Published On: Thu, Nov 7th, 2013

Sleepless surgeons operate as well as refreshed ones

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All surgery has its risks, but the prospect of being cut open by someone who has not slept the night before may not necessarily be cause for alarm. Researchers from the University of Western Ontario claim that there is no correlation between lack of sleep and adverse patient outcomes.

In a study, published in JAMA, researchers challenged the idea that sleepy surgeons do not perform as well as their sleep-refreshed counterparts.

In a retrospective cohort study using administrative health care databases in Ontario, Canada, Dr. Christopher Vinden and colleagues set out to establish whether surgeons operating the night before experienced more complications in elective surgery performed the next day.

The research says:

“Lack of sleep is associated with impaired performance in many situations. To theoretically prevent medical errors, work-hour restrictions on surgeons in training were imposed. There are now proposals for similar work-hour restrictions on practicing surgeons.”

Drawing on data collected from 102 community hospitals, Dr. Vinden and his team identified 2,078 patients who had undergone elective laparoscopic cholecystectomy (keyhole surgery to remove the gallbladder) where the surgeon had operated the night before.

Working extra hours

Terming these “at-risk” surgeries, the researchers randomly matched them with four other similar operations carried out by the same surgeon in the same year, on days when there was no evidence of having operated the night before. This resulted in a total of 10,390 operations performed by 331 different surgeons.

The most common outcome was conversion from keyhole surgery to open cholecystectomy – involving a large incision into the abdomen to take out the gallbladder.

Although this may not be viewed as a complication, most patients would prefer the keyhole option and view open surgery as an unwelcome outcome. It is also noted that this may serve as an aggregate end point for many complications.

Other adverse outcomes included iatrogenic injury (an injury caused by the surgery), such as accidental puncture or laceration to the bile duct, bowel or major blood vessel, and death within 30 days of surgery.

Dr. Vinden and his researchers did not find any statistical difference between conversion rates to open operations whether or not the surgeon had operated the previous night – 2.2% versus 1.9% with no overnight operation.

Findings for iatrogenic injuries were again similar, with 0.7% versus 0.9%, and death rates were less than or equal to 0.2% for surgeons who had worked the night before, compared with 0.1% for those who had not.

Surgeons ‘must self-assess fatigue level’

The researchers conclude their study by noting:

“Several studies found no association between surgeon sleep deprivation as assessed by operating the night prior to an operation or when surgeons report few hours of sleep and patient outcomes. Prior studies were limited because of small sample sizes and being from single academic institutions. Consequently, there is insufficient evidence to conclude that surgeon performance is compromised by insufficient sleep the night prior to performing surgery.”

“Restructuring health care delivery to prevent surgeons operating during the day after they operated the previous night would have important cost, staffing and resource implications.”

The study does not comment on how often the surgeons skipped sleep, or indeed, if they did sleep on the nights they were not operating. But it makes sense that physicians will appraise their own capabilities before any surgery.

Dr. Michael J. Zinner and Dr. Julie Ann Fresichlag say in an editorial accompanying the study:

“Just as each patient undergoing an operation requires an individualized assessment and operative plan, each surgeon must objectively self-assess fatigue level and honestly determine whether the surgical skills necessary for daytime operations following operating the night before will be comparable to those skills and capabilities following a good night’s sleep. Patient safety and surgeon well-being deserve no less.”

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