Addressing Sleep Problems After Surgery

Every year, hundreds of thousands of individuals worldwide undergo gallbladder surgery. And although the standard procedure for gallbladder removal nowadays is laparoscopic cholecystectomy, which does not require a patient to stay at the hospital for a long time, there are still cases when an open surgery is required. As such, we often get inquiries about post-operative care and sleep problems after surgery. Difficulty sleeping and staying asleep or insomnia after surgery is common among recovering patients. This is true not just among those who have had their gallbladders removed but for everyone who has had any type of major surgery.

What are the reasons behind sleep problems after surgery? What are the effects of sleep disturbances on post-operative recovery? How can we improve the quality of sleep among recovering patients?

The Normal Sleep Pattern

Sleep is not a process that is homogenous or the same throughout. It is divided into two forms – rapid eye movement (REM) and non-rapid eye movement (N-REM). Based on their electro-physical characteristics, the N-REM is subdivided further into four stages ranging from light sleep to very deep sleep.

Each sleep phase affects the overall circadian rhythm responsible for the sleep-wake cycle and various homeostatic mechanisms (for more information on circadian rhythm, read our blog) Therefore, if sleep is important for the normal function of healthy individuals, can you imagine how crucial it is for someone who is recuperating?

Common Sleep Problems after Surgery

Sleep problems may take on different forms. According to sleep studies among post-operative patients, it may be one or a combination of the following:

  • severe sleep deprivation (having very little or no sleep)
  • sleep fragmentation (waking up multiple times during sleep)
  • decrease or loss of the REM phase
  • decrease or loss of the very deep N-REM sleep stage
  • decreased sleep time
  • frequent nightmares

The likelihood of these sleep problems occurring during post-operative care and recovery are affected by different factors like age, other existing health conditions prior to surgery, type of anesthesia, environmental stress, and severity of surgical trauma.

The most probably cause of insomnia after surgery is the stress response to the trauma of surgery. The metabolic and hormonal responses to this stress are quite dramatic. Pituitary gland hormones are released as well as the sympathetic nervous system fight or flight hormones. Metabolically, blood sugar levels may rise in response to the traumatic stress and/or the time period without food may also cause a drop in blood sugar which may lead to insomnia.

Inflammation from injured tissues may contribute to wakefulness, even without noticeable pain, but pain in itself is a major factor. It is hard to sleep when in pain and as a catch 22, lack of sleep can make both pain and inflammation worse.

Factors Related to Sleep Problems after Surgery

1. Severity of surgical trauma

Sleep deprivation is more severe after major surgery. For example, patients who had open cholecystectomy had more sleep disturbances recorded during the night of surgery compared to those who had laparoscopic procedure with the same general anesthesia.

2. Environmental Stress

After surgery, patients often have to spend the first few days of their recovery in the hospital. And although this set-up can provide them with the best post-operative care, the hospital environment may also increase the likelihood of sleep problems after surgery. In a 2018 study among ICU patients, some of the environmental stressors identified were:

  • Thirst
  • Presence of tubes in the nose or mouth
  • Not being in control of self
  • Inability to sleep
  • Pain
  • Inability to move
  • Limited interaction time with family and friends
  • Room Temperature
  • Unfamiliar noise and smell
  • Constant movement and checking by doctors and nurses

Aside from the abovementioned environmental factors within the hospital and at home during recovery, there are a lot of other physical, emotional and mental stress that a patient has to deal with that may cause insomnia after surgery.

3. Type of Anesthesia

The use of regional anesthesia instead of general anesthesia is helpful to relieve sleep problems after surgery. In a study comparing 162 patients undergoing abdominal hysterectomy, those who have had spinal anesthesia experienced less problems with sleep in the night after surgery. Another similar study among 376 surgical patients showed that those with regional anesthesia had better sleep during recovery. One possible reason is the reduced opioid consumption before the surgical procedure.

4. Age

The elderly often have a more difficult time adjusting their sleep after undergoing surgery. Younger patients are more capable of adapting to environmental changes. Sleep apnea, a sleep disorder, is also common among older individuals.

5. Other existing health conditions

Other health conditions not addressed by the surgery may also affect the amount and quality of sleep among recovering patients. For example, those with respiratory conditions or sleep disorders pre-surgery still have to deal with it post-operative.

Harmful Effects of Sleep Problems after Surgery

Sleep is related with numerous biological functions such as metabolism, immune function, hormone secretion, body temperature regulation, glucose balance, and intestinal function, among others. During sleep, our body repairs and recharges itself so it’ll be ready for activities the following day. Sleep problems after surgery definitely contribute to more challenging post-operative care and longer recovery time.

Increased Catabolism or Breakdown of Cells  

For post-operative patients, getting a good sleep after the procedure and during recovery will significantly help in speeding up the body’s normal healing process. During deep sleep, the body’s anabolic activity is at its peak. Anabolism is the normal biochemical reaction within the body responsible for building up cells and tissues. The opposite reaction (the breakdown of cells) is called catabolism, which is noted to be heightened because of surgical stress and sleep deprivation.

Hypersensitivity to pain

Aside from increased catabolic activity, sleep problems also affect our body’s pain perception. Recent studies have shown that the way we respond to pain after surgery may depend on the quality of sleep after the procedure. Sleep problems after surgery may produce a hyper-analgesic state wherein our body’s pain tolerance is significantly decreased and pain seems to be magnified. And as mentioned earlier, it works both ways – sleep deprivation can increase pain in the same way that the presence of pain may be the cause for the patient’s inability to get proper sleep.

