SLEEP/ W AKE CYCLE OF W OMEN SUBMI TTED TO ELECTI VE GYNECOLOGI CAL SURGERY
W I TH A ONE- DAY HOSPI TAL STAY
Maria Crist ina Zaros1 Maria Filom ena Ceolim2
Zar os MC, Ceolim MF. Sleep/ w ake cycle of w om en subm it t ed t o elect ive gy necological sur ger y w it h a one- day hospit al st ay. Rev Lat ino- am Enfer m agem 2008 set em br o- out ubr o; 16( 5) : 838- 43.
The aim of t his descript ive st udy w as t o com pare preoperat ive and post - operat ive sleep/ w ake cycle ( SWC) pat t er ns of 22 w om en under going elect iv e sur ger y , w it h up t o one day of hospit alizat ion. The st udy w as approved by t he local Review Board. Volunt ary wom en ( average age 39 ± 9) filled out a Sleep Journal for 23 consecut ive days, before and aft er t he surgery ( 46 days t ot al) . Dat a were analyzed wit h Wilcoxon’s m at ched-pairs t est . The findings showed slight and t ransit ory SWC changes ( increased lat ency, reduced efficiency and later wake- up tim e) after the surgery. Nevertheless, sleep quality was im proved and there was a fast return to t he SWC pat t erns observed before t he int ervent ion, perhaps due t o t he early exposit ion t o daily rout ine, e.g. t he environm ent al clues t hat are im port ant t o rhyt hm ic synchronizat ion.
DESCRI PTORS: sleep; surgery; nursing; wom en; hospit alizat ion
CI CLO VI GI LI A/ SUEÑO DE MUJERES SOMETI DAS A CI RUGÍ A GI NECOLÓGI CA ELECTI VA
CON UN DÍ A DE HOSPI TALI ZACI ÓN
Est e est udio t uv o com o obj et iv o com par ar las car act er íst icas del ciclo v igilia/ sueño ( CVS) de 22 m uj er es som et idas a cir ugía ginecológica elect iv a con hast a un día de hospit alización, ent r e las et apas pr e y post operat oria. El est udio fue aprobado por el Com it é de Ét ica de la inst it ución. Las volunt arias ( 39 ± 9 años) llenaron un Diario del Sueño durante 23 días consecutivos, antes y después de la cirugía ( 46 días en total) . Los dat os fueron com parados por m edio de la prueba de Wilcoxon para m uest ras pareadas. Lo encont rado reveló alt eraciones discret as y t ransit orias del CVS ( aum ent o de la lat encia, reducción de la eficiencia y despert ar m ás t ardío) después de la cirugía, sin em bargo con m ej oría de la calidad del sueño y rápido ret orno a las características anteriores a la intervención, talvez por la exposición precoz a la rutina del día a día, o sea, a las señales am bient ales relevant es para la sincronización del rit m o.
DESCRI PTORES: sueño; cirugía; enferm ería; m uj eres; hospit alización
CI CLO VI GÍ LI A/ SONO DE MULHERES SUBMETI DAS A CI RURGI A GI NECOLÓGI CA ELETI VA
COM UM DI A DE HOSPI TALI ZAÇÃO
Este estudo teve com o obj etivo com parar as características do ciclo vigília/ sono ( CVS) de 22 m ulheres subm etidas a cir ur gia ginecológica elet iv a com at é um dia de hospit alização, ent r e as et apas pr é e pós- oper at ór ia. O estudo foi aprovado pelo Com itê de Ética da instituição. As voluntárias ( 39± 9 anos) preencheram um diário de sono durante 23 dias consecutivos, antes e após a cirurgia ( 46 dias no total) . Os dados foram com parados por m eio do t est e de Wilcoxon para am ost ras pareadas. Os achados revelaram alt erações discret as e t ransit órias do CVS ( aum ent o da lat ência, r edução da eficiência e desper t ar m ais t ar dio) após a cir ur gia, por ém , com m elhora da qualidade do sono e rápido retorno às características anteriores à intervenção, talvez pela exposição precoce à rot ina do dia- a- dia, ou sej a, às pist as am bient ais relevant es para a sincronização do rit m o.
DESCRI TORES: sono; cirurgia; enferm agem ; m ulheres; hospit alização
1
M. Sc. in Nu r sin g, e- m ail: m cr iszar os@y ah oo. com . br ; 2 Ph . D., Facu lt y, Facu lt y of Medical Scien ces, Cam pin as St at e Un iv er sit y, Brazil, e- m ail: fceolim @fcm .unicam p.br.
I NTRODUCTI ON
I
n t he 20t h cent ury, wom en st art ed t o have access t o new w or k ar eas and, w it h t he changes int h e fam ily st r u ct u r e, m or e t im e for t h em selv es an d
m or e op p or t u n i t i es f or n ew ach i ev em en t s b esi d es
m ar r iag e an d ot h er s t h at ar e com p lim en t ar y t o it ,
such as w or k and educat ion( 1).
