Background & Aims

Despite implementation of multimodal analgesia protocols, access to acute pain service teams, and intense research efforts to identify high-risk patients, pain control after surgery remains challenging.1,2 Preoperative sleep disturbance, e.g., poor sleep quality and impaired sleep continuity, may heighten acute postoperative pain intensity and increase analgesic consumption, with negative implications for recovery, mental and physical health outcomes.3,4 The main objective of the current review was to investigate the relationship between preoperative sleep disturbance and acute postoperative pain control.

Methods

This study was conducted as a systematic review and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The protocol for this systematic review was registered with PROSPERO (ID = CRD42023456435). Four electronic databases (MEDLINE, EMBASE, CINAHL and CENTRAL) were systematically searched from inception to December 2023. Two independent reviewers screened titles, abstracts, and full-text articles; extracted data; and assessed risk of bias for each included study, using the Newcastle-Ottawa scale. The primary outcome was any measure of association between preoperative sleep (disturbance) and acute postoperative pain control. The acute postoperative period was defined as ?1 week postoperative; pain outcomes >1 week to <3 months postoperative were denominated subacute.

Results

The search identified 26 prospective cohort studies and 3 retrospective cohort studies (16104 participants). Of the 29 included studies, 23 focused on preoperative insomnia symptoms, and three studies each focused on preoperative objective sleep continuity or sleep-disordered breathing. Meta-analysis, based on five studies with 1226 participants, showed that clinically significant preoperative insomnia symptoms were associated with moderate to severe pain intensity on the first postoperative day (odds ratio 2.69 (95% confidence interval 2.03-3.57), p<0.0001). Qualitative analysis showed relatively robust associations between preoperative insomnia symptoms, impaired sleep continuity and poorer acute, as well as subacute, postoperative pain control. Data related to sleep-disordered breathing were relatively limited with mixed findings. Eleven studies were assessed to be at high risk of bias; notably, baseline pain was not controlled for in 19/29 studies.

Conclusions

Based on data from 29 observational studies, including meta-analysis of five studies, there is a relatively strong relationship between preoperative sleep disturbance and poorer acute as well as subacute postoperative pain control. Given that insomnia is a potentially modifiable risk factor, interventions targeting sleep prior to surgery may improve postoperative pain control.

References

1.Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology. 2013;118:934-944.
2.Park R, Mohiuddin M, Arellano R, Pogatzki-Zahn E, Klar G, Gilron I. Prevalence of postoperative pain after hospital discharge: systematic review and meta-analysis. Pain Rep. 2023;8:e1075.
3.Bjurstrom MF, Irwin MR. Perioperative Pharmacological Sleep-Promotion and Pain Control: A Systematic Review. Pain Pract. 2019;19:552-569.
4.Yang MMH, Hartley RL, Leung AA, et al. Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ Open. 2019;9:e025091.

Presenting Author

Martin F. Bjurström

Poster Authors

Martin Flores Bjurström, MD, PhD

M.D., Ph.D.

Uppsala University

Lead Author

Andrea Niklasson (M.S.)

Department of Surgical Sciences, Uppsala University, Uppsala, Sweden

Lead Author

Patrick Finan (Ph.D.)

Department of Anesthesiology, University of Virginia School of Medicine, VA, USA

Lead Author

Michael T Smith PhD CBSM

Johns Hopkins School of Medicine

Lead Author

Alexandra Forsberg (M.L.I.S.)

Department of Clinical Sciences Lund, Lund University, Lund, Sweden

Lead Author

Nicholas Dietz (M.D.)

Department of Neurosurgery, University of Louisville, Louisville, KY, USA

Lead Author

Thomas Kander (M.D.

Ph.D.)

Department of Clinical Sciences Lund, Lund University, Lund, Sweden

Lead Author

Mads U Werner

MD

DanTrials, Zelo Phase 1 Unit, Copenhagen University Hospitals–Bispebjerg Hospital, Denmark

Lead Author

Michael R. Irwin (Ph.D.)

Department of Psychiatry and Biobehavioral Sciences, Cousins Center for Psychoneuroimmunology

Lead Author

Eva Kosek

Karolinska Institutet, Stockholm, Sweden

Lead Author

Topics

  • Systematic Reviews/Meta-Analysis