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Studies such as the ones described previously are just beginning to establish the true picture of sleepiness and fatigue in medical personnel. From studies of the performance of fatigued individuals in other domains, we know that professionals become increasingly vulnerable to the degrading effects of sleepiness as the sleep debt accumulates. It may be difficult to determine a causal relationship between anesthetist fatigue and patient outcome. However, it is clear that if the anesthetist is not awake, he or she cannot possibly be aware. Such a lapse in vigilance is unacceptable. Furthermore, the anesthetist cannot prevent sleep by willpower alone, because it is a fundamental physiologic drive. Demands for clinical services must be balanced against the potential for reduced vigilance and error by seriously fatigued practitioners, anesthetists, and surgeons alike.
Because fatigue is such a widespread and insidious problem, it is important to determine ways to counteract its effects. Countermeasures, which are methods that institutions or practitioners can use to minimize the negative effects of sleepiness and fatigue on performance, include:
The first step in addressing sleepiness and fatigue of medical personnel is to educate practitioners and the administrators of health care institutions about the impact of sleep issues on work performance, mood, job satisfaction, and health. Education is a relatively simple and inexpensive countermeasure that can be implemented immediately. Educational programs covering sleep deprivation, circadian disruption and fatigue, and countermeasures have been enthusiastically adopted by an increasing fraction of the aviation community.[375] [376] Similar programs should be developed for the health care community. Education alone is sufficient for some individuals and institutions to change their work and sleep habits or their organizational and scheduling procedures. However, it is likely that education will not be sufficient to address this issue fully.
Good sleep habits include the following: regularity of bedtime and wake-up time; sufficient time for sustained and individually adequate sleep; restriction of alcohol, caffeine, and nicotine prior to bedtime; and use of exercise, nutrition, and environmental factors so that they enhance rather than disturb sleep. [377] A regular sleep schedule is an important part of optimal sleep hygiene, but it is often not possible for medical personnel, given the requirement to cover clinical needs on a 24-hour basis. Medical personnel should make greater efforts to maintain as constant a sleep schedule as possible and to maximize sleep opportunities prior to and after periods of reduced sleep.
Social drug use can have profound effects on sleep. Physicians often use caffeine in order to stay awake during on-call periods, but often its use could be more strategic. Strategic use (i.e., use when its alerting effects are needed) of caffeine requires knowledge about its onset and duration of action. Besides its alerting effects, caffeine produces an increase in awakenings and decreases the total nocturnal sleep time if ingested close to sleep opportunities. Individuals who ingest large amounts of caffeine and who have nocturnal sleep disturbances should limit or cease their caffeine intake. Nicotine is a stimulant that produces effects similar to those of caffeine. Alcohol is often used successfully to initiate sleep, but its effect on sleep architecture after sleep onset can be devastating. After ingestion of alcohol, frequent awakenings from sleep occur that can be associated with increased sympathetic nervous system activity, often manifested by headache, sweating, and tachycardia. Clearly, use of these substances should be restricted near bedtime.
Physicians often lack good nutritional habits, especially during long duty periods. Meals may be skipped or ingested quickly whenever there is adequate time. If one is hungry prior to bedtime, it is best to avoid eating or drinking heavily because this, too, can disturb sleep.
The effects of age can make optimum sleep habits difficult to achieve. The number of awakenings per night rises after the age of 45 years, corresponding to decreased sleep efficiency (time in bed versus total sleep time), and there is increased sleep fragmentation. The ability to initiate sleep at any time during a 24-hour day is diminished after the age of 25 years, and "sleeping in" to make up for lost sleep is more difficult as individuals grow older. Sleep-related disorders such as breathing disruptions (obstructive sleep apnea) and periodic limb movements also become more common with age.
Ideally, the sleep setting should be a dark, quiet room devoid of sources of interruptions such as pets, telephones, pagers, and children. The sleeping surface and environmental temperature should be comfortable. Psychological stressors increase baseline physiologic arousal and can impair the quality and quantity of sleep. For example, reviewing the previous day's events or attempting to plan tomorrow's activities while trying to fall asleep is not conducive to sleep. An effort should be made to separate the work of the day with a period of relaxation prior to attempting to initiate sleep.
Although other industries have openly recognized the reality of vigilance decrements resulting from fatigue and sleepiness, the health care system has not. Rest breaks and rotation of task duties are mandatory for air traffic controllers and are part of naval ship command procedures in an attempt to prevent potential lapses in vigilance. Short breaks have been shown to increase productivity and job satisfaction, and they probably also
The optimal timing and length of breaks are unknown, but a periodic relief from duty should be taken when possible. Cooper and coworkers[379] [380] studied the effects of intraoperative exchange of anesthesia personnel. Although in some cases the process of relieving OR personnel caused a problem, it more frequently was associated with the discovery of a preexisting problem. The positive effect of relief of personnel probably depends on the quality of the handover briefing conducted by anesthetists.