Besi d es t h ese a ch i ev em en t s, a d v a n ces i n
w o m e n ’ s h e a l t h c a r e c a n b e r e p r e s e n t e d b y t h e
i m p r o v em en t o f w i d el y u sed su r g i ca l t ech n i q u es.
Cu r r en t ly, cer t ain g y n ecolog ical su r g er ies, su ch as
sur gical hy st er oscopy and gy necological lapar oscopy
can be perform ed wit hin a one- day hospit al st ay. Such
in t er v en t ion s h av e b een em p loy ed m or e an d m or e
f r equ en t ly, du e t o t h e dif f er en t iat ed pr e an d post
-oper at or y r out ine in r elat ion t o m edium - and lar
ge-size surgeries, since t hey offer a low risk of infect ion
and allow for a prom pt ret urn t o daily act ivit ies( 2).
H o w e v e r, o t h e r c o n s e q u e n c e s o f t h e s e
p r o c e d u r e s , s u c h a s c h a n g e s i n t h e r h y t h m i c
pr ocesses of t he or ganism , can negat iv ely affect t he
pat ien t ’s h ealt h . Hospit alizat ion an d su r gical st r ess,
by cau sin g ch an ges in t h e w om an ’s ph y siology an d
d aily r ou t in e, can cau se d isor d er s in h er b iolog ical
rhythm s, am ong which the sleep/ wake cycle ( SWC)( 3- 4).
Every act ivit y of a living being is t he result of
m ult iple biochem ical and physiological pr ocesses t hat
ar e t em por ally or ganized, i. e. r hy t hm ic. This cy clical
rout ine is as ancient as life it self, in order t o allow for
sy nchr onicit y w it h t he ex t er nal env ir onm ent( 5).
I n t he hum an being, t he SWC is accom panied
by daily v ar iat ion s in ot h er r h y t h m s, su ch as body
t e m p e r a t u r e , r e s p i r a t o r y a n d h e a r t r a t e , b l o o d
co m p o si t i o n a n d n e a r l y a l l o t h e r b o d y f u n ct i o n s.
Besides k eepin g t h is ph ase r elat ion st able w it h t h e
o t h e r e n d o g e n o u s r h y t h m s, t h e SW C sh o u l d b e
sy nchr onized w it h env ir onm ent al and social r hy t hm s,
cont ribut ing t o t he at t ainm ent of a prim ordial int ernal
econ om y in t h e or g an ism . Th is sy n ch r on izat ion is
known as “ t em poral organizat ion”, and is fundam ent al
for t he int egrat ion of living beings wit h environm ent al
t em por al m ar k er s( 5 ).
Th e SWC d esy n ch r on izat ion in t h e h u m an
bein g can lead t o sleep disor der s an d en t ail sh or t
-an d m ed iu m - t er m con seq u en ces. Am on g t h e m ost
im p or t an t ar e sleep d ep r iv at ion , w h ich m ay cau se
c h a n g e s i n t h e i m m u n e f u n c t i o n , r e d u c t i o n o f
awareness and dam age t o physiological and cognit ive
f u n ct i o n s, a l so d e cr e a si n g t h e se n sa t i o n o f w e l l
-being( 6).
Sev er al d ay s m ay b e n ecessar y t o r est or e
sy n ch r o n i zat i o n( 7 ), co m p r eh en d i n g t h e m o m en t o f
p o st - su r g i ca l r eco v er y, w h en t h e i n t eg r i t y o f t h e
or gan ic f u n ct ion s is essen t ial. Th e in st abilit y of t h e
b iolog ical r h y t h m s, cau sed b y su r g ical st r ess, can
int er fer e in t he im m une r esponse, in t he healing of
t he sur gical w ound and r esist ance t o infect ion( 3 ). I n
t h i s se n se , su r g i ca l i n t e r v e n t i o n s r e q u i r i n g sh o r t
h o sp i t a l st a y s co u l d r e su l t i n l o w e r i m p a ct a n d
alt erat ion on t he SWC, besides t he well- known effect s
o f t h e r ed u ct i o n o f st r esso r ag en t s an d t h e r i sk s
inher ent t o t his t y pe of pr ocedur e.
I t is believed t hat t his st udy can cont ribut e t o
k n o w l e d g e o n t h e e f f e c t s o f a s o c i o - t e m p o r a l
challenge, such as a sur gical pr ocedur e, on w om en’s
SWC. Th e st u d y is r elev an t , sin ce it is r elat ed t o
w om en’s healt h and w ell- being, and also because it
pr ov ides healt hcar e pr ofessionals w it h elem ent s t hat
can aid in t he healt hcare offered t o t he pat ient .
