What are the effects of sleep deprivation and fatigue in surgical practice?

Sleep deprivation and fatigue have long been linked with accidents in high-risk industries and serious errors in the medical profession, but their effects on surgical performance are less well understood. This article outlines the important functions that human sleep serves and describes the neurobehavioral effects of wakefulness extension and mental fatigue that are relevant to surgical performance, including attentional failure, risk taking, and decision-making bias. Methods used to explore the effects of sleep deprivation and fatigue on surgical performance, from laboratory studies to outcomes data, are discussed; the findings are summarized; and important deficiencies in the literature are highlighted. Future strategies to mitigate performance decline, such as novel assessment tools and countermeasures with proven efficacy, are presented, and their deployment is discussed in the context of key ethical principles.

[1]  C. Tribble,et al.  Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes. , 2005, The Annals of thoracic surgery.

[2]  Vinod Venkatraman,et al.  Sleep deprivation elevates expectation of gains and attenuates response to losses following risky decisions. , 2007, Sleep.

[3]  D. Dinges,et al.  The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. , 2003, Sleep.

[4]  Guang-Zhong Yang,et al.  “Circadian Cortical Compensation”: A Longitudinal Study of Brain Function During Technical and Cognitive Skills in Acutely Sleep-Deprived Surgical Residents , 2010, Annals of surgery.

[5]  C. Sargent,et al.  Mismatch between subjective alertness and objective performance under sleep restriction is greatest during the biological night , 2012, Journal of sleep research.

[6]  N. Mackworth.  The Breakdown of Vigilance during Prolonged Visual Search 1 , 1948 .

[7]  Rajesh Aggarwal,et al.  Assessment and feedback in the skills laboratory and operating room. , 2010, The Surgical clinics of North America.

[8]  C. Saper,et al.  Hypothalamic regulation of sleep and circadian rhythms , 2005, Nature.

[9]  Robert V Rege,et al.  Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. , 2003, American journal of surgery.

[10]  Thomas J Balkin,et al.  Sustaining executive functions during sleep deprivation: A comparison of caffeine, dextroamphetamine, and modafinil. , 2009, Sleep.

[11]  C. Tribble,et al.  Sleep deprivation does not affect operative results in cardiac surgery. , 2004, The Annals of thoracic surgery.

[12]  Kevin A. Johnson,et al.  Decreased brain activation during a working memory task at rested baseline is associated with vulnerability to sleep deprivation. , 2005, Sleep.

[13]  D. Baldwin,et al.  Sleep deprivation and fatigue in residency training: results of a national survey of first- and second-year residents. , 2004, Sleep.

[14]  B. Hamilton,et al.  Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. , 2009, Journal of the American College of Surgeons.

[15]  Pasquale Strazzullo,et al.  Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. , 2011, European heart journal.

[16]  M. Klingensmith,et al.  Surgeon workhours in the era of limited resident workhours. , 2004, Journal of the American College of Surgeons.

[17]  Stuart R. Lipsitz,et al.  Patterns of Technical Error Among Surgical Malpractice Claims: An Analysis of Strategies to Prevent Injury to Surgical Patients , 2007, Annals of surgery.

[18]  A. Darzi,et al.  Laparoscopic Skills Suffer on The First Shift of Sequential Night Shifts: Program Directors Beware and Residents Prepare , 2008, Annals of surgery.

[19]  J A Horne,et al.  One night of sleep loss impairs innovative thinking and flexible decision making. , 1999, Organizational behavior and human decision processes.

[20]  S. Hauser,et al.  Kidney's nightshift, kidney's nightmare? Comparison of daylight and nighttime kidney transplantation: impact on complications and graft survival. , 2008, Transplantation proceedings.

[21]  D. Bates,et al.  Effect of reducing interns' work hours on serious medical errors in intensive care units. , 2004, The New England journal of medicine.

[22]  M. Fried,et al.  Effects of a Twenty‐Four Hour Call Period on Resident Performance During Simulated Endoscopic Sinus Surgery in an Accreditation Council for Graduate Medical Education–Compliant Training Program , 2005, The Laryngoscope.

[23]  A. Darzi,et al.  Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator , 1998, The Lancet.

[24]  Sethuraman Panchanathan,et al.  Effect of fatigue on psychomotor and cognitive skills. , 2008, American journal of surgery.

[25]  D. Asch,et al.  Time of Day Is Associated With Postoperative Morbidity: An Analysis of the National Surgical Quality Improvement Program Data , 2008, Annals of surgery.

[26]  Rajesh Aggarwal,et al.  Warm-up in a Virtual Reality Environment Improves Performance in the Operating Room , 2010, Annals of surgery.

[27]  N. Ayas,et al.  The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: A patient simulator study* , 2010, Critical care medicine.

[28]  Lisa Y. M. Chuah,et al.  Sleep Deprivation Biases the Neural Mechanisms Underlying Economic Preferences , 2010, The Journal of Neuroscience.

[29]  Brian E. Cade,et al.  Effect of reducing interns' weekly work hours on sleep and attentional failures. , 2004, The New England journal of medicine.

[30]  S. Vosburg,et al.  Modafinil Attenuates Disruptions in Cognitive Performance During Simulated Night-Shift Work , 2006, Neuropsychopharmacology.

[31]  Jorge Ortiz,et al.  Operative Start Times and Complications After Liver Transplantation , 2010, American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons.

[32]  A. Darzi,et al.  Effect of Pharmacological Enhancement on the Cognitive and Clinical Psychomotor Performance of Sleep-Deprived Doctors: A Randomized Controlled Trial , 2012, Annals of surgery.

[33]  W. Ricci,et al.  Is after-hours orthopaedic surgery associated with adverse outcomes? A prospective comparative study. , 2009, The Journal of bone and joint surgery. American volume.