If anesthetists are unable to obtain a break during long work periods, there are other measures that they can take to remain alert. They can engage other OR personnel in conversation (although this, too, can be distracting), thereby increasing the level of stimulation in the environment. Walking around and standing up are also techniques that decrease subjective (but not physiologic) sleepiness. If anesthetists are having microsleep events, which may be noticed by other personnel rather than by the anesthetists themselves, fatigue is already very severe, and complete sleep is imminent. In such a situation, the practitioner must secure additional assistance in surveillance of the patient and, if necessary, obtain relief to allow him or her to sleep.
If adequate sleep during the night cannot be obtained, naps can be used to decrease sleepiness and to improve performance. Based on circadian physiology, as discussed earlier, there are two periods during the 24-hour day that are optimal for naps. These are the periods when the body is already physiologically prepared for sleep, corresponding to the two circadian lulls (approximately 2 PM to 6 PM and 2 AM to 6 AM). Napping at times when circadian rhythms are instructing wakefulness is not easily accomplished and can be counterproductive. [381] [382]
The optimal nap length for most individuals is about 45 minutes; this duration acutely improves alertness, allows improved performance, and minimizes the possibility of sleep inertia on awakening.
Napping may alter regular nocturnal sleep. Depending on the timing and length of the nap, sleep initiation and maintenance may be more difficult. Increased sleep latency and decreased total sleep time are commonly seen in people who have taken long (2-hour) naps during the day.
Therefore, the decision whether to nap is complex. Data from NASA studies of flight crews demonstrate that, on the whole, napping is a useful countermeasure to fatigue and sleep deprivation.[362] However, no single recommendation can be made for the use of naps in any work environment, and there are as yet no data on the use of naps in the health care domain.
Further complicating the appropriate use of napping by medical professionals is the finding that physicians have an individual and cultural tendency to ignore or to minimize the effect of fatigue and sleep deprivation. The culture of medicine views work breaks and naps as signs of weakness. The military has addressed similar attitudes with the concept of "power napping." Troops are strongly encouraged to take naps of 10 minutes to 1 hour when the situation permits, in order to increase their strength and performance. This approach appropriately presents the idea of napping in a positive light as a sign of wisdom and strength, rather than one of cowardice and frailty.
Sleep inertia corresponds to the period of reduced ability to function optimally immediately on awakening. This phenomenon usually occurs when individuals are awakened out of slow-wave sleep and is manifested by grogginess and impaired performance lasting as long as 15 to 30 minutes after awakening. Sleep inertia can also occur after being awakened from normal sleep and is most common during the early morning circadian trough (2 AM to 6 AM). Depending on the preexisting level of sleepiness, individuals that take naps longer than 40 minutes are at a greater risk for sleep inertia on awakening. Sleep inertia can be important to health care professionals who may be awakened out of deep sleep to provide emergency care to patients (e.g., emergency cesarean section or emergency intubation). If urgent work can be anticipated, the sleeping individual should be awakened with sufficient time (at least 15 minutes) to minimize the fogginess and performance decrement associated with sleep inertia. If sleep inertia is unavoidable, it would be wise for the affected person to ask for help until the grogginess dissipates.
A few studies have evaluated the use of sedative-hypnotics for promotion of sleep during nonduty hours by nonmedical personnel (e.g., to assist in daytime sleep after a night shift).[356] Many questions remain unanswered regarding the quality of sleep obtained after using hypnotics, the severity of hangover effects, and the potential risks of abuse. Melatonin, which is a hormone secreted by the pineal gland, may have promise as a nonaddictive daytime sleep-inducing agent, but the results of existing studies are controversial.
Stimulants may have a role in the maintenance of alertness during periods of extreme sleepiness. Modafinil is a non-amphetamine alertness-enhancing drug that has been approved for use in narcolepsy. The side effect profile of this drug is so promising that it is being extensively studied by the military and shift workers as a non-addicting adjunct for alertness management. Its use in health care is also being studied but cannot be sanctioned at this point. The use of sedatives and potent stimulants to manipulate sleep is not considered an appropriate option for anesthetists. Caffeine is used frequently to increase alertness temporarily, but there are caveats about its use, as discussed earlier.[355] [356] Caffeine should be used strategically to maximize its effect when needed. Strategic use of caffeine includes (1) knowledge of its onset (15 to 30 minutes) and duration of action (3 to 4 hours) and (2) use when alertness is required and the opportunity to sleep is minimal.
Countermeasures should be studied and implemented in health care. There are major financial incentives to maintain the status quo. If an anesthesiologist knows that he or she is impaired (from fatigue or for any other reason), he or she should enlist the assistance of a colleague so as to not negatively impact patient safety.
Timed cycles of bright light and darkness have been used in certain circumstances to facilitate adaptation to shift work. Exposure to bright light (>7000–12,000 lux) and darkness at the appropriate points in the circadian cycle has been shown to reset the circadian pacemaker by 12 hours over 2 to 3 days.[383] This important finding demonstrates the ability to make significant changes in the circadian system relatively quickly. However, resetting the circadian timekeeper is critically dependent on the timing, intensity, and duration of exposure to light and to "total" darkness. Being off by only an hour can prevent the desired effect. Adhering to such time-critical schedules for this treatment is probably impractical for anesthetists, given the many work-related and social factors that affect their activities. Research on light treatment continues and may eventually result in more practical treatment regimens.
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