Patients' night-time pain, analgesic provision and sleep after surgery

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.

PTH levels, sleep quality, and cognitive function in primary hyperparathyroidism

BACKGROUND

Cognitive function in patients with primary hyperparathyroidism (PHPT) may be affected and be identified to have been linked to the level of parathyroid hormone (PTH). Previous studies have suggested that patients with PHPT present poor sleep quality, which might interact with cognitive decline. The purpose of this study was to determine whether sleep quality mediates the association between PTH level and cognitive function and investigate whether surgery improves sleep quality and cognition in PHPT patients.

METHODS

Between June 2019 and August 2022, we recruited 146 patients diagnosed with PHPT (n = 146). We collected clinical data from medical records and evaluated sleep quality and cognition preoperatively and 2 months postoperatively by using the Pittsburgh Sleep Quality Index and Min-Mental State Examination. We examined the mediation effects of sleep disturbance and latency on correlations between PTH level and cognitive impairment by using the Bootstrap method.

RESULTS

The sleep quality and cognitive function were correlated with PTH level before surgery. Sleep latency or sleep disturbance exhibited a partial mediating effect on the association between PTH level and MMSE scores in PHPT patients (p < 0.05). In PHPT patients, there was a significant decline in PTH levels and an improvement in cognitive function post-surgery compared to pre-surgery, but no significant differences in sleep quality.

CONCLUSION

Sleep disturbance and sleep latency may mediate the association between PTH level and cognitive impairment in PHPT before surgery. The surgery could reduce PTH levels and improve cognition, but might not improve sleep quality in PHPT patients.

Assessment of Perioperative Sleep Characteristics Using Subjective and Objective Methods: A Secondary Analysis of Prospective Cohort Study

Perioperative sleep disturbances may impact healing and negatively affect the patient's perception of well-being. Therefore, accurately assessing postoperative sleep characteristics is necessary to treat sleep disturbances. This study is a secondary data analysis of research investigating the association between sleep and cognition in a perioperative setting. This study compares sleep characteristics between the St. Mary's Hospital Sleep Questionnaire and WatchPAT, a portable sleep apnea testing device. The goal of this study is to compare an objective measurement of sleep quality (WatchPAT) with a traditional questionnaire. One hundred and one patients who underwent elective, noncardiac surgical procedures wore a WatchPAT and completed the St. Mary's Hospital Sleep Questionnaire for three nights: two preoperative and one postoperative night. In the preoperative period, a Bland-Altman analysis showed an agreement Watch PAT and the St Mary's hospital sleep questionnaire except for sleep fragmentation. A good to fair correlation during the preoperative period was observed with both sleep latency and total sleep time. In the postoperative period, no correlation was observed between the St. Mary's Hospital Sleep Questionnaire data and WatchPAT data. Our study indicates that some potential factors affecting sleep and cognition such as admission type, depression, anesthesia type, and sleep apnea may limit patients' ability to report their sleep characteristics after surgery. Therefore, relying solely on one sleep assessment method is not advisable.

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.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

Preemptive Intravenous Nalbuphine for the Treatment of Post-Operative Visceral Pain: A Multicenter, Double-Blind, Placebo-Controlled, Randomized Clinical Trial

INTRODUCTION

Post-operative visceral pain is common in early postoperative period after laparoscopic surgery. As a kappa opioid receptor agonist, the antinociceptive effects of nalbuphine in visceral pain are consistent across a multitude of experimental conditions irrespective of species. We hypothesized that preemptive nalbuphine can decrease the visceral pain for patients with incisional infiltration of ropivacaine after laparoscopic cholecystectomy.

METHODS

In a multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial, 2094 participants scheduled for laparoscopic cholecystectomy were randomly assigned to receive nalbuphine (Nal group, n = 1029) or placebo (Con group, n = 1027). The Nal group received intravenous nalbuphine 0.2 mg·kg^-1 and the Con group received saline in a similar way. The primary endpoint was the effect of nalbuphine on post-operative visceral pain intensity scores within 24 h postoperatively. The total amount of analgesic as well as complications were recorded.

RESULTS

A total of 1934 participants were analyzed. Nalbuphine reduced the visceral pain both at rest (β = - 0.1189, 95% CI - 0.23 to - 0.01, P = 0.037) and movement (β = - 0.1076, 95% CI - 0.21 to - 0.01, P = 0.040) compared with placebo. Patients in the Nal group required less frequent supplemental analgesic administration during the first 24 h after surgery. There were fewer patients in the Nal group who experienced nausea and vomiting (PONV) (P = 0.008).

CONCLUSIONS

Preemptive nalbuphine administered at a dose of 0.2 mg·kg^-1 was safe and effective at reducing the postoperative visceral pain and supplemental analgesic use in patients undergoing laparoscopic cholecystectomy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry; ChiCTR1800014379.

Effect of the use of earplugs and eye masks on the quality of sleep after major abdominal surgery: a randomised controlled trial

Significant sleep disturbance can occur following major abdominal surgery. We aimed to evaluate the effectiveness of earplugs and eye masks in improving sleep quality and patient satisfaction, reducing nursing demands and in the incidence of delirium in patients after major abdominal surgery. We conducted a randomised controlled trial in 100 patients undergoing major abdominal surgery. We randomly allocated participants to sleep with or without earplugs and eye masks on postoperative days 1-3. The primary outcome measure was sleep quality as measured by the Richards-Campbell Sleep Questionnaire. Secondary outcomes were patient satisfaction, frequency of nursing demand and incidence of delirium measured by the Neelon and Champagne Confusion Scale. Median (IQR [range]) sleep scores were 64 (38-74 [0-100] and 60 (44-82 [18-100]) for the control and intervention groups, respectively (p = 0.310). Age and Pittsburgh Sleep Quality Index scores were found to be significant factors affecting sleep quality. There were no differences in patient satisfaction, reduction in frequency of nursing demands or incidence of delirium on postoperative days 1-3 after major abdominal surgery. The compliance rate in the intervention group was 60-65%. This study has demonstrated that the use of earplugs and eye masks did not contribute to improvements in sleep quality. Of note, sleep quality was moderate, with higher age and worse baseline sleep quality contributing to worse sleep scores. More studies are needed to investigate interventions to improve sleep quality after major abdominal surgery.

