Postoperative sleep disruptions: A potential catalyst of acute pain?

The Impact of Sleep Position Preferences on the Sleep Quality, Comfort and Catheter Care Quality in Patients After Endoscopic Nasobiliary Drainage: A Cross-Sectional Study

AIMS AND OBJECTIVES

This study aimed to investigate the impact of sleep position preferences (SPP) on sleep quality, comfort and catheter care quality in patients after endoscopic nasobiliary drainage (ENBD).

DESIGN

This was an observational prospective study.

METHODS

This study included 167 participants with common bile duct stones (CBDS) who underwent ENBD from the gallstone ward of a hospital as a convenience sample. Data were collected between June 2022 and August 2023. The study utilised the Pittsburgh Sleep Quality Index, Athens Insomnia Scale, comfort level, medical device-related pressure injuries (MDRPI), catheter displacement, bile drainage volume and a self-designed questionnaire on demographic and clinical data for data collection. Data analysis included chi-square tests and one-way analysis of variance, with differences between two groups assessed using the LSD-t test. The STROBE checklist was followed.

RESULTS

The postoperative sleep quality of ENBD patients was rated at (8.65 ± 2.91) points. Significant variations in sleep quality were evident among ENBD patients with different SPPs (p < 0.01). Patients favouring left-side and supine positions demonstrated differences in sleep quality compared to those favouring the right-side position (t = 1.45, p < 0.05; t = 1.72, p < 0.01). However, when comparing patients favouring the supine position to those favouring the left-side position, the difference in sleep quality was not statistically significant (t = 0.26, p > 0.05). The postoperative comfort score of ENBD patients was recorded at (5.67 ± 1.54) points. Significant variances in comfort levels were observed among ENBD patients with different SPPs (p < 0.01). Patients favouring left-side and supine positions exhibited differences in comfort levels compared to those favouring the right-side position (t = 1.02, p < 0.05; t = 0.78, p < 0.01). Nevertheless, when comparing patients favouring the supine position to those favouring the left-side position, the difference in comfort level was not statistically significant (t = -0.24, p > 0.05). Among ENBD patients with different SPPs, there were no statistically significant differences in the occurrence of MDRPI, catheter displacement and 24-h bile drainage volume (p > 0.05).

CONCLUSIONS

The sleep quality and comfort of patients following ENBD are suboptimal, warranting increased attention from healthcare providers. Nasobiliary tube conversion and fixation via the right nostril can negatively impact the sleep quality and comfort of patients with a preference for right-side sleeping. Preoperative training focusing on adjusting sleep positions is recommended, particularly for these patients. Alternatively, personalised modifications in the positioning and fixation of the nasal catheter could be made based on patients' sleeping position preferences. A multidisciplinary team, including nurses and surgeons, should collaboratively develop tailored nasobiliary drainage plans.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the importance of addressing sleep quality and comfort in patients undergoing nasobiliary drainage. It is recommended that patients with a preference for the right lateral sleeping position receive preoperative training to adjust their sleep posture. Alternatively, the nasobiliary tube's exit and fixation points should be customised based on individual sleep preferences. A multidisciplinary team, including nurses and surgeons, should collaborate to develop personalised nasobiliary drainage plans.

Postoperative Implementation of Virtual Reality and Wearable Devices: Opportunities and Challenges

OBJECTIVE

To examine implementation of virtual reality (VR) and Fitbit wearable activity devices in postoperative recovery.

METHODS

This was a prospective, 4-arm, randomized controlled trial of patients undergoing inpatient head and neck surgery at a tertiary academic center from November 2021 to July 2022. Patients were randomized to Control, VR, Fitbit, or combined VR + Fitbit groups. Patients in the VR groups were brought VR headsets to use throughout each day, and patients in the Fitbit groups wore Fitbit devices and were encouraged to achieve 2,000 daily steps. The primary outcome was average daily opioid use, measured as milligram morphine equivalents (MME).

RESULTS

There were 80 patients included. The majority of patients were male (68.8%), and mean age was 58.8 ± 14.4 years. Only the combined VR + Fitbit cohort was associated with reduced average daily opioid use (VR + Fitbit: 8.8 [20.6] MME vs. Control: 26.4 [37.4] MME, p = 0.02). Patients in intervention groups also had higher hospital satisfaction (p = 0.02). VR was utilized 26% of the time it was provided, with mean use time of 23.8 ± 7.8 min. Mean post-VR subjective pain reduction was 1.0 ± 1.3, and there were three mild adverse events of neck or nasal discomfort. Among the Fitbit groups, there were no adverse events and daily step counts ≥2,000 steps were achieved 45% of the time.

CONCLUSION

Implementation of VR and wearable activity devices in postoperative recovery appears well tolerated and may facilitate further development of Enhanced Recovery After Surgery (ERAS) protocols, though there are challenges to maximizing device usage.

LEVEL OF EVIDENCE

II. Laryngoscope, 2025.

Intraoperative Sleep Spindle Activity and Postoperative Sleep Disturbance in Elderly Patients Undergoing Orthopedic Surgery: A Prospective Cohort Study

Purpose

This study aimed to investigate the relationship between intraoperative sleep spindle activity and postoperative sleep disturbance (PSD) in elderly orthopedic surgery patients.

Patients and Methods

In this prospective observational cohort study, we collected intraoperative electroencephalography (EEG) data from 212 elderly patients undergoing orthopedic surgery from May 2023 to December 2023. We used the Athens Insomnia Scale to assess sleep quality on postoperative day (POD) 1 and POD 3 and analyzed the correlation between intraoperative sleep spindle activity and PSD through logistic regression.

Results

The incidence of PSD was 65.6% on POD 1 and 41.9% on POD 3. On the first day, there were no significant differences in intraoperative sleep spindle characteristics between PSD and non-postoperative sleep disturbance (non-PSD) patients. However, by the third day, PSD patients showed lower sigma power compared to non-PSD patients, as well as lower spindle density in the bilateral frontopolar (Fp1/Fp2) and bilateral temporal (F7/F8) channels, with shorter average spindle duration (P < 0.05). Multivariate logistic regression analysis suggested that the average spindle density in F7/F8 channels (OR 0.543, 95% CI 0.375-0.786; P = 0.001) was an independent risk factor for PSD on POD 3. Furthermore, Mini-Mental State Examination (MMSE) could independently predict PSD on POD 1 (OR 0.806, 95% CI 0.656-0.991; P = 0.041) and POD 3 (OR 0.701, 95% CI 0.562-0.875; P = 0.002). Pain on movement and at rest were independently associated with PSD on POD 1 (OR 1.480, 95% CI 1.200-1.824; P < 0.001) and POD 3 (OR 1.848, 95% CI 1.166-2.927; P = 0.009), respectively.

Conclusion

Intraoperative mean spindle density in the F7/F8 channels was an independent risk factor for PSD on POD 3 in elderly patients undergoing orthopedic surgery. MMSE and postoperative pain also independently increased the risk of PSD.

Efficacy of Preemptive Topical Lidocaine 5% Plaster in the Prevention of Post-Craniotomy Pain, a Randomized Clinical Trial

Objective

The current landscape is characterized by a dearth of effective, safe, simple, and noninvasive methods for preventing pain following craniotomy. This clinical trial seeks to evaluate the efficacy profile of preemptive application of a topical 5% lidocaine patch in alleviating post-craniotomy pain.

Methods

This was a multi-centric, prospective randomized placebo-controlled triple-blind clinical trial. Eligible patients were randomly assigned to either the masked intervention group, who received lidocaine 5% white hydrogel plasters (N = 90), or the placebo control group who received plain hydrogel plasters of the same pattern, size, appearance and material as L5Ps, but free of lidocaine (N = 90). Primary outcome was the pain intensity (Visual Analogue Scale at 24 h) after craniotomy. Secondary outcomes included: intra-operative analgesics consumption, pain intensity, cumulative rescue analgesics consumption, sleeping scores, adverse effects such as skin reactions, etc. The intention-to-treat analyses and the per-protocol analyses were used.

Results

There were no statistically significant differences in the VAS scores at 24 h after craniotomy (P = 0.539). However, subgroup analysis for female and male patients showed that statistically significant differences were found in VAS scores in male patients (0 [0, 3] in the masked intervention group at 24 h after craniotomy and 3 [1, 4.5] in the placebo control group, P = 0.017). There were no obvious side effects directly associated with preemptive L5P.

Conclusion

Preemptive lidocaine 5% plaster as a safe technique was not found to be effective in reducing post-craniotomy pain, but potential gender disparities in the outcomes of this method warrant further investigation.

Trial Registration

ClinicalTrials.Gov (NCT04169854).

Impaired Basal Forebrain Cholinergic Neuron GDNF Signaling Contributes to Perioperative Sleep Deprivation-Induced Chronicity of Postsurgical Pain in Mice Through Regulating Cholinergic Neuronal Activity, Apoptosis, and Autophagy

AIMS

This study investigated the roles of lateral basal forebrain glial cell line-derived neurotrophic factor (GDNF) signaling and cholinergic neuron activity, apoptosis, and autophagy dysfunction in sleep deprivation-induced increased risk of chronic postsurgical pain (CPSP) in mice.

METHODS

Sleep deprivation (6 h per day from -1 to 3 days postoperatively) was administered to mice receiving skin/muscle incision and retraction (SMIR) to determine whether perioperative sleep deprivation induces mechanical and thermal pain hypersensitivity, increases the risk of chronic pain, and causes changes of basal forebrain neurons activity (c-Fos immunostaining), apoptosis (cleaved Caspase-3 expression), autophagy (LC3 and p62 expression) and GDNF expression. Adeno-associated virus (AAV)-GDNF was microinjected into the basal forebrain to see whether increased GDNF expression could reverse sleep deprivation-induced changes in pain duration and cholinergic neuron apoptosis and autophagy. Cholinergic neurons were further depleted by mu p75-SAP to examine whether the pain-prolonging effects of sleep deprivation still exist.

