Original Research—Sleep Medicine and Surgery
Correlation between Sleep Disruption on Postoperative Pain Anya Miller, MD1, Thomas Roth, PhD1, Timothy Roehrs, PhD1, and Kathleen Yaremchuk, MD1
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Abstract 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 = 20.31; 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 = 20.35, 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.
T
he overall perception of sleep in the hospital is that it is fragmented and uncomfortable. It is common for numerous people to walk in and out of patient rooms, as well as experience noise in the hallway and bright lights in the hospital room and hallways. Some of these disturbances may be necessary for administering safe patient care, but an unintended consequence may be poor sleep with increased demands for pain control and increased length of stay. Sleep deprivation has been found in prior studies to have negative effects on wound healing, immunity, mental status, and mortality.1 Studies in the intensive care unit (ICU), where patients are the most critically ill, demonstrate as many as 40 to 50 sleep disturbances per night.2,3 Noise levels in the hospital can in some places be as loud as a subway,4 hindering patient sleep as well. While some degree of sleep loss may be attributable to hospital factors, individual patient factors must be evaluated as contributors to impaired sleep. Pain has been identified as a cause of poor sleep quality. Poor sleep quality has been associated with increased pain perception.5 Narcotics, while they alleviate pain, also result in negative changes in sleep architecture.6 Using a combination of actigraphy and sleep diaries, this study sought to identify the amount of sleep disruption that occurs in the postoperative inpatient hospital setting, the relationship between sleep disruption and the amount of postoperative narcotics used, patient subjective pain perception, and hospital length of stay.
Methods Patients treated at Henry Ford Hospital in Detroit, Michigan, undergoing total knee or hip arthroplasty were asked to participate in the study. The study was approved by the Institutional Review Board of Henry Ford Hospital. Fifty patients were recruited during their preoperative education sessions, during which their role in the study was 1
Keywords sleep, pain, hospital course, length of stay, complications, arthroplasty Received July 13, 2014; revised January 8, 2015; accepted January 20, 2015.
Otolaryngology– Head and Neck Surgery 2015, Vol. 152(5) 964–968 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815572127 http://otojournal.org
Henry Ford Health System, Detroit, Michigan, USA
This article was presented at the 2014 AAO-HNSF Annual Meeting & OTO EXPO; September 21-24, 2014; Orlando, Florida. Corresponding Author: Anya Miller, MD, Henry Ford Health System, 2799 West Grand Blvd, Detroit, MI 48202, USA. Email: [email protected]
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explained and informed consent was obtained. Postoperatively, patients were asked to wear an actigraph on their wrist (Actiwatch 2; Philips Respironics, Andover, Massachusetts) and complete a sleep diary (see Appendix 1 at www.otojournal.org) during their hospital stay. The actigraph was placed on the wrist opposite the arm with the IV. Use of actigraphy as a valid sleep measurement tool has been previously demonstrated.7 Because of the variation in length of stay, only the first 2 nights of a patient’s hospital stay were recorded with the actigraph. Patients with a normal hospital course, based on a standardized perioperative protocol, had an anticipated discharge on postoperative day (POD) 2 or 3. Following surgery, each patient was transferred from the postanesthesia care unit (PACU) to the general surgical floor specific to the orthopedic service with a standardized postoperative protocol. This floor observes a ‘‘quiet time’’ where lights in the halls are dimmed between 10 pm and 6 am and patient doors are closed. Each patient room is private. Patient medical records were examined for preoperative comorbidities, including sleep disorders and American Society of Anesthesiologists (ASA) Physical Status classification system, postoperative complications, pain level, and amount of pain medication administered. Sleep duration and efficiency were assessed using Actiwatch Respironics software (Philips Respironics). Epochs were set at 15 seconds with recording starting immediately after placement of the watch on the patient and ending when the device was removed the morning of POD 2. The awake index was calculated by number of awakenings divided by the time difference between the initiation of sleep and the offset of sleep. Nursing records were reviewed for patient pain scores. Pain scores were reported on a visual analog scale of 1 to 10 with 10 being extreme pain and 1 being little to no pain. In a 24-hour period, only patients’ minimum and maximum pain scores were used in the statistical analysis and not all of their pain scores reported throughout the day. The nursing medication administration records (MAR) were examined for narcotic administration. Each patient was on a standardized pain medication protocol that had been developed by the department of orthopedics (see Appendix 2 at www.otojournal.org). Narcotic administration for this study was measured by the amount of as-needed (prn) medication the patient received. A narcotic conversion table was used to convert medications to oxycodone equivalents for uniform comparison.8 No patients received hypnotic medications. Spearman correlations were made between sleep parameters: sleep duration (minutes of sleep), sleep efficiency, and awake index, with pain scores for POD 0 and 1. Spearman correlations were also made between sleep duration, sleep efficiency, and awake index with narcotic use on POD 0 and 1. Pearson correlations were made between sleep duration, sleep efficiency, and awake index with the length of hospital stay. A 2-sample t test was used to compare patients with and without complications against their sleep duration, sleep efficiency, and awake index.