The efficacy of acupuncture in postoperative sleep quality: a literature review

PURPOSE

General anesthesia may affect the quality of postoperative sleep, especially after surgery on elderly patients. The decline of postoperative sleep quality may produce harmful effects on the postoperative recovery of patients. In this review, we summarized the efficacy and potential mechanism of acupuncture on postoperative sleep quality.

METHODS

We review the effect of general anesthesia on circadian sleep rhythm. In addition, to provide evidence about the impairment of decreased postoperative sleep quality, we also emphasize the mechanism of acupuncture alleviates factors that affect sleep quality after general anesthesia.

RESULTS

The application of acupuncture technology has been helpful to improve sleep quality and alleviate postoperative complications affecting postoperative sleep quality after general anesthesia.

CONCLUSION

Acupuncture at different acupoints could effectively improve body's neurotransmitter levels and regulate biological clock genes through various mechanisms, and then improve postoperative sleep quality. Large-scale multi-center trials are needed to verify these findings.

Electroacupuncture: A New Approach for Improved Postoperative Sleep Quality After General Anesthesia

General anesthesia produces a state of drug-induced unconsciousness that is controlled by the extent and duration of administered agents. Whether inhalation or intravenous in formulation, such agents may interfere with normal sleep-wake cycles, impairing postoperative sleep quality and creating complications. Electroacupuncture is a new approach widely applied in clinical practice during recent years. This particular technology helps regulate neurotransmitter concentrations in the brain, lowering norepinephrine and dopamine levels to improve sleep quality. It also alleviates surgical pain that degrades postoperative sleep quality after general anesthesia by downregulating immune activity (SP, NK-1, and COX-1) and upregulating serotonin receptor (5-HT1AR, 5-HT2AR) and endocannabinoid expression levels. However, large-scale, multicenter studies are still needed to determine the optimal duration, frequency, and timing of electroacupuncture for such use.

Sleep Patterns and Quality Among Inpatients Recovering From Elective Surgery: A Mixed-Method Study

BACKGROUND

Sleep is necessary for recovery from physiological insults such as surgery. Although previous research has focused on sleep in the intensive care unit and medical setting, little is known about sleep quality among inpatients recovering from elective surgery. Therefore, we examined sleep quality and barriers to sleep among postsurgical inpatients.

METHODS

We conducted an explanatory sequential mixed-method study among adult general-care surgical inpatients who underwent elective surgery. We used a quantitative survey to examine sleep quality and interruptions followed by a qualitative phone interview with a subsample of participants to examine barriers and aids to sleep in the hospital. Results were analyzed using descriptive statistics of survey data and descriptive coding of interview transcripts.

RESULTS

Of 113, 102 (90%) eligible patients completed the survey. Less than half (n = 48, 47%) of patients reported sleeping well the previous night and 93% reported less sleep in the hospital compared with at home. Patients reported a median of 5 (4-7) interruptions each night. Patients with >3 sleep interruptions were more likely to report poor sleep than those with ≤3 interruptions (P < 0.001). Phone interview responses cited barriers to sleep including staff interruptions and roommate noise when sharing a room but not pain. Patients suggested that improved timing and knowledge of interruptions or noise-reduction aids would facilitate sleep.

CONCLUSIONS

Most patients do not sleep well while recovering from elective surgery in the hospital, and most sleep disruptions are modifiable. Minimizing interruptions at night by clustering care, informing patients of scheduled interruptions, and increasing access to noise-reduction aids may improve sleep quality. Optimal efforts to improve sleep quantity and quality will ultimately require a multilevel, multicomponent strategy.

Postoperative sleep disorders and their potential impacts on surgical outcomes

Postoperative sleep disturbance is a common occurrence with significant adverse effects on patients including delayed recovery, impairment of cognitive function, pain sensitivity and cardiovascular events. The development of postoperative sleep disturbance is multifactorial and involves the surgical inflammatory response, the severity of surgical trauma, pain, anxiety, the use of anesthetics and environmental factors such as nocturnal noise and light levels. Many of these factors can be managed perioperatively to minimize the deleterious impact on sleep. Pharmacological and non-pharmacological treatment strategies for postoperative sleep disturbance include dexmedetomidine, zolpidem, melatonin, enhanced recovery after surgery (ERAS) protocol and controlling of environmental noise and light levels. It is likely that a combination of pharmacological and non-pharmacological therapies will have the greatest impact; however, further research is required before their use can be routinely recommended.