RESULTS

Perioperative sleep deprivation enhanced pain sensation and prolonged pain duration in SMIR mice, which was accompanied by decreased cholinergic neuron activity and GDNF expression, increased apoptosis, and autophagy dysfunction in the substantia innominata (SI), magnocellular preoptic nucleus (MCPO), and horizontal diagonal band Broca (HDB) (hereafter lateral basal forebrain). Normalizing cholinergic neuron GDNF expression by AAV-GDNF in the lateral basal forebrain inhibited apoptosis and autophagy dysfunction and mitigated sleep deprivation-induced pain maintenance. Mice with selective lesion of lateral basal forebrain cholinergic neurons were resistant to the pain-enhancing and prolonging effects of sleep deprivation and the pain-alleviating effects of AAV-GDNF therapy.

CONCLUSIONS

Perioperative sleep deprivation promotes chronicity of postsurgical pain possibly through decreasing basal forebrain GDNF signaling and causing cholinergic neuronal apoptosis and autophagy dysfunction.

Postoperative use of sleep aids and delirium in older adults after major surgery: A retrospective cohort study

BACKGROUND

Sleep aids are commonly prescribed to treat sleep disturbance, a modifiable risk factor for postoperative delirium in older patients. The use of melatonin receptor agonists in the postoperative period has been increasing. The comparative safety of melatonin receptor agonists, zolpidem, and temazepam remains uncertain.

METHODS

This retrospective study included 22,083 patients ≥65 years old who initiated melatonin receptor agonists, zolpidem, or temazepam after major surgery in the Premier Healthcare Database 2009-2018. We performed propensity score-based overlap weighting and estimated the risk ratio (RR) and risk difference (RD) of postoperative delirium as the primary outcome and a composite of delirium or new antipsychotic initiation, pneumonia, and in-hospital mortality as secondary outcomes.

RESULTS

The mean age of the study population was 78 (SD, 7) years and 50% were female. There was no significant difference in the risk of postoperative delirium among patients treated with melatonin receptor agonists (3.4%, reference group), zolpidem (2.9%; RR [95% CI], 0.9 [0.7-1.2]; RD [95% CI] per 100 persons, -0.3 [-1.1 to 0.6]), and temazepam (3.1%; 0.9 [0.7-1.1]; RD [95% CI] per 100 persons, -0.5 [-1.2 to 0.3]). The risks of delirium or new antipsychotic initiation, pneumonia, and in-hospital mortality were also similar among all groups.

CONCLUSIONS

Melatonin receptor agonists were not associated with a lower risk of postoperative delirium and other adverse outcomes compared with zolpidem and temazepam in older adults after major surgery.

Effect of General Anesthesia vs Regional Anesthesia on Sleep Disturbance in Elderly Patients After Discharge from the Hospital for 3 Months

Purpose

This study aims to investigate the impact of anesthetic methods on the occurrence of postoperative sleep disorders in elderly patients following their discharge from the hospital for 3 months.

Patients and Methods

This retrospective observational cohort study included elderly patients aged >60 years who had undergone general and regional anesthesia from 1 June 2023 to 31 December 2023. These patients were then assessed for sleep by telephone callback using the Athens Insomnia Scale after discharge from the hospital three months later. The duration of pain and sleep disturbance experienced by patients following discharge was also recorded.

Results

Following propensity score matching, 308 individuals were included in the study (154 in the GA group and 154 in the RA group). Compared with general anesthesia (11.7%), regional anesthesia (5.2%) reduced the prevalence of sleep disorders in elderly patients after discharge from the hospital. However, the duration of sleep disturbance and pain exhibited no statistically significant difference between the two groups (p=0.818; p=0.211).

Conclusion

Regional anesthesia was associated with a reduction in the incidence of sleep disorders in elderly patients after discharge from the hospital for 3 months.

Dexmedetomidine Promotes NREM Sleep by Depressing Oxytocin Neurons in the Paraventricular Nucleus in Mice

Dexmedetomidine (DEX) is a highly selective α2-adrenoceptor agonist with sedative effects on sleep homeostasis. Oxytocin-expressing (OXT) neurons in the paraventricular nucleus (PVN) of the hypothalamus (PVNOXT) regulate sexual reproduction, drinking, sleep-wakefulness, and other instinctive behaviors. To investigate the effect of DEX on the activity and signal transmission of PVNOXT in regulating the sleep-wakefulness cycle. Here, we employed OXT-cre mice to selectively target and express the designer receptors exclusively activated by designer drugs (DREADD)-based chemogenetic tool hM3D(Gq) in PVNOXT neurons. Combining chemogenetic methods with electroencephalogram (EEG) /electromyogram (EMG) recordings, we found that cannula injection of DEX in PVN significantly increased the duration of non-rapid eye movement (NREM) sleep in mice. Furthermore, the chemogenetic activation of PVNOXT neurons using i.p. injection of clozapine N-oxide (CNO) after cannula injection of DEX to PVN led to a substantial increase in wakefulness. Electrophysiological results showed that DEX decreased the frequency of action potential (AP) and the spontaneous excitatory postsynaptic current (sEPSC) of PVNOXT neurons through α2-adrenoceptors. Therefore, these results identify that DEX promotes sleep and maintains sleep homeostasis by inhibiting PVNOXT neurons through the α2-adrenoceptor.

Continuous cuff pressure control on middle-aged and elderly patients undergoing endoscopic submucosal dissection of the esophagus effect of airway injury

OBJECTIVE

Assessment of the effect of continuous cuff pressure control on airway injury in middle-aged and elderly patients undergoing endoscopic submucosal dissection (ESD).

METHOD

A total of 104 eligible middle-aged and elderly patients requiring esophageal ESD from July 2022-September 2023 at the First Affiliated Hospital of Nanchang University were selected and randomly divided into two groups: the group undergoing general anesthesia tracheal intubation with continuous control of cuff pressure after intubation (Group A, n = 51) and the group undergoing general anesthesia tracheal intubation with continuous monitoring without control of cuff pressure (Group B, n = 53). After endotracheal intubation in Group A, under the guidance of an automatic cuff pressure controller, the air was used to inflate the tracheal cuff until the cuff pressure was 25-30cmH2O. The cuff pressure after intubation was recorded, and then the cuff pressure parameters were directly adjusted in the range of 25-30cmH2O until tracheal extubation after the operation. After endotracheal intubation, patients in Group B inflated the tracheal cuff with clinical experience, then monitored and recorded the cuff pressure with a handheld cuff manometer and instructed the cuff not to be loosened after being connected to the handheld cuff manometer-continuous monitoring until the tracheal extubation, but without any cuff pressure regulation. The patients of the two groups performed esophageal ESD. The left recumbent position was taken before the operation, and the cuff's pressure was recorded. Then, insert the gastrointestinal endoscope to find the lesion site and perform appropriate CO2 inflation to display the diseased esophageal wall for surgical operation fully. After determining the location, the cuff pressure of the two groups was recorded when the cuff pressure was stable. After the operation, the upper gastrointestinal endoscope was removed and the cuff pressure of the two groups was recorded. Postoperative airway injury assessment was performed in both groups, and the incidence of sore throat, hoarseness, cough, and blood in sputum was recorded. The incidence of postoperative airway mucosal injury was also observed and recorded in both groups: typical, episodic congestion spots and patchy local congestion.

RESULT

The incidence of normal airway mucosa in Group A was higher than that in Group B (P < 0.05). In comparison, the incidence of occasional hyperemia and local plaque congestion in Group A was lower than in Group B (P < 0.05).

CONCLUSION

Continuous cuff pressure control during operation can reduce airway injury in patients with esophageal ESD and accelerate their early recovery after the operation.

Virtual reality exposure reduce acute postoperative pain in female patients undergoing laparoscopic gynecology surgery: A Randomized Control Trial (RCT) study

STUDY OBJECTIVE

Few studies have focused on the effect of virtual reality (VR) exposure on postoperative acute pain in adult female patients undergoing gynecology surgery.

DESIGN

A randomized control trial (RCT) study.

SETTING

At Beijing Fuxing Hospital.

PATIENTS

115 patients aged between 20 and 60 years, American Society of Anesthesiologists (ASA) physical status I - II were consecutively enrolled and randomly divided into VR group (n = 58) or control group (n = 57).

INTERVENTIONS

Patients in the VR group received 15 min of VR video viewing before surgery.

MEASUREMENTS

The primary outcome was acute postoperative pain at 8 h which was measured by the Visual Analogue Scale (VAS) scores. The secondary outcomes including the use of analgesic drugs, the incidence of moderate pain and postoperative recovery which were recorded 24 h after surgery. The Hospital Anxiety and Depression Scale (HADS) was also used to evaluate patients' emotional status before surgery.

MAIN RESULTS

The VAS scores at 30 min [2 (1,2) vs. 3 (2,3)], 2 h [2 (2,3) vs. 4 (3,4)], 4 h [3 (2,4) vs. 4 (4,5)], 8 h [3 (2,4) vs. 4 (4,5)], 12 h [2 (2,3) vs. 4 (3,4)], 24 h [1 (1,2) vs. 3 (2,3)] after surgery. Generalized estimation equation (GEE) indicated that VR intervention was negatively correlated with postoperative VAS values (β = -0.830, S.E = 0.199, 95%CI (-1.220,-0.439), Wald χ2 = 17.359, p<0.05), in the meanwhile, VR also lower the incidence of moderate pain (VAS > 4) at 8 h postoperatively (12.1% vs 31.0%, p = 0.013). However, the 24 h tramadol usage remained unchanged. Patients in the VR group had better sleep quality (6.33 ± 2.3 vs. 4.12 ± 2.5, p < 0.001) and lower incidence of nausea (43.1% vs. 63.2%, p < 0.05), dizziness (0% vs. 14.0%, p < 0.05), and headache (12.1% vs. 29.8%, p < 0.05). VR could reduce the median HADS scores (9.81 ± 6.1 vs 3.14 ± 3.9, p < 0.001) and blood pressure preoperatively.

CONCLUSIONS

VR intervention can reduce acute postoperative pain with better postoperative recovery and lower preoperative anxiety level in adult female patients undergoing laparoscopic gynecology surgery.

Effects of oral pregabalin on postoperative sleep of patients after video-assisted thoracoscopic surgery: a randomized double-blind controlled trial

BACKGROUND

The aim of this study was to explore the effect of oral pregabalin at varying concentrations on postoperative sleep of patients undergoing video-assisted thoracic surgery (VATS), and to identify the optimal dosage.

