Effects of dexmedetomidine administered for postoperative analgesia on sleep quality in patients undergoing abdominal hysterectomy

doi:10.1016/j.jclinane.2016.10.022

Journal of Clinical Anesthesia

Volume 36, February 2017, Pages 118-122

https://doi.org/10.1016/j.jclinane.2016.10.022 Get rights and content

Highlights

•
Patients experience significant sleep disturbance after hysterectomy.
•
Dexmedetomidine infusion with sufentanil provides sound analgesia.
•
Dexmedetomidine infusion for postoperative analgesia improves sleep quality.

Abstract

Study objective

To evaluate the effects of postoperative dexmedetomidine infusion on sleep quality in patients undergoing abdominal hysterectomy.

Design

Randomized, double-blind study.

Setting

Postoperative recovery area and ward.

Patients

Sixty patients of American Society of Anesthesiologists physical status I or II scheduled for elective hysterectomy were enrolled.

Interventions

Patients in group C received sufentanil infusion (a continuous dosage of 0.02 μg kg⁻¹ h⁻¹, a bolus dose of 0.02 μg/kg, a 10-minute lockout interval), and patients in group D received combined infusion of sufentanil with dexmedetomidine (a continuous dosage of sufentanil 0.02 μg kg⁻¹ h⁻¹ with dexmedetomidine 0.05 μg kg⁻¹ h⁻¹, a bolus doses of sufentanil 0.02 μg/kg with dexmedetomidine 0.05 μg/kg, a 10-minute lockout interval).

Measurements

Polysomnography (PSG) was performed on the following 3 nights: the night before surgery (PSG1), the first night after surgery (PSG2), and the second night after surgery (PSG3). Postoperative pain scores using visual analog scoring scale, levels of sedation, and cumulative sufentanil consumptions were also recorded.

Results

After surgery, patients suffered from significant sleep disturbance with a lower sleep efficiency index and subjective sleep quality and a higher arousal index at PSG2 and PSG3. Compared with group C, postoperative administration of dexmedetomidine significantly improved the sleep efficiency index and subjective sleep quality. Although the rapid eye movement and N3 stage sleep did not differ between the 2 groups, the N1 stage and arousal index were lower and the N2 stage in group D at PSG2 and PSG3 was higher. Compared with group C, patients in group D have better pain relief with a lower visual analog scoring scale and cumulative sufentanil consumptions at 6, 24, and 48 hours after surgery.

Conclusions

Dexmedetomidine infusion not only offers effective analgesia but also improves postoperative sleep quality in patients undergoing hysterectomy.

Introduction

Studies showed that after major surgery, most patients experience significant disturbance in their sleep architecture, which is characterized by markedly reduced rapid eye movement (REM) sleep and slow wave sleep [1], [2], [3]. Postoperative sleep disturbance may contribute to cardiovascular, neurological, immunological, and metabolic complications, leading to increased morbidity [4], [5], [6], [7], [8]. Thus, improving the postoperative sleep quality probably has a positive effect on the recovery of surgical patients.

Dexmedetomidine, a selective α₂-adrenergic receptor agonist, which is characterized by sedative, sympatholytic, and analgesic effects, has been effectively used for postoperative analgesia in patients undergoing cesarean delivery and hysterectomy [9], [10]; however, whether or not it also has a positive effect on postoperative sleep quality in these patients is to be investigated. Alexopoulou et al [11] noted that in critically ill patients, dexmedetomidine infusion during the night resulted in light sedation, thereby improving sleep quality by increasing sleep efficiency and stage 2; however, Oto et al [12] concluded that nighttime infusion of dexmedetomidine induced severely disturbed sleep architecture in mechanically ventilated patients because there was no evidence of slow wave sleep and REM sleep.

This randomized, placebo-controlled study was designed to investigate the effects of dexmedetomidine used as an adjuvant analgesic through patient-controlled analgesia (PCA) on postoperative sleep quality in patients undergoing abdominal hysterectomy.

