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resident sleep and fatigue

Objectives. By the end of this session, participants will be able to:List 4 effects of sleep loss and fatigueList 2 warning signs of fatigue in othersList 2 warning signs of fatigue in yourselfDescribe the most effective way of using naps to combat fatigueDescribe the most effective way of using caffeine to combat fatigue.

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resident sleep and fatigue

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    1. Resident Sleep and Fatigue Jennifer Peel, PhD Director of Education, Office of GME

    3. Why are we concerned about resident fatigue?

    4. Patient Safety Resident Safety and Well-Being

    5. Fatigue & Safety Faulty decision making by sleep-deprived managers contributed to the untoward launch of the space shuttle Challenger (1986 Presidential Commission) Probable cause of the Exxon Valdez grounding was the fatigue of the individual sailing the ship (NTSB)

    6. Chernobyl Three Mile Island 15-20% of transportation accidents (this is greater than drugs and alcohol combined!) (Akerstedt, 2000)

    7. Increased tolerance for risk (Shingledecker & Holding, 1974) Passivity and avoidance of effort (Graeber, 1988) Decreased cognitive function (attention, vigilance, decision-making) (Howard, 2002) Psychomotor function comparisons between sleep deprivation and alcohol blood level (Dawson, 1997) Let’s look more closely at the last study listed here. Forty subjects participated in two counterbalanced experiments. In one they were kept awake for 28 hours and in the other they were asked to consume 10-15 g of alcohol at 30-min intervals until their mean blood alcohol concentration reached 0.10% They measured cognitive psychomotor performance at half-hourly intervals using a computer-administered test of hand-eye coordination. Results are presented as percentage of performance at the start of the session. Performance decreased significantly in both conditions. Let’s look more closely at the last study listed here. Forty subjects participated in two counterbalanced experiments. In one they were kept awake for 28 hours and in the other they were asked to consume 10-15 g of alcohol at 30-min intervals until their mean blood alcohol concentration reached 0.10% They measured cognitive psychomotor performance at half-hourly intervals using a computer-administered test of hand-eye coordination. Results are presented as percentage of performance at the start of the session. Performance decreased significantly in both conditions.

    8. Performance decreased significantly in both conditions. Between the 10th and 26th hours of wakefulness, mean relative performance on the hand-eye coordination task decreased by 0.74% per hour. After 17 hours of sustained wakefulness, cognitive psychomotor performance decreased to a level equivalent to the performance impairment observed at blood alcohol concentration of 0.05% After 24 hours of sustained wakefulness, cognitive psychomotor performance decreased to a level equivalent to the performance deficit observed at a blood alcohol concentration of 0.10%. If I was a patient, the first question I’d ask you is, “How long have you been up?”Performance decreased significantly in both conditions. Between the 10th and 26th hours of wakefulness, mean relative performance on the hand-eye coordination task decreased by 0.74% per hour. After 17 hours of sustained wakefulness, cognitive psychomotor performance decreased to a level equivalent to the performance impairment observed at blood alcohol concentration of 0.05% After 24 hours of sustained wakefulness, cognitive psychomotor performance decreased to a level equivalent to the performance deficit observed at a blood alcohol concentration of 0.10%. If I was a patient, the first question I’d ask you is, “How long have you been up?”

    9. Slower response time on monitoring tasks for fatigued anesthesia residents (Denisco, et al., 1987) Reduced speed/quality in simulated intubation task for emergency physicians (Smith-Coggins, et al., 1994) Slower time and more errors in simulated laparoscopic task for surgeons (Taffinder, et al., 1998) Reduced alertness, falling asleep, and behavior changes in tasks using a patient simulator (Howard, et al., 1998)

    10. Higher risk of unintended dural puncture in obstetric epidural procedures at night than during the day (Aya, et al., 1999) Increases (45%) in post-operative complications for resident surgeons after a day on call (Haynes, et al., 1995)

    11. Needle sticks and exposure to blood borne pathogens (increases by 50% at night) Health effects that may result from fatigue Increased risk of obstetrical complications for pregnant residents (Osborn, 1990) Premature labor twice as common Preeclampsia is twice as likely High rates of depression (Valko, 1975) Increased mortality with severe shortening of daily sleep (Kripke, et al., 1979)

    12. Increased risk of car accidents: Kowalenko, et al. (2000) Marcus & Loughlin (1996) Steele, et al. (1999) Kowalenko, et al. (2000) Emergency Medicine Residents (697) 17% had a total of 157 MVCs/6.7 times more likely to have a MVC due to falling asleep at the wheel during their residency Marcus & Loughlin (1996) Pediatric Residents v. Faculty 12.5% of the faculty had fallen asleep while at the wheel at a stop light over the preceding three years compared to 44% of residents Steele, et al, (1999) Emergency Medicine Residents 8% reported crashes and 58% reported near crashes Analysis showed that the frequency of MVCs and near-MVCs was positively related to the total number of night shifts worked per month. Kowalenko, et al. (2000) Emergency Medicine Residents (697) 17% had a total of 157 MVCs/6.7 times more likely to have a MVC due to falling asleep at the wheel during their residency Marcus & Loughlin (1996) Pediatric Residents v. Faculty 12.5% of the faculty had fallen asleep while at the wheel at a stop light over the preceding three years compared to 44% of residents Steele, et al, (1999) Emergency Medicine Residents 8% reported crashes and 58% reported near crashes Analysis showed that the frequency of MVCs and near-MVCs was positively related to the total number of night shifts worked per month.