METHODS

A total of 120 VATS-treated patients admitted from June 2023 to October 2023 were randomly assigned to be orally administered with 75 mg pregabalin, 150 mg pregabalin and starch capsules (control group) at a 1:1:1 ratio. One capsule of pregabalin (75 mg) and one capsule of placebo with the same shape and odor, two capsules of pregabalin (150 mg), and two capsules of placebo with the same shape and odor were administered orally to patients in the three groups on the night of surgery, and in the morning and evening of postoperative days 2 and 3. The primary outcome was the incidence of postoperative sleep disturbance (PSD) on postoperative day 1 (POD1). The secondary outcomes included the St.Mary's Hospital Sleep Questionnaire (SMH), the Pittsburg Sleep Quality Index (PSQI) and pain intensity measured with a Numerical Rating Scale (NRS). Multivariate logistic regression analysis was performed to identify risk factors for PSD in VATS-treated patients.

RESULTS

The incidence of PSD on POD1 in the 75 mg pregabalin group and 150 mg pregabalin group was significantly lower than that of the control group (45.0% vs. 42.5% vs. 72.5%; P<0.0167 for two-by-two comparisons of groups A and B with group C, respectively). The SMH scores at night on POD1-3 were significantly higher in the 75 mg pregabalin group and 150 mg pregabalin group than those of the control group (P<0.05). Since there was definitive lower incidence of pain in the experimental groups,the median NRS scores of the incisional pain on POD2-3 were significantly lower in the 75 mg pregabalin group and 150 mg pregabalin group (P<0.05). The incidence of dizziness in the 150 mg pregabalin group was significantly higher than that of the 75 mg pregabalin group and control group (55.0% vs. 25.0% vs. 32.5%; P<0.0167 for two-by-two comparisons of groups A and C with group B, respectively). NRS score on POD1, preoperative PSQI and Self-Rating Depression Scale scores were risk factors for PSD in VATS-treated patients.

CONCLUSIONS

Oral administration of 75 mg or 150mg pregabalin for consecutive three days after VATS effectively reduces the incidence of PSD and improves the quality of sleep.

Combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane block for postoperative analgesia in gastric cancer patients: A double-blinded randomized controlled trial

STUDY OBJECTIVE

We conducted this double-blinded randomized controlled trial to examine whether the combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane (TAP) block could improve analgesia efficacy and duration for gastric cancer patients.

DESIGN

Randomized controlled trial.

SETTING

The preoperative area, operating room, postanesthesia recovery room and bed ward.

PATIENTS

A total of 312 adult patients (104 per group) with gastric cancer were included.

INTERVENTIONS

Patients received bilateral subcostal TAP block with three different anesthetics (60 ml 0.25% ropivacaine added with 10 mg dexamethasone and 1 μg·kg-1 dexmedetomidine [A] or 10 mg dexamethasone [B] or 1 μg·kg-1 dexmedetomidine [C]).

MEASUREMENTS

The primary outcome was the incidence of moderate-to-severe pain 24 h on movement. Secondary outcomes included incidence of moderate-to-severe pain, pain score, opioids use, recovery quality and adverse events.

MAIN RESULTS

The incidence of moderate-to-severe pain on movement 24 h postoperatively of group A was significantly lower than group B (45.19% vs 63.46%; RR 0.71; 95% CI, 0.55 to 0.92) and group C (45.19% vs 73.08%, RR 0.62; 95% CI, 0.49 to 0.79). The median moving pain scores decreased significantly at 24 h (3.00 [3.00,5.00] vs 4.00 [3.00,6.00] vs 4.00 [3.00,5.00]; P < 0.001). There were significant differences in the opioids consumption within the first 24 h (27.5 [17.0,37.2] vs 30.0 [20.0,42.0] vs 32.0 [25.0,44.0] mg; P = 0.01) and the duration to first rescue analgesia (65.5 ± 26.7 vs 45.9 ± 34.5 vs 49.2 ± 27.2 h; P = 0.04).

CONCLUSIONS

The combination with dexamethasone and dexmedetomidine as adjuvants for TAP block reduced the incidence of moderate-to-severe pain and pain score both on movement and at rest at 24 h with prolonged duration to first rescue analgesia after gastric cancer surgery.

TRIAL REGISTRATION NUMBER

ChiCTR2000037981.

Sleep quality after autologous breast reconstruction

BACKGROUND

Sleep is a fundamental aspect of human health and well-being, but is often interrupted in a hospital setting. Especially after surgery, poor sleep quality can negatively affect postoperative recovery and quality of life. Therefore, the aim of this study was to gain insights into the quality of sleep in patients after autologous breast reconstruction and evaluate factors associated with the quality of sleep.

MATERIALS AND METHODS

In this single-center observational cohort study, participants completed a sleep diary, including the Pittsburgh sleep quality index (PSQI) and EQ-5D-5L quality of life questionnaire, before surgery, during hospital admission, and two weeks and three months postoperative. Additional variables such as pain and anesthesia duration were collected.

RESULTS

Twenty-nine patients were included. Before the surgery, 58% of them experienced poor quality of sleep, with a median PSQI score of 5.0. During hospital admission, 83% of the patients had poor quality of sleep, with a PSQI score of 6.0. The PSQI score two weeks postoperative increased to 7.0 and decreased three months postoperative to 5.0. Patients with pain scores >4 ("pain" group), had higher median PSQI scores than patients with pain scores ≤4 ("no pain" group) at all postoperative time points previously mentioned. No correlation was observed between anesthesia duration or quality of life.

CONCLUSION

Poor sleep quality was experienced by most women after autologous breast reconstruction, especially in those with higher postoperative pain scores. This knowledge offers an opportunity to improve the postoperative care for such patients.

Effect of desflurane maintenance on postoperative sleep quality in patients undergoing elective breast surgery: A non-inferiority randomized controlled trial

BACKGROUND

Postoperative sleep disturbance (PSD) is prevalent in perioperative patients，and has significant impact on postoperative recovery and prognosis. The aim of this study was to investigate the effect of desflurane maintenance on postoperative sleep quality, in order to optimize patients' perioperative sleep management.

METHOD

A total of 118 patients undergoing elective breast surgery were randomized to receive either desflurane-based volatile anesthesia (desflurane group) or propofol-based total intravenous anesthesia (propofol group) for anesthesia maintenance. The primary outcome was the quality of sleep, which was assessed by the Pittsburgh Sleep Quality Index (PSQI) on 3 days after operation (POD3). Secondary outcomes were PSQI on postoperative day 7 (POD7) and 30 (POD30), and postoperative anxiety, depression, and pain score, as well as objective sleep parameters including total sleep time (TST), WASO (Wakefulness after sleep onset), REM (Rapid eye movement) and NREM (Non-rapid Eye Movement) measured by Fitbit Charge 2TM during the initial 3 postoperative days.

RESULTS

The global PSQI scores on POD3 in the desflurane group was non-inferior to that in the propofol group [mean (SD) 8.47 (3.46) vs. 7.65 (3.16); mean difference (95 % CI) 0.82 (-0.43, 2.07); p < 0.001 for non-inferiority]. There were no significant differences in PSQI scores on POD3 and POD7. In addition, the score of anxiety, depression, and pain on the 3rd, 7th, and 30th day after surgery have no significant differences between the propofol and the desflurane group, respectively. The postoperative NREM was higher in the desflurane group than that in the propofol group.

CONCLUSION

The effects of desflurane-based volatile anesthesia maintenance on postoperative sleep quality is not inferior to that of propofol-based total intravenous anesthesia, and these two drugs may have different effects on the sleep structure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04805775.

Discharge Opioid Dose Indirectly Associated With Functional Outcomes 2 Weeks After Shoulder and Knee Arthroscopy in a US Military Sample

INTRODUCTION

Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes.

METHODS

In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis.

RESULTS

Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14.

CONCLUSION

Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed.

Quality of Postoperative Pain Management in Orthopedic Patients and Its Impact on Sleep Quality and Patient Satisfaction: An Integrative Review

Pain is one of the most common manifestations in the postoperative stage and it has a detrimental effect on both sleep and patient satisfaction. Consequently, this integrative review seeks to identify the outcomes of pain management specifically concerning sleep quality and patient satisfaction among the patients receiving orthopedic surgeries. In a stepwise manner, peer-reviewed articles manually searched in four databases including Scopus, Science Direct, PubMed, and CINAML (Cumulated Index to Nursing and Allied Health Literature) published between 2019 and 2023 were selected. The current review finally encompassed 22 studies. The review elaborates and reaffirms the notion that pain after surgery is still a critical issue that impacts the quality of patients' sleep as well as their overall satisfaction. Chronic sleep disturbance is generally linked with pain while other factors such as light exposure and hospital environment were found to influence sleep quality. It is thus crucial to develop clear multifaceted pain management guidelines that include patient-tailored pharmacological and non-pharmacological interventions aimed at helping patients recover better, sleep better, and be satisfied with the procedures and results.

Intraoperative dexmedetomidine on postoperative sleep disturbance in older patients undergoing major abdominal surgery: A randomized controlled trial protocol

Background

Postoperative sleep disturbance (PSD) occurs frequently in patients who undergo major abdominal surgical procedures. Dexmedetomidine is a promising agent to improve the quality of sleep for surgical patients. We designed this trial to investigate the effects of two different doses of intraoperative dexmedetomidine on the occurrence of PSD in elderly patients who have major abdominal surgery.

Methods

In this randomized, double-blind, controlled trial, 210 elderly patients aged ≥65 years will be randomized, with an allocation ratio of 1:1:1, to two dexmedetomidine groups (intraoperative infusion of 0.3 or 0.6 μg/kg/h) and a normal saline placebo group. The primary endpoint is the occurrence of PSD on the first night after surgery, assessed using the Athens Insomnia Scale. The secondary endpoints are (1) the incidence of PSD during the 2nd, 3rd, 5th, 7th, and 30th nights postoperatively; (2) pain at rest and on movement at 24 and 48 h postoperatively, assessed using the Numerical Rating Scale; (3) the incidence of postoperative delirium during 0-7 days postoperatively or until hospital discharge, assessed using the 3-min Confusion Assessment Method; (4) depressive symptoms during 0-7 days postoperatively or until hospital discharge, assessed using the 15-items Geriatric Depression Scale; and (5) quality of recovery on postoperative days 1, 2, and 3, assessed using the 15-items Quality of Recovery Scale. Patients' sleep data will also be collected by Xiaomi Mi Band 7 for further analysis.