Table 1. Patient Demographics. Variable Age, y n Mean (SD) Median (min, max) Sex, No. (%) Female Male Body mass index, kg/m2 Mean (SD) Median Race, No. (%) Black White Hispanic Length of hospital stay, d Mean (SD) Median (min, max) ASA class, No. (%) 1 2 3 4 Sleep disorder, No. (%) None OSA but not on CPAP OSA on BiPAP OSA on CPAP Complications, No. (%) Major Minor None
Value
50 65.1 (10.8) 66.0 (30.0, 85.0) 34 (68) 16 (32) 34.2 (7.3) 33.6 31 (62) 18 (36) 1 (2) 3.3 (1.8) 3 (1, 11) 1 (2) 16 (32) 32 (64) 1 (2) 44 (88) 2 (4) 1 (2) 3 (6) 6 (12) 12 (24) 32 (64)
Abbreviations: ASA, American Society of Anesthesiologists; BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; OSA, obstructive sleep apnea.
Results Of the 50 patients in the study, 34 (68%) were female and 16 (32%) were male, with a mean age of 65.1 years. All patients wore the actigraph for at least 2 days, but only 1 patient filled out the sleep diary. The only statement recorded on the diary was that the patient had not had any sleep. Of the 6 patients with obstructive sleep apnea, 4 were treated with continuous positive airway pressure or bilevel positive airway pressure. The other 2 patients were not receiving any treatment (Table 1). The overall complication rate was 36% (18/50), with 6 patients having major complications and 12 with minor complications. Major complications were defined as respiratory events requiring intubation, ICU admission, myocardial infarction, or joint infection. Minor complications were defined as acute blood loss anemia, urinary retention, or
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Table 2. Pain and Sleep Parameters. Parameter
Mean (SD)
POD 0 Minimum pain score Maximum pain score Range for pain score Narcotic usage (mg of oxycodone) Minutes of sleep Efficiency, % Awake Index, number/h POD 1 Minimum pain score Maximum pain score Range for pain score Narcotic usage (mg of oxycodone) Minutes of sleep Efficiency, % Awake index, number/h
1.0 7.2 6.3 27.9 419.0 61.2 5.5
(1.6) (2.8) (2.7) (26.2) (228.7) (24.8) (3.0)
1.3 7.1 5.8 37.4 375.5 66.5 5.4
(1.8) (2.0) (2.2) (35.3) (207.0) (21.0) (3.2)
Abbreviation: POD, postoperative.
superficial wound drainage without infection. None of the patients required transfer to the ICU or intubation while wearing the actigraph. Sleep parameters and pain outcomes for POD 0 and POD 1 are reported in Table 2. Sleep parameters were analyzed in relation to patientreported subjective pain scores (Table 3). Reduced minutes of sleep on POD 1 was correlated significantly with increased pain scores on POD 1 (r = 20.31, P = .032), indicating that increased pain correlates with decreased sleep duration. There was also a significant correlation between higher pain scores on POD 0 and increased sleep efficiency on POD 1 (r = 0.38, P = .009), indicating that increased pain on POD 0 correlates with more efficient sleep the following night. Narcotic use on POD 0 was examined for its effect on the sleep-pain relation on POD 1 (Table 4). After controlling for narcotic usage, the previously significant relation between maximum pain on POD 0 and sleep efficiency on
POD 1 (P = .009), was reduced to P = .053 and no longer significant. This held true for range of pain scores on POD 0 and sleep efficiency on POD 1 (P = .03), which became not significant as well (P = .076). When comparing sleep parameters with overall complication rates (minor and major complications), there was no significance (Table 5). Length of stay was compared against sleep duration, efficiency, and awake index. A significant correlation was found between length of stay and sleep efficiency on POD 0 (r = 20.35, P = .01), indicating that lower sleep efficiency correlated with an increased length of stay (Table 6).