Section snippets

Materials and methods

This study was performed between January 2015 and December 2015, and the study protocol was approved by the Ethics Committee of University Hospital of Qingdao (No.2014MZ04) on December 25, 2014. Informed written consent was obtained from all patients before study enrollment.

Results

Of all the 60 patients enrolled, 1 patient was excluded because of failed PSG measurements. The 2 groups were similar in terms of patient characteristics, intraoperative data, and recovery time at PACU (Table 1).

Compared with group C, patients in group D had a lower VAS (1.5 [0.3, 2.3], 1.3 [0.4, 2.2], and 1.0 [0.3, 2.2] vs 3.0 [2.1, 5.1], 3.0 [1.7, 4.5], and 2.5 [1.2, 3.8]) and a lower cumulative sufentanil consumption (9.0 ± 0.8, 35.0 ± 5.6, and 68.0 ± 6.5 vs 12.0 ± 1.0, 48.5 ± 5.8, and 87.5 ± 7.5; μg)

Discussion

This study aimed to investigate whether combined infusion of dexmedetomidine and sufentanil for postoperative analgesia could improve sleep quality in patients undergoing abdominal hysterectomy. The results showed that patients with abdominal hysterectomy suffer from obvious sleep disturbance characterized with a lower sleep efficiency and quality and a higher arousal index by decreasing REM and stage 3 sleep and increasing stage 1 sleep. Although there was no improvement in postoperative REM

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Cited by (47)