Discussion

The findings of this trial will provide clinical evidence for improving the quality of sleep among elderly patients undergoing major abdominal surgery.

Ethics and dissemination

This trial was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (No. 2023-160). The results will be published in a peer-reviewed journal.

Trial registration

Chinese Clinical Trial Registry (ChiCTR2300073163).

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Effect of Third Molar Surgery on Sleep Health Parameters of Young Adults: An Observational Study

Background and Objectives: The role of surgical extraction of the third molar in patients' sleep quality remains unclear, although it is one of the most common oral surgical procedures. The aim of this study is to assess the changes in patient-reported sleep health outcomes after third molar surgery and to investigate any associations between sleep parameters and post-extraction pain. Materials and Methods: Young adults without known comorbidities who were in need of mandibular third molar surgical extraction were included. All participants completed a sleep diary, the Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI) and Athens Insomnia Scale (AIS) questionnaires, which were used to assess sleep habits, daytime sleepiness, sleep quality and insomnia severity one week before and after extraction. In addition, a visual analog scale was completed postoperatively to assess the perception of pain. Results: Out of 75 patients who completed the study protocol, 32 (42.7%) were males and 43 (57.3%) were females, with a mean age of 24.01 (±3.43) years. Postoperatively, statistically significant higher scores were observed for PSQI [4.85 (±2.32) before vs. 5.39 (±2.75) after, p = 0.041], AIS [5.56 (±3.23) before vs. 6.91 (±4.06) after, p < 0.001] and average weekly number of nocturnal awakenings [2.01 (±3.72) before vs. 4.19 (±5.20) after, p < 0.001] but not for ESS, average weekly sleep duration and average weekly sleep onset latency. Pain perception was increased in patients who slept worse on almost all seven postoperative days, although this did not reach statistical significance. Conclusions: Third molar surgery impacts sleep quality and insomnia severity in the first week after extraction, while there is no effect on daytime sleepiness. The worsening of subjective sleep symptoms after extraction may be associated with an increased perception of pain.

Effects of intraoperative sodium oxybate infusion on post-operative sleep quality in patients undergoing gynecological laparoscopic surgery: A randomized clinical trial

STUDY OBJECTIVE

Post-operative sleep quality is an important factor that influences post-operative recovery. Sodium oxybate has been used to treat sleep disturbances associated with various pathological conditions. However, whether intraoperative intravenous infusion of sodium oxybate improves post-operative sleep quality is unknown. This study aimed to examine the effects of sodium oxybate on the post-operative sleep quality of patients who underwent gynecological laparoscopic surgery.

DESIGN

A single-center, prospective, two-arm, double-blinded randomized controlled trial.

SETTING

The Shengjing Hospital of China Medical University in Liaoning, China.

PATIENTS

We enrolled 180 adult patients (90 for each group) undergoing elective gynecological laparoscopic surgery, and 178 patients (89 for each group) were included in the final analysis.

INTERVENTIONS

Patients were randomly allocated in a 1:1 ratio to receive either sodium oxybate (30 mg kg-1) or an equivalent volume of saline after intubation. The patients, anesthetists, and follow-up staff were blinded to group assignment.

MEASUREMENTS

The primary outcome was sleep quality measured using the Richards-Campbell Sleep Questionnaire (RCSQ) on post-operative days (PODs) one and three. Secondary outcomes included post-operative pain measured using the visual analog scale, sleep quality at one and three months post-operatively measured using the Pittsburgh Sleep Quality Index, and factors associated with post-operative sleep quality.

MAIN RESULTS

Analysis with generalized estimating equations showed that sodium oxybate significantly improved post-operative sleep quality, as represented by increased total RCSQ scores (mean difference (95% CI); 9 (2, 16), P = 0.010) over PODs one and three. There was no difference in post-operative pain between the two groups over PODs one and three or in post-operative sleep quality over one and three months post-operatively. Age, surgery type, start time of surgery, and use of sufentanil-based patient-controlled intravenous analgesia were significantly associated with post-operative sleep quality.

CONCLUSIONS

Intraoperative sodium oxybate infusion improved post-operative sleep in patients who underwent gynecological laparoscopic surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, Clinical trial number: ChiCTR2200061460.

Mindfulness-Based Interventions for Surgical Patients and Impact on Postoperative Outcomes, Patient Wellbeing, and Satisfaction

Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.

Nociceptor spontaneous activity is responsible for fragmenting non-rapid eye movement sleep in mouse models of neuropathic pain

Spontaneous pain, a major complaint of patients with neuropathic pain, has eluded study because there is no reliable marker in either preclinical models or clinical studies. Here, we performed a comprehensive electroencephalogram/electromyogram analysis of sleep in several mouse models of chronic pain: neuropathic (spared nerve injury and chronic constriction injury), inflammatory (Freund's complete adjuvant and carrageenan, plantar incision) and chemical pain (capsaicin). We find that peripheral axonal injury drives fragmentation of sleep by increasing brief arousals from non-rapid eye movement sleep (NREMS) without changing total sleep amount. In contrast to neuropathic pain, inflammatory or chemical pain did not increase brief arousals. NREMS fragmentation was reduced by the analgesics gabapentin and carbamazepine, and it resolved when pain sensitivity returned to normal in a transient neuropathic pain model (sciatic nerve crush). Genetic silencing of peripheral sensory neurons or ablation of CGRP+ neurons in the parabrachial nucleus prevented sleep fragmentation, whereas pharmacological blockade of skin sensory fibers was ineffective, indicating that the neural activity driving the arousals originates ectopically in primary nociceptor neurons and is relayed through the lateral parabrachial nucleus. These findings identify NREMS fragmentation by brief arousals as an effective proxy to measure spontaneous neuropathic pain in mice.

Comparison of early patient-reported outcomes between uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small-cell lung cancer

BACKGROUND

Analysis of patient-reported outcomes (PROs) offers valuable insights into distinguishing the effects of closely related medical procedures from the patient's perspective. In this study we compared symptom burden in patients undergoing uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small cell lung cancer (NSCLC).

METHODS

This study included patients with peripheral NSCLC from an ongoing longitudinal prospective cohort study (CN-PRO-Lung 3) who underwent segmentectomy or wedge resection with tumor diameter ≤ 2 cm and consolidation tumor ratio (CTR) ≤ 0.5. PROs data were collected using the Perioperative Symptom Assessment for Lung Surgery questionnaire pre-operatively, daily post-surgery up to the fourth hospitalization day, and weekly post-discharge up to the fourth week. Propensity score matching and a generalized estimation equation model were employed to compare symptom severity. In addition, short-term clinical outcomes were compared.

RESULTS

In total, data of 286 patients (82.4%) undergoing segmentectomy and 61 patients (17.6%) undergoing wedge resection were extracted from the cohort. No statistically significant differences were found in the proportion of moderate-to-severe symptoms and mean scores for pain, cough, shortness of breath, disturbed sleep, fatigue, drowsiness, and distress during the 4-day postoperative hospitalization or the 4-week post-discharge period before or after matching (all p > 0.05). Compared with segmentectomy, wedge resection showed better short-term clinical outcomes, including shorter operative time (p = 0.001), less intraoperative bleeding (p = 0.046), and lower total hospital costs (p = 0.002).

CONCLUSIONS

The study findings indicate that uniportal thoracoscopic segmentectomy and wedge resection exert similar early postoperative symptom burden in patients with peripheral NSCLC (tumor diameter ≤ 2 cm and CTR ≤ 0.5).

CLINICAL TRIAL REGISTRATION

Not applicable.

Impact of the addition of dexmedetomidine to patient-controlled intravenous analgesia on postoperative pain-sleep interaction cycle and delirium: A systematic review and meta-analysis of randomized controlled trials

Background

The reciprocal nexus between sleep and pain is well-documented, with the deleterious impact of operative trauma potentially playing a pivotal role in the dysregulation of this interplay, which could significantly contribute to the manifestation of postoperative delirium (POD). Studies have investigated the effect of adding dexmedetomidine (DEX) to patient-controlled intravenous analgesia (PCIA) pumps on postoperative pain-sleep interaction cycle and POD, but conclusions remained uncertain. The objective of this investigation is to perform a meta-analysis that thoroughly assesses the impact of integrating DEX into PCIA, focusing on analgesic effectiveness, sleep quality, and the incidence of delirium in postoperative patients.

Methods

PubMed, Embase, Cochrane Library, SinoMed, and Wanfang Data Knowledge Service Platform were searched, for publications in any language, from database inception to September 2023. Our analysis encompassed randomized controlled trials (RCTs) that examine the therapeutic efficacy and risk profile of adding DEX to the PCIA on the postoperative pain-sleep interaction cycle, by focusing on changes in postoperative analgesia (Visual analog scale (VAS) score), sleep efficiency, sleep structure, subjective sleep score (Assen insomnia scale and numerical rating scale) and adverse event rate.

Results

34 RCTs (4324 patients) were analyzed. This study shows DEX improved analgesia and reduced VAS scores at 6, 12, and 24 h after surgery. Sleep efficiency was enhanced on the 1st and 2nd postoperative night. DEX improved sleep structure at the 1st postoperative night by reducing non-rapid eye movement stage 1 (N1) sleep and increasing non-rapid eye movement stage 2 (N2) and non-rapid eye movement stage 3 (N3) sleep. At the 2nd night, DEX reduced N1 sleep and increased N2 sleep, but not N3 sleep. Data from AIS and NRS showed improvement in subjective sleep scores on the 1st postoperative night and 2nd night. Additionally, DEX decreased the occurrence of POD on the 24 h and first-three days.

Conclusion

This study shows that the typical DEX doses added to PCIA with sufentanil were 2-5 μg/kg or approximately 200-250 μg, and the addition of DEX to PCIA can improve pain-sleep interaction cycle from multiple perspectives, and further decrease the occurrence of POD.

Pain in Austrian hospitals: evaluation of 1089 in-patients

BACKGROUND

Despite the existence of internationally consistent guidelines for the management of pain, efficient regional anesthesia techniques, safe pain medications, and organizational structures, e.g., acute pain services, various studies have shown that pain is still common among both surgical and non-surgical in-patients.