Discussion The results of this study suggest that poor sleep efficiency is associated with greater narcotic usage and that pain is associated with decreased sleep duration. The relationship between surgery, anesthesia, and postoperative course is complex. This study attempted to control for at least one variable, surgical procedure and perioperative course. By including only patients with similar surgeries and perioperative course, the impact of sleep and pain medications could be studied. The effects of general anesthesia on postoperative sleep are well studied.9-11 Uniformly, patients display decreased total sleep time, abolishment of rapid eye movement (REM) sleep, and decreased slow-wave sleep on the first postoperative night regardless of narcotic usage.9-12 While stages of sleep were not analyzed as part of this study, compared with normative values,13 patients in this study had a marked reduction in their sleep efficiency: 61.2% vs 88.3% in the normal population. The awake index was also markedly increased at 5.5 compared with 3.2 in normal subjects. While we included only one type of surgical procedure in this study to control for general anesthesia, Humphries14 included medical and surgical patients for a longer duration. This duration was selected by Humphries to allow time for the sedating effects of general anesthesia to wear off. Patients with thoracic and large abdominal surgeries were included. Most athroplasty patients were discharged by POD 3, and since narcotic use tended to decrease by then, it
Table 3. Sleep Parameters Compared with Patient Reported Pain.a Minutes of Sleep
POD 0 Minimum pain score Maximum pain score POD 1 Minimum pain score Maximum pain score
Sleep Efficiency
Awake Index
POD 0
POD 1
POD 0
POD 1
POD 0
POD 1
–0.017 (.907) –0.074 (.618)
–0.093 (.531) 0.114 (.439)
0.284 (.053) 0.170 (.252)
0.054 (.717) 0.378 (.009)
0.012 (.940) 0.111 (.467)
–0.141 (.342) 0.093 (.533)
0.030 (.840) –0.277 (.057)
–0.311 (.032) –0.141 (.337)
0.044 (.768) –0.120 (.421)
0.013 (.932) 0.262 (.075)
0.009 (.954) –0.113 (.459)
–0.041 (.784) –0.257 (.082)
Abbreviation: POD, postoperative day. a Values are presented as correlation coefficients (P values). Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on October 6, 2015
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Table 4. Sleep Parameters Compared with Narcotic Use.a Minutes of Sleep Narcotic Use POD 0 POD 1
Sleep Efficiency
Awake Index
POD 0
POD 1
POD 0
POD 1
POD 0
POD 1
–0.026 (.858) 0.075 (.613)
0.242 (.097) –0.105 (.480)
0.232 (.116) 0.107 (.474)
0.231 (.119) 0.221 (.135)
0.278 (.064) 0.149 (.329)
0.067 (.652) –0.141 (.346)
Abbreviation: POD, postoperative day. a Values are presented as correlation coefficients (P values).
Table 5. Sleep Parameters Compared with Major and Minor Complications. Variable
Major (n = 6), Mean (SD)
Minor (n = 12), Mean (SD)
None (n = 32), Mean (SD)
P Value
243.3 (219.1) 38.8 (38.0) 4.9 (3.4)
454.7 (197.1) 66.6 (24.3) 4.9 (3.3)
440.4 (232.2) 65.4 (23.9) 5.7 (3.0
.13 .10 .79
457.0 (333.9) 57.2 (22.9) 6.5 (3.7)
393.4 (200.3) 73.2 (12.9) 4.5 (2.9)
352.0 (181.4) 66.0 (22.8) 5.3 (3.2)
.50 .33 .58
POD 0 Minutes of sleep Efficiency, % Awake index, number/h POD 1 Minutes of sleep Efficiency, % Awake index, number/h Abbreviation: POD, postoperative day.
Table 6. Sleep Parameters Compared with Length of Hospital Stay. Sleep
Efficiency
Awake Index
Length of Hospital Stay, d
POD 0
POD 1
POD 0
POD 1
POD 0
POD1
Correlation coefficient P value
–0.194 .187
0.180 .220
–0.355 .015
–0.005 .974
–0.038 .803
0.112 .453
Abbreviation: POD, postoperative day.
