Sleep and Performance Principles and Strategies for MDs

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Sleep and Performance Principles and Strategies
for MDs

• Dayton Childrens Hospital
• Mark Splaingard MD
• 4/11/12
• Mark.Splaingard_at_Nationwidechildrens.edu

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Goals of Talk

• Evaluate the impact of sleep deprivation and
  sleep inertia on different aspects of learning
  and performance.                                  
                     
•  Distinguish between early and late signs and
  symptoms of impairment due to sleep deprivation.
• Assess various strategies to optimize performance
  during periods of inadequate sleep. 

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Shift Work

• About 12 of USA work force engages in night work
• About 25 of American work force has a
  rotating work shift schedule
• Society has come to depend on continuous
  operations in fields such as transportation,
  public safety and health care

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Linking Fatigue to Performance

• Estimates that as many as 98,000 patients die/yr
  as a result of medical errors in hospitals
• 20 of fatal traffic accidents and 30 of heavy
  truck accidents directly related to sleepiness
• High profile events related lack of sleep as
  factor
• Bell Commission NY-1989
• Exxon Valdez 1989 11.2m gallon oil spill-
  2B
• Arkansas River barge - I40 bridge-2002

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• HOW
• MUCH
• SLEEP
• IS
• NECESSARY?

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Sleep Morphology

• 4 stages 1-3, REM
• sleep onset latency 20-30 minutes
• cycles are 70-90 minutes
• Normal adult TST 7.4/-0.9 hr
• 9 college students sleptgt9 hrs

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Percentiles for TST per 24 hrs
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Normal Sleep Morphology - 6 yo.
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Sleep Deprivation

• With REM sleep deprivation, normal volunteers
  were agitated and aggressive
• With SWS deprivation, normal volunteers were more
  physically uncomfortable (vague aches, more
  somatic pain, general malaise)
• If sleep deprived SWS recovers 1st, whereas REM
  takes 1 or 2 nights before rebound

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Why do we need sleep?

• Cerebral glycogen depletion occurs during
  extended wakefulness inducing adenosine release
• Adenosine binds A1 adenosine receptors augmenting
  the drive for sleep

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Bedtime Rituals

• Shhh!
• This is Daddys bedtime secret
• for today.
• Man is born broken.
• He lives by mending.
• The grace of God is glue!

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Neurotransmitters in Sleep

• Increase in dopamine, norepi/epinephrine, orexin,
  glutamine, histamine, acetylcholine, serotonin
• Increase Wakefulness
• Increase in GABA, adenosine, melatonin
• Increase Sleepiness

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Resident Sleepiness

• 80/30 Rule started in July 2003
• 80 hr work week still far exceeds the maximum
  work hours for pilots (34hr/w) and commercial
  drivers (60hr/w)
• Limiting work time provides
• Opportunity
• Increase sleep improve performance

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Resident Sleepiness

• Admitted to possibly dozing while writing
  notes (69)
• possibly dozing while reviewing medication
  lists (61)
• 50 failed to identify they fell asleep even
  when sleep documented by EEG
• Dissociation between subjective/ objective
  performance
• Increase in medical errors 20-36 higher with
  every third schedule (80 hrs) than modified
  63 hours/week

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The 80/30 rule will increase residents amount
of sleep and improve performance of tasks

• A. True
• B. False
• C. Unknown

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Studies of Resident Performance

• Anesthesiology residents, even when not on call
  for 2 full days have pathological daytime sleep
  latencies comparable with narcoleptic patients
• Internal medicine residents did not get extra
  sleep as measured by actigraph on post call
  nights
• Surgical residents self report 5-6 hrs. of sleep
  across week regardless of call schedule

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Health Effects of Sleep Loss in Residents

• Increase stress, depression, burnout
• Increased body/physical complaints
• Pregnancy related complications- premature
  labor
• MOST IMPORTANT
• Higher motor vehicle crash rates during
  residency training, particularly during
  Post call periods

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A car traveling 55 mph on a 2 lane highway will
drift off the road onto the shoulder within how
many seconds of operator unresponsiveness?

• A. 2 seconds
• B. 4 seconds
• C. 8 seconds
• D. 12 seconds

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Psychomotor Ability
Dawson. Nature 1997
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Time of Day Effect on Neurobehavioral Performance
during Chronic Sleep Restriction

• N90, Ages 21-49 y, 44 F
• 10 days sleep deprivation 4.2-8.2 hrs
• Performance on PVT every 2 hrs during wake
• Findings
• Less sleep time resulted in faster accumulation
  of deficits
• Time of day affects performance/sleepiness
• Deficits greatest at 8 am.
• Deficits smallest at 4-6 pm

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Warning Signs of Sleepiness

• Falling asleep in conference or rounds
• Feeling restless or irritable with staff,
  colleagues, family or friends
• Having to check your work repeatedly
• Having difficulty focusing on patient care
• Feeling that you really just dont care

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Effect of a night on call for staff

• Swedish University hospital
• 15 anesthesiologist vs. 17 pediatricians / ENTs
• Mean age 40 y (26-55 y), 44 F
• Effect of 1 day work and overnight call on
  subsequent function
• Actigraphy and Karolinska Sleepiness Scale
• Findings
• Similar between groups - 3h sleep night on call
• 7 h sleep night after call, 6 night sleep usual
• Scores for mental fatigue and feeling well
  rested returned to baseline after 2nd night
  recovery sleep

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• HOW
• MUCH
• WORK
• IS
• NECESSARY?