Th er ef or e, t h is st u d y aim s t o com p ar e t h e
SWC char act er ist ics of w om en subm it t ed t o elect iv e
gy necological sur ger y w it h a m ax im um hospit al st ay
of 24 hours, from t he pre- operat ory t o t he im m ediat e
p o st - o p e r a t o r y st a g e s, a n d t o d e scr i b e t h e t i m e
int erval necessary, in t he post - operat ory, for t he SWC
t o r et ur n t o t he char act er ist ics of t he pr e- oper at or y
st ag e.
CASUI STI C AND METHOD
Th i s i s a d escr i p t i v e, cr o ss- sect i o n al f i el d
st udy, w it h a quant it at iv e appr oach, developed at a
hospit al t hat sees t o pat ient s wit h healt hcare insurance
and t hose who pay for t heir t reat m ent , in t he cit y of
Lim eir a ( SP) , Br azil.
Twent y- t wo wom en, aged 24 t o 64 years old,
p ar t i ci p at ed i n t h e st u d y. Th ey m et t h e f o l l o w i n g
inclusion cr it er ia: indicat ion of elect iv e gy necological
su r ger y ; pr edict ed h ospit al st ay of u p t o 2 4 h ou r s,
in clu din g on e n igh t in h ospit al f or im m ediat e post
-oper at or y per iod; v olunt ar y par t icipat ion, by signing
t h e t er m of con sen t ; au t h or izat ion t o par t icipat e in
t h e st u d y b y t h e assi st an t p h y si ci an ; a m i n i m u m
int er v al of 2 3 day s bet w een t he init ial int er v iew for
dat a collect ion an d t h e su r ger y dat e. Th e ex clu sion
cr i t er i a, i n t u r n , w er e: No t sp en d i n g t h e n i g h t i n
eit her before or aft er t he surgery; present ing surgical
com plicat ions; post - operat ory int ernm ent due t o t hese com p licat ion s.
The inst rum ent s used for dat a collect ion were: Qu est ion n air e f or I d en t if icat ion of Pop u lat ion ( QI ) ,
Addit ional Dat a Sheet for Sur ger y and I nt er nm ent – Ficha de Dados Adicionais de Cir ur gia e I nt er nação ( FDACI ) , elabor at ed f or t h e st u dy ; Sleep Jou r n al – Diário de Sono ( DS) . They w er e all filled out by t he v olu n t eer s t h em selv es, af t er r eceiv in g or ien t at ion s fr om t h e r esear ch er.
QI and FDACI were em ployed t o charact erize t h e w om en st u d ied , ob t ain in g , r esp ect iv ely,
socio-dem ographical dat a and inform at ion about t he surgical pr ocedur es ( FDACI ) . The DS w as filled out w it h t he follow ing infor m at ion about t he SWC: t im e of going t o bed, sleep beginning, t im e of awakening, lat ency,
int er r upt ions, lengt h, efficiency and qualit y of sleep, perm anence in bed, nap lengt h, physical act ivit y and lev el of anx iet y. This inst r um ent w as applied in t w o s t a g e s , b e f o r e a n d a f t e r t h e s u r g e r y, e a c h
com prehending t hree weeks and three to four weekends, with each stage totaling 23 consecutive days.
At first , t he obt ained dat a were subm it t ed t o d e s c r i p t i v e a n a l y s i s ( t a b l e s o f f r e q u e n c y a n d
m e a s u r e m e n t s o f p o s i t i o n a n d d i s p e r s i o n ) . I n f o r m a t i o n f r o m t h e D S w a s e m p l o y e d t o ch a r a ct e r i ze t h e v o l u n t e e r s’ SW C i n e a ch o f t h e st ag es. Th ese d at a w er e an al y zed w eek- b y - w eek ,
separat ely, including only w eek day s in t his analy sis. Th e f u r t h est p r e- op er at or y w eek f r om t h e su r g er y d a y w a s n a m e d Pr 3 , f o l l o w e d b y Pr 2 a n d Pr 1 ( i m m e d i a t e l y b e f o r e t h e s u r g e r y ) . I n t h e p o s t
-oper at or y st age, t he Po1 , Po2 and Po3 w eek s w er e obt ained, wit h Po3 being t he furt hest from t he surgery day. Nex t , t he w eek s of each st age w er e com par ed,
in p air s. Dat a ab ou t t h e w eek en d s w er e an aly zed
together, com paring the pre- and post-operatory stages. W i l co x o n ’ s t est f o r m a t ch ed - sa m p l es w a s u se d t o a n a l y z e t h e ch a r a ct e r i st i cs o f t h e SW C b et w een t h e st ag es, as w ell as t h e in t r ain d iv id u al
var iet y ( st andar d deviat ions) of t hese char act er ist ics. The result s were considered significant when p < 0.05. The st udy was approved by t he Review Board at t he aut hors’ inst it ut e of affiliat ion, on April 19, 2005.
The volunt eers signed t he t erm of consent , elaborat ed accor d i n g t o t h e g u i d el i n es of Resol u t i on 1 9 6 / 9 6 , w hich r egulat es r esear ch w it h hum an beings.