was felt that capturing the first and second nights of sleep would yield adequate information on patients’ pain and their sleep parameters. The interplay of narcotics and pain is complex since each independently disturbs sleep. This patient population had preexisting pain due to osteoarthritis requiring joint replacement. It is difficult to say to what effect these patients’ prior sleep disturbance or anxiety relating to surgery may have had on their sleep after surgery. Insight into the contributing factors for poor sleep might have been gained if patients had completed their sleep diaries. When the patients were questioned as to why they did not fill out the diaries, some stated that they had simply chosen not to, forgot, or were too busy to fill out the forms. In fact, all total arthroplasty patients were mobilized early on POD 1 and mobilized multiple times throughout the day through standardized individual and group physical therapy sessions. It is reasonable to associate increased pain scores with decreased sleep duration (as was found for minutes of sleep on POD 1, which decreased with higher minimum pain
scores on POD 1 [P = .031]). However, the finding that a higher maximum pain score on POD 0 correlates with more efficient sleep on POD 1 (P = .009) is more surprising. In a study by Closs,15 patients reported that their sleep was aided by the administration of narcotics to alleviate pain. It is possible that patients with more pain the first day may be encouraged to increase use of narcotics the next day and are better able to manage their pain, resulting in increased sleep efficiency the following night. The sleep debt from the previous night may also contribute to the increased sleep efficiency the subsequent night. If more nights of sleep were recorded, it is possible that more evidence for this would emerge.
Conclusions The interplay of patient’s sleep with general anesthesia, narcotics, and pain is complex. Results from this study show that increased pain scores are associated with decreased sleep duration. Improvements in pain control and sleep efficiency may result in a decrease in length of stay.
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Acknowledgments We thank Michelle Jankowski, PhD, of Henry Ford Hospital’s biostatistical department for statistical analysis and Lige Kaplan, MD, Michael Laker, MD, and Michael Mott, MD, for allowing us to use their patients for participation in this study.
Author Contributions Anya Miller, data collection, interpretation and analysis of data, design of work, drafting manuscript, approval of final version, agreement to be accountable for all aspects of the work; Thomas Roth, design of work, analysis, revision of manuscript, approval of final version, agreement to be accountable for all aspects of the work; Timothy Roehrs, design of work, analysis, revision of manuscript, approval of final version, agreement to be accountable for all aspects of the work; Kathleen Yaremchuk, conception and design of work, revision of manuscript, approval of final version, agreement to be accountable for all aspects of the work.
Disclosures Competing interests: Thomas Roth, consultant: Abbott, Accadia, Acogolix, Acorda, Actelion, Addrenex, Alchemers, Alza, Ancel, Arena, AstraZeneca, Aventis, AVER, Bayer, BMS, BTG, Cephalon, Cypress, Dove, Elsai, Elan, Eli Lilly, Evotec, Forest, Glaxo Smith Kline, Hypnion, Impax, Intec, Intra-Cellular, Jazz, Johnson and Johnson, King, Ludbeck, McNeil, MediciNova, Merck, Neurim, Neurocrine, Neurogen, Novartis, Orexo, Organon, Otsuka, Prestwick, Proctor and Gamble, Pfizer, Purdue, Resteva, Roche, Sanofi, Schering Plough, Sepracor, Servier, Shire, Somaxon, Syrex, Takeda, TransOral, Vanda, Vivometrics, Wyeth, Yamanuchi, Xenoport. Grants: Aventis, Cephalon, Glaxo Smith Kline, Neurocrine, Pfizer, Sanofi, Schering Plough, Sepracor, Somaxon, Syrex, Takeda, TransOral, Wyeth, Xenoport. Speakers: Cephalon, Sanofi, Takeda. Sponsorships: None. Funding source: None.
Supplemental Material
2. Tamburri LM, DiBrienza R, Zozula R, Redeker NS. Nocturnal care interactions with patients in critical care units. Am J Crit Care. 2004;13:102-112, quiz 14-15. 3. Celik S, Oztekin D, Akyolcu N, Issever H. Sleep disturbance: the patient care activities applied at the night shift in the intensive care unit. J Clin Nurs. 2005;14:102-106. 4. McLaren E, Maxwell-Armstrong C. Noise pollution on an acute surgical ward. Ann R Coll Surg Engl. 2008;90:136-139. 5. Redeker NS. Sleep in acute care settings: an integrative review. J Nurs Scholarsh. 2000;32:31-38. 6. Knill RL, Moote CA, Skinner MI, Rose EA. Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week. Anesthesiology. 1990;73:52-61. 7. Sadeh A, Hauri PJ, Kripke DF, Lavie P. The role of actigraphy in the evaluation of sleep disorders. Sleep. 1995;18:288-302. 8. Opioid Equianalgesic Doses. Monthly Prescribing Reference; 2012. 9. Lehmkuhl P, Prass D, Pichlmayr I. General anesthesia and postnarcotic sleep disorders. Neuropsychobiology. 1987;18:37-42. 10. Moote CA, Knill RL. Isoflurane anesthesia causes a transient alteration in nocturnal sleep. Anesthesiology. 1988;69:327-331. 11. Rosenberg-Adamsen S, Kehlet H, Dodds C, Rosenberg J. Postoperative sleep disturbances: mechanisms and clinical implications. Br J Anaesth. 1996;76:552-559. 12. Cronin AJ, Keifer JC, Davies MF, King TS, Bixler EO. Postoperative sleep disturbance: influences of opioids and pain in humans. Sleep. 2001;24:39-44. 13. Walsleben JA, Kapur VK, Newman AB, et al. Sleep and reported daytime sleepiness in normal subjects: the Sleep Heart Health Study. Sleep. 2004;27:293-298. 14. Humphries JD. Sleep disruption in hospitalized adults. Medsurg Nurs. 2008;17:391-395. 15. Closs SJ. Patients’ night-time pain, analgesic provision and sleep after surgery. Int J Nurs Stud. 1992;29:381-392.