OBJECTIVE

The primary objective of this study was to evaluate, on a multi-center basis, the point pain prevalence of surgical and non-surgical in-patients. We further analyzed pain intensities, in-hospital pain triggers, pain-related impairments, pain assessments, patient information about pain, and patient satisfaction with pain therapy. This benchmark information should lead to better implementation of pain management strategies and thus improve health care quality.

METHODS

We surveyed all adult in-patients in three general hospitals in Austria (general hospital Klagenfurt am Wörthersee, general hospital Villach, general hospital Wolfsberg) on the index day with two standardized questionnaires for both surgical and non-surgical patients.

RESULTS

Overall, a pain prevalence of 40.0%, with no statistically significant difference between surgical and non-surgical patients, was shown. Higher pain prevalence in female patients, high pain prevalence in the age group 18-30 years, and highest pain prevalence in the age group over 90 years old was found. Overall pain intensity was relatively low, but unacceptable maximum pain within the preceding 24 h was shown. Different in-hospital pain triggers like patient's care and mobilization were found. Our survey has shown that pain has an impact on personal hygiene, mobilization, mood, sleep, and appetite. However, patients were very satisfied with their pain therapy.

CONCLUSION

Medical staff and nurses have to be sensitized to the urgent need to improve pain management strategies.

Efficacy of epidural esketamine on postoperative sleep quality after laparoscopic and robotic lower abdominal surgeries: a study protocol for randomised, double-blind, controlled trial

INTRODUCTION

Postoperative sleep disturbances significantly impair postoperative recovery. The administration of intravenous esketamine has been shown to potentially improve postoperative sleep quality. However, the effectiveness of epidural esketamine in improving postoperative sleep quality remains to be elucidated. This study aims to explore the impact of both intraoperative and postoperative use of epidural esketamine on the postoperative sleep quality of patients undergoing minimally invasive lower abdominal surgeries.

METHODS AND ANALYSIS

This randomised, double-blind, parallel-group, placebo-controlled trial will be conducted at the Fudan University Shanghai Cancer Centre. A total of 128 adults undergoing minimally invasive lower abdominal surgeries will be randomly allocated in a 1:1 ratio to either the esketamine group or the placebo group. In the esketamine group, epidural esketamine will be administered intraoperatively (0.2 mg/kg) and postoperatively (25 mg). Postoperatively, all patients will receive epidural analgesia. The primary outcome of the study is the incidence of poor sleep quality on the third day after surgery. The sleep quality assessment will be conducted using the Pittsburgh Sleep Quality Index and a Numeric Rating Scale of sleep. The main secondary outcomes include postoperative pain and anxiety and depression scores. The postoperative pain, both rest pain and movement pain, will be assessed using a Numerical Rating Scale within 5 days after surgery. Anxiety and depression scores will be evaluated using the Hospital Anxiety and Depression Scale both before and after the surgery. Safety outcomes will include delirium, fidgeting, hallucinations, dizziness and nightmares. The analyses will be performed in accordance with intention-to-treat principle ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Ethics Committee of the Shanghai Cancer Centre (2309281-9). Prior to participation, all patients will provide written informed consent. The results of the trial are intended to be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2300076862.

Perioperative insomnia trajectories and functional outcomes after total knee arthroplasty

ABSTRACT

Longitudinal total knee arthroplasty (TKA) studies indicate that a substantial percentage of patients continue to experience clinically significant pain and functional impairment after surgery. Insomnia has been associated with poorer surgical outcomes; however, previous work has largely focused on long-term postsurgical insomnia. This study builds on previous work by examining sleep and pain outcomes about perioperative insomnia trajectories. Insomnia symptoms (using the Insomnia Severity Index) during the acute perioperative period (2 weeks pre-TKA to 6 weeks post-TKA) were used to classify participants into perioperative insomnia trajectories: (1) No Insomnia (ISI < 8), (2) New Insomnia (baseline < 8; postoperative ≥ 8 or ≥6-point increase), (3) Improved Insomnia (baseline ≥ 8, postoperative < 8 or ≥6-point decrease), and (4) Persistent Insomnia (ISI ≥ 8). Insomnia, pain, and physical functioning were assessed in participants with knee osteoarthritis (n = 173; M age = 65 ± 8.3, 57.8% female) at 5 time points: 2 weeks pre-TKA, post-TKA: 6 weeks, 3 months, 6 months, and 12 months. Significant main effects were seen for insomnia trajectory and time, and trajectory-by-time interactions for postoperative insomnia, pain severity, and physical functioning ( P' s < 0.05). The Persistent Insomnia trajectory had the worst postoperative pain at all follow-ups and marked insomnia and physical functioning impairment post-TKA ( P' s < 0.05). The New Insomnia trajectory had notable long-term insomnia (6 weeks to 6 months) and acute (6 weeks) postoperative pain and physical functioning ( P' s < 0.05). Findings indicated a significant relationship between perioperative insomnia trajectory and postoperative outcomes. Results of this study suggest that targeting presurgical insomnia and preventing the development of acute postoperative insomnia may improve long-term postoperative outcomes, with an emphasis on persistent perioperative insomnia due to poorer associated outcomes.

Microglial voltage-dependent anion channel 1 signaling modulates sleep deprivation-induced transition to chronic postsurgical pain

STUDY OBJECTIVES

This study verified that sleep deprivation before and after skin/muscle incision and retraction (SMIR) surgery increased the risk of chronic pain and investigated the underlying roles of microglial voltage-dependent anion channel 1 (VDAC1) signaling.

METHODS

Adult mice received 6 hours of total sleep deprivation from 1 day prior to SMIR until the third day after surgery. Mechanical and heat-evoked pain was assessed before and within 21 days after surgery. Microglial activation and changes in VDAC1 expression and oligomerization were measured. Minocycline was injected to observe the effects of inhibiting microglial activation on pain maintenance. The VDAC1 inhibitor 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS) and oligomerization inhibitor VBIT-4 were used to determine the roles of VDAC1 signaling on microglial adenosine 5' triphosphate (ATP) release, inflammation (IL-1β and CCL2), and chronicity of pain.

RESULTS

Sleep deprivation significantly increased the pain duration after SMIR surgery, activated microglia, and enhanced VDAC1 signaling in the spinal cord. Minocycline inhibited microglial activation and alleviated sleep deprivation-induced pain maintenance. Lipopolysaccharide (LPS)-induced microglial activation was accompanied by increased VDAC1 expression and oligomerization, and more VDAC1 was observed on the cell membrane surface compared with control. DIDS and VBIT-4 rescued LPS-induced microglial ATP release and IL-1β and CCL2 expression. DIDS and VBIT-4 reversed sleep loss-induced microglial activation and pain chronicity in mice, similar to the effects of minocycline. No synergistic effects were found for minocycline plus VBIT-4 or DIDS.

CONCLUSIONS

Perioperative sleep deprivation activated spinal microglia and increases the risk of chronic postsurgical pain in mice. VDAC1 signaling regulates microglial activation-related ATP release, inflammation, and chronicity of pain.

Validated Wearable Device Shows Acute Postoperative Changes in Sleep Patterns Consistent With Patient-Reported Outcomes and Progressive Decreases in Device Compliance After Shoulder Surgery

Purpose

To assess the utility of a validated wearable device (VWD) in examining preoperative and postoperative sleep patterns and how these data compare to patient-reported outcomes (PROs) after rotator cuff repair (RCR) or total shoulder arthroplasty (TSA).

Methods

Male and female adult patients undergoing either RCR or TSA were followed up from 34 days preoperatively to 6 weeks postoperatively. Sleep metrics were collected using a VWD in an unsupervised setting. PROs were assessed using the following validated outcome measures: Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function questionnaire; American Shoulder and Elbow Surgeons self-evaluation questionnaire; visual analog scale assessing pain; and Disabilities of the Arm, Shoulder and Hand questionnaire. Data were analyzed preoperatively and at 2-week intervals postoperatively with χ2 analysis to evaluate device compliance. Sleep metrics and PROs were evaluated at each interval relative to preoperative values within each surgery type with an analysis of variance repeated on time point. The relation between sleep metrics and PROs was assessed with correlation analysis.

Results

A total of 57 patients were included, 37 in the RCR group and 20 in the TSA group. The rate of device compliance in the RCR group decreased from 84% at surgery to 46% by 6 weeks postoperatively (P < .001). Similarly, the rate of device compliance in the TSA group decreased from 81% to 52% (P < .001). Deep sleep decreased in RCR patients at 2 to 4 weeks (decrease by 10.99 ± 3.96 minutes, P = .021) and 4 to 6 weeks postoperatively (decrease by 13.37 ± 4.08 minutes, P = .008). TSA patients showed decreased deep sleep at 0 to 2 weeks postoperatively (decrease by 12.91 ± 5.62 minutes, P = .045) and increased rapid eye movement sleep at 2 to 4 weeks postoperatively (increase by 26.91 ± 10.70 minutes, P = .031). Rapid eye movement sleep in the RCR group and total sleep in the TSA group were positively correlated with more favorable PROs (P < .05).

Conclusions

VWDs allow for monitoring components of sleep that offer insight into potential targets for improving postoperative fatigue, pain, and overall recovery after shoulder surgery. However, population demographic factors and ease of device use are barriers to optimized patient compliance during data collection.

Level of Evidence

Level IV, diagnostic case series.

Associations between perioperative sleep patterns and clinical outcomes in patients with intracranial tumors: a correlation study

Objective

Although the quality of perioperative sleep is gaining increasing attention in clinical recovery, its impact role remains unknown and may deserve further exploration. This study aimed to investigate the associations between perioperative sleep patterns and clinical outcomes among patients with intracranial tumors.

Methods

A correlation study was conducted in patients with intracranial tumors. Perioperative sleep patterns were assessed using a dedicated sleep monitor for 6 consecutive days. Clinical outcomes were gained through medical records and follow-up. Spearman's correlation coefficient and multiple linear regression analysis were applied to evaluate the associations between perioperative sleep patterns and clinical outcomes.

