For many people, there is a noticeable deterioration in the quality of sleep after a surgery [1]. Around 50% of patients hospitalized overnight after surgery have sleep disturbances [1]. Unfortunately, poor post-operative sleep is related to negative outcomes such as a higher risk of delirium, increased sensitivity to pain, and poorer recovery [1]. One study found that a greater amount of sleep disturbances in the first six months following a percutaneous coronary intervention was related to a higher likelihood of the patient having a major cardiac event four years later [2]. Thus, the necessity for quality sleep, especially following a surgery, remains crucial. Normal sleep has the following cycles: N1 (light sleep) → N2 → N3 (slow wave sleep (SWS)) → N2 → Rapid Eye Movement (REM) [1] and the most common sleep disturbance is a loss of the amount of time spent in REM [3]. While this is disturbance is still difficult to reverse, scientists have developed novel pharmacological and nonpharmacological ways to improve overall post-operative sleep.
Pharmacological interventions are typically given before bedtime and include benzodiazepines, nonbenzodiazepine sedatives, and melatonin [1, 3]. Benzodiazepines are often prescribed post-surgery to improve sleep but there is conflicting evidence about their effectiveness for this purpose [3]. Some studies have found benzodiazepines to be effective at decreasing sleep fragmentation, such that patients wake up less during the night [4]. However, others suggest that benzodiazepines may disrupt sleep cycles by decreasing the amount of time spent in REM, which is dangerous considering that loss of REM sleep is already a problem for post-operative patients [3]. Some popularly prescribed nonbenzodiazepine sedatives to improve post-surgery sleep are zolpidem and dexmedetomidine. Post-operative patients given zolpidem reported increased sleep quality, decreased fatigue, and had decreased sleep fragmentation but they had the same disrupted REM sleep cycles as the control group [5]. Patients given dexmedetomidine stayed asleep for longer, had increased N2 and decreased N1 sleep, and improved sleep quality compared to control groups [6, 7]. Melatonin, a naturally produced hormone that regulates sleep-wake cycles, may be found at lower levels in post-operative patients due to blood loss [1]. One study found that post-operative patients given melatonin had a one-hour increase in the amount of sleep they had compared to a placebo group [8]. While a meta-analysis found inconclusive results for melatonin to improve post-operative sleep [3], melatonin given to patients recovering from breast cancer surgeries and prostatectomies reported improved sleep quality [1].
Nonpharmacological interventions to promote sleep quality are classified into two categories: changes to the patient’s surgical experience and changes to the patient’s post-operative environment. Since aspects of the surgical experience, such as the surgery severity and anesthesia type, relate to the severity of sleep disturbances, changing these are effective ways to improve post-operative sleep [1]. Doctors can improve sleep quality by using regional anesthesia instead of general anesthesia [1]. Kjølhede et al. [9] found that women who received regional anesthesia (spinal anesthesia) instead of general anesthesia during a hysterectomy had better quality of sleep following the surgery. Doctors may also opt to do less invasive surgeries since the severity of sleep disturbances is positively correlated to surgery severity [1]. Encouraging patients to wear ear plugs and eye masks increases sleep quality and efficiency but only by a small amount [10]. Additionally, maintaining a quiet and dim environment and decreasing interruptions from nighttime care activities is shown to increase sleep quality and sleep efficiency post-surgery [11].
Some sleep disturbance after surgery may be unavoidable but with the right combination of pharmacological and nonpharmacological interventions, the disruption to sleep can be minimal.
References:
- Su, X., & Wang, D. X. (2018). Improve postoperative sleep: what can we do?. Current opinion in anaesthesiology, 31(1), 83–88. doi:10.1097/ACO.0000000000000538
- Fernandes, M. et al. (2014). Symptoms of Disturbed Sleep Predict Major Adverse Cardiac Events After Percutaneous Coronary Intervention. Canadian Journal of Cardiology, 30(1), 118 – 124. doi: 10.1016/j.cjca.2013.07.009
- Kanji, S. et al. (2016). Pharmacological interventions to improve sleep in hospitalised adults: a systematic review. BMJ Open. 6(7). doi: 10.1136/bmjopen-2016-012108
- Guilleminault, Christian. (1990). Benzodiazepines, breathing, and sleep. The American Journal of Medicine, 88(3), S25 – S28. doi: 10.1016/0002-9343(90)90282-I
- Krenk, L., Jennum, P., Kehlet, H. (2014). Postoperative sleep disturbances after zolpidem treatment in fast-track hip and knee replacement. Journal of Clinical Sleep Medicine. 10(3), 321-326. doi: 10.5664/jcsm.3540
- Alexopoulou, C., M.D. et al. (2014). Effects of Dexmedetomidine on Sleep Quality in Critically Ill Patients: A Pilot Study. Critical Care Medicine. 121, 801-807. doi: 10.1097/ALN.0000000000000361
- Wu et al. (2016). Low-dose Dexmedetomidine Improves Sleep Quality Pattern in Elderly Patients after Noncardiac Surgery in the Intensive Care Unit: A Pilot Randomized Controlled Trial. Anesthesiology. 125(5), 979-991. doi: 10.1097/ALN.0000000000001325
- Bourne, R.S., Mills, G.H. & Minelli, C. (2008) Melatonin therapy to improve nocturnal sleep in critically ill patients: encouraging results from a small randomised controlled trial. Crit Care 12, R52. doi:10.1186/cc6871
- Kjølhede P1, Langström P, Nilsson P, Wodlin NB, Nilsson L. (2012). The impact of quality of sleep on recovery from fast-track abdominal hysterectomy. Journal of Clinical Sleep Medicine. 8(4), 395-402. doi: 10.5664/jcsm.2032
- Hu et al. (2015). Non-pharmacological interventions for sleep promotion in the intensive care unit. The Cochrane Database of Systematic Reviews. 10. doi: 10.1002/14651858.CD008808.pub2
- Li, S.Y., Wang, T.J., Wu, V., Liang, S.Y., Tung, H.H. (2011). Efficacy of controlling night-time noise and activities to improve patients’ sleep quality in a surgical intensive care unit. Journal of Clinical Nursing. 30(3-4), 396-407. doi: 10.1111/j.1365-2702.2010.03507.x