The Impact of Morning Surgery or Afternoon Surgery on Postoperative Sleep Quality and Melatonin Levels of Elderly Patients: A Prospective, Randomized Study

Effects of remimazolam and propofol on sleep rhythm and delirium after spinal surgery in elderly patients

OBJECTIVE

This study aims to investigate the effects of remimazolam on postoperative melatonin secretion, sleep rhythm, and postoperative delirium (POD) in elderly patients undergoing spinal surgery.

METHODS

We selected 120 elderly patients scheduled for elective spinal surgery (lumbar interbody fusion via a posterior approach) under general anaesthesia from November 2023 to January 2024. They were divided into 2 groups according to medication, the remimazolam group (R group) and the propofol group (P group), with 60 patients in each group. The R group received an induction dose of remimazolam 0.2 ~ 0.3 mg/kg, followed by a continuous infusion of remimazolam at 0.1-0.2 mg/kg/h for maintenance. The P group received an induction dose of propofol 1.5 ~ 2.0 mg/kg, followed by a continuous infusion of propofol at 4-6 mg/kg/h for maintenance. Melatonin and cortisol concentrations were measured at 04:00 on the day of surgery and postoperative days 1, 2, and 3. The Pittsburgh Sleep Quality Index (PSQI) and resting visual analog scale (VAS) pain scores were recorded on the day before surgery, and on postoperative days 1 and 2, as well as prior to discharge. Additionally, we documented extubation time, PACU stay duration, total and effective button presses on the analgesia pump, instances of supplemental analgesia, and occurrence of complications.

RESULTS

Compared to the P group, the R group exhibited significantly shorter extubation time and PACU stay duration (P < 0.05). On postoperative days 1 and 2 at 04:00, melatonin concentrations were significantly higher, cortisol concentrations were significantly lower, and PSQI scores were significantly reduced in the R group (P < 0.05). The incidence of POD and postoperative sleep disturbance (POSD) was also significantly lower in the R group (P < 0.05). Furthermore, on postoperative day 1, the PSQI and resting VAS pain scores in the R group were significantly lower compared to the P group (P < 0.05). There were no statistically significant differences between the two groups in terms of surgery duration, anaesthesia duration, total and effective analgesia pump button presses, supplemental analgesia rates, intraoperative hypotension, or incidences of postoperative nausea, vomiting, dizziness, and respiratory depression (P > 0.05).

CONCLUSION

The use of remimazolam in elderly patients undergoing spinal surgery has a minimal impact on postoperative melatonin and cortisol secretion rhythms and sleep patterns, and may reduce the incidence of POD and alleviate postoperative sleep disturbances.

Intraoperative Dexmedetomidine Infusion Improved Postoperative Sleep Quality and Melatonin Secretion in Patients Undergoing Elective Thoracoscopic Lung Surgery: A Prospective, Randomized Study

Background

Dexmedetomidine has been reported to improve postoperative sleep quality. However, the underlying mechanism remains unclear. This study aimed to investigate the effect of intraoperative dexmedetomidine infusion on postoperative sleep quality and changes in melatonin secretion in older patients undergoing elective thoracoscopic lung surgery.

Methods

A total of 126 older patients were randomly divided into two groups: dexmedetomidine group (Group D), which received continuous dexmedetomidine infusion at 0.3-0.5 µg/(kg·h) combined with propofol during surgery, and propofol group (Group P), which received propofol alone. The primary outcome was the postoperative sleep quality on the first postoperative night, assessed by the Richards-Campbell Sleep Questionnaire (RCSQ). Secondary outcomes included sleep quality scores on the second and third postoperative nights, melatonin concentrations postoperatively, and the incidence of delirium on the first and seventh postoperative days (discharge day).

