| Background The proportion of sleep disorders is increasing nowadays due to the hot competition and increased working pressure as well as the accelerated pace Perioperative sleep disturbances are quite common because of fear,anxiety,pain or environmental interference.Sleep deficiency may induce the dysfunctions of autonomic nervous system,endocrine system,and cardiovascular system,especially the central nervous system,which plays a regulatory role in general anesthesia.Sleep deprivation can increase the sensitivity of anesthetics,and sleep disorders may increase the postoperative neurological complications.However,up to now,the influence of sleep disorders on the effect of general anesthetics has not been reported,and it is not clear which changes in sleep mode increase the occurrence of postoperative delirium Therefore,the study aims to observe the effect of sleep disorders on dosage or sensitivity of general anesthetics and the possible mechanism,as well as changes of sleep parameters to increase the incidence of postoperative delirium,so as to provide reference for clinical practice,and improve the quality of anesthesia,thus reduce perioperative complicationsObjective(1)To investigate whether sleep disorder has an effect on the anesthetic effect of sevoflurane,and to observe whether there is a difference between the plasma orexin-A concentration of patients with sleep disorders and normal sleepers,and if there’s a correlation between the orexin-A concentration and sevoflurane effect.(2)The effect of sleep disturbance on the anesthesia efficacy of propofol was studied.The correlation between plasma orexin-A concentration and effect room concentration of propofol with target controlled infusion was observed too.(3)To study the risk factors of postoperative delirium(POD),and find out whether preoperative sleep disorder was an independent risk factor of POD,and which parts of sleep parameters,such as sleep latency,wake-up time and sleep duration,were closely related to the occurrence of POD.Method(1)44 patients of women undergoing breast surgery,aged 40～60 years,American Society of anesthesiologists(ASA)Ⅰ～Ⅱ,were recruited.The score of PSQI was used to evaluate sleep quality.PSQI>7 was defined as sleep disorders(SD group,n=20),and PSQI≤7 was defined as normal sleeps(control group,n=19).General anesthesia was induced by 8 vol%sevoflurane combined 100%oxygen with flow rate of 6 L/min,using the method of vital capacity.After loss of consciousness,the inhalation concentration was slowly reduced to the preset concentration of 1.0 vol%Patients were required to open their eyes after stabilization of 10 minutes.MACawake was determined by Dixon ’up and down’ method.According to the positive or negative response of the previous patient to the verbal command,the preset concentration of the next patient was increased or decreased by 0.2 vol%.The plasma orexin-A was measured before the observation.The general characteristics,blood glucose,end expiratory carbon dioxide and the fluid volumes were recorded.The end expiratory sevoflurane concentration and response of each patient were also recorded.(2)Sixty-eight patients scheduled elective surgery,aged 40～60,ASA grade Ⅰ～Ⅱ,were recruited for the observation.Patients were divided into two groups by PSQI score,PSQI>7 represents sleep disorders(SD group,n=32),PSQI≤7 represents normal sleeps(NS group,n=34).Plasma orexin-A was measured before the observation.After the completion of venous access,oxygen inhalation and monitoring,propofol was infused with target controlled infusion in a step-by-step manner under the monitoring of bispectral index(BIS).The initial concentration of plasma(Cp)was set at 1.0ug/ml When the concentration of effect site(Ce)reached the same concentration,CP was increased by 0.2ug/ml every 30 seconds,and the patients were called every 15 seconds to open their eyes until unconsciousness.Keep on increase the concentration of the Cp until BIS is less than 60,stop increasing the concentration of the Cp and stabilize for 5 minutes,and then stop infusion.The patients were asked again to open their eyes every 15 seconds until recovery.The Ce of propfol were recorded when loss of consciousness,BIS lower than 60,and recoverary of consciousness.(3)106 patients undergoing resection of esophageal cancer,age above 65 years old,ASA Ⅰ～Ⅱ,were recruited for the oberservation.General anesthesia was induced by intravenous anesthetics and after that double lumen bronchus catheter was inserted.During the operation,general anesthesia was conducted by using intravenous combined with inhalation anesthetics.Vasoactive drugs were used properly to maintain the hemodynamics.Ventilator parameters should be adjusted to avoid hypoxemia during one lung ventilation.Patients were transferred to the recovery room after the operation,patient-controlled intravenous analgesia was implied routinely.After the tracheal tube was removed,patients returned to the ward.CAM scale was used to evaluate whether postoperative delirium occurred during 1-5 days after operation.General information,Charlson’s complication index,PSQI score,sleep latency,wake-up time,total sleep time and effective sleep time in the scale were recorded,and the proportion of awakening to total sleep time(WASO)was calculated.The anesthesia time,urine volume and postoperative delirium were also recorded.Results(1)MACawake of sevoflurane was significantly higher in the sleep disordered group[0.80%(95%confidence interval,0.683-0.926%)],compared to the control group[0.60%(95%CI,0.493-0.689%)],and the relative median potency between two groups was 0.750(95%CI,0.236-0.969).Patients with sleep disorders had significantly higher orexin-A levels than control(72.17 ± 18.24 vs 36.16 ± 14.18 pg/mL).A significant,positive relationship was detected between orexin-A level and probability of awakening(OR=1.081,95%CI is 1.020-1.146,P=0.008).(2)Compared with the normal sleepers,the concentration of orexin-A was higher in the SD group(P<0.05).The Ce of propfol were significantly higher in the SD group when loss of consciousness,BIS lower than 60,and recovery of consciousness(P<0.05).There was a positive correlation between the plasma orexin-A concentration and Ce of propofol at different stages(group SD,r=0.635,0.415,0.467;group NS,r=0.635,0.415,0.467;P<0.05).(3)Compared with the normal sleepers,sleep latency,wake-up time was increased while the effective sleep time decreased.With the increase of age in all patients,the waking time and WASO was increased significantly,the effective sleeping time decreased significantly(P<0.05).Sleep disorders,wake-up time and WASO were independent risk factors for POD in logistic regression analyzation(P<0.05).Patients with sleep disorders had a higher risk of postoperative delirium(RR=0.06,95%Cl=0.008-0.312,P<0.001),and frequent arousal increased the risk.Conclusions(1)Patients with sleep disorders had a higher MACawake value of sevoflurane compared with the patients with normal sleep habits,and that may be related to the increase of plasma orexin-A level.(2)Patients with sleep disorders need higher effect site concentration of propofol with target-controled infusion,and the potential mechanism may be related to the increase of plasma orexin-A level too.(3)Preoperative sleep disorders,especially with increased arousal or decreased sleep efficiency,are independent risk factors for postoperative delirium. |
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