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 Researchers who looked at U.S. death rates after so-called
exploratory laparotomies, which are done in trauma victims to
discover the extent of injuries, found similar mortality both day
and night.
“Obviously, no one wants to get into an accident, but you can be
reassured that whether it occurs during the day or at night, the
outcomes in terms of mortality will be the same,” said study author
Dr. Daniel Tran, assistant professor of surgery at Howard University
College of Medicine.
“This is important because exploratory laparotomies are done in life
and death situations when it’s not possible to wait for a better
time of day to operate,” he told Reuters Health.
Tran and colleagues analyzed 2007-2010 data from the National Trauma
Databank on 16,096 exploratory laparotomies started between midnight
and 6 a.m. and 15,109 between 7 a.m. and 5 p.m.
The average patient age was 36, and close to 80 percent were men.
Most injuries were caused by car crashes, gunshots and stabbings.
After daytime surgeries, 16.1 percent of patients died during their
hospital stay. After middle-of-the-night surgeries, 11.5 percent
died while in the hospital - but the difference wasn’t statistically
significant after adjusting for other variables like patient age and
severity of the injuries.
Patients treated during the day were typically older and had more
severe injuries.
“People who are involved in a lot of traumas at night can tend to be
younger, and it can involve drinking,” said Dr. Angela Gardner,
associate professor in the department of emergency medicine at the
University of Texas Southwestern in Dallas and past president of the
American College of Emergency Physicians.
The study found the lowest mortality when the surgery began between
4 a.m. and noon.
“There is a common belief that if you scheduled surgery, you should
try to schedule in the morning,” said Gardner, who wasn’t involved
in the study. “This data would certainly support that.”
One limitation of the study, published in The American Journal of
Surgery, is the lack of data on individual surgeons, such as how
experienced they are or how many hours they had worked before
starting the operation.
The findings also might not be relevant for more complex surgeries,
said Dr. Carlos Pellegrini, chair of the surgery department at the
University of Washington in Seattle and a past president of the
American College of Surgeons.
“The exploratory laparotomy in general is a relatively
straightforward procedure for which mortality or morbidity are very
low,” said Pellegrini, who wasn’t involved in the study.
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Pinpointing how sleep deprivation impacts surgical outcomes – and at
what point a surgeon tips from fatigued, but functional, to
exhausted and error-prone, is difficult. The idea that surgeons
might make more mistakes at night is based on evidence linking
disturbed sleep cycles and internal body clocks to impaired motor
skills and diminished cognitive function in shift workers and night
workers.
In a separate study in the same journal, Danish researchers
monitored 30 surgeons for four days and found that working nights
negatively affected circadian rhythm, the 24-hour cycle that tells
the body when to sleep and regulates physiological functions.
The researchers tested for two hormones – melatonin, which rises
with fatigue, and cortisol, which increases with stress – starting a
day before surgeons worked a 17-hour overnight shift and continuing
for two days after.
Melatonin fell during the night shifts, indicating an abnormal
circadian rhythm.
“Being awake in artificial light disrupts the circadian rhythm,”
lead study author Dr. Ilda Amirian, from the department of surgery
at Herlev Hospital, University of Copenhagen.
Cortisol, a stress hormone which might increase during a complex
surgical procedure, was lower during the night shift than on the
other days.
Results might be different in the U.S., where many surgeons work
longer hours than in Denmark, Amirian said.
Still, taken together, the studies suggest that surgeons can adapt
to night shifts, Pellegrini noted
“It is extremely difficult in a single study to account for every
variable that impacts performance,” Pellegrini said. “The studies
here add to a growing body of evidence suggesting that surgeons,
particularly experienced surgeons, can devise techniques to
compensate for sleep disruption.”
(This version of the story revises paras 1, 2 and 7 to clarify that
deaths occurred during the patient's hospital stay, not necessarily
during the surgery.)
SOURCE: http://bit.ly/1Dn10Ct and http://bit.ly/1zGlUdb The American
Journal of Surgery, online January 19 and 21, 2015.
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