Impact of the addition of dexmedetomidine to patient-controlled intravenous analgesia on postoperative pain-sleep interaction cycle and delirium: A systematic review and meta-analysis of randomized controlled trials
2024, Heliyon
The reciprocal nexus between sleep and pain is well-documented, with the deleterious impact of operative trauma potentially playing a pivotal role in the dysregulation of this interplay, which could significantly contribute to the manifestation of postoperative delirium (POD). Studies have investigated the effect of adding dexmedetomidine (DEX) to patient-controlled intravenous analgesia (PCIA) pumps on postoperative pain-sleep interaction cycle and POD, but conclusions remained uncertain. The objective of this investigation is to perform a meta-analysis that thoroughly assesses the impact of integrating DEX into PCIA, focusing on analgesic effectiveness, sleep quality, and the incidence of delirium in postoperative patients.
PubMed, Embase, Cochrane Library, SinoMed, and Wanfang Data Knowledge Service Platform were searched, for publications in any language, from database inception to September 2023. Our analysis encompassed randomized controlled trials (RCTs) that examine the therapeutic efficacy and risk profile of adding DEX to the PCIA on the postoperative pain-sleep interaction cycle, by focusing on changes in postoperative analgesia (Visual analog scale (VAS) score), sleep efficiency, sleep structure, subjective sleep score (Assen insomnia scale and numerical rating scale) and adverse event rate.
34 RCTs (4324 patients) were analyzed. This study shows DEX improved analgesia and reduced VAS scores at 6, 12, and 24 h after surgery. Sleep efficiency was enhanced on the 1st and 2nd postoperative night. DEX improved sleep structure at the 1st postoperative night by reducing non-rapid eye movement stage 1 (N1) sleep and increasing non-rapid eye movement stage 2 (N2) and non-rapid eye movement stage 3 (N3) sleep. At the 2nd night, DEX reduced N1 sleep and increased N2 sleep, but not N3 sleep. Data from AIS and NRS showed improvement in subjective sleep scores on the 1st postoperative night and 2nd night. Additionally, DEX decreased the occurrence of POD on the 24 h and first-three days.
This study shows that the typical DEX doses added to PCIA with sufentanil were 2–5 μg/kg or approximately 200–250 μg, and the addition of DEX to PCIA can improve pain-sleep interaction cycle from multiple perspectives, and further decrease the occurrence of POD.
Influence of Regional Analgesia on Self-Reported Quality of Sleep After Gynecological Abdominal Surgery: A Secondary Analysis of a Randomized Trial
2024, Journal of Obstetrics and Gynaecology Canada
To determine whether intrathecal morphine (ITM) analgesia in abdominal surgery for presumed gynecological malignancy was associated with better self-reported sleep quality postoperatively compared with epidural analgesia (EDA), and to evaluate risk factors for bad sleep quality.
A secondary analysis of a randomized open controlled trial, comparing ITM and EDA as postoperative analgesia in 80 women undergoing laparotomy under general anaesthesia in an enhanced recovery after surgery framework. A total of 38 women allocated to ITM and 39 to EDA completed the study. The Swedish Postoperative Symptoms Questionnaire assessed symptoms and sleep quality during the first postoperative week. Multiple logistic regression models evaluated risk factors. The results are presented as adjusted odds ratios with 95% CIs.
The sleep quality night-by-night did not differ significantly between the women who had ITM or EDA. Risk factors for bad sleep quality for night 1 were age (0.91; 0.84–0.99), operation time (1.02; 1.00–1.03), and opioid consumption (0.96; 0.91–0.99). For night 2, regular use of hypnotics preoperatively (15.81; 1.52–164.27) and opioid consumption (1.07; 1.00–1.14) were independent risk factors for bad sleep. After the second night, no risk factors were disclosed.
ITM and EDA did not appear to affect the sleep quality postoperatively differently in women undergoing laparotomy for presumed gynecological malignancy. Risk factors for self-reported bad sleep quality varied during the first 3 days after surgery. Younger age, longer operation time, and preoperative use of hypnotics were associated with bad sleep quality, whereas the effect of opioid consumption on sleep quality varied depending on the time since surgery. These findings merit further studies.