Additional supporting information may be found at http://otojournal .org/supplemental.
References 1. Flaherty JH. Insomnia among hospitalized older persons. Clin Geriatr Med. 2008;24:51-67, vi.
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Correlation between Sleep Disruption on Postoperative Pain Anya Miller, MD1, Thomas Roth, PhD1, Timothy Roehrs, PhD1, and Kathleen Yaremchuk, MD1
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Abstract 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 = 20.31; 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 = 20.35, 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.
T
he overall perception of sleep in the hospital is that it is fragmented and uncomfortable. It is common for numerous people to walk in and out of patient rooms, as well as experience noise in the hallway and bright lights in the hospital room and hallways. Some of these disturbances may be necessary for administering safe patient care, but an unintended consequence may be poor sleep with increased demands for pain control and increased length of stay. Sleep deprivation has been found in prior studies to have negative effects on wound healing, immunity, mental status, and mortality.1 Studies in the intensive care unit (ICU), where patients are the most critically ill, demonstrate as many as 40 to 50 sleep disturbances per night.2,3 Noise levels in the hospital can in some places be as loud as a subway,4 hindering patient sleep as well. While some degree of sleep loss may be attributable to hospital factors, individual patient factors must be evaluated as contributors to impaired sleep. Pain has been identified as a cause of poor sleep quality. Poor sleep quality has been associated with increased pain perception.5 Narcotics, while they alleviate pain, also result in negative changes in sleep architecture.6 Using a combination of actigraphy and sleep diaries, this study sought to identify the amount of sleep disruption that occurs in the postoperative inpatient hospital setting, the relationship between sleep disruption and the amount of postoperative narcotics used, patient subjective pain perception, and hospital length of stay.
Methods Patients treated at Henry Ford Hospital in Detroit, Michigan, undergoing total knee or hip arthroplasty were asked to participate in the study. The study was approved by the Institutional Review Board of Henry Ford Hospital. Fifty patients were recruited during their preoperative education sessions, during which their role in the study was 1
Keywords sleep, pain, hospital course, length of stay, complications, arthroplasty Received July 13, 2014; revised January 8, 2015; accepted January 20, 2015.
Otolaryngology– Head and Neck Surgery 2015, Vol. 152(5) 964–968 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815572127 http://otojournal.org
Henry Ford Health System, Detroit, Michigan, USA
This article was presented at the 2014 AAO-HNSF Annual Meeting & OTO EXPO; September 21-24, 2014; Orlando, Florida. Corresponding Author: Anya Miller, MD, Henry Ford Health System, 2799 West Grand Blvd, Detroit, MI 48202, USA. Email: [email protected]
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explained and informed consent was obtained. Postoperatively, patients were asked to wear an actigraph on their wrist (Actiwatch 2; Philips Respironics, Andover, Massachusetts) and complete a sleep diary (see Appendix 1 at www.otojournal.org) during their hospital stay. The actigraph was placed on the wrist opposite the arm with the IV. Use of actigraphy as a valid sleep measurement tool has been previously demonstrated.7 Because of the variation in length of stay, only the first 2 nights of a patient’s hospital stay were recorded with the actigraph. Patients with a normal hospital course, based on a standardized perioperative protocol, had an anticipated discharge on postoperative day (POD) 2 or 3. Following surgery, each patient was transferred from the postanesthesia care unit (PACU) to the general surgical floor specific to the orthopedic service with a standardized postoperative protocol. This floor observes a ‘‘quiet time’’ where lights in the halls are dimmed between 10 pm and 6 am and patient doors are closed. Each patient room is