RESULTS
The populat ion consist ed of 22 wom en, whose
age varied from 24 t o 64 years old ( average age: 39 ± 9 y ear s old) , su bm it t ed t o elect iv e gy n ecological surgery. Am ong t hem , 64% were m arried, 86% lived w it h ot h er p eop le ( u su ally f am ily m em b er s) , 6 4 %
report ed having college or post graduat e educat ion, 82% held j obs out side t he house and 36% had an incom e bet ween one and five t im es t he m inim um wage.
S u r g i c a l a c c e s s w a s d i s t r i b u t e d a m o n g
abdom inal ( 41% ) , v aginal ( 41% ) and br east ( 18% ) . The procedure last ed from 15 t o 85 m inut es, averaging 4 5 ( ± 1 8 ) m i n u t e s . Ge n e r a l a n e s t h e s i a w a s predom inant , used in 64% of t he volunt eers, followed
by peridural in 27% and spinal in 9% . The durat ion of anest hesia varied from 30 t o 140 m inut es, averaging 73 ( ± 25) m inut es.
Th e SW C ch a r a ct e r i st i cs w e r e co m p a r e d
bet w een t h e pr e- an d post - operat or y st ages, w eek-by - w eek , f or t h e w eek day s. Th e av er age v alu es of
t hese charact er ist ics ar e pr esent ed in Table 1.
s e l b a i r a
V Pre-operatoryStage Post-operatorystage
3 r P k e e
W WeekPr2 WeekPr1 WeekPo1 WeekPo2 WeekPo3
d e b o t g n i o g f o e m i
T 22h58min 22h52min 23h00min 22h54min 23h01min 23h03min
g n i n n i g e b p e e l
S 23h25min 23h25min 23h33min 23h33min 23h34min 23h28min
y c n e t a l p e e l
S 26min 34min 33min 39min 33min 26min
) t n u o m a ( s n o it p u r r e t n
I 1.3 1.1 1.1 1.1 1.3 1.0
g n i n e k a w a f o e m i
T 6h34min 6h42min 6h43min 7h03min 6h43min 6h46min
h t g n e l p e e l
S 431min 435min 429min 452min 428min 436min
d e b n i e c n e n a m r e
P 457min 470min 463min 490min 462min 463min
y c n e i c if f e p e e l
S 95% 93% 93% 92% 93% 94%
* y t il a u q p e e l
S 6.3 6.2 6.1 6.8 6.9 7.2
h t g n e l p a
N 13min 7min 5min 13min 13min 8min
y t i v it c a l a c i s y h
P 11min 9min 7min 1min 4min 1min
y t e i x n a f o l e v e
L *† 6.3 4.8 3.6 7.2 6.5 7.1
Table 1 – Charact erist ics of t he sleep/ wake cycle ( SWC) in t he pre- and post - operat ory st ages, w eek- by- w eek,
accor ding t o t he Sleep Jour nal ( n= 22) : Av er age v alues. Lim eir a, 2005- 2006
* = evaluat ed wit h t he 10- cent im et er Visual Analogue Scale.
W h e n t h e S W C v a l u e s w e r e c o m p a r e d
bet w een t h e w eek f u r t h est f r om su r ger y ( Pr 3 ) an d
t h e f i r st p o st - o p er at o r y w eek ( Po 1 ) , a si g n i f i can t
differ ence w as obser v ed ( p < 0. 05, Wilcox on’s t est )
in t he following variables: sleep latency, higher in Po1;
t im e of awakening, lat er in Po1; perm anence in bed,
l o n g er i n Po 1 ; sleep ef f icien cy, l o w er i n Po 1 . No
sign if ican t dif f er en ces w er e f ou n d bet w een Pr 3 an d
t h e secon d p ost - op er at or y w eek ( Po2 ) . Wh en Pr 3
w as com p ar ed w it h t h e t h ir d p ost - op er at or y w eek
( Po 3 ) , a si g n i f i can t d i f f er en ce w as o b ser v ed o n l y
f or t h e v ar iab le len gt h of ph y sical act iv it y, h ig h er
in Pr 3 .
When Pr 2 w as com par ed w it h t he fir st post
-op er at or y w eek ( Po1 ) , sig n if ican t d if f er en ces w er e
observed ( p < 0.05, Wilcoxon’s t est ) in t he follow ing
v ar i ab l es: t im e of aw ak en in g, l at er i n Po 1 ; sleep
lengt h, longer in Po1; perm anence in bed, longer in
Po1 . No sign ifican t differ en ces w er e obser v ed w h en
Pr2 was com pared t o t he second post - operat ory week
( Po2) . Bet ween Pr2 and t he t hird post - operat ory week
( Po 3 ) , t h e r e w e r e si g n i f i ca n t d i f f e r e n ce s i n t h e
follow ing var iables: sleep qualit y, rat ed as bet t er in
Po3, and level of anxiet y, lower in Po3.
