Sleep disturbances after open heart surgery

doi:10.1016/S0002-9149(77)80191-4

The American Journal of Cardiology

Volume 39, Issue 2, February 1977, Pages 196-201

https://doi.org/10.1016/S0002-9149(77)80191-4 Get rights and content

This study was designed to document quantitatively the sleep disturbances that occur after open heart surgery and to investigate a group of patients who underwent a thoracic surgical procedure not involving cardiopulmonary bypass. Nine patients were studied, six after open heart surgery and three after partial or complete pneumonectomy. In each patient, sleep patterns were recorded with use of all night polygraphy before and after operation and for up to 5 weeks on follow-up studies. After open heart surgery, patients manifested considerable suppression of electrophysiologic evidence of sleep as well as prolonged suppression of both rapid eye movement and slow wave sleep patterns. In the three patients subjected to thoracotomy these sleep indexes returned to preoperative levels much earlier. Evidence of stage 2 sleep was present in one of the three patients with thoracotomy on the first postoperative night, and in two of the three both rapid eye movement and slow wave sleep returned to preoperative levels by the time of hospital discharge. It is concluded that patients undergoing open heart surgery experience both acute and chronic disruptions of sleep that last well beyond the hospital period of convalescence. These sleep disturbances have considerable relevance for postoperative management.

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Sleep disturbances are common in postsurgical patients, especially those admitted to the intensive care unit (ICU) after major surgery [1–6].
In previous studies, low-dose dexmedetomidine supplemented opioid analgesia improved sleep architecture but increased sedation level. Herein we tested the hypothesis that mini-dose dexmedetomidine supplemented analgesia improves sleep structure without increasing sedation.
In this randomized trial, 118 older patients (≥65 years) following major noncardiac surgery were randomized to receive patient-controlled intravenous analgesia supplemented with either placebo or dexmedetomidine (median 0.02 μg kg⁻¹ h⁻¹) for up to 3 days. Polysomnogram was monitored from 9:00 p.m. on the day of surgery until 6:00 a.m. on the first day after surgery. Our primary outcome was the percentage of non-rapid eye movement stage 2 (N2) sleep. Secondary outcomes included other sleep structure parameters during the night of surgery and the sedation score during the first five postoperative days.
All 118 patients completed the study; of these, 85 were included in sleep structure analysis. Dexmedetomidine supplemented analgesia increased the percentage of N2 sleep (median difference, 10%; 95% CI, 1%–20%; P = 0.03). It also prolonged total sleep time (median difference, 78 min; 95% CI, 21 to 143; P = 0.01), increased sleep efficiency (median difference, 14%; 95% CI, 4%–26%; P = 0.01), decreased percentage of N1 sleep (median difference, −10%; 95% CI, −20% to −1%; P = 0.04), and lowered sleep fragmentation index (median difference, −1.6 times⋅h⁻¹; 95% CI, −3.7 to 0.1; P = 0.04). Sedation score within 5 days did not differ between the two groups.
Supplementing intravenous analgesia with mini-dose dexmedetomidine improved sleep structure without increasing sedation in older patients recovering from major surgery.
www.clinicaltrials.gov (NCT03117790), registered 2 April 2017.
Sleep Neurobiology and Critical Care Illness
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Surgical ICU patients best illustrate this fact because PSG can be performed at baseline (before surgery) and after anesthesia using a standardized regimen. The results showed marked reduction or elimination of slow wave sleep and REM sleep during the first 2 postoperative nights, with a significant rebound of REM sleep in the third or fourth postoperative night,33–36,41 contrasting with little35 or no rebound of slow wave sleep.34,36 These results also highlight the need for longitudinal studies describing changes in sleep over time according to the reason for ICU admission and to disease severity.
Sleep Neurobiology and Critical Care Illness
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Sleep fragmentation and decreased SWS and REM sleep were reported in an ICU [35], but were less marked than in the postoperative period, and this single factor could not explain all postsurgical sleep changes. Regarding surgical stress, the magnitude and duration of surgery have been related to sleep disturbances [9,38,44]. Although surgery duration was related to the duration of sleep complaints, especially in heart surgery [44], surgical trauma appears to be a major sleep disturbance factor, with potential mechanisms being endocrine, autonomic, and inflammatory stress responses to surgery [9,38].
Despite the substantial advances in the understanding of pain mechanisms and management, postoperative pain relief remains an important health care issue. Surgical patients also frequently report postoperative sleep complaints. Major sleep alterations in the postoperative period include sleep fragmentation, reduced total sleep time, and loss of time spent in slow wave and rapid eye movement sleep. Clinical and experimental studies show that sleep disturbances may exacerbate pain, whereas pain and opioid treatments disturb sleep. Surgical stress appears to be a major contributor to both sleep disruptions and altered pain perception. However, pain and the use of opioid analgesics could worsen sleep alterations, whereas sleep disruptions may contribute to intensify pain. Nevertheless, little is known about the relationship between postoperative sleep and pain. Although the sleep–pain interaction has been addressed from both ends, this review focuses on the impact of sleep disruptions on pain perception. A better understanding of the effect of postoperative sleep disruptions on pain perception would help in selecting patients at risk for more severe pain and may facilitate the development of more effective and safer pain management programs.
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Sleep abnormalities are common and underrecognized in hospitalized patients. Sleep restriction is common and can have undesirable behavioral and physiologic effects. The general pattern of polysomnographic abnormalities observed in hospitalized patients is reduction in total sleep time, stages R (rapid eye movement), and N3 (slow wave) and increase in stage N1 percentage. Sleep is also fragmented with more arousals and awakenings. Multiple factors are responsible for sleep disruption in hospitalized patients and include environmental noise. Abnormalities in melatonin secretion leading to circadian rhythm abnormalities have also been noted. Hospitalized patients may also present with symptoms of obstructive sleep apnea. Protocols for sleep enhancement and management of obstructive sleep apnea are being implemented at various hospitals. Outcome data are awaited from these measures.
Sedation and sleep disturbances in the ICU
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Although many studies have shown that the total number of sleep hours may be normal over 24 hours, they are distributed across day and night in short periods.3,4,6 A disproportionate amount of time is spent in light sleep (non–rapid eye movement [NREM] sleep stages I and II) and wakefulness and a relatively small percentage of time in deep sleep (slow wave sleep [SWS], formerly referred to as NREM stages III and IV) and rapid eye movement (REM) sleep.3,5,7,8,10,11 Experimental models of sleep fragmentation and sleep stage deprivation have demonstrated many of the same consequences as with periods of total sleep deprivation, but controlled studies have not been done in the critically ill.12,13

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^*: This work was supported in part by Grant 1 R03 MH 25349-01 from the National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland

View full text

Clinical StudySleep disturbances after open heart surgery*

Ann Thorac Surg

Psychosomatics

Electroencephalogr Clin Neurophysiol

J Psychosom Res

Severe psychiatric disturbances in the postoperative period—a five-year survey of Belfast hospitals

J Ment Sci

Psychological disturbances associated with open-heart surgery

Am J Psychiatry

Post-cardiotomy delirium

Am J Psychiatry

Psychiatric complications of open-heart surgery

N Engl J Med

Prevention of psychosis following open-heart surgery

Am J Psychiatry

Central nervous system dysfunction following open-heart surgery

Jama

A polygraphic sleep study of five cardiotomy patients

Clinical Study
Sleep disturbances after open heart surgery*