Results

Of 110 patients, 48 (43.6%) were men, with a median age of 57 years. A total of 618 days of data on perioperative sleep patterns were collected and analyzed. Multiple linear regression models revealed that the preoperative blood glucose was positively related to the preoperative frequency of awakenings (β = 0.125; 95% CI = 0.029-0.221; P = 0.011). The level of post-operative nausea and vomiting was negatively related to perioperative deep sleep time (β = -0.015; 95% CI = -0.027--0.003; P = 0.015). The level of anxiety and depression was negatively related to perioperative deep sleep time, respectively (β = -0.048; 95% CI = -0.089-0.008; P = 0.020, β = -0.041; 95% CI = -0.076-0.006; P = 0.021). The comprehensive complication index was positively related to the perioperative frequency of awakenings (β = 3.075; 95% CI = 1.080-5.070; P = 0.003). The post-operative length of stay was negatively related to perioperative deep sleep time (β = -0.067; 95% CI = -0.113-0.021; P = 0.005). The Pittsburgh Sleep Quality Index was positively related to perioperative sleep onset latency (β = 0.097; 95% CI = 0.044-0.150; P < 0.001) and negatively related to perioperative deep sleep time (β = -0.079; 95% CI = -0.122-0.035; P < 0.001).

Conclusion

Perioperative sleep patterns are associated with different clinical outcomes. Poor perioperative sleep quality, especially reduced deep sleep time, has a negative impact on clinical outcomes. Clinicians should, therefore, pay more attention to sleep quality and improve it during the perioperative period.

Clinical trial registration

http://www.chictr.org.cn, identifier: ChiCTR2200059425.

The prevalence and risk factors of sleep disturbances in surgical patients: A systematic review and meta-analysis

Determining the prevalence and risk factors related to sleep disturbance in surgical patients would be beneficial for risk stratification and perioperative care planning. The objectives of this systematic review and meta-analysis are to determine the prevalence and risk factors of sleep disturbances and their associated postoperative complications in surgical patients. The inclusion criteria were: (1) patients ≥18 years old undergoing a surgical procedure, (2) in-patient population, and (3) report of sleep disturbances using a validated sleep assessment tool. The systematic search resulted in 21,951 articles. Twelve patient cohorts involving 1497 patients were included. The pooled prevalence of sleep disturbances at preoperative assessment was 60% (95% Confidence Interval (CI): 50%, 69%) and the risk factors for postoperative sleep disturbances were a high preoperative Pittsburgh sleep quality index (PSQI) score indicating preexisting disturbed sleep and anxiety. Notably, patients with postoperative delirium had a higher prevalence of pre- and postoperative sleep disturbances and high preoperative wake after sleep onset percentage (WASO%). The high prevalence of preoperative sleep disturbances in surgical patients has a negative impact on postoperative outcomes and well-being. Further work in this area is warranted.

Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization

This article addresses the issue of patient sleep during hospitalization, which the Society of Anesthesia and Sleep Medicine believes merits wider consideration by health authorities than it has received to date. Adequate sleep is fundamental to health and well-being, and insufficiencies in its duration, quality, or timing have adverse effects that are acutely evident. These include cardiovascular dysfunction, impaired ventilatory function, cognitive impairment, increased pain perception, psychomotor disturbance (including increased fall risk), psychological disturbance (including anxiety and depression), metabolic dysfunction (including increased insulin resistance and catabolic propensity), and immune dysfunction and proinflammatory effects (increasing infection risk and pain generation). All these changes negatively impact health status and are counterproductive to recovery from illness and operation. Hospitalization challenges sleep in a variety of ways. These challenges include environmental factors such as noise, bright light, and overnight awakenings for observations, interventions, and transfers; physiological factors such as pain, dyspnea, bowel or urinary dysfunction, or discomfort from therapeutic devices; psychological factors such as stress and anxiety; care-related factors including medications or medication withdrawal; and preexisting sleep disorders that may not be recognized or adequately managed. Many of these challenges appear readily addressable. The key to doing so is to give sleep greater priority, with attention directed at ensuring that patients' sleep needs are recognized and met, both within the hospital and beyond. Requirements include staff education, creation of protocols to enhance the prospect of sleep needs being addressed, and improvement in hospital design to mitigate environmental disturbances. Hospitals and health care providers have a duty to provide, to the greatest extent possible, appropriate preconditions for healing. Accumulating evidence suggests that these preconditions include adequate patient sleep duration and quality. The Society of Anesthesia and Sleep Medicine calls for systematic changes in the approach of hospital leadership and staff to this issue. Measures required include incorporation of optimization of patient sleep into the objectives of perioperative and general patient care guidelines. These steps should be complemented by further research into the impact of hospitalization on sleep, the effects of poor sleep on health outcomes after hospitalization, and assessment of interventions to improve it.

Evaluation of Sleep Quality and Its Relationship With Pain, Mood, and Physical Function After Orthopaedic Trauma Surgery: A Prospective Cohort Study

INTRODUCTION

Sleep disturbances are associated with pain and mental health. We prospectively compared a cohort of patients with orthopaedic trauma with a control group to establish the prevalence and duration of sleep disturbance and associations between sleep disturbance and pain, mood scores, and functional outcome scores.

METHODS

Subjects were patients with orthopaedic trauma undergoing in-patient surgical procedures and healthy control subjects from the community. Questionnaires completed by all subjects included the VAS numerical pain rating scale, the abbreviated profile of mood states, Patient-Reported Outcomes Measurement Information System Physical Function, and Patient-Reported Outcomes Measurement Information System Sleep Disturbance. Control subjects completed the surveys once, and subjects with trauma completed them at 2, 6, and 24 weeks postoperatively.

RESULTS

Healthy control subjects (28.6 ± 13.2) were significantly younger than patients with trauma (41.8 ± 18.9) ( P < 0.001). Compared with control subjects, at 2-week follow-up visit, patients with trauma had worse sleep ( P < 0.001) and worse mood ( P = 0.006). Across the study period, patients with trauma showed improvements in physical function ( P < 0.001) and pain (at rest [ P = 0.02], during activity [ P = 0.02], and at night [ P = 0.002]). In patients with trauma, better sleep disturbance scores were associated with better mood and less pain for all pain metrics ( P < 0.001).

DISCUSSION

Patients with orthopaedic trauma have worse sleep disturbance scores at 2 weeks postoperatively compared with normal control subjects; this difference attenuated at 6 weeks. Sleep disturbance was found to markedly correlate with pain and mood, with worse sleep quality associated with higher pain and worse mood. Improvement in sleep quality across 24 weeks postoperatively was associated with improvement in mood scores.

CONCLUSION

Patients should be counseled about the likely development of sleep disturbance and the possible association with worse emotional/mental health with worse sleep. Physicians should consider incorporating a multidisciplinary approach to the management of these select patients.

Effects of dexmedetomidine on postoperative sleep quality: a systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVES

To assess the effect of dexmedetomidine (DEX) on postoperative sleep quality using polysomnography (PSG) to identify possible interventions for postoperative sleep disturbances.

METHODS

An electronic search of PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science was conducted from database inception to November 20, 2022. Randomized controlled trials (RCTs) on the effect of DEX administration on postoperative sleep quality using PSG or its derivatives were included. No language restrictions were applied. The sleep efficiency index (SEI), arousal index (AI), percentages of stage N1, N2 and N3 of non-rapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep were measured in our meta-analysis.

RESULTS

Five studies, involving 381 participants were included. Administration of DEX significantly improved SEI, lowered AI, decreased the duration of stage N1 sleep and increased the duration of stage N2 sleep compared to placebo groups. There were no significant differences in the duration of stage N3 sleep and REM sleep. DEX administration lowered the postoperative Visual Analogue Scale (VAS) score and improved the Ramsay sedation score with no adverse effect on postoperative delirium (POD). However, high heterogeneity was observed in most of the primary and secondary outcomes.

CONCLUSIONS

Our study provides support for the perioperative administration of DEX to improve postoperative sleep quality. The optimal dosage and overall effect of DEX on postoperative sleep quality require further investigation using large-scale randomized controlled trials.

Transcutaneous Electrical Acupoint Stimulation Improves Postoperative Sleep Quality in Patients Undergoing Laparoscopic Gastrointestinal Tumor Surgery: A Prospective, Randomized Controlled Trial

INTRODUCTION

This study was conducted to observe the effect of transcutaneous electrical acupoint stimulation (TEAS) on the postoperative sleep quality of patients undergoing gastrointestinal tumor surgery and to verify the possible mechanism.

METHODS

Eighty-three patients were allocated to the TEAS or Sham group. Patients in the TEAS group received TEAS treatment (disperse-dense waves; frequency, 2/100 Hz) on bilateral Shenmen (HT7), Neiguan (PC6) and Zusanli (ST36) points for 30 min each time, total three times in the perioperative period. In the Sham group, electrodes were placed; however, no current was given. Sleep quality was assessed on the day before surgery (P1) and the first and third days after surgery (D1 and D3) using the Pittsburgh Sleep Quality Index (PSQI) and Athens Insomnia Scale (AIS). Postoperative pain was assessed using visual analog scale (VAS) 72 h postoperatively. The incidences of abdominal distension, dizziness, postoperative nausea and vomiting (PONV) and pulmonary complications were recorded. Serum levels of inflammatory cytokines and the expression of key factors of oxidative stress and key molecules of the nuclear factor erythroid 2-related factor 2/antioxidant response element (Nrf2/ARE) signal pathway were measured.

RESULTS

TEAS ameliorated sleep quality at D1 and D3 (PSQI P < 0.05, AIS P < 0.05) and decreased postoperative pain as demonstrated by lower VAS scores compared to the Sham group (P < 0.05). The incidences of abdominal distension and PONV were also lower in the TEAS group. Markers of oxidative stress were increased (P < 0.05), and the serum concentration of interleukin-6 (IL-6) was significantly lower in the TEAS group. The key mediators of the Nrf2/ARE pathway were enhanced after TEAS.

CONCLUSION

Perioperative TEAS improved postoperative sleep quality, reduced postoperative pain and alleviated postoperative adverse effects in patients undergoing laparoscopic gastrointestinal tumor surgery resection. This may be associated with activating Nrf2/ARE signal pathway and decreasing its inflammatory actions.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( http://www.chictr.org.cn/index.aspx ), ChiCTR2100054971.