The com par ison bet w een t he w eek closer t o
t he sur gical int er v ent ion ( Pr 1) and t he fir st w eek of
t h e p ost - op er at or y st ag e ( Po1 ) y ield ed sig n if ican t
d i f f e r e n c e s ( p < 0 . 0 5 , W i l c o x o n ’ s t e s t ) f o r t h e
v ar i ab l es: t im e of aw ak en in g, l at er i n Po 1 ; sleep
lengt h, longer in Po1; perm anence in bed, longer in
Po1; and level of anxiet y, lower in Po1. When Pr1 and
t h e s e c o n d p o s t - o p e r a t o r y w e e k ( Po 2 ) w e r e
com par ed, t h er e w as a sign if ican t dif f er en ce in t h e
level of anxiet y, low er in Po2, and, bet w een Pr1 and
t h e t h ir d p ost - op er at or y w eek ( Po3 ) , a sig n if ican t
differ ence in sleep qualit y w as found, bet t er in Po3,
and in t he level of anxiety, lower in Po3.
Re g a r d i n g t h e S W C c h a r a c t e r i s t i c s a t
w eek en d s, sig n if ican t d if f er en ces w er e ob ser v ed in
t he v ar iable lengt h of physical act ivit y, higher in t he
pr e- oper at or y st age in r elat ion t o t he post - oper at or y
st a g e . Ta b l e 2 sh o w s t h e a v e r a g e v a l u e s o f t h e
volunt eer’s SWC charact erist ics, during t he w eekends
of t hese t w o st ages.
s e l b a i r a
V Pre-operatorystage Post-operatorystage
d e b o t g n i o g f o e m i
T 23h37min 23h25min
g n i n n i g e b p e e l
S 24h30min 23h55min
y c n e t a l p e e l
S 26min 29min
) t n u o m a ( s n o it p u r r e t n
I 1.3 1.1
g n i n e k a w a f o e m i
T 07h46min 07h43min
h t g n e l p e e l
S 465min 467min
d e b n i e c n e n a m r e
P 490min 497min
y c n e i c if f e p e e l
S 94% 93%
* y t il a u q p e e l
S 6.5 7.1
h t g n e l p a
N 31min 24min
y t i v it c a l a c i s y h
P † 10min 3min
* ) 1 1 = n ( y t e i x n a f o l e v e
L ‡ 5.4 7.1
Table 2 – Charact er ist ics of t he sleep/ w ak e cy cle at
t he weekends of t he pre- operat ory and post - operat ory
st a g e s, a cco r d i n g t o t h e Sl e e p Jo u r n a l s ( n = 2 2 ) :
av er age v alues. Lim eir a, 2 0 0 5 - 2 0 0 6
* evaluat ed wit h t he 10- cent im et er Visual Analogue Scale. † p < 0.05, Wilcoxon’s t est
‡ 11 volunt eers est im at ed t his variable; t he higher t he value, t he lower t he
degree of anxiet y.
I nt r aindiv idual v ar iabilit y w as found low er in t he pre- operat ory st age for charact erist ics like lat ency, sl eep l en g t h , ef f i ci en cy a n d t i m e o f aw ak en i n g, w her eas, in t he post - oper at or y st age, char act er ist ics
lik e sleep qualit y and level of anxiet y show ed low er i n t r a i n d i v i d u a l v a r i a b i l i t y. Th e a v e r a g e v a l u e s o f int r aindiv idual v ar iabilit y for t he SWC char act er ist ics, in t he pre- operat ory and post - operat ory st ages,
week-by- w eek, can be found in Table 3.
Tab le 3 – I n t r ain d iv id u al v ar iab il i t y of sl eep / w a k e cy cle ch ar act er ist ics ( SWC) , w eek- b y - w eek , in t h e
p r e- o p er at o r y an d p o st - o p er at o r y st ag es ( n = 2 2 ) . Lim eir a, 2 0 0 5 - 2 0 0 6
s e l b a i r a V e g a t s y r o t a r e p o -e r
P Post-operatorystage
k e e W 3 r P k e e W 2 r P k e e W 1 r P k e e W 1 o P k e e W 2 o P k e e W 3 o P * d e b o t g n i o g f o e m i
T 40 36 32 43 38 42
* g n i n n i g e b p e e l
S 36 37 37 43 42 44
* y c n e t a l p e e l
S 15 14 16 23 25 14
) t n u o m a ( s n o it p u r r e t n
I 0.9 0.9 0.7 0.8 1.0 0.6
* g n i n e k a w a f o e m i
T 30 24 30 44 36 35
* h t g n e l p e e l
S 42 47 43 65 51 58
* d e b n i e c n e n a m r e
P 44 46 40 63 51 57
) % ( y c n e i c if f e p e e l
S 3 3 3 5 5 3
y t il a u q p e e l
S † 2.2 1.8 2.0 1.7 1.7 1.4
* h t g n e l p a
N 15 8 10 15 15 9
* y t i v it c a l a c i s y h
P 12 5 7 2 6 3
† y t e i x n a f o l e v e
L ‡ 1.8 2.5 2.1 1.0 1.6 1.1
* in m inut es
† = evaluat ed wit h t he 10- cent im et er Visual Analogue Scale. ‡ = 11 volunt eers est im at ed t his variable.