Gabapentin Does Not Appear to Improve Postoperative Pain and Sleep Patterns in Patients Who Concomitantly Receive Regional Anesthesia for Lower Extremity Orthopedic Surgery: A Randomized Control Trial

In recent years, gabapentin has gained popularity as an adjuvant therapy for the treatment of postoperative pain. Numerous studies have shown a decrease in pain score, even with immediate postoperative activity, which is significant for early post-op ambulation and regaining functionality sooner. However, studies have been in conclusive in patients undergoing lower extremity orthopedic surgery. For this reason, we hoped to study the effect of gabapentin on postoperative pain in patients undergoing total knee arthroplasty, total hip arthroplasty, or a hip fracture repair. This was done in the setting of ensuring adequate postoperative analgesia with regional blocks and opioid PCA, as is protocol at our institution. Given the sedative effects of gabapentin and the potential for improving postoperative sleep patterns, we also studied the drug's effect on this aspect of our patient's postoperative course. We utilized the Pittsburg Sleep Quality Index and Visual Analog Scale for pain to obtain a more objective standardized score amongst our study population. Our results indicate that gabapentin does not offer any additional relief in pain or improve sleep habits in patients who have received either a femoral or lumbar plexus block for lower extremity orthopedic surgery. This trial is registered with NCT01546857.

A prospective analysis of sleep deprivation and disturbance in surgical patients

Introduction

Sleep deprivation has a potentially deleterious effect on postoperative recovery. The aim of our prospective study was to identify the factors contributing to postoperative sleep deprivation and disturbance in order to recommend improvements in postoperative care.

Methods

102 consecutive patients attending for elective general and orthopaedic surgery were interviewed preoperatively (baseline) and postoperatively on their duration of sleep, number of wakenings during the night, factors contributing to sleep loss and the use of analgesia and night sedation.

Results

Patients woke up a median of 5 times in the first postoperative night compared to a median of 3 times preoperatively (p = 0.01). Pain was the predominant factor preventing sleep, affecting 39% of patients preoperatively and 48% of patients on the first postoperative day. Other factors included noise from other patients and nursing staff, and using the toilet. Analgesia was taken by more than 90% of patients in the first two days, this number gradually reducing over the postoperative period. On the other hand, in the first two postoperative days, only about 5% of patients had night sedation.

Discussion and conclusions

Apart from highlighting the need for effective pain management postoperatively, we believe that our study supports the drive towards single bed bays, where steps can be taken to minimize the impact of environmental factors on sleep.

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This study is a prospective questionnaire survey of 102 surgical patients who procedures over a set time period.

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The aim of the study was to determine factors contributing to sleep deprivation postoperatively on a surgical ward.

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Unexpectedly, patients were not sleep deprived postoperatively but slept more during the daytime.

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Pain and noise were the main factors contributing to sleep deprivation.

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The authors then conclude that their study supports a drive towards single bed bays.

Correlation between Sleep Disruption on Postoperative Pain

Objectives

To identify the amount of sleep disruption that occurs in the postoperative inpatient hospital setting, determine the relationship between sleep disruption and the quantity of narcotics taken for postoperative pain, and determine if hospital length of stay is related to sleep disruption.

Study Design

Prospective cohort study.

Setting

Single tertiary care academic institution.

Subjects and Methods

Fifty patients undergoing total hip or knee arthroplasty at Henry Ford Hospital in Detroit, Michigan, between January 2013 and November 2013 were asked to wear an actigraph during their postoperative hospital stay. Total sleep time, sleep efficiency, awake index, total narcotic use, visual analog pain scores, and postoperative complications were analyzed.

Results

Overall sleep efficiency was 61.2% and 66.5% with an awake index of 5.5 and 5.4 for each of the postoperative nights measured. A significant correlation was found between increased self-reported pain scores and decreased total sleep time ( r = −0.31; P = .03). Spearman correlations between total sleep time, sleep efficiency, and awake index were made with narcotic use on postoperative day (POD) 0 and 1. Longer hospital length of stay was significantly correlated with decreased sleep efficiency ( r = −0.35, P = .01). Complication rates were not statistically different compared with sleep parameters.

Conclusion

Better control of a patient’s pain is associated with greater sleep efficiency and total sleep time. Improvements in sleep efficiency in hospitalized patients may be associated with a decrease in length of stay.

Postoperative sleep disturbances after zolpidem treatment in fast-track hip and knee replacement

STUDY OBJECTIVES

Previous studies have demonstrated pronounced reduction of REM sleep on the first nights following major surgery which may influence pain, analgesic use, and recovery. This placebo-controlled, randomized, double-blind study set out to evaluate the effect of zolpidem on sleep architecture in an elderly population undergoing fast-track total hip and knee arthroplasty (THA/TKA) with length of stay < 3 days.

METHODS

Twenty patients (≥ 60 years) undergoing THA or TKA in a standardized setup with spinal anesthesia and multimodal opioid-sparing postoperative analgesia were included. Polysomnography measures were performed for 2 nights, 1 night at home prior to surgery and on the first night after surgery, when the patient received placebo or zolpidem 10 mg. Analgesic use, pain levels, and subjective measures of fatigue and sleep quality were recorded. Analysis of sleep data was performed according to the American Academy of Sleep Medicine manual.

RESULTS

Objective sleep data did not show a significant difference between groups in any of the sleep stages. However, subjective data on sleep quality and fatigue showed significantly less fatigue and better sleep quality in the zolpidem group (p < 0.05), and reduced objectively recorded number of arousals (p = 0.004). Levels of pain and opioid use were similar in the 2 groups.

CONCLUSIONS

Our objective data did not support the primary hypothesis that one night's treatment with zolpidem would significantly improve sleep architecture following major surgery, although there was improved feeling of sleep quality and fatigue associated with fewer postoperative arousals.

CITATION

Krenk L; Jennum P; Kehlet H. Postoperative sleep disturbances after zolpidem treatment in fast-track hip and knee replacement.

The impact of quality of sleep on recovery from fast-track abdominal hysterectomy

STUDY OBJECTIVES

To examine the impact of mode of anesthesia on perceived quality of sleep and to analyze the perceived quality of sleep in affecting recovery from surgery.