Pretreatment of the ROS Inhibitor Phenyl-N-tert-butylnitrone Alleviates Sleep Deprivation-Induced Hyperalgesia by Suppressing Microglia Activation and NLRP3 Inflammasome Activity in the Spinal Dorsal Cord

Sleep deprivation, a common perioperative period health problem, causes ocular discomfort and affects postsurgical pain. However, the mechanism of sleep deprivation-induced increased pain sensitivity is elusive. This study aims to explore the role of ROS in sleep deprivation (SD)-induced hyperalgesia and the underlying mechanism. A 48-h continuous SD was performed prior to the hind paw incision pain modeling in mice. We measured ROS levels, microglial activation, DNA damage and protein levels of iNOS, NLRP3, p-P65 and P65 in mouse spinal dorsal cord. The involvement of ROS in SD-induced prolongation of postsurgical pain was further confirmed by intrathecal injection of ROS inhibitor, phenyl-N-tert-butylnitrone (PBN). Pretreatment of 48-h SD in mice significantly prolonged postsurgical pain recovery, manifesting as lowered paw withdrawal mechanical threshold and paw withdrawal thermal latency. It caused ROS increase and upregulation of iNOS on both Day 1 and 7 in mouse spinal dorsal cord. In addition, upregulation of NLRP3 and p-P65, microglial activation and DNA damage were observed in mice pretreated with 48-h SD prior to the incision. Notably, intrathecal injection of PBN significantly reversed the harmful effects of SD on postsurgical pain recovery, hyperalgesia, microglial activation and DNA damage via the NF-κB signaling pathway. Collectively, ROS increase is responsible for SD-induced hyperalgesia through activating microglial, triggering DNA damage and enhancing NLRP3 inflammasome activity in the spinal dorsal cord.

Perioperative sleep deprivation activates the paraventricular thalamic nucleus resulting in persistent postoperative incisional pain in mice

Background

The duration of postsurgical pain is closely correlated with perioperative stress. Most patients suffer short-term sleep disorder/deprivation before and/or after surgery, which leads to extended postsurgical pain by an undetermined mechanism. The paraventricular thalamus (PVT) is a critical area that contributes to the regulation of feeding, awakening, and emotional states. However, whether the middle PVT is involved in postoperative pain or the extension of postoperative pain caused by perioperative sleep deprivation has not yet been investigated.

Methods

We established a model of postoperative pain by plantar incision with perioperative rapid eye movement sleep deprivation (REMSD) 6 h/day for 3 consecutive days in mice. The excitability of the CaMKIIα⁺ neurons in the middle PVT (mPVT^CaMKIIα) was detected by immunofluorescence and fiber photometry. The activation/inhibition of mPVT^CaMKIIα neurons was conducted by chemogenetics.

Results

REMSD prolonged the duration of postsurgical pain and increased the excitability of mPVT^CaMKIIα neurons. In addition, mPVT^CaMKIIα neurons showed increased excitability in response to nociceptive stimuli or painful conditions. However, REMSD did not delay postsurgical pain recovery following the ablation of CaMKIIα neurons in the mPVT. The activation of mPVT^CaMKIIα neurons prolonged the duration of postsurgical pain and elicited anxiety-like behaviors. In contrast, inhibition of mPVT^CaMKIIα neurons reduced the postsurgical pain after REMSD.

Conclusion

Our data revealed that the CaMKIIα neurons in the mPVT are involved in the extension of the postsurgical pain duration induced by REMSD, and represented a novel potential target to treat postoperative pain induced by REMSD.

The effect of therapeutic touch and music rest on sleep parameters in children with liver transplantation

PURPOSE

This study was conducted to evaluate the effect of therapeutic touch and music rest on the sleep of children with liver transplantation.

DESIGN AND METHODS

The data of the study were collected between February 2021 and November 2021. The study was completed with 50 patients included in the therapeutic touch and music rest groups. Therapeutic touch and music practices were applied for three consecutive days, once a day and 20 min. Before and after the practices, the 24-h sleep of the children was evaluated with actigraphy.

RESULTS

It was determined that the time in bed, total sleep time, and sleep efficiency of the children in the therapeutic touch group increased after the procedure. On the other hand, it was determined that the time in bed, and total sleep time increased, and the onset latency decreased after the procedure in the children in the music rest group. It was determined that the effects of therapeutic touch and music rest applications on sleep parameters after the procedure were similar.

CONCLUSION

It has been determined that therapeutic touch and music rest applications have an improving effect on the sleep of children with liver transplantation.

PRACTICE IMPLICATIONS

Music rest and therapeutic touch, which are non-pharmacological methods that do not increase the burden of the liver, can be used by health professionals to support the sleep of children with liver transplantation.

Deep sleep and beeps II: Sleep quality improvement project in general surgery patients

BACKGROUND

Poor sleep leads to poor health outcomes. Phase I of our sleep quality improvement project showed severe sleep disturbance in the ward setting. We implemented a novel PostOp Pack to improve sleep quality.

METHODS

Patients underwent elective, general surgery procedures. Fitbit trackers measured total sleep time. Patients completed the inpatient Richards-Campbell Sleep Questionnaire, which combines 5 domains into a cumulative score (0-100). Patients completed the outpatient Pittsburgh Sleep Quality Index preoperatively and postoperatively. Patients received the PostOp Pack, which included physical items and a sleep-protective order set to reduce nighttime awakenings. Patients from phase I served as the historical control. The primary outcome was the percentage of patients with Richards-Campbell Sleep Questionnaire total sleep score ≥50. The secondary outcomes included the mean Richards-Campbell Sleep Questionnaire domain scores and Fitbit total sleep time.

RESULTS

A total of 49 patients were compared with 64 historical controls. The percentage of patients with a total sleep score ≥50 was significantly higher in patients receiving a PostOp Pack versus historical control (69% vs. 44%, difference 26%, 95% confidence interval 6.1-45%, P = .01). The mean Richards-Campbell Sleep Questionnaire Total Sleep Score was significantly higher in patients with a PostOp Pack (62 vs 49, mean difference 13, 95% confidence interval 6-21, P ≤ .01). The PostOp Pack Richards-Campbell Sleep Questionnaire domain scores were significantly higher in various areas: Sleep Latency (68 vs 49, P ≤ .01), Awakenings (56 vs 40, P = .01), Sleep Quality (61 vs 49, P = .02), and Noise Disturbance (70 vs 59, P = .04). Of all patients, 92% would use PostOp Pack again in a future hospitalization. No patients had a failure to rescue event with PostOp Pack. The mean total sleep time was significantly improved with PostOp Pack on night 1 (6.4 vs 4.7 hours, P = .03).

CONCLUSION

The PostOp Pack improves inpatient sleep quality and is safe.

Effect of Intraoperative Esketamine Infusion on Postoperative Sleep Disturbance After Gynecological Laparoscopy: A Randomized Clinical Trial

IMPORTANCE

Postoperative sleep disturbance (PSD) is common in patients after surgery.

OBJECTIVE

To examine the effect of intraoperative esketamine infusion on the incidence of PSD in patients who underwent gynecological laparoscopic surgery.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, double-blind, placebo-controlled randomized clinical trial was conducted from August 2021 to April 2022 in the First Affiliated Hospital of Zhengzhou University in China. Participants included patients aged 18 to 65 years with an American Society of Anesthesiologist Physical Status classification of I to III (with I indicating a healthy patient, II a patient with mild systemic disease, and III a patient with severe systemic disease) who underwent gynecological laparoscopic surgery. Patients were randomly assigned to either the esketamine group or control group. Data were analyzed using the per protocol principle.

INTERVENTIONS

Patients in the esketamine group received a continuous infusion of esketamine, 0.3 mg/kg/h, intraoperatively. Patients in the control group received an equivalent volume of saline.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of PSD on postoperative days (PODs) 1 and 3. Postoperative sleep disturbance was defined as a numeric rating scale score of 6 or higher or an Athens Insomnia Scale score of 6 points or higher. The secondary outcomes included postoperative anxiety and depression scores using the Hospital Anxiety and Depression Scale, postoperative pain using the visual analog scale, postoperative hydromorphone consumption, and risk factors associated with PSD.

RESULTS

A total of 183 female patients were randomized to the control group (n = 91; median [IQR] age, 45 [35-49] years) and the esketamine group (n = 92; median [IQR] age, 43 [32-49] years). The incidence of PSD in the esketamine group was significantly lower than in the control group on POD 1 (22.8% vs 44.0%; odds ratio [OR], 0.38 [95% CI, 0.20-0.72]; P = .002) and POD 3 (7.6% vs 19.8%; OR, 0.33 [95% CI, 0.13-0.84]; P = .02). There were no differences in postoperative depression and anxiety scores between the 2 groups. Postoperative hydromorphone consumption in the first 24 hours (3.0 [range, 2.8-3.3] mg vs 3.2 [range, 2.9-3.4] mg; P = .04) and pain scores on movement (3 [3-4] vs 4 [3-5] points; P < .001) were significantly lower in the esketamine group than in the control group. On multivariable logistic regression, preoperative depression (OR, 1.31; 95% CI, 1.01-1.70) and anxiety (OR, 1.67; 95% CI, 1.04-1.80) scores, duration of anesthesia (OR, 1.04; 95% CI, 1.00-1.08), and postoperative pain score (OR, 1.92; 95% CI, 1.24-2.96) were identified as risk factors associated with PSD.

CONCLUSIONS AND RELEVANCE

Results of this trial showed the prophylactic effect of intraoperative esketamine infusion on the incidence of PSD in patients who underwent gynecological laparoscopic surgery. Further studies are needed to confirm these results.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR2100048587.

The effects of dexmedetomidine for patient-controlled analgesia on postoperative sleep quality and gastrointestinal motility function after surgery: A prospective, randomized, double-blind, and controlled trial

Background: Postoperative poor sleep quality and decreased gastrointestinal motility function are common clinical problems. This study investigated the effects of dexmedetomidine (DEX) combined with sufentanil for patient-controlled analgesia (PCA) on postoperative sleep quality and gastrointestinal motility function after surgery in patients with colorectal cancer.