Significant result s ( p < 0.05, Wilcoxon’s t est ) :
Lat en cy ( Pr 1 < Po2 ) ; Tim e of aw ak en in g ( Pr 2 < Po1 ) ;
S l e e p l e n g t h ( Pr 3 < Po 1 ; Pr 2 < Po 1 ; Pr 1 < Po 1 ) ;
Pr 3 < Po 2 ; Pr 1 < Po 1 ; Pr 1 < Po 2 ) ; Qu a l i t y ( Pr 3 > Po 1 ;
Pr 3 > Po 2 ; Pr 3 > Po 3 ) ; Ph y si ca l a ct i v i t y ( Pr 3 > Po 1 ; Pr 3 > Po 2 ; Pr 3 > Po 3 ) ; Le v e l o f a n x i e t y ( Pr 2 > Po 1 ; Pr 2 > Po2 ; Pr 2 > Po3 )
DI SCUSSI ON
Am ong t he wom en st udied, 82% were in t he
3 0 - 5 0 y e a r - o l d r a n g e , w h i ch co r r e sp o n d s t o t h e result s of ot her aut hors, since gynecological surgeries are concent rat ed in t his age group( 8). Most volunt eers were m arried and lived wit h t heir fam ilies, which is in
accor d an ce w it h t h e f em ale sh ar e of t h e Br azilian p o p u l a t i o n . Ho w ev er, t h e l ev el s o f ed u ca t i o n a n d i n co m e w e r e h i g h e r t h a n t h o se u su a l l y f o u n d i n Br azil( 9 ).
Th e d et ailed com p ar ison of t h ese w om en ’s SWC during t he pre- and post - operat ory st ages ( t hree w eek s ea ch ) b r o u g h t f i n d i n g s t h a t w er e p a r t i a l l y con sist en t w it h ot h er st u d ies f ocu sed on r elat ion s
bet w een sleep pat t er ns befor e and aft er sur ger ies(
10-1 10-1 )
. W h e n t h e w e e k f u r t h e s t f r o m t h e s u r g i c a l int ervent ion was com pared wit h t he first week of t he post - oper at or y st age, t he lat t er show ed ev idence of
low er qualit y sleep: higher lat ency, lat er awak ening, longer perm anence in bed and low er sleep efficiency. How ever, in t he t hir d w eek aft er sur ger y, t he lengt h of ph y sical act iv it y w as t h e on ly ch ar act er ist ic w it h
sig n if ican t d if f er en ces w h en com p ar ed t o t h e p r e-operat ory st age, show ing t hat t he SWC had ret urned t o t h e ch a r a ct e r i st i cs i t h a d b e f o r e t h e su r g i ca l in t er v en t ion . Th e r ed u ct ion of sleep ef f icien cy w as
f ou n d in st u d ies p er f or m ed w it h p oly som n og r ap hy, w h i ch sh o w s a l t e r e d sl e e p p a t t e r n s i n t h e p o st -operat ory period, when overnight sleep is int errupt ed several t im es. Such alt erat ions are usually found aft er
lar ge- scale sur ger ies, w hile lapar oscopic sur ger ies do not seem t o reproduce t his pat t ern. This fact has been a t t r i b u t e d t o l o w e r s u r g i c a l s t r e s s c a u s e d b y en d o sco p i c su r g er i es w h en co m p a r ed t o o p en - a i r
p r o c e d u r e s . Th e s t u d i e s p e r f o r m e d w i t h p o l y s o m n o g r a p h y h a v e e v a l u a t e d t h e s l e e p i n g pat t erns for up t o six post - operat ory night s, at m ost . Th er ef or e, t h e r eal len g t h of su ch p er t u r b at ion s is
not w ell- det er m ined( 10). I n a st u dy com par in g sleep q u a l i t y o f p a t i en t s su b m i t t ed t o ch o l ecy st ect o m y t h r o u g h l a p a r o s c o p i c s u r g e r y a n d l a p a r o t o m y, m o n i t o r i n g f o u r d a y s p r i o r a n d f o u r w e e k s a f t e r
s u r g e r y, p a t t e r n s c o m p a t i b l e w i t h l i g h t e r s l e e p d i so r d er s w er e o b ser v ed i n p at i en t s su b m i t t ed t o laparoscopy. However, sleep qualit y worsened for bot h
groups in t he post - operat ory period. The laparoscopy pat ient s did not show im pr ov em ent s unt il t he four t h w e e k a f t e r t h e su r g e r y, a n d t h o se su b m i t t e d t o lapar ot om y r epor t ed a discr et e im pr ov em ent by t he f ou r t h w eek , n ot sign if ican t w h en com par ed t o t h e pr e- oper at or y per iod. I n bot h gr oups, t he am ount of sleep in t er r u pt ion s in cr eased in t h e fir st w eek aft er surgery, but not in t he subsequent w eeks( 11).