private. Patient medical records were examined for preoperative comorbidities, including sleep disorders and American Society of Anesthesiologists (ASA) Physical Status classification system, postoperative complications, pain level, and amount of pain medication administered. Sleep duration and efficiency were assessed using Actiwatch Respironics software (Philips Respironics). Epochs were set at 15 seconds with recording starting immediately after placement of the watch on the patient and ending when the device was removed the morning of POD 2. The awake index was calculated by number of awakenings divided by the time difference between the initiation of sleep and the offset of sleep. Nursing records were reviewed for patient pain scores. Pain scores were reported on a visual analog scale of 1 to 10 with 10 being extreme pain and 1 being little to no pain. In a 24-hour period, only patients’ minimum and maximum pain scores were used in the statistical analysis and not all of their pain scores reported throughout the day. The nursing medication administration records (MAR) were examined for narcotic administration. Each patient was on a standardized pain medication protocol that had been developed by the department of orthopedics (see Appendix 2 at www.otojournal.org). Narcotic administration for this study was measured by the amount of as-needed (prn) medication the patient received. A narcotic conversion table was used to convert medications to oxycodone equivalents for uniform comparison.8 No patients received hypnotic medications. Spearman correlations were made between sleep parameters: sleep duration (minutes of sleep), sleep efficiency, and awake index, with pain scores for POD 0 and 1. Spearman correlations were also made between sleep duration, sleep efficiency, and awake index with narcotic use on POD 0 and 1. Pearson correlations were made between sleep duration, sleep efficiency, and awake index with the length of hospital stay. A 2-sample t test was used to compare patients with and without complications against their sleep duration, sleep efficiency, and awake index.
Table 1. Patient Demographics. Variable Age, y n Mean (SD) Median (min, max) Sex, No. (%) Female Male Body mass index, kg/m2 Mean (SD) Median Race, No. (%) Black White Hispanic Length of hospital stay, d Mean (SD) Median (min, max) ASA class, No. (%) 1 2 3 4 Sleep disorder, No. (%) None OSA but not on CPAP OSA on BiPAP OSA on CPAP Complications, No. (%) Major Minor None
Value
50 65.1 (10.8) 66.0 (30.0, 85.0) 34 (68) 16 (32) 34.2 (7.3) 33.6 31 (62) 18 (36) 1 (2) 3.3 (1.8) 3 (1, 11) 1 (2) 16 (32) 32 (64) 1 (2) 44 (88) 2 (4) 1 (2) 3 (6) 6 (12) 12 (24) 32 (64)
Abbreviations: ASA, American Society of Anesthesiologists; BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; OSA, obstructive sleep apnea.
Results Of the 50 patients in the study, 34 (68%) were female and 16 (32%) were male, with a mean age of 65.1 years. All patients wore the actigraph for at least 2 days, but only 1 patient filled out the sleep diary. The only statement recorded on the diary was that the patient had not had any sleep. Of the 6 patients with obstructive sleep apnea, 4 were treated with continuous positive airway pressure or bilevel positive airway pressure. The other 2 patients were not receiving any treatment (Table 1). The overall complication rate was 36% (18/50), with 6 patients having major complications and 12 with minor complications. Major complications were defined as respiratory events requiring intubation, ICU admission, myocardial infarction, or joint infection. Minor complications were defined as acute blood loss anemia, urinary retention, or
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Table 2. Pain and Sleep Parameters. Parameter
Mean (SD)
POD 0 Minimum pain score Maximum pain score Range for pain score Narcotic usage (mg of oxycodone) Minutes of sleep Efficiency, % Awake Index, number/h POD 1 Minimum pain score Maximum pain score Range for pain score Narcotic usage (mg of oxycodone) Minutes of sleep Efficiency, % Awake index, number/h
1.0 7.2 6.3 27.9 419.0 61.2 5.5
(1.6) (2.8) (2.7) (26.2) (228.7) (24.8) (3.0)
1.3 7.1 5.8 37.4 375.5 66.5 5.4
(1.8) (2.0) (2.2) (35.3) (207.0) (21.0) (3.2)
Abbreviation: POD, postoperative.