Results

On the first postoperative night, Group D had a higher sleep quality score compared to Group P (57±11.4 vs 53±10.3; [95% CI, 1.1 to 8.7];P = 0.012), with no difference between the groups on the second and third postoperative nights. There was no statistically significant difference in the preoperative and postoperative night 3 urine 6-SMT concentrations between the two groups (P > 0.05); however, Group D had significantly higher urine 6-SMT concentrations on postoperative nights 1 and 2 compared to Group P (27 (24, 30) vs 21 (17, 24); [95% CI, -8.56 to -4.73]; P = 0.000. 28 (25, 30) vs 26 (21, 27); [95% CI, -4.37 to -1.65]; P = 0.000). There was no significant difference in the incidence of postoperative delirium between the two groups (P=0.65).

Conclusion

Continuous intraoperative infusion of dexmedetomidine can effectively improve sleep quality during the first postoperative night by promoting melatonin secretion over the first two postoperative nights.

The impact of diurnal variations on emergence delirium following general anesthesia and surgery in children

Background

Emergence delirium (ED) is a widely recognized issue that prolongs mechanical ventilation and post-anesthesia care unit (PACU) resuscitation time, consequently increasing hospital costs and mortality. Postoperative disturbance in circadian rhythms, commonly leading to sleep disorders, has been identified as a significant risk factor for ED. However, the influence of surgery timing (morning vs. afternoon) on the incidence of ED in pediatric patients undergoing general anesthesia remains unknown.

Methods

Patients aged 2-6 years who were operated on under general anesthesia with a bispectral index value between 50 and 60 were categorized based on anesthesia start time into either the morning surgery group (Group M, 8:00-12:00) or the afternoon surgery group (Group A, 13:00-17:00). The primary outcome was the post-extubation incidence of ED assessed by the Cornell Assessment of Pediatric Delirium (CAPD) score. Secondary outcomes included extubation time, duration of PACU stay, and adverse postoperative events and complications.

Results

We recruited a total of 560 patients, 280 in group M and 280 in group A. Compared to Group M, Group A exhibited a significantly higher incidence of ED (p < 0.001), elevated CAPD scores (p < 0.001), and prolonged PACU stays (p < 0.001). Notably, there was no significant difference in extubation time and anesthesia-related adverse events or other postoperative complications between the groups.

Conclusion

Our study highlights that the time of surgery significantly affects the incidence of ED, CAPD scores, and PACU stay duration in children. Further validation of these findings may guide future strategies to reduce ED.

Diurnal variation of postoperative delirium in elderly patients undergoing esketamine anesthesia for elective noncardiac surgery: a randomized clinical trial

BACKGROUND

Postoperative delirium (POD) is a serious and common complication. The aim of present study is to investigate the diurnal variation of POD and the effects of esketamine in elderly patients.

METHODS

A randomized, double-blind, placebo-controlled clinical trial with factorial design was conducted. Patients (aged 65 to 85 years) with normal Mini-Mental State Examination (MMSE) score were stratified by age (≤70 vs. >70) and American Society of Anesthesiologists physical status classification (Ⅱ vs. Ⅲ), then randomly assigned to either morning (08:00-12:00) or afternoon (14:00-18:00) noncardiac operation under general anesthesia with or without esketamine administration (0.2 mg/kg). The primary outcome was the incidence of POD (3-Minute Diagnostic Interview for Confusion Assessment Method-defined Delirium, 3D-CAM) on postoperative days 1, 3, and 7. The secondary outcomes were the scores of MMSE and Hospital Anxiety and Depression Scale. The intention-to-treat analysis of the outcomes were performed by generalized estimating equation.

RESULTS

Six patients who did not receive an intervention because of canceled operation were excluded after randomization. The datasets containing 426 cases were analyzed following the intention-to-treat principle after handling missing data via multiple imputation method. The incidence of POD declined from about 55% on postoperative day 1 to 31 and 18% on postoperative days 3 and 7, respectively. Afternoon operation [B=-0.583, OR (95% CI) 0.558 (0.319-0.976); P=0.041], but not esketamine, significantly decreased the incidence of POD. Both esketamine and operation time failed to significantly affect MMSE, HAD, and NRS score. There was no interaction among operation time, esketamine, and follow up time.