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3 MD elements of patient safety

• Capacity recognize too tired to perform
• Commitment altruistic dedication to child
• Competence expertise to perform tasks
• competence vs expertise 10,000 hrs
• deliberate practice and specific feedback
• 80h/wk vs 110/wk 2y lt experience in 5 y
• quality v quantity

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Sleep Deprivation
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Sleep Deprivation

• Self monitoring of sleepiness is notoriously poor
• Fluency Accuracy Speed
• Initial losses in decision making, creative
  thinking/problem solving, speed
• Factual knowledge is relatively insensitive to
  the effects of sleep deprivation
• Act by rote with overlearned behaviors/ shift
  from persistence to perseveration

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Performance in Sleep Deprivation

• Genetic vulnerability
  
• Age
• Chronic sleep deprivation
• Circadian effects (time of day)
• Clinical experience (over learned skill)
• Task demands ( task gt 5-10 minutes are harder)
• Clinical workload (degree of multi-tasking)
  reaction time , vigilance and manual
  dexterity- most affected

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Sleep inertia is_____?

• A. Inability to move ones limbs upon first
  awakening.
• B. Increased transition time from REM (dream) to
  nondream sleep.
• C. Inability to fall asleep.
• D. Confusion, disorientation and impaired
  reaction time upon awakening.

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Sleep Inertia

• Worse under sleep deprived conditions
• Varies with sleep stage
• worse in Stage 4 sleep awakening
• Most likely to occur upon an abrupt arousal from
  a sleep period lt 2 hrs
• Adenosine may be the neurobiological substrate
  of sleep inertia

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2 emerging areas

• 5 minute delay concept
• delay between SO and beneficial recovery
• Accounts for the reduced restorative value of
  fragmented sleep
• Mathematical modeling of sleep performance
• Predict steady state cognitive performance with gt
  4 h sleep but disproportionate buildup of
  performance impairment lt 4 h

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Strategies to Overcome Performance Decrements
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Countermeasures for Sleepiness

• Drugs
• (Caffeine, Ritalin, Modafinil)
• Physical Environment
• (Bright lights, exercise)
• Sleep
• cat naps, sustained naps, sleep quality

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Why do we drink coffee ?

• Current most popular theory is as a
  countermeasure to sleep inertia
• Bolus of caffeine reaches peak plasma level
  within 30 minutes after intake and passes the
  blood brain barrier almost immediately
• Problem is recreational vs. therapeutic use of
  caffeine

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Caffeine

• Most widely used CNS stimulant
• Blocks adenosine receptors causing wakefulness
• No Doz 100mg caffeine 1 cup of coffee
• PROBLEM
• Too high of doses are used routinely

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Caffeine Content of Foods and Drugs

• Drugs
• No Doz, max. Strength Vivarin 1 tab 200
• Excedrin 2 tabs 130
• NoDoz, regular strength 1 tab 100
• Coffee
• Grande (Starbucks) 16 oz
  550
• Coffee, brewed 8 oz 135
• Maxwell House 8 oz
  110
• Cappuchino/Latte (Starbucks) 16 oz 70
• Espresso (Starbucks) 1 oz
  35
• Tea
• Snapple Ice Tea, all varieties 16 oz 42
• Lipton Natural Brew Iced Tea Mix
• (unsweetened) 8 oz 25-45
• Lipton Tea 8 oz
  35-40
• in mg

• Soft Drinks
• Mountain Dew 12 oz 55
• Surge 12 oz 52
• Diet Coke 12 oz 46
• Dr. Pepper (reg or diet) 12 oz 42
• Sunkist Orange Soda 12 oz 42
• Minute Maid Orange Soda 12 oz 0
• Red Bull 8.5 oz 80
• Planet Java Tremble 9.5 oz 129
• Krank 17 oz 100
• Milk
• Chocolate 12 oz
  15
• Frozen Desserts
• Starbucks Coffee Ice Cream,
• assorted flavors 1
  cup 40-60
• Haagen-Dazs Coffee
• Ice Cream 1
  cup 58

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Modafinil (Provigil)

• Discovered in 1978
• Marketed 1998 for 2 indications narcolepsy and
  shift work sleepiness
• Nap in a pill
• Side effects nausea, headaches, interferes with
  oral contraceptives
• 240/mo
• Cocaine addiction- modulates dopamine ?

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Countermeasure for Sleepiness

• EXPECT YOUR LIKELY IMPAIRMENT
• SOME Sleep is Always better than NONE
• NAP whenever you can
• Use low doses of caffeine continuously ie. 0.3
  mg/kg/hr. to reduce sleep inertia
• Plan modifications to home sleeping environment
• Get as much sleep as you can before shifts

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In an adult awake for 24 hours continuously from
700am, at what time is performance worst and
why?

1. 1am peak GH surge
2. 2 am end of final slow wave sleep cycle
3. 4 am - Nadir of body temperature
4. 4 am peak cortisol release
5. 659am greatest cumulative fatigue

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Insomnia

• I cant seem to get use to the fact,
• Im tense and nervous and I cant relax.
• Cant sleep, beds on fire
• Dont touch me,
• Im a real live wire

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Poor Quality Nocturnal Sleep

• Medical/ Psychiatric disorders
• Sleep disorders
  OSA, RLS, Sleep Phase Delay
• Environmental factors
• Pets, Children, disruptive bed partner
• Drug/Alcohol usage
• metabolize 1 beer/shot, 6 ounces wine/hr
  
  
  
  
  with subsequent
  arousal

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Insomnia

• 10 of insomniacs have medical problem
• 90 of insomnias
• Situational
• Interpersonal
• Psychological
• Existential

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Interpersonal
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Sleepiness Suggestions

• Never make an important decision Supine!
• Eyelids tell you when you sleepy.
• Drive smart. Remember a 4 second micro sleep
  crashes you off the highway
• Try to avoid starting a shift with a sleep debt
• Avoid time pressure as much as possible
• Know thy self