Déterminer si l’analgésie par morphine intrathécale (IT) lors d’une intervention chirurgicale abdominale en cas de tumeur gynécologique présumément maligne est associée à une meilleure qualité autodéclarée du sommeil après l’opération comparativement à l’analgésie péridurale, et évaluer les facteurs de risque du sommeil de mauvaise qualité.
Analyse secondaire d’un essai clinique randomisé ouvert comparant la morphine IT à la péridurale pour l’analgésie postopératoire chez 80 femmes subissant une laparotomie sous anesthésie générale dans un protocole ERAS. Au nombre des participantes, 38 ont été assignées au groupe morphine IT et 39 au groupe péridural. Le questionnaire SPSQ (Swedish Postoperative Symptoms Questionnaire) a été utilisé pour évaluer les symptômes et la qualité du sommeil pendant la première semaine postopératoire. Les facteurs de risque ont été évalués au moyen de modèles de régression logistique multiple. Les résultats sont présentés sous forme de rapports de cotes ajustés avec un intervalle de confiance à 95 %.
La qualité du sommeil évaluée par nuit ne différait pas significativement entre les deux groupes. Les facteurs de risque du sommeil de mauvaise qualité pour la première nuit étaient l’âge (0,91; 0,84–0,99), le temps opératoire (1,02; 1,00–1,03) et la consommation d’opioïdes (0,96; 0,91–0,99). Pour la deuxième nuit, la prise régulière d’hypnotiques avant l’opération (15,81; 1,52–164,27) et la consommation d’opioïdes (1,07; 1,00–1,14) étaient des facteurs de risque indépendants d’un mauvais sommeil. Après la deuxième nuit, aucun facteur de risque n’a été rapporté.
Aucune différence notoire n’a été observée quant à l’incidence de la morphine IT et de la péridurale sur la qualité du sommeil postopératoire chez les femmes subissant une laparotomie en cas de tumeur gynécologique présumément maligne. Les facteurs de risque du sommeil de mauvaise qualité autodéclaré ont varié pendant les trois premiers jours postopératoires. Le jeune âge, le temps opératoire plus long et la prise préopératoire d’hypnotiques étaient associés au sommeil de mauvaise qualité, tandis que l’effet de la consommation d’opioïdes sur la qualité du sommeil variait selon le temps écoulé depuis l’opération. Ces observations devraient toutefois faire l’objet d’autres études.
Dexmedetomidine at Home for Intractable Dystonia and Insomnia in Children With Special Needs: A Case Series
2023, Journal of Pain and Symptom Management
We know that syndromic conditions and severe chronic diseases can be associated with symptoms that may interfere with sleep, significantly impacting the life quality of children and caregivers. Drugs commonly used in treating insomnia, such as melatonin, benzodiazepines, niaprazine, and antihistamines, are often either ineffective or associated with adverse effects, requiring new therapeutic perspectives. Dexmedetomidine is a selective alpha-2 agonist with hypnotic and anxiolytic effects, which, by stimulating alpha-2 adrenergic receptors in the locus coeruleus, induces sleep comparable to stages 2–3 of the non-REM phase without substantially affecting the respiratory drive during sedation. Its use has already been extensively described in pediatric intensive care or procedural sedation literature. In 2018, the Italian Medicines Agency (Agenzia Italiana Del Farmaco AIFA) authorized the off-label use of dexmedetomidine outside of intensive care in Children undergoing palliative treatment to control distressing symptoms related to pathology and refractory sleep disorders, and the literature reported cases of children who received dexmedetomidine at home.
Our study aims to describe the home use of dexmedetomidine in children with insomnia or intractable dystonic states.
We conducted a retrospective analysis through a questionnaire addressed to 12 Italian pediatric palliative care centers regarding the home use of dexmedetomidine in sleep disorders and intractable dystonic states.
We collected a case series of 9 children treated with dexmedetomidine at home, 8 via intranasal and 1 via intravenous route. All children received the first drug administration in the hospital or hospice during a dedicated admission, under close monitoring of vital signs parameters for 72 hours (3 days, range 2–7 days). After discharge, the potential side effects of the drug were explained to the patient's families, and, once informed consent was obtained, the home administration of dexmedetomidine continued, with follow-up by the palliative care team. At home, dexmedetomidine was administered for 3000 days (minimum 1 month, maximum 36 months). The first patient was treated for 1095 days, from 2019 to 2021 (discontinued due to underlying condition-related death).