I n spit e of t he changes observed in t he SWC char act er ist ics, t he w om en ex pr essed, in t he pr esent st udy, significant im provem ent s in sleep qualit y during t he post - operat ory st age, especially in t he t hird week aft er surgery, w hen com pared w it h t he pre- operat ory st age. Such result s are, at first , unexpect ed, because it w as consider ed t hat t he sleep qualit y could r et ur n t o t h e lev els of t h e pr e- oper at or y lev el, in st ead of showing im provem ent s. Lit erat ure m ent ions t hat sleep qualit y decr eases in t he fir st day s aft er t he sur gical int er v ent ion, r et ur ning t o t he pr e- oper at or y lev els at v a r i e d i n t e r v a l s , b u t t h e r e a r e n o r e p o r t s o f im pr ov em en t in sleep qu alit y in t h e post - oper at or y period, as found in t his st udy( 11- 12).
The lengt h of phy sical act iv it y w as t he only v ar i ab l e w i t h a si g n i f i can t d i f f er en ce b et w een t h e weekends of t he pre- and post - operat ory st ages, wit h a post - operat ory reduct ion in t he pract ice of physical a ct i v i t i e s. Th i s r e su l t i s co h e r e n t , b e ca u se su ch a ct i v i t i e s a r e n o t r e co m m e n d e d a f t e r a su r g i ca l i n t e r v e n t i o n . Th e r e f o r e , t h i s r e d u ct i o n w o u l d b e expect ed t o lead t o a decrease in t he sleep qualit y of t he w om en in t his st udy, since, now aday s, it seem s con sen su al, in lit er at u r e, t h at r egu lar m ediu m - an d long- t er m phy sical act iv it y cont r ibut es t o good sleep qualit y, and t hat acut e effect s of physical exercise on a n i g h t ’ s sl e e p a r e i n e x i st e n t( 1 3 ). Op p o si n g t h i s ex pect at ion, sleep qualit y w as super ior in t he post -oper at or y st age.
Wom en show low er int raindiv idual var iabilit y in charact er ist ics lik e sleep lat ency, lengt h, efficiency and t im e of aw ak ening, in t he pr e- oper at or y st age,
part icularly in t he week prior t o t he surgery, in relat ion t o t he t w o post - oper at or y w eek s. I n r elat ion t o t he t hird week aft er t he surgery, no significant differences w er e det ect ed. Besides, t he qualit y of sleep and t he lev el of anx iet y show ed low er v ar iabilit y in t he post -oper at or y st age. Sev er al aut hor s associat e t he low er SWC v ar iabilit y t o bet t er qualit y sleep, w hich w ould b e in ag r eem en t w it h t h e ev id en ce of t h e p r esen t st udy, where sleep qualit y was higher in t he t hird post-operat or y w eek t han befor e t he sur ger y. Am ong t he
r e c o m m e n d e d s l e e p h y g i e n e p r a c t i c e s , t h e m aint enance of a r egular schedule for going t o bed and aw ak ening is consider ed beneficial( 16).
I n t his st udy, t he early ret urn of t he w om en t o t h eir d aily act iv it ies seem s t o h av e f av or ed t h e m aint enance of t he SWC char act er ist ics in t he post -o p e r a t -o r y s t a g e . I n f u t u r e i n v e s t i g a t i -o n s , i t i s im por t ant t o obt ain, besides new r egist er s about t he SWC, d at a ab ou t r ou t in e act iv it ies in t h e p r e- an d post - operat or y w eek s, such as t im es of w or k , st udy, leisur e, m eals and m edicat ion int ak e. Monit or ing t he
changes in t hese act ivit ies and ret urning t o t he usual rout ine will cont ribut e t o elucidat e possible correlat ions wit h t he sleeping pat t erns, which, in t he present st udy,
can on ly b e su g g est ed . By k n ow in g t h ese asp ect s bet t er, t he nur se w ill be able t o int er vene, pr oposing or offer ing t em por al clues t hat w ill cont r ibut e t o t he s y n c h r o n i z a t i o n o f t h e SW C, t h u s a i d i n g i n t h e r ecov er y of t he indiv idual.
FI NAL CONSI DERATI ONS
Accor din g t o t h e f in din gs of t h is st u dy, t h e
elect ive gynecological sur ger y w it h a hospit al st ay of u p t o 2 4 h o u r s c a u s e s d i s c r e t e a n d t r a n s i t o r y alt er at ions in t he SWC, and it quick ly r et ur ns t o t he ch a r a ct e r i st i cs o b se r v e d b e f o r e t h e i n t e r v e n t i o n , perhaps by favoring t he early exposit ion of t he wom an t o t he daily r out ine, i. e. t he r elev ant env ir onm ent al clues for t he sy nchr onizat ion of t he r hy t hm .