METHODS

A randomized, controlled, open multicenter trial was conducted in 5 hospitals in Southeast Sweden. One-hundred eighty women scheduled for fast-track abdominal hysterectomy for benign conditions were randomized to spinal anesthesia or general anesthesia; 162 women completed the trial; 82 allocated to spinal anesthesia and 80 to general anesthesia. Symptoms and perceived quality of sleep after surgery were registered daily in the Swedish Postoperative Symptoms Questionnaire.

RESULTS

Women in the general anesthesia group experienced bad quality of sleep the night after surgery significantly more often than the women who had spinal anesthesia (odds ratio [OR] 2.45; p = 0.03). This was almost exclusively attributed to a significantly higher consumption of opioids postoperatively in the general anesthesia group. Risk factors for bad quality of sleep during the first night postoperatively were: opioids (OR 1.07; p = 0.03); rescue antiemetics (OR 2.45; p = 0.05); relative weight gain (OR 1.47; p = 0.04); summary score of postoperative symptoms (OR 1.13; p = 0.02); and stress coping capacity (OR 0.98; p = 0.01). A longer hospital stay was strongly associated with a poorer quality of sleep the first night postoperatively (p = 0.002).

CONCLUSIONS

The quality of sleep the first night after abdominal hysterectomy is an important factor for recovery. In fast-track abdominal hysterectomy, it seems important to use anesthesia and multimodal analgesia reducing the need for opioids postoperatively and to use strategies that diminish other factors that may interfere negatively with sleep. Efforts to enhance quality of sleep postoperatively by means of preventive measures and treatment of sleep disturbances should be included in fast-track programs.

Sleep disturbances after fast-track hip and knee arthroplasty

BACKGROUND

Major surgery is followed by pronounced sleep disturbances after traditional perioperative care potentially leading to prolonged recovery. The aim was to evaluate the rapid eye movement (REM) sleep duration and sleep architecture before and after fast-track hip and knee replacement with length of stay (LOS) <3 days. The primary endpoint was REM sleep duration on the first postoperative night compared with before operation.

METHODS

Ten subjects (≥60 yr) receiving spinal anaesthesia and multimodal opioid-sparing postoperative analgesia for total hip or knee arthroplasty were included. Ambulatory polysomnography was performed one night before operation at home, continuously during hospitalization, and on the fourth postoperative night at home. Sleep staging was performed according to the American Academy of Sleep Medicine manual. Opioid use, pain, and inflammatory response (C-reactive protein) were also evaluated.

RESULTS

The mean LOS was 1.5 (1-2) days. The mean REM sleep time decreased from a mean of 18.2 (9.5-23.5)% of total sleep time to 1.2 (0-5.8)% on the first postoperative night (P=0.002); awake time increased from 19.1 (3.7-44.4)% to 44.3 (12.2-70.6)% (P=0.009); and sleep architecture on the first postoperative night was more disturbed than before operation. Sleep architecture normalized on the fourth postoperative night. There was no association between opioid use, pain scores, and inflammatory response with a disturbed sleep pattern.

CONCLUSIONS

Despite ultra-short LOS and provision of spinal anaesthesia with multimodal opioid-sparing analgesia, REM sleep was almost eliminated on the first postoperative night after fast-track orthopaedic surgery but returned to pre-admission levels when at home on the fourth postoperative night.

Sedation and sleep disturbances in the ICU

Sedation in the ICU is, paradoxically, both a cause and a potential treatment for the sleep disruption almost universally observed in the critically ill. A patient-focused sedation strategy that minimizes unnecessary medication, avoids medication withdrawal, addresses the specific impediments to sleep, and serves as an adjunct to attentive environmental control may ultimately serve patients best.

Effects of preoperative oral melatonin medication on postoperative analgesia, sleep quality, and sedation in patients undergoing elective prostatectomy: a randomized clinical trial

PURPOSE

Our intention was to assess the effectiveness of preoperative oral melatonin medication on sedation, sleep quality, and postoperative analgesia in patients undergoing elective prostatectomy.

METHODS

Fifty-two ASA I-II patients undergoing elective prostatectomy were included in this study, randomly divided into two groups. Patients received an oral placebo (n = 26) or 6 mg melatonin (n = 26) the night before and 1 h before surgery. All patients received a standard anesthetic protocol. At the end of surgery, all patients received tramadol i.v. via a PCA device. Extubation time, intraoperative fentanyl consumption, and recovery time were assessed at the end of the operation. Pain scores, tramadol consumption, and sedation scores were assessed at 1, 2, 4, 6, 12, 18, and 24 h postoperatively, and sleep quality and subjective analgesic efficacy were assessed at 24 h after surgery.

RESULTS

There were no significant differences in demographic data between the groups. Extubation time and recovery time from anesthesia were significantly longer in the melatonin group (P < 0.05). Intraoperative fentanyl usage, pain scores, and tramadol consumption were significantly lower in the melatonin group (P < 0.05). The postoperative sleep quality of patients was significantly better in the melatonin group than in the control group (P < 0.05). Postoperative VAS of pain was significantly lower in the melatonin group compared with the control group at 1, 2, 4, 6, 12, 18, and 24 h postoperatively (P < 0.05). Subjective analgesic efficacy of patients was significantly different between groups (P < 0.05). The sedation scores were significantly higher in the melatonin group than in the control group at 1 h and 2 h after surgery (P < 0.05).

CONCLUSIONS

Preoperative oral melatonin administration decreased pain scores and tramadol consumption and enhanced sleep quality, sedation scores, and subjective analgesic efficacy during the postoperative period.