superficial wound drainage without infection. None of the patients required transfer to the ICU or intubation while wearing the actigraph. Sleep parameters and pain outcomes for POD 0 and POD 1 are reported in Table 2. Sleep parameters were analyzed in relation to patientreported subjective pain scores (Table 3). Reduced minutes of sleep on POD 1 was correlated significantly with increased pain scores on POD 1 (r = 20.31, P = .032), indicating that increased pain correlates with decreased sleep duration. There was also a significant correlation between higher pain scores on POD 0 and increased sleep efficiency on POD 1 (r = 0.38, P = .009), indicating that increased pain on POD 0 correlates with more efficient sleep the following night. Narcotic use on POD 0 was examined for its effect on the sleep-pain relation on POD 1 (Table 4). After controlling for narcotic usage, the previously significant relation between maximum pain on POD 0 and sleep efficiency on
POD 1 (P = .009), was reduced to P = .053 and no longer significant. This held true for range of pain scores on POD 0 and sleep efficiency on POD 1 (P = .03), which became not significant as well (P = .076). When comparing sleep parameters with overall complication rates (minor and major complications), there was no significance (Table 5). Length of stay was compared against sleep duration, efficiency, and awake index. A significant correlation was found between length of stay and sleep efficiency on POD 0 (r = 20.35, P = .01), indicating that lower sleep efficiency correlated with an increased length of stay (Table 6).
Discussion The results of this study suggest that poor sleep efficiency is associated with greater narcotic usage and that pain is associated with decreased sleep duration. The relationship between surgery, anesthesia, and postoperative course is complex. This study attempted to control for at least one variable, surgical procedure and perioperative course. By including only patients with similar surgeries and perioperative course, the impact of sleep and pain medications could be studied. The effects of general anesthesia on postoperative sleep are well studied.9-11 Uniformly, patients display decreased total sleep time, abolishment of rapid eye movement (REM) sleep, and decreased slow-wave sleep on the first postoperative night regardless of narcotic usage.9-12 While stages of sleep were not analyzed as part of this study, compared with normative values,13 patients in this study had a marked reduction in their sleep efficiency: 61.2% vs 88.3% in the normal population. The awake index was also markedly increased at 5.5 compared with 3.2 in normal subjects. While we included only one type of surgical procedure in this study to control for general anesthesia, Humphries14 included medical and surgical patients for a longer duration. This duration was selected by Humphries to allow time for the sedating effects of general anesthesia to wear off. Patients with thoracic and large abdominal surgeries were included. Most athroplasty patients were discharged by POD 3, and since narcotic use tended to decrease by then, it
Table 3. Sleep Parameters Compared with Patient Reported Pain.a Minutes of Sleep
POD 0 Minimum pain score Maximum pain score POD 1 Minimum pain score Maximum pain score
Sleep Efficiency
Awake Index
POD 0
POD 1
POD 0
POD 1
POD 0
POD 1
–0.017 (.907) –0.074 (.618)
–0.093 (.531) 0.114 (.439)
0.284 (.053) 0.170 (.252)
0.054 (.717) 0.378 (.009)
0.012 (.940) 0.111 (.467)
–0.141 (.342) 0.093 (.533)
0.030 (.840) –0.277 (.057)
–0.311 (.032) –0.141 (.337)
0.044 (.768) –0.120 (.421)
0.013 (.932) 0.262 (.075)
0.009 (.954) –0.113 (.459)
–0.041 (.784) –0.257 (.082)
Abbreviation: POD, postoperative day. a Values are presented as correlation coefficients (P values). Downloaded from oto.sagepub.com at UNIV CALIFORNIA SANTA BARBARA on October 6, 2015
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Table 4. Sleep Parameters Compared with Narcotic Use.a Minutes of Sleep Narcotic Use POD 0 POD 1
Sleep Efficiency
Awake Index
POD 0
POD 1
POD 0
POD 1
POD 0
POD 1
–0.026 (.858) 0.075 (.613)
0.242 (.097) –0.105 (.480)
0.232 (.116) 0.107 (.474)
0.231 (.119) 0.221 (.135)
0.278 (.064) 0.149 (.329)
0.067 (.652) –0.141 (.346)
Abbreviation: POD, postoperative day. a Values are presented as correlation coefficients (P values).
Table 5. Sleep Parameters Compared with Major and Minor Complications. Variable
Major (n = 6), Mean (SD)
Minor (n = 12), Mean (SD)
None (n = 32), Mean (SD)
P Value
243.3 (219.1) 38.8 (38.0) 4.9 (3.4)
454.7 (197.1) 66.6 (24.3) 4.9 (3.3)
440.4 (232.2) 65.4 (23.9) 5.7 (3.0
.13 .10 .79
457.0 (333.9) 57.2 (22.9) 6.5 (3.7)
393.4 (200.3) 73.2 (12.9) 4.5 (2.9)
352.0 (181.4) 66.0 (22.8) 5.3 (3.2)
.50 .33 .58
POD 0 Minutes of sleep Efficiency, % Awake index, number/h POD 1 Minutes of sleep Efficiency, % Awake index, number/h Abbreviation: POD, postoperative day.