All patients observed a persistent benefit from the treatment on symptoms, and none of them discontinued dexmedetomidine administration due to drug-related adverse effects or perceived lack of therapeutic efficacy.
Therefore, its use at home may represent a promising therapeutic approach for intractable sleep disorders or dystonic states in pediatric palliative care children. Further studies are needed to confirm our results.
Mini-dose esketamine–dexmedetomidine combination to supplement analgesia for patients after scoliosis correction surgery: a double-blind randomised trial
2023, British Journal of Anaesthesia
Patients often experience severe pain after scoliosis correction surgery. Esketamine and dexmedetomidine each improves analgesia but can produce side-effects. We therefore tested the hypothesis that a mini-dose esketamine-dexmedetomidine combination safely improves analgesia.
Two hundred male and female adults having scoliosis correction surgery were randomised to patient-controlled sufentanil analgesia (4 μg kg⁻¹ in normal saline) with either a combined supplement (esketamine 0.25 mg ml⁻¹ and dexmedetomidine 1 μg ml⁻¹) or placebo. The primary outcome was the incidence of moderate-to-severe pain within 72 h, defined as a numeric rating scale (NRS: 0=no pain and 10=worst pain) score ≥4 at any of seven time points. Amongst secondary outcomes, subjective sleep quality was assessed with an NRS score (0=best sleep and 10=worst sleep) for the first five postoperative nights.
There were 199 subjects included in the intention-to-treat analysis. Mean infusion rates were 5.5 μg kg⁻¹ h⁻¹ for esketamine and 0.02 μg kg⁻¹ h⁻¹ for dexmedetomidine. The primary outcome incidence was lower with the combined supplement (65.7% [65/99]) than with placebo (86.0% [86/100]; relative risk 0.76; 95% confidence interval: 0.65–0.90; P=0.001). Subjects given the combined supplement had lower pain intensity at rest at five time points (median difference –1 point; P≤0.005), lower pain intensity with movement at six time points (median difference –1 point; P≤0.001), and better subjective sleep quality for the first 5 postoperative nights (median difference –2 to –1 points; P<0.001). Adverse events did not differ between groups.
The mini-dose esketamine–dexmedetomidine combination safely improved analgesia and subjective sleep quality after scoliosis correction surgery.
NCT04791059.
Effect of mini-dose dexmedetomidine supplemented intravenous analgesia on sleep structure in older patients after major noncardiac surgery: A randomized trial
2023, Sleep Medicine
Citation Excerpt :
In a small randomized trial, 60 healthy women (30–55 years) following abdominal hysterectomy received patient-controlled analgesia with either sufentanil alone or a combination of sufentanil and dexmedetomidine (background infusion rate 0.05 μg kg−1 h−1) [24]. The results confirmed that patients given dexmedetomidine had improved sleep quality, as manifested by increased sleep efficiency and N2 sleep and decreased arousal index and N1 sleep; however, these patients had increased sedation level [24]. The effect of dexmedetomidine supplemented analgesia on sedation was also reported in a recent meta-analysis [25].
In previous studies, low-dose dexmedetomidine supplemented opioid analgesia improved sleep architecture but increased sedation level. Herein we tested the hypothesis that mini-dose dexmedetomidine supplemented analgesia improves sleep structure without increasing sedation.
In this randomized trial, 118 older patients (≥65 years) following major noncardiac surgery were randomized to receive patient-controlled intravenous analgesia supplemented with either placebo or dexmedetomidine (median 0.02 μg kg⁻¹ h⁻¹) for up to 3 days. Polysomnogram was monitored from 9:00 p.m. on the day of surgery until 6:00 a.m. on the first day after surgery. Our primary outcome was the percentage of non-rapid eye movement stage 2 (N2) sleep. Secondary outcomes included other sleep structure parameters during the night of surgery and the sedation score during the first five postoperative days.
All 118 patients completed the study; of these, 85 were included in sleep structure analysis. Dexmedetomidine supplemented analgesia increased the percentage of N2 sleep (median difference, 10%; 95% CI, 1%–20%; P = 0.03). It also prolonged total sleep time (median difference, 78 min; 95% CI, 21 to 143; P = 0.01), increased sleep efficiency (median difference, 14%; 95% CI, 4%–26%; P = 0.01), decreased percentage of N1 sleep (median difference, −10%; 95% CI, −20% to −1%; P = 0.04), and lowered sleep fragmentation index (median difference, −1.6 times⋅h⁻¹; 95% CI, −3.7 to 0.1; P = 0.04). Sedation score within 5 days did not differ between the two groups.
