaths were considered to have been totally unexpected. Of 16 such patients undergoing autopsy, pulmonary embolism was the cause of death in five. In the remaining 11 patients, death occurred at night in eight (P < 0.005). Five of the seven patients without an autopsy died at night (P < 0.04); overall, 13 of 18 unexpected deaths occurred at night-time. These results suggest a need for further studies of sleep- and respiration-related effects on postoperative nocturnal cardiac function. The efficacy of monitoring during this apparent high-risk period should be evaluated.
67 citations
58 citations
TL;DR: Episodes of hypoxaemia and tachycardia frequently occur together after surgery but are rarely associated with ST deviation, which is often present at the same time as ST deviation.
Abstract: Background. Episodic hypoxaemia, cardiac arrhythmias, and myocardial ischaemia may be related after major abdominal surgery. Methods. We studied 52 patients on the second and third nights after major abdominal operations, using continuous pulse oximetry and Holter ECG. We recorded the amount of time spent with oxygen saturation values less than 90, 85, and 80% during the night, and noted episodes of hypoxaemia, tachycardia, bradycardia, and ST-segment changes. Results. In 87 study nights there were 2403 (individual range 1–229) episodes of hypoxaemia, 3509 (individual range 1–234) episodes of tachycardia, and 265 (individual range 1–73) episodes of ST segment deviation. Of the 52 patients, 50 had episodes of hypoxaemia and tachycardia, and 19 patients had one or more episodes of ST segment deviation. For 38% of the episodes of ST deviation, there was an episode of hypoxaemia at the same time and in 16% there was an episode of tachycardia. ST deviation was only noted in 4% of the episodes of hypoxaemia and in 1% of the episodes of tachycardia. Conclusion. Episodes of hypoxaemia and tachycardia frequently occur together after surgery but are rarely associated with ST deviation. Hypoxaemia or tachycardia is often present at the same time as ST deviation occurs.
35 citations
TL;DR: After laparotomy, total sleep time increased and there was a change in diurnal sleep distribution, and sleep architecture was disturbed for ?
Abstract: Background: The aim of this study was to examine subjective sleep quality before and after laparoscopic vs open abdominal surgery. Methods: Twelve patients undergoing laparoscopic cholecystectomy and 15 patients undergoing laparotomy were evaluated with the aid of a sleep questionnaire from 4 days before until 4 weeks after surgery. Results: Following laparoscopic surgery, total sleep time increased during the 1 st week after the operation compared with preoperative values (p = 0.02), whereas sleep duration during weeks 2, 3, and 4 did not differ from the times reported preoperatively. Following laparotomy, sleep duration increased during the 1st, 3rd, and 4th weeks after the operation compared with preoperative values (p < 0.05). All patients experienced postoperative circadian sleep disturbance, with significantly more sleep during the daytime compared with preoperative values; the disturbance was present 1 week after laparoscopy and 4 weeks after laparotomy. Conclusions: After laparotomy, total sleep time increased and there was a change in diurnal sleep distribution. These sleep alterations were less pronounced after laparoscopic cholecystectomy. Thus, sleep architecture was disturbed for ≥4 weeks after major abdominal surgery but for only 1 week after laparoscopic cholecystectomy.
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TL;DR: The sympathovagal balance (LF/HF) is more stable during SA than during GA in patients with a high risk of ischemic heart disease, however, the postoperative decrease in HRV bands is independent of the anesthetic technique.
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