Sedation and sleep disturbances in the ICU

The need for compassionate care of the critically ill often compels clinicians to treat these patients with pharmacologic sedation. Although patients may appear to be asleep under the influence of these sedating medications, the relationship between sleep and sedation is complex and not fully understood. These medications exert their effects at different points along the central nervous system's natural sleep pathway, leading to similarities and differences between the two states. This relationship is important because critically ill patients sleep poorly and this phenomenon has been linked to poor intensive care unit outcomes. Therefore, greater awareness of the effects of these medications on sleep may lead to sedation protocols that further improve outcomes. This article reviews the relationship between sedation and sleep from physiologic and clinical perspectives.

The knowledge and educational experiences of student nurses regarding sleep promotion in hospitals

AIM

This study explored the knowledge and educational experiences of student nurses regarding sleep and its promotion in hospitals.

BACKGROUND

Nurses have a key role to play in sleep promotion, with the knowledge of sleep an important component of skilled patient care. From a review of the literature, minimal research was found on what student nurses know, or how they learn about, sleep and its promotion.

METHODS

A mixed method approach was used. 1. Questionnaires were completed by student volunteers in the last six months of their nursing programme(n = 120) from four Higher Education Institutions.2. Semi-structured interviews were carried out with a sample of the students (n = 26).

RESULTS

The students lacked a complete knowledge about basic sleep physiology. Their knowledge of sleep disruption and sleep promoting factors was more evident, although this was generally not based on empirical evidence. The students viewed knowledge of sleep and its promotion positively, but reported that their educational programmes did not prepare them in this respect. The students felt that they had learnt most about sleep promotion through clinical experience, from staff, patients and their own life experiences, though this learning was unstructured.

CONCLUSIONS

These findings highlight the need to address the acquisition of knowledge and skills for the promotion of sleep in a structured learning framework in pre-registration nursing programmes. Academic and clinical staff need to be proactive in this respect.

Chronobiological characteristics of postoperative pain: diurnal variation of both static and dynamic pain and effects of analgesic therapy

BACKGROUND

Previous postoperative investigations report morning peaks in analgesic administration. However, few studies have examined diurnal variation of both pain and analgesic consumption and little is known about dynamic pain in this context.

METHODS

The diurnal pattern of postoperative pain is described using pain intensity and analgesic consumption data from a recently published hysterectomy trial.

RESULTS

In the presence of patient-controlled analgesia with morphine, pain at 8 a.m. was significantly higher (P<0.05) than at noon, 4 p.m. or 8 p.m. on postoperative day one (for rest pain and pain evoked by sitting, forced expiration and cough) and on postoperative day two (for pain evoked by forced expiration and cough only). This temporal pattern was observed both with and without the co-administration of non-opioid analgesics (gabapentin and/or rofecoxib). Morphine use during the four hours preceding 8 a.m. on either postoperative day was not significantly lower than any of the other corresponding time intervals.

CONCLUSIONS

Based on data from our post-hysterectomy analgesic clinical trial, static and dynamic pain in the morning appears to be more intense than pain later in the day. This pattern was observed in the presence of substantial nocturnal morphine use. Based on these and other previous observations, specifically designed investigations are needed to better characterize the clinical, neurohormonal and neurophysiological features of postoperative circadian pain variation - including pain during sleeping hours. If the above observations are replicated, future study of nocturnal sustained-release opioids as well as time-shifting the administration of non-opioid co-analgesic drugs to the very early morning may be warranted.

The role of COX-2 inhibitors in the treatment of postoperative pain

Postoperative pain requires treatment not only to provide comfort to patients but also to improve postoperative outcome. Anti-inflammatory compounds are an important component of multimodal analgesia in the postoperative period. The newer cyclooxygenase (COX)-2 inhibitors are as effective as classical nonsteroidal anti-inflammatory drugs (NSAIDs) in this setting. However, COX-2 inhibitors offer a number of advantages over NSAIDs when used to treat postoperative pain. These include a reduced incidence of gastrointestinal ulceration and no inhibitory effect on platelet function and thereby a reduced risk of blood loss. Other benefits are less impairment of bone healing and no induction of bronchospasm in patients with aspirin-sensitive asthma. Increased cardiovascular thromboembolic events by COX-2 inhibitors have been reported after coronary artery bypass graft surgery only, but in general, surgery studies the incidence of such complications was comparable to placebo. Overall, COX-2 inhibitors offer a number of advantages over classical NSAIDs in the postoperative pain setting, but require the same caution with regard to renal effects.

Postoperative sleep disturbance in pediatric patients using patient-controlled devices (PCA)

BACKGROUND

Sleep disturbance has not been well quantified in pediatric postoperative management, yet has broad implications in pain management as well as upon the physical and psychological well-being of the young patient admitted for surgery. We aimed to describe sleep disturbance in this population using patient-controlled analgesia (PCA) and then identify the predictors of disturbed sleep.

METHODS

A retrospective audit and analysis of sleep disturbance in postoperative pediatric patients using PCA devices were performed in a postoperative surgical ward population of a major tertiary referral center. PCA presses were used as a proxy measure of sleep. The description of the sleep disturbance included an unadjusted and adjusted analysis of the proposed predictors of sleep disturbance: age, sex, nature of presentation, operation type, PCA opioid type, presence of background infusion, postoperative night number, and adjuvant medication. All data were entered into an access database developed for the audit and analyzed using stata 8.0.

RESULTS

The first 126 children prescribed PCA devices in the year 2004 were audited. One-third of patients in the population prescribed PCA experienced sleep disturbance. Observed predictors of sleep disturbance include older children (OR: 0.86, P=0.001) and those receiving a background infusion (OR: 0.19, P=0.002). Other predictors were not significant.