A st udy about t he biological rhyt hm s becom es increasingly fascinating, and the actions developed from their observation can benefit the patients, consolidating the goals of healthcare professionals’ actions.
REFERENCES
1. Villela W. Saúde int egr al, r epr odut iva e sexual da m ulher. I n: Araúj o MJO, Souza MJ, Ver ar do MT, Francisquet t i PPSN, Mo r a i s RR, Bo n ci a n i RD F, e t a l . Sa ú d e d a s m u l h e r e s -ex p er iên cia e p r át ica d o colet iv o f em in ist a s-ex u alid ad e e saúde. São Paulo: Colet iv o Fem inist a Sex ualidade e Saúde; 2 0 0 0 .
2 . D o n ad i o N, Al b u q u er q u e Net o LC, ed i t o r es. Co n sen so Br a si l e i r o e m Vi d e o e n d o sco p i a Gi n e co l ó g i ca . Sã o Pa u l o : Ar t es Méd i cas; 2 0 0 1 .
3. Farr L, Todero C, Boen L. Reducing disrupt ion of circadian t em perat ur e r hy t hm follow ing sur ger y. Biol Res Nur s 2 0 0 1 ; 2 ( 4 ) : 2 5 7 - 6 6 .
4 . Fu r l a n i R, Ce o l i m MF. Sl e e p q u a l i t y o f w o m e n w i t h gynecological and br east cancer. Rev Lat ino- am Enfer m agem 2 0 0 6 ; 1 4 ( 6 ) : 8 7 2 - 8 .
5. Marques N, Menna- Barret o L. organizadores. Cronobiologia: pr in cípios e aplicações. São Pau lo: Edu sp; 2 0 0 3 .
6 . Bu y sse D J. D i a g n o si s a n d Asse ssm e n t o f Sl e e p a n d Ci r c a d i a n Rh y t h m D i s o r d e r s . J Ps y c h i a t r Pr a c t i c e 2 0 0 5 ; 1 1 ( 2 ) : 1 0 2 - 1 5 .
7 . Redek er NS, Ruggier o JS, Hedges C. Sleep is r elat ed t o p h y si ca l f u n ct i o n a n d em o t i o n a l w el l - b ei n g a f t er ca r d i a c su r g er y. Nu r s Res 2 0 0 4 ; 5 3 ( 3 ) : 1 5 4 - 6 2 .
8. Cost a AAR, Am orim MMR, Cursino T. Hist erect om ia vaginal v er su s h ist er ect om ia abdom in al em Mu lh er es sem pr olapso g en i t al , em m at er n i d ad e- esco l a d o Reci f e: en sai o cl ín i co r an d om izad o. RBGO 2 0 0 3 ; 2 5 ( 3 ) : 1 6 9 - 7 6 .
9. I nst it ut o Brasileiro de Geografia e Est at íst ica, I BGE. Censo Dem ográfico: perfil das m ulheres responsáveis pelo dom icílio no Br asil. Rio de Janeir o; 2000.
10. Rosenberg J. Sleep dist urbance aft er non- cardiac surgery. Clin Rev 2 0 0 1 ; 5 ( 2 ) : 1 2 9 - 3 7 .
1 1 . Gögen u r I , Rosen ber g- Adam sem S, Kill C, Kj aer sgear d M, Ke h l e t H, Ro se n b e r g J. La p a r o sco i c ch o l e cy st e ct o m y causes less sleep dist ur bance t han open abdom inal sur ger y. Su r g En d oscop y 2 0 0 1 ; 1 5 : 1 4 5 2 - 5 .
12. Rosenberg- Adam sem S, Kehlet H, Dodds C, Rosenberg J. Post oper at iv e sleep dist u r ban ces: m ech an ism s an d clin ical im plicat ion s. Br J An aest h esia 1 9 9 6 ; 7 6 : 5 5 2 - 9 .
1 3 . St ep an sk i EJ, Wy at t JK. Use of sleep h y g ien e in t h e t r eat m ent of insom nia. Sleep Med Rev 2003; 7 ( 3) : 215- 25. 14. Kain ZN, Caldw ell- Andr ew s AA. Sleeping Char act er ist ics of adu lt s u n der goin g ou t pat ien t elect iv e su r ger y : a coh or t st u d y. J Clin An est h esia 2 0 0 3 ; 1 5 : 5 0 5 - 9 .
15. Tung A, Medelson WB. Anest hesia and sleep. Sleep Med Rev 2 0 0 4 ; 8 : 2 1 3 - 2 5 .
16. Monk TH, Rey nolds CF, Buy sse DJ, DeGrazia JM, Kupfer D J. Th e r e l a t i o n s h i p b e t w e e n l i f e s t y l e r e g u l a r i t y a n d subj ect ive sleep qualit y. Chr onobiol I nt 2003; 20( 1) : 97- 107.