CONCLUSION

Elderly patients undergoing elective noncardiac surgery in the afternoon displayed lower POD incidence than those operated in the morning. A single low-dose of esketamine before general anesthesia induction failed to significantly decrease the risk of POD but decrease the risk of intraoperative hypotension and emergence agitation.

Association between kidney stones and poor sleep factors in U.S. adults

The purpose of our study is to examine the correlation between sleep factors and the prevalence of kidney stones in US adults. A total of 34,679 participants from the National Health and Nutrition Examination Survey 2007 to 2018 were included in the analyses. Sleep data collection included: presleep factors (difficulty falling asleep, sleep onset latency), intra-sleep factors (risk index of obstructive sleep apnea, restless leg syndrome, difficulty maintaining sleep), post-sleep factors (daytime sleepiness, non-restorative sleep), sleep schedule and duration, and sleep quality. Logistic regression models were used to analyze the correlation between sleep factors and the prevalence of kidney stones. Among the 34,679 participants, the overall incidence of kidney stones was 9.3%. The presence of presleep factors (difficulty falling asleep [odds ratios [OR], 1.680; 95% CI, 1.310-2.150], prolonged sleep onset latency [OR, 1.320; 95% CI, 1.020-1.700]), intra-sleep factors (higher risk index of obstructive sleep apnea [OR, 1.750; 95% CI, 1.500-2.050], restless leg syndrome [OR, 1.520; 95% CI, 1.150-1.990], difficulty maintaining sleep [OR, 1.430; 95% CI, 1.130-1.810]), post-sleep factors (daytime sleepiness [OR, 1.430; 95% CI, 1.220-1.680], non-restorative sleep [OR, 1.400; 95% CI, 1.110-1.760]), short sleep duration (OR, 1.190; 95% CI, 1.080-1.310), mediate sleep quality (OR, 1.140; 95% CI, 1.020-1.290), and poor sleep quality (OR, 1.500; 95% CI, 1.310-1.720) are linked to the occurrence of kidney stones. However, short sleep onset latency, bedtime and wake-up time were not significantly associated with the prevalence of kidney stones. These findings showed positive associations between higher kidney stone prevalence and poor sleep factors.

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.

Telehealth and Biological Rhythm: Deficits and Benefits for Orthopedic Postoperative Consultations

The Article Abstract is not available.  

Prophylactic effect of exogenous melatonin and melatonin receptor agonists on postoperative delirium in elderly patients: a systemic review and meta-analysis of randomized controlled trials

BACKGROUND

The prophylactic effect of exogenous melatonin and melatonin receptor agonists (MMRAs) on postoperative delirium (POD) in elderly patients remains controversial.

OBJECTIVE

This study aimed to assess the prophylactic effect of MMRAs on POD by conducting a systemic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We systematically searched four electronic databases including PubMed, Web of Science, Cochrane Library, and Embase for the eligible studies up to February 28, 2023. The Cochrane risk of bias tool was used for assessing the risk of bias in the included RCTs. The occurrence of POD was the primary outcome. The quality of evidence was evaluated by Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

A total of 11 RCTs comprising patients (MMRA group: 777 patients and placebo group: 781 patients) were included. The results of the meta-analysis showed that the MMRA group had a lower occurrence of POD than the placebo group (risk ratio = 0.70, 95% confidence interval: 0.51-0.97, P < 0.05, I2 = 59%). The subgroup analysis showed that melatonin significantly reduced the occurrence of POD (moderate-quality evidence), whereas ramelteon and tryptophan had no significant impact (moderate-quality evidence).

CONCLUSION

Existing evidence suggested that perioperative use of melatonin can prevent POD in elderly patients.