CONCLUSIONS

Sleep disruption is common in children-prescribed PCA opioid analgesia. Older children and those receiving a background infusion were observed to experience less sleep. Other proposed predictors were not found to be reliable. Further investigation into the predictors of disturbed sleep in the postoperative patient is warranted.

Sleep quality in hospitalized patients

AIMS AND OBJECTIVES

The objective of this study was to evaluate and compare sleep quality of the hospitalized patients and matched healthy controls.

BACKGROUND

Although the functions of sleep are not clearly understood, it is generally accepted that it is necessary for the maintenance of good health. Hospitalized patients' sleep may not be refreshing or restorative. The reasons for this can be categorized into three groups: environmental, physiological and psychological.

DESIGN AND METHODS

This research was conducted at the Cumhuriyet University Hospital in Turkey. One hundred and fifty hospitalized patients (psychiatry = 50; orthopaedic + general surgery + cardiovascular surgery + urology = 50; internal medicine + chest diseases + infectious diseases + physical therapy and rehabilitation = 50) and 50 healthy controls constituted the sample. The researchers administered to the patient and control groups Sociodemographic Information Form and the Pittsburgh Sleep Quality Index. We compared sociodemographic and illness variables with sleep characteristics. The following statistical analyses were used in order to evaluate the data: variance analysis, Tukey HSD test, Student's t-test, Kruskall-Wallis test.

RESULTS

We found that patients in psychiatric ward experienced worse sleep quality than the other patients, worse in female patients than male patients, and worse sleep characteristics in patients than controls.

CONCLUSIONS

Health professionals must be educated about sleep and must provide intervention when needed. Relevance to clinical practice. The enhancing of sleep quality accelerates to the recovery from illness.

Postoperative delirium: the tryptophan dyregulation model

A model previously presented by Uchida in this journal [Med. Hypotheses 53 (1997) 103] described a mechanism for postoperative delirium. It described an increased level of melatonin resulting in a central "serotonin shortage". This construct adequately explained only the hypoactive type of delirium. Recently it has been shown that a reduction in urinary metabolites of melatonin is associated with hyperactive delirium, whereas urinary metabolites were increased in the hypoactive variant. These findings suggest that this initial paradigm requires modification. We propose that both the agitation seen in hyperactive delirium, and the somnolence associated with the hypoactive form could be explained by a disturbance of central tryptophan homeostasis. It is postulated that intervention in the form of melatonin administration may restore tryptophan levels, and prevent delirium.

Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery-report of four cases

PURPOSE

Continuous interscalene brachial plexus blockade (CIBPB) in a hospital setting can provide excellent surgical conditions and postoperative analgesia for major shoulder surgery. This is a case report of four patients on the efficacy and advantages of CIBPB for postoperative analgesia at home.

CASE REPORTS

Four patients scheduled for rotator cuff repair under CIBPB were discharged home the day of surgery with an interscalene catheter connected to an automated infusion pump administering 0.2% ropivacaine at 10 mL x hr(-1) for 72 hr. Prior to discharge, patients and their attendant were given verbal and written instructions concerning local anesthetic toxicity and explicit contact information for an anesthesiologist or nurse. Outcomes were measured pre- and postoperatively, including verbal analogue pain scores (pain VAS), verbal analogue nausea scores (nausea VAS), side effects, cognitive function (mini-mental state questionnaire), sleep (hours/night), and patient satisfaction (Likert scale). Postoperative VAS scores over three days were very low. Two patients reported only one episode of nausea. There were no complications associated with local anesthetic toxicity or catheter use. Cognitive function improved over three days. Sleep increased from a mean of five hours before surgery to seven hours over the next three nights. Patient satisfaction with care was high. Significant cost savings were documented.

CONCLUSION

The use of CIBPB for 72 hr in patients undergoing major ambulatory shoulder surgery can result in good analgesia with minimal opioid requirement, cost savings and possibly improvement in outcome measures.

Sleep and aging

Synthesis of studies of sleep and aging show major increases occur in nighttime awakening and major decreases occur in sleep depth over the life span. Fatigue and drowsiness during the day, with increased napping, and earlier bedtimes, are also prevalent in the elderly. Interventions that impact these sleep variables, as well as sleep variables that change less dramatically, are needed. All indications are that the promotion of restorative sleep and daytime well-being in older adults will continue to be an important part of nursing practice affecting even more people as the population ages. Although nurses have only begun to identify and study interventions that promote sleep in nursing environments, nursing is in a position to make major contributions to the health and well-being of older adults who experience sleep disruption, especially sleep disruptions secondary to illness and aging.

Optimizing perioperative pain management

All nurses, regardless of specialty or practice setting, must provide effective measures to relieve their patients' pain. Uncontrolled pain can result in negative consequences, such as impaired cardiac functioning and neuroplastic changes in the spine and brain. This article discusses the problem of uncontrolled pain and perioperative nurses' role in relieving pain, including assessing pain and providing pharmacological and nonpharmacological relief.

Comparison of patient-controlled epidural analgesia with and without night-time infusion following gastrectomy

To assess the analgesic efficacy and side effects of a supplemental night-time infusion in patient-controlled epidural analgesia (PCEA) after gastrectomy, we carried out a randomized, double-blind study. The number of requests were lower (P<0.005) in the PCEA plus night-time infusion group than in the PCEA alone group during the postoperative nights. Patients who had a PCEA plus night-time continuous infusion, slept with fewer interruptions than those who had only the PCEA. VAS pain scores on coughing were significantly lower (P<0.05) in the PCEA plus infusion group than in the PCEA alone group during the night following postoperative day 1. In conclusion, a night-time infusion in PCEA following gastrectomy decreases the incidence of postoperative pain, provides a better sleep pattern, and reduces the degree of the pain associated with coughing during the night.