Increased stress

In the same way that stress can cause sleep disturbance, lack of good sleep can also make stress worse. In animal models, it is proven that sleep deprivation increases oxidative stress and free radical production as well as the production of pro-inflammatory cytokines. These are all implicated in poor post-operative recovery. As an effect of increased stress, patients recovering from surgery may have more mood swings, impaired concentration, erratic behavior, and decreased psychological performance. Memory loss is also mentioned.

What can we do about sleep problems after surgery?

Considering the factors which increase the likelihood of sleep problems after surgery, there is not much that we can do. Things like age, pre-existing health conditions, type of anesthesia, or the severity of surgical trauma are all beyond our control. However, there is a lot we can do to help reduce stress during the recovery period.

1. Pain management

There are non-pharmacological and pharmacological measures to help manage post-op pain. Examples of nonpharmacological pain management techniques include:

  • Physical therapy
  • Acupuncture
  • Neuro-stimulation
  • Hypnosis

The use of medication to manage pain in order to sleep, is usually decided by the attending physician.

2. Reduce Inflammation

As part of our body’s immune response, we experience inflammation during the post-surgery healing process. Unfortunately, our body’s own attempt to protect itself through the inflammatory response can also significantly contribute to pain. To help manage it, you may do the following:

  • Castor Oil Packs – We usually recommend this for gallbladder, liver, and stomach problems but you may also use it to reduce inflammation. Not only will the heat soothe and relax you, it may also help in reducing stress and anxiety by kicking in the parasympathetic system.
  • Allergy diet – It is important to watch what you eat, especially during recovery. If you don’t steer clear of allergens, it will only make your inflammation worse. Make sure that you take a lot of natural anti-inflammatories like turmeric and beet.
  • Supplements – Supplements like Clinical Glutathione and Nature’s Edge Curcu-Gel (turmeric) may help in addressing inflammation.
3. Stress reduction

Depending on the stressor, there are a number of ways we can reduce stress experienced by patients after surgery. Relaxation techniques, massage, and touch therapy are just some post-operative care practices that can be done even while in the hospital.

Massage, or just a simple touch, has long been known to improve sleep, reduce stress, and lessen the intensity of pain, among many other benefits. Massage helps release serotonin, also known as happy hormone. Studies show that a simple back rub can elevate levels of oxytocin and decrease heart rate.

A positive state of mind is also very important for the recovery of patients. Remember why placebo does wonders? It is crucial after surgery that we desire and will ourselves to get better.  If socialization could help, then reach out to friends and family. To avoid boredom and confusion while inside the hospital, engage in easy activities or hobbies. Try to ease in to your regular schedule to help your body adapt and recuperate faster.

Lastly, slowly incorporate exercise and physical activities that are appropriate for your recovery status. Simple arm lifts, stretching, or walking that will not affect the surgery area can be helpful in reducing stress.

4. Improved sleeping conditions

As mentioned earlier, there are environmental factors in the hospital or at home that may significantly affect the quality of sleep. Noise management, lower room temperature, avoidance of thirst and eating well, are some of the things that can easily be monitored so that sleep problems after surgery can be minimized.

Below are some other things that may improve your sleeping condition and address your insomnia after surgery:

  • Avoid using your cellphone, TV, or other electronics before sleeping.
  • Use a white noise machine, at home or in the hospital.
  • Turn the lights off completely if you can. Light of any kind can suppress the secretion of melatonin, the hormone that makes us sleep and relax.
  • Get enough sunlight during the daytime.
  • Aromatherapy with natural essential oils like lavender, bergamot, or chamomile may help calm your nerves and get you ready for sleep.

 

References:

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Baratloo, A., Rouhipour, A., Forouzanfar, M. M., Safari, S., Amiri, M., & Negida, A. (2016). The role of caffeine in pain management: a brief literature review. Anesthesiology and pain medicine, 6(3).

Chillot, R. (2013). The power of touch. Psychology today, 11.

Dolan, R., Huh, J., Tiwari, N., Sproat, T., & Camilleri-Brennan, J. (2016). A prospective analysis of sleep deprivation and disturbance in surgical patients. Annals of medicine and surgery, 6, 1-5.

Finan, P. H., Goodin, B. R., & Smith, M. T. (2013). The association of sleep and pain: an update and a path forward. The Journal of Pain, 14(12), 1539-1552.

Gögenur, I., Wildschiøtz, G., & Rosenberg, J. (2007). Circadian distribution of sleep phases after major abdominal surgery. British journal of anaesthesia, 100(1), 45-49.

Gültekin, Y., Özçelik, Z., Akıncı, S. B., & Yorgancı, H. K. (2018). Evaluation of stressors in intensive care units. Turkish journal of surgery, 34(1), 5.

Kulkarni, A., Kaushik, J. S., Gupta, P., Sharma, H., & Agrawal, R. K. (2010). Massage and touch therapy in neonates: the current evidence. Indian pediatrics, 47(9), 771-776.

Rosenberg-Adamsen, S., Kehlet, H., Dodds, C., & Rosenberg, J. (1996). Postoperative sleep disturbances: mechanisms and clinical implications. British journal of anaesthesia, 76(4), 552-559.

Study of Melatonin on Sleep, Pain, and Confusion After Joint Replacement Surgery (2012)

Su, X., & Wang, D. X. (2018). Improve postoperative sleep: what can we do?. Current opinion in anaesthesiology, 31(1), 83.