Supplementing intravenous analgesia with mini-dose dexmedetomidine improved sleep structure without increasing sedation in older patients recovering from major surgery.
www.clinicaltrials.gov (NCT03117790), registered 2 April 2017.
Dexmedetomidine infusion for emergence coughing prevention in patients undergoing an endovascular interventional procedure: A randomized dose-finding trial
2022, European Journal of Pharmaceutical Sciences
Citation Excerpt :
Notably, the fentanyl equivalent amount was relatively low in our study, with a median dose of around 185 µg. DEX administration with diverse protocols (e.g. only postoperative 0.1 μg·kg−1·h−1 infusion for 15 h, or 0.05 μg·kg−1 loading followed by 0.05 μg·kg−1·h−1 infusion through patient-controlled analgesia regimen) (Chen et al., 2017; Wu et al., 2016) have been proven to assist in postoperative sleep quality and disturbance, as assessed using different questionnaires (e.g. Numeric Rating Scales for sleep quality, or St. Mary Hospital Sleep Questionnaire) (Duan et al., 2020; Mao et al., 2020). When compared to a high DEX dose (> 0.2 μg·kg−1·h−1), a low one (0.1–0.2 μg·kg−1·h−1) showed more efficiency for ameliorating severe sleep disturbance (Cai et al., 2020).
Dexmedetomidine has been introduced in emergence coughing, agitation, and shivering prevention. This study aimed to investigate the optimal dose of dexmedetomidine for emergence cough prophylaxis.
In this randomized, double-blinded, and prospective trial, 356 patients scheduled for an endovascular interventional procedure were randomly assigned to 0.3 (D 0.3), 0.4 (D 0.4), 0.5 (D 0.5), and 0.6 (D 0.6) μg·kg⁻¹·h⁻¹ dexmedetomidine rate, or saline control (C), from anesthesia induction until the end of surgery. The primary outcomes measured were cough grade and frequency. Additionally, groups were compared according to mean arterial pressure (MAP), heart rate, agitation, shivering, postoperative nausea and vomiting (PONV), extubation time, sedation scores, and postoperative first night sleep quality (secondary outcomes).
A total of 351 patients were included in the analysis. The respective incidences of D 0.3, D 0.4, and D 0.5 versus C group were: 78.6%, 68.6%, 53.4% and 42.9% vs 89.7% for cough (p = 0.002, p < 0.001, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 30%, 27.1%, 20.5%, 15.7% vs 44.1% for agitation (p = 0.04, p = 0.003, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 8.6%, 7.1%, 6.8%, 5.7% vs 22.1% for shivering (p = 0.027, p = 0.013, p = 0.01, and p = 0.01 between D 0.3, D 0.4, D 0.5 and D 0.6 vs C, respectively); and 52.9%, 57.1%, 42.5%, 44.3% vs 61.8% for poor sleep quality (p = 0.02 and p = 0.04 between group D 0.5 and D 0.6 vs C, respectively). D 0.4, D 0.5 and D 0.6 showed lower MAP during extubation, compared with the C group. Also, D 0.5 and D 0.6 presented a slight delay in extubation (3.1 and 3.3 min longer than C; p = 0.002 and p < 0.001, respectively). Meanwhile, the frequency of atropine, vasopressor administration, PONV and dizziness were similar to the control.
Both 0.5 and 0.6 μg·kg⁻¹·h⁻¹ dexmedetomidine infusion rates effectively mitigated emergence coughing with prolonged extubation time, besides sleep disturbance. D 0.4, D 0.5, and D 0.6 reduced agitation and sustained hemodynamic stability. Finally, the four doses applied were effective in shivering attenuation.

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^☆: Disclosures: None.

^☆☆: Conflicts of interest: None.

^★: Presentation: None.

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Original ContributionEffects of dexmedetomidine administered for postoperative analgesia on sleep quality in patients undergoing abdominal hysterectomy☆,☆☆,★

Highlights

Abstract

Study objective

Design

Setting

Patients

Interventions

Measurements

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Br J Anaesth

Br J Anaesth

Br J Anaesth

Br J Anaesth

Sleep Med Rev

Pain

J Pain

Sleep deprivation: impact on cognitive performance

Neuropsychiatr Dis Treat

Partial night sleep deprivation reduces natural killer and cellular immune responses in humans

FASEB J

Effects of sleep and sleep deprivation on interleukin-6, growth hormone, cortisol, and melatonin levels in humans

J Clin Endocrinol Metab

Sleep apnea and cardiovascular disease

Am J Respir Crit Care Med

Effect of dexmedetomidine combined with sufentanil for post–caesarean section intravenous analgesia: a randomised, placebo-controlled study

Eur J Anaesthesiol

Original Contribution
Effects of dexmedetomidine administered for postoperative analgesia on sleep quality in patients undergoing abdominal hysterectomy☆,☆☆,★