Living with a chronic leg ulcer: an insight into patients' experiences and feelings

OBJECTIVES

This study sought to ascertain patient need and help health-care professionals to understand the effects of chronic leg ulceration from a patient's perspective.

METHOD

A qualitative grounded theory approach was used. A purposeful sample of eight participants (six females and two males) was selected. All were under the care of a district nurse and had over a year's history of venous leg ulceration. Data were collected by interview.

RESULTS

Five major categories developed, relating to the 'physical experience', 'loss of control', 'vision of the future', 'carer's perspective' and 'health-care professional and patient relationship'.

CONCLUSION

Although the physical and psychological effects of leg ulceration featured prominently in this study, these were heavily influenced by the relationship between the participant and the health-care professional.

Symptom experience in women after hysterectomy

OBJECTIVE

To review the literature addressing the symptom experience of women after hysterectomy.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as texts and references cited in articles. Key concepts in the searches included hysterectomy, sleep disturbance and pain, hysterectomy and fatigue, hysterectomy, depression, and depressed mood.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1970, with an emphasis on new findings from 1990 to 2000. Sixty-four citations were identified as useful to this review.

DATA EXTRACTION

Data were organized under the following headings: women and hysterectomy, biopsychosocial perspectives, common symptoms after hysterectomy (pain, disturbed sleep, fatigue, depressed mood, anxiety), and significance of review (implications).

DATA SYNTHESIS

Literature suggests that after a hysterectomy, women experience complications during the postoperative recovery period that may vary with the type of surgical procedure. During this period, the quantity and quality of sleep as well as other symptoms (pain, fatigue, anxiety, and depression) are influenced by various physiologic, psychologic, and social factors. Despite limited evidence that sleep problems may occur frequently during the recovery period, only a few researchers have systematically examined sleep patterns in women after hysterectomy. None of these studies, however, used objective sleep measures or examined multiple dimensions of these women's lives.

CONCLUSIONS

This review conceptualized the women's symptom experience as the experience of specific symptoms (pain, sleep disturbance, fatigue, depressed mood, and anxiety) that were influenced by biopsychosocial factors.

Interactive relationships between hospital patients' noise-induced stress and other stress with sleep

OBJECTIVE

The purpose of this study was to test the hypothesis that hospital noise-induced subjective stress would interact with other subjective environmental and personal stress in a relationship with poorer patient sleep.

METHODS

A secondary data analysis was done using correlations and hierarchical multiple regression. Ninety-seven cardiac patients participated after transfer from critical care to a general unit. The independent variables were assessed with Topf's 24-item Disturbance Due to Hospital Noise Scale and 5-point items for other environmental stress (ie, bed, lights) and personal stress (ie, pain, anxiety). Sleep was evaluated with the Verran and Snyder-Halpern Sleep Scale.

RESULTS

Hierarchical multiple regression led to a multiple R of 0.435 (P <.01). An interaction term, subjective noise stress x subjective bed stress x subjective pain x subjective anxiety accounted for a significant amount of sleep variance (12%, F = 13.63, P =.000). Subjective bed stress x subjective pain accounted for an additional 5% (F = 6.4, P =.013).

CONCLUSIONS

Studies using research designs that assess relationships between multiple patient stress variable interactions and sleep or other stress-related outcomes may produce more accurate results than studies on the independent effects of different types of stress.

Sleep disturbances after non-cardiac surgery

After major non-cardiac surgery sleep pattern is usually disturbed with initial suppression of rapid eye movement sleep with a subsequent rebound during the first post-operative week. Deep sleep is also suppressed for several days after the operation and subjective sleep quality is impaired. The sleep disturbances seem to be related to the magnitude of trauma and thereby to the surgical stress response and/or post-operative opioid administration. Post-operative sleep disturbances may contribute to the development of early post-operative fatigue, episodic hypoxaemia, haemodynamic instability and altered mental status, all with a potential negative effect on post-operative outcome. Minimizing surgical trauma and avoiding or minimizing use of opioids for pain relief may prevent or reduce post-operative sleep disturbances. Post-operative sleep pattern represents an important research field, since it may have a significant negative on post-operative outcome. 2001 Harcourt Publishers Ltd

Pain after gynecologic surgery

This article provides a descriptive profile of pain in 80 women during the first 2 days after gynecologic surgery in 4 hospitals. Surgical procedures included abdominal hysterectomy, oophorectomy, and laparotomy. Average pain was moderate on both days, but paired t tests indicated that pain increased significantly during ambulation on day 1 (P = .009, sensation; P < .001, distress) and on day 2 (P = .007, sensation; P = .030, distress). They both (P = .001) decreased significantly during rest on day 1, but not on day 2. Analysis of quartiles indicated that one fourth of the sample suffered severe sensation pain at all points on day 1 (60 to 74 mm on a 100-mm visual analogue scale), and moderate to severe sensation on day 2 (40 to 60 mm). The lowest quartile had mild pain on both days (11 to 28 mm on day 1, and 7 to 14 mm on day 2). Some patients (30%) reported that pain interrupted their sleep on the first 2 nights, and difficulty sleeping on the first postoperative night for any reason (65%) was related to greater pain during the next 2 days (r = .25 to .43). Although 41% of the women had previously used relaxation techniques for stress or pain, only 9% used it for pain after surgery. Results suggest that postoperative patients have moderate to severe pain that is incompletely relieved with patient-controlled analgesia. Nurses should encourage patients to press the patient-controlled analgesia button more often, report unrelieved pain, and use nonpharmacologic interventions.