[34]  J. Freischlag,et al.  Surgeon distress as calibrated by hours worked and nights on call. , 2010, Journal of the American College of Surgeons.

[35]  A. Darzi,et al.  Pharmacological enhancement of performance in doctors , 2010, BMJ : British Medical Journal.

[36]  S. Redline,et al.  Short duration of sleep increases risk of colorectal adenoma , 2011, Cancer.

[37]  D. Dawson,et al.  Fatigue, alcohol and performance impairment , 1997, Nature.

[38]  S. Jones.  Acute Care Surgery Performed by Sleep Deprived Residents: Are Outcomes Affected? , 2011 .

[39]  A. Darzi,et al.  Effect of caffeine and taurine on simulated laparoscopy performed following sleep deprivation , 2011, The British journal of surgery.

[40]  W. Ghali,et al.  Does surgeon fatigue influence outcomes after anterior resection for rectal cancer? , 2008, American journal of surgery.

[41]  D. Mozingo.  Jack Barney award: The effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons , 2009 .

[42]  Maarten A. S. Boksem,et al.  Effects of mental fatigue on attention: an ERP study. , 2005, Brain research. Cognitive brain research.

[43]  John A. Detre,et al.  Imaging brain fatigue from sustained mental workload: An ASL perfusion study of the time-on-task effect , 2010, NeuroImage.

[44]  C. Czeisler,et al.  Sleep deprivation, elective surgical procedures, and informed consent. , 2010, The New England journal of medicine.

[45]  S. Folkard.  Black times: temporal determinants of transport safety. , 1997, Accident; analysis and prevention.

[46]  E. Copeland,et al.  Impact of sleep deprivation on medium-term psychomotor and cognitive performance of surgeons: Prospective cross-over study with a virtual surgery simulator and psychometric tests , 2010 .

[47]  D. Dinges,et al.  Sleep Deprivation and Vigilant Attention , 2008, Annals of the New York Academy of Sciences.

[48]  John A Groeger,et al.  Early morning executive functioning during sleep deprivation is compromised by a PERIOD3 polymorphism. , 2008, Sleep.

[49]  David M Gaba,et al.  Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. , 2006, Annals of emergency medicine.

[50]  Nick Glozier,et al.  Is sleep duration related to obesity? A critical review of the epidemiological evidence. , 2008, Sleep medicine reviews.

[51]  C. Sargent,et al.  Dynamics of neurobehavioral performance variability under forced desynchrony: evidence of state instability. , 2011, Sleep.

[52]  T. Abe,et al.  The effects of a nighttime nap on the error-monitoring functions during extended wakefulness. , 2012, Sleep.

[53]  Usha Kreaden,et al.  Visual cues as a surrogate for tactile feedback during robotic‐assisted laparoscopic prostatectomy: posterolateral margin rates in 1340 consecutive patients , 2010, BJU international.

[54]  C. D. de Virgilio,et al.  Trauma surgery performed by "sleep deprived" residents: are outcomes affected? , 2010, Journal of surgical education.

[55]  Michael W. L. Chee,et al.  Lapsing when sleep deprived: Neural activation characteristics of resistant and vulnerable individuals , 2010, NeuroImage.

[56]  L. Stitt,et al.  Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. , 2011, Archives of surgery.

[57]  Guang-Zhong Yang,et al.  Evaluation of Orientation Strategies in Laparoscopic Cholecystectomy , 2010, Annals of surgery.

[58]  G. Tononi,et al.  Human cortical excitability increases with time awake. , 2013, Cerebral cortex.

[59]  M. Chee,et al.  Lapsing during Sleep Deprivation Is Associated with Distributed Changes in Brain Activation , 2008, The Journal of Neuroscience.

[60]  D. Dinges,et al.  Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. , 2004, Sleep.

[61]  Giulio Tononi,et al.  Sleep and Synaptic Homeostasis: Structural Evidence in Drosophila , 2011, Science.

[62]  J. Freischlag,et al.  Burnout and Medical Errors Among American Surgeons , 2010, Annals of surgery.

[63]  E. DeMaria,et al.  Night Call Does Not Impair Learning of Laparoscopic Skills , 2005, Surgical innovation.

[64]  Carol A. Keohane,et al.  Risks of complications by attending physicians after performing nighttime procedures. , 2009, JAMA.

[65]  Nick Sevdalis,et al.  Observational Teamwork Assessment for Surgery: Construct Validation With Expert Versus Novice Raters , 2009, Annals of surgery.

[66]  Ngianga-Bakwin Kandala,et al.  Meta-analysis of short sleep duration and obesity in children and adults. , 2008, Sleep.

[67]  Kanav Kahol,et al.  Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect. , 2009, Journal of the American College of Surgeons.

[68]  V. Naik,et al.  A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: the role of deliberate practice. , 2011, The Journal of thoracic and cardiovascular surgery.

[69]  T. Grantcharov,et al.  Laparoscopic performance after one night on call in a surgical department: prospective study , 2001, BMJ : British Medical Journal.

[70]  R. Flin,et al.  Non-technical skills for surgeons in the operating room: a review of the literature. , 2006, Surgery.

[71]  Rhona Flin,et al.  How do surgeons make intraoperative decisions? , 2007, Quality and Safety in Health Care.

[72]  Greg Jorgensen,et al.  Napping and nightshift work: Effects of a short nap on psychomotor vigilance and subjective sleepiness in health workers , 2007 .

[73]  M. Schwedler,et al.  Are Postoperative Complications Related to Resident Sleep Deprivation? , 1995, Southern medical journal.

[74]  M. Carskadon,et al.  Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. , 2005, JAMA.