Table 6. Sleep Parameters Compared with Length of Hospital Stay. Sleep
Efficiency
Awake Index
Length of Hospital Stay, d
POD 0
POD 1
POD 0
POD 1
POD 0
POD1
Correlation coefficient P value
–0.194 .187
0.180 .220
–0.355 .015
–0.005 .974
–0.038 .803
0.112 .453
Abbreviation: POD, postoperative day.
was felt that capturing the first and second nights of sleep would yield adequate information on patients’ pain and their sleep parameters. The interplay of narcotics and pain is complex since each independently disturbs sleep. This patient population had preexisting pain due to osteoarthritis requiring joint replacement. It is difficult to say to what effect these patients’ prior sleep disturbance or anxiety relating to surgery may have had on their sleep after surgery. Insight into the contributing factors for poor sleep might have been gained if patients had completed their sleep diaries. When the patients were questioned as to why they did not fill out the diaries, some stated that they had simply chosen not to, forgot, or were too busy to fill out the forms. In fact, all total arthroplasty patients were mobilized early on POD 1 and mobilized multiple times throughout the day through standardized individual and group physical therapy sessions. It is reasonable to associate increased pain scores with decreased sleep duration (as was found for minutes of sleep on POD 1, which decreased with higher minimum pain
scores on POD 1 [P = .031]). However, the finding that a higher maximum pain score on POD 0 correlates with more efficient sleep on POD 1 (P = .009) is more surprising. In a study by Closs,15 patients reported that their sleep was aided by the administration of narcotics to alleviate pain. It is possible that patients with more pain the first day may be encouraged to increase use of narcotics the next day and are better able to manage their pain, resulting in increased sleep efficiency the following night. The sleep debt from the previous night may also contribute to the increased sleep efficiency the subsequent night. If more nights of sleep were recorded, it is possible that more evidence for this would emerge.
Conclusions The interplay of patient’s sleep with general anesthesia, narcotics, and pain is complex. Results from this study show that increased pain scores are associated with decreased sleep duration. Improvements in pain control and sleep efficiency may result in a decrease in length of stay.
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Otolaryngology–Head and Neck Surgery 152(5)
Acknowledgments We thank Michelle Jankowski, PhD, of Henry Ford Hospital’s biostatistical department for statistical analysis and Lige Kaplan, MD, Michael Laker, MD, and Michael Mott, MD, for allowing us to use their patients for participation in this study.
Author Contributions Anya Miller, data collection, interpretation and analysis of data, design of work, drafting manuscript, approval of final version, agreement to be accountable for all aspects of the work; Thomas Roth, design of work, analysis, revision of manuscript, approval of final version, agreement to be accountable for all aspects of the work; Timothy Roehrs, design of work, analysis, revision of manuscript, approval of final version, agreement to be accountable for all aspects of the work; Kathleen Yaremchuk, conception and design of work, revision of manuscript, approval of final version, agreement to be accountable for all aspects of the work.
Disclosures Competing interests: Thomas Roth, consultant: Abbott, Accadia, Acogolix, Acorda, Actelion, Addrenex, Alchemers, Alza, Ancel, Arena, AstraZeneca, Aventis, AVER, Bayer, BMS, BTG, Cephalon, Cypress, Dove, Elsai, Elan, Eli Lilly, Evotec, Forest, Glaxo Smith Kline, Hypnion, Impax, Intec, Intra-Cellular, Jazz, Johnson and Johnson, King, Ludbeck, McNeil, MediciNova, Merck, Neurim, Neurocrine, Neurogen, Novartis, Orexo, Organon, Otsuka, Prestwick, Proctor and Gamble, Pfizer, Purdue, Resteva, Roche, Sanofi, Schering Plough, Sepracor, Servier, Shire, Somaxon, Syrex, Takeda, TransOral, Vanda, Vivometrics, Wyeth, Yamanuchi, Xenoport. Grants: Aventis, Cephalon, Glaxo Smith Kline, Neurocrine, Pfizer, Sanofi, Schering Plough, Sepracor, Somaxon, Syrex, Takeda, TransOral, Wyeth, Xenoport. Speakers: Cephalon, Sanofi, Takeda. Sponsorships: None. Funding source: None.
Supplemental Material
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Additional supporting information may be found at http://otojournal .org/supplemental.
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