Factors affecting the administration of analgesia to patients following repair of a fractured hip

Fracture of the neck of femur, or hip, has become common in older females and the resulting pain is often a factor in inhibiting early mobilization following surgical repair. Since the administration of analgesia is dependant upon decision-making of the nurse, this study concentrated on what influences nurses in the administration of analgesia to patients following surgical repair of a fractured hip. A review of the literature identifies the main influencing factors as nurses' lack of knowledge and the drug prescription, and suggests that education is the key enabler. However, much of this research is limited to controlled situations outside the clinical setting with a focus on the internal processes of decision-making. This ethnographic multiple-case study aimed to analyse factors which influence nurses' decision-making in the clinical setting and define behaviours in context. Following periods of participant observation and observation of documentation, semi-structured interviews were conducted to explore further the rationale behind nurses' decisions. Factors found to influence decision-making were: time, organization of care, influence of shift worked, impact of the multidisciplinary team (MDT), concerns over the use of opioid analgesia, and information giving and collection. These influences were found to be dependant on location (ward), and shift, with the factor of time providing a tension between all influences. The study findings suggest that education alone will not improve the administration of analgesia. It recommends that the voice of patients is heard more clearly, that the administration of analgesia is separated from the routine drug round, that attention is paid to how decision-making by nurses is supported in clinical settings, and that education be organized on a multidisciplinary basis. In addition, further research should be carried out in the clinical setting.

A tentative model for developing strategic and clinical nursing quality indicators: postoperative pain management

The purpose of the study was to evaluate the usefulness of a tentative model, based on important aspects of surgical nursing care, for designing strategic and clinical quality indicators. Objective postoperative pain management was chosen for the model because it is a priority area in surgical nursing care. Items within a questionnaire were designed by using the tentative model as a base and by means of a literature review. The questionnaire, directed to clinical nurses (n = 233), was compiled to establish the validity and the usefulness of the indicators. Fourteen items were assessed as essential for achieving high quality outcomes in postoperative pain management (11 as realistic to carry out, and 13 as possible for nurses to influence) with mean scores > or = 4 (on a 5-point scale). The conclusion reached was that the tentative model combined with a literature search was found to be effective for designing items that might be useful as strategic and clinical indicators of quality in postoperative pain management.

AHCPR clinical practice guideline on surgical pain management: adoption and outcomes

Pain management practices and short-term patient outcomes in nine acute care hospitals in Milwaukee, Wisconsin, were studied at two points in time. One-and-a-half years after the Agency for Health Care Policy and Research's (AHCPR) Clinical Practice Guideline on Acute Pain Management was published, data from 330 adult surgical patients were collected (Time I). These data were contrasted with data from 373 adult surgical patients collected 2 years later (Time II). There were significant increases in the percentage of patients who reported being taught how to report pain using a pain rating scale and about setting a pain goal preoperatively; in the percentage of patient hospital records with at least one documented numeric pain rating; and in the percentage of patients who received analgesics by intravenous administration. However, pain management practices continued to differ from recommendations in the AHCPR guideline. No significant improvement was noted in the short-term outcomes of patient-rated pain or patient satisfaction with pain management. Availability of well-published guidelines alone may be insufficient to ensure comprehensive adoption of guidelines that are multidimensional in nature and to obtain improvements in patient outcome.

Implementation of research findings to reduce postoperative pain at night

This study was designed to introduce and evaluate a research-based intervention to improve night-time pain management. It involved the provision of patient information and the introduction of structured night-time pain assessment. The implementation of the intervention was undertaken by local opinion leader. The study involved 417 patients from two matched orthopaedic wards in a before and after trial with comparison group. Outcomes of night-time pain control were elicited from ward documentation and patients by structured interviews on the second postoperative morning. These incorporated retrospective pain assessments, analgesic provision and nursing comfort measures provided the previous night. The intervention was associated with statistically significant reductions in both average and worst overnight pain scores. The frequency of night-time pain assessment by nursing staff increased significantly, although patients did not volunteer reports of pain more frequently and analgesics and other comfort measures were no more frequent. The intervention required an investment in educational support but no additional resources were needed for the successful reduction in pain scores.

Thinking of the future and walking back to normal: an exploratory study of patients' experiences during recovery from lower limb fracture

Admission to hospital following a traumatic lower limb fracture is undoubtedly a stressful life event; however, few studies have detailed this from the patient's perspective. By exploring patients' experiences of hospitalization with lower limb trauma, this study aimed to explicate some of the factors impinging on the recovery trajectory. Patients' perceptions of the events influencing their strategies for coping with stress, hospitalization and temporary incapacity were investigated using a qualitative methodology. A convenience sample of nine patients was recruited from an orthopaedic ward in a district general hospital in Wales. The respondents used health diaries to document their recovery for up to 6 weeks after emergency surgery. These diaries were validated and supplemented by semi-structured interviews. Following their traumatic injuries, our respondents were subjected to a variety of stressors and uncertainties. They coped with this period of uncertainty by positive attempts to gain control over their situations, guided by an over-riding desire to 'return to normal' and assisted by the caring attributes of their nurses. From the experiences and events documented, this study was able to identify several stressors which could have been mitigated by optimization of the technical aspects of care, including the management of pain.

[Cultural effect on postoperative pain]

The objective of this study was to describe the influence of culture on 12 surgical patients. The data was collected by interviews and the analysis was based on the framework of the qualitative methodology. The results showed four categories of influence: the type of pain, the expectancy by pain, the meaning of the pain and the pain management. The meaning apprehended is suffering and was verbalized by metaphors. The study considers the importance of the cultural comprehension about pain by the nurse.