Methods: Patients undergoing colorectal cancer surgery were randomly divided into three groups, DEX 0, 200, or 400 μg, each combined with sufentanil 150 μg for PCA immediately after surgery. The primary outcome was sleep quality in the first 7 days after surgery based on the Athens Insomnia Scale (AIS) score. The secondary outcome was postoperative gastrointestinal motility recovery evaluated by the time of first flatus, first feces and first diet. Postoperative pain intensity, side effects and the length of postoperative hospital stay were also compared among groups. The study was registered with the Chinese Clinical Trial Registry (https://www.chictr.org.cn/enIndex.aspx, ChiCTR2000032601).

Results: Ultimately, 210 cases were included. Sleep quality was better in the DEX 200 μg group and DEX 400 μg group than in the DEX 0 μg group. Overall, in the DEX 200 μg group and DEX 400 μg group, the AIS score (p < 0.05) and the incidence of sleep disturbance (7.3%, 4.5% vs. 19.6%, p < 0.001) were lower than those in the DEX 0 μg group in the first 7 days after surgery. There were no significant differences in postoperative gastrointestinal motility among the three groups in the total surgical categories (p > 0.05). In the laparoscopic surgery patients of each group, the time of postoperative first flatus (p = 0.02) and first feces (p = 0.01) was significantly longer in the DEX 400 μg group than in the DEX 0 μg group. There were no differences in postoperative pain intensity, side effects or length of postoperative hospital stay (p > 0.05).

Conclusion: The continuous infusion of DEX (200 or 400 μg) for PCA significantly improved postoperative sleep quality after colorectal cancer surgery. DEX (200 μg) was better at improving postoperative sleep quality without affecting gastrointestinal motility function than DEX (400 μg) in patients who underwent laparoscopic colorectal cancer surgery.

Monitoring postoperative ambulation and sleep after head and neck surgery: A feasibility and utility study using wearable devices

BACKGROUND

To evaluate use of wearable activity devices to monitor trends in ambulation and sleep after head and neck surgery.

METHODS

Patients utilized Fitbit devices after surgery. Daily activity and sleep scores, step counts, and total sleep time (TST) were obtained.

RESULTS

There were 30 patients within the final cohort. Trends in step counts after specific procedures were identified, and higher subjective activity level correlated with step counts (r = 0.25, 95% CI = 0.07-0.41). Among patients with complete step data (n = 24), POD1 steps ≥200 were associated with reduced length of stay (4.5 ± 1.7 days vs. 7.2 ± 4.0 days, 95% CI = 0.33-5.0). Mean TST was 5.4 ± 2.5 h, TST correlated with subjective sleep scores (r = 0.25, 95% CI = 0.03-0.044), and clinical events associated with sleep-wake transitions on Fitbit devices were identified.

CONCLUSIONS

Wearable activity devices appear feasible for monitoring trends in postoperative ambulation and sleep. Use of these devices may facilitate postoperative recovery.

Changes in actigraphy metrics associated with PROMIS measures after orthopaedic surgery

AIM

This study examined the feasibility of integrating actigraphy devices into orthopaedic surgical settings to assess the concurrent validity between objective actigraphy data and PROMIS measures. Additionally, the association between changes in actigraphy data and longitudinal changes in PROMIS measures was examined.

METHODS

Data were collected from 17 participants using actigraphy devices the week prior to and after orthopaedic surgery from 02/2019 to 03/2020. Participants completed PROMIS measures (Physical Function, Sleep Disturbance, Pain Interference) preoperatively and up to 6 months postoperatively. Nonparametric correlations (r_s ) assessed for concurrent validity. Linear mixed-effects models examined the association between changes in actigraphy data and PROMIS measures.

RESULTS

Prolonged wake after sleep onset was associated with increased sleep disturbances (r_s  = 0.49; p = 0.045) and pain interference (r_s  = 0.51; p = 0.04). Changes in pain interference were correlated with increased awakenings (r_s  = 0.54; p = 0.03). Increased wake after sleep onset was associated with worsening sleep disturbance (β = 0.12; p = 0.01) and pain interference scores over the postoperative period (β = 0.12; p = 0.02).

CONCLUSIONS

This study is among the first to examine changes in objective actigraphy data and longitudinal PROMIS measures following orthopaedic surgery and illustrates the feasibility of incorporating actigraphy into surgical settings to evaluate postoperative recovery.

Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty

BACKGROUND

Lack of sleep is associated with adverse effects on postsurgical pain and recovery. We hypothesized that a multimodal sleep pathway, including nonpharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, could improve patient analgesia and sleep after total shoulder arthroplasty.

METHODS

We performed a prospective randomized controlled study in which patients undergoing anatomic and reverse total shoulder arthroplasty were treated with or without an interventional multimodal sleep pathway. This pathway included nursing-directed nonpharmacologic measures that promote sleep hygiene and pharmacologic interventions with low-dose zolpidem and melatonin at bedtime. All patients underwent a standardized multimodal analgesia protocol with scheduled acetaminophen, naproxen, and gabapentin, as well as a single-shot interscalene regional nerve block.

RESULTS

This study enrolled 125 patients (64 in control group and 61 in interventional group) with similar demographic characteristics. The interventional group showed less oral morphine milligram equivalent (MME) consumption on postoperative day (POD) 0 (44.8 ± 36.1 MMEs vs. 60.9 ± 42.1 MMEs, P = .01) and showed a trend toward lower POD 0 visual analog scale pain scores (2.6 ± 1.8 vs. 3.3 ± 3.0, P = .06). Visual analog scale pain scores and MME consumption were similar on POD 1. The interventional group showed a longer objective sleep duration by quantitative wrist actigraphy (5.9 ± 3.1 hours vs. 4.6 ± 2.7 hours, P = .008), with better sleep quality assessed by the Leeds Sleep Evaluation Questionnaire (0-100 scale; 50.3 ± 26.8 vs. 38.5 ± 27.8, P = .01). The 2 groups showed similar satisfaction with pain management (89.2% vs. 79.6%, P = .16) and sleep management (82.1% vs. 76.8%, P = .48). There was no difference in the length of inpatient stay (32.2 ± 14.8 hours vs. 34.1 ± 12.8 hours, P = .44).

CONCLUSION

In the setting of a regional and multimodal analgesia recovery plan for shoulder arthroplasty patients undergoing inpatient observation, the use of an interventional sleep pathway appears to be safe and beneficial, with improved analgesia, reduced opioid use, increased sleep duration, and improved reported sleep quality during the postoperative recovery period.

Acute pain assessments and records: a pilot study of digital transformation

BACKGROUND

Pain is a leading cause of disability worldwide. Pain assessments are an essential part of evidence-based care and management. Among comparable care providers, there is variation in how nurses document assessments as well as the content in them, and there is a notable associated administrative burden.

AIMS

This study evaluated the impact and significance of a new, structured, digitised pain assessment form from quality, safety and efficiency standpoints.

METHODS

Samples of pain assessments were examined at three consecutive stages: first, the pre-existing form was used, then the new structured form was introduced and, finally, the structured form was taken away and nurses went back to completing the original form. Assessments were scored by two clinical analysts against 18 clinically defined pain-related characteristics and factors. The time taken to extract and interpret the assessments was also recorded. Statistically significant changes were assessed using Welch's t-tests and Fisher's exact tests.

FINDINGS

There was a significant improvement in data quality using the new structured form compared with the pre-existing template, including an increase in the capture of five safety-related variables. Less time was needed to extract and interpret data with the new form.

CONCLUSION

Intelligent structured forms are highly effective for documenting pain assessments, and offer notable benefits in quality, safety, and efficiency.

Melatonin pretreatment prevents propofol-induced sleep disturbance by modulating circadian rhythm in rats

Postoperative sleep disorder frequently occurs in patients after surgery. Sleep disturbance aggravates pain, anxiety, and delirium, which is an important risk factor for poor recovery. Circadian rhythm disorder induced by general anesthesia plays important role in postoperative sleep disorders. A large number of clinical studies have shown that various forms and duration of general anesthesia can lead to postoperative sleep disorders. In this study, the effect of prolonged propofol anesthesia on biological rhythm was comprehensively evaluated by wireless physiological telemetry system, and the therapeutic effect of exogenous melatonin pretreatment was further investigated. The results showed that prolonged propofol anesthesia had significant impacts on the circadian rhythm of sleep, body temperature, locomotor activity and endogenous melatonin secretion within 24 h following anesthesia, resulting in diminished oscillation amplitude. In hypothalamus, the expression of circadian factor PER and CRY were inhibited by propofol, possibly through activation of CAMK-CREB signaling pathway. Post-translational factors GSK-3β, SIRT1, AMPK were also involved in the regulation of circadian factors after propofol anesthesia. Melatonin pretreatment could restore circadian rhythm process by regulating circadian factor expression through post-translational modulation and prohibit the over-synthesis of melatonin in pineal gland. This study verified the effects of anesthetics on circadian rhythm and further evaluated the potential therapeutic effect of melatonin on postoperative circadian rhythm and sleep disorders.

The Effect of Improving Preoperative Sleep Quality on Perioperative Pain by Zolpidem in Patients Undergoing Laparoscopic Colorectal Surgery: A Prospective, Randomized Study

Methods

A prospective, randomized study was conducted with 88 patients undergoing laparoscopic colorectal surgery. The experimental group (S group, n = 44) was given 10 mg of zolpidem tartrate one night before the surgical procedure, while no medication was given to the control group (C group, n = 44). The primary outcome was the intraoperative remifentanil consumption. Sufentanil consumption, average patient-controlled analgesia (PCA) effective press times, the visual analog scale (VAS) scores, and incidences of postoperative nausea and vomiting (PONV) were recorded at 6 h (T1), 12 h (T2), and 24 h (T3) postoperatively.

Results

The intraoperative remifentanil consumption was significantly lower in the S group than that in the C group (p < 0.01). Sufentanil consumption at 6 h and 12 h postoperatively was significantly lower in the S group than that in the C group (p < 0.05); average PCA effective press times and VAS scores, at 6 h and 12 h postoperatively, were significantly lower in the S group than those in the C group (p < 0.01); differences between groups 24 h postoperatively were not significant. No significant between-group difference was noted in the incidence of nausea and vomiting.

Conclusion

Improving patients' sleep quality the night before surgical procedure by zolpidem can decrease the usage of intraoperative analgesics and reduce postoperative pain.