    13. 2006 End-of-Year Survey

    14. Effects of Sleep Loss and Fatigue Voluntary and involuntary sleep latencies shorten Microsleeps intrude into wakefulness and cause lapses in attention Time-on-task decrements Learning and recall deficits Working memory and related executive functions decline Decreased ability to estimate your own ability to function (Van Dongen, et al., 2003)

    15. The sleepier you are, the less accurate your perception of degree of impairment. Studies show that sleepy people underestimate their level of sleepiness and overestimate their alertness. In a study of anesthesia residents, they did not perceive themselves to be asleep almost half of the time they had actually fallen asleep. Residents were wrong 76% of the time when they reported having stayed awake.In a study of anesthesia residents, they did not perceive themselves to be asleep almost half of the time they had actually fallen asleep. Residents were wrong 76% of the time when they reported having stayed awake.

    16. Physiology of Sleep & Fatigue Every adult has a genetically hard-wired sleep requirement that does not change with age and cannot be trained. Sleep is a physiologic drive state similar to hunger or thirst. When sleep requirements are not met a “sleep debt” ensues and sleepiness becomes manifest. Now you know why this topic is of great concern and is receiving so much attention. Let’s shift for a few minutes and talk about the physiology of sleep.Now you know why this topic is of great concern and is receiving so much attention. Let’s shift for a few minutes and talk about the physiology of sleep.

    17. Circadian Factors Circadian clock located in the supra-chiasmatic nucleus of the hypothalamus Clock extremely resistant to change Programmed for 2 periods of decreased alertness 3-7 am 1-4 pm (Siesta!) Now that we know the sleep deprivation and fatigue are a problem and we have talked about how powerful our internal clocks are, let’s focus on recognizing sleepiness and fatigue then we’ll discuss strategies to manage it.Now that we know the sleep deprivation and fatigue are a problem and we have talked about how powerful our internal clocks are, let’s focus on recognizing sleepiness and fatigue then we’ll discuss strategies to manage it.

    18. Recognizing Fatigue (in others) Difficultly appreciating a complex situation while avoiding distraction Keeping track of the current situation and updating strategies Thinking laterally and being innovative Assessing risk and/or anticipating consequences Maintaining interest in outcomes Controlling mood and avoiding inappropriate behavior

    19. Specific Behaviors Nodding off Lethargy Irritability Poor coordination Difficulty with short-term recall Tardiness or absences Impoverished speech Flattened affect Disinhibition

    20. Recognizing Fatigue (in yourself) Falling asleep in conferences Feeling restless and irritable with staff, colleagues, family, friends Having to check your work repeatedly Having difficulty focusing on the care of your patients Feeling like you really just don’t care

    21. Tools Epworth Sleepiness Scale Pittsburgh Sleep Quality Index ESS=assesses the tendency to fall asleep in various situations of daily living PSQI=questionnaire about sleep quality and disturbances over a 1 month interval.ESS=assesses the tendency to fall asleep in various situations of daily living PSQI=questionnaire about sleep quality and disturbances over a 1 month interval.

    22. Epworth Sleepiness ScaleNormal is < 6/worrisome is >8 The ESS asks the user, “How likely are you to doze off or fall asleep in the following situations, in contrast to just being tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.” (Emphasis added.) An ESS score of 10 points or higher is indicative of daytime sleepiness An ESS score of 16 points or higher indicates a high level of daytime sleepiness The ESS asks the user, “How likely are you to doze off or fall asleep in the following situations, in contrast to just being tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.” (Emphasis added.) An ESS score of 10 points or higher is indicative of daytime sleepiness An ESS score of 16 points or higher indicates a high level of daytime sleepiness

    23. Strategies to Combat Fatigue Naps Caffeine Good sleep habits Other drugs and light therapy

    24. Naps are good!

    25. The Art of Taking Naps Planned naps can improve subsequent alertness and performance (Dinges, et al. 1987) Allow up to 45 minutes for sleep (reduces the likelihood of awakening in REM and experience sleep inertia) Don’t take a nap too close to a planned sleep period Allow a 15 minute wake-up period following a nap

    26. Caffeine The strategic use of caffeine involves ingestion at times that will promote alertness and performance during periods of vulnerability. A significant performance and alertness boost can be obtained from 200 mg of caffeine, with positive effects at does ranging from 100 to 600 mg.

    27. Caffeine reaches peak concentrations in the bloodstream 30-60 minutes after consumption. Typically takes 4-6 hours for its effects to wear off.

    28. How does caffeine work? Ergogenic=increases the capacity for mental and physical labor Adenosine antagonist

    29. Adenosine

    31. Caffeine Metabolites Theobromine=vasodilator, increases oxygen and nutrient flow to brain and muscles Theophylline=smooth muscle relaxant, increases heart rate and efficiency Paraxanthine=increase lipolyis, leads to increased glycerol and fatty acids (fuel) in blood

    32. Caffeine Content

    33. Coffee Starbucks Vente 550 mg Starbucks Grande 375 mg Starbucks Tall 250 mg Espresso (2 oz.) 100 mg Instant Coffee 65-100 mg

    34. Other NoDoz (maximum strength) 200 mg Excedrin (2) 130 mg HD Coffee Ice Cream 58 mg Dark Chocolate (1 oz.) 35 mg Milk Chocolate (1 oz.) 15 mg

    35. Caffeine Tolerance & Withdrawal adenosine receptors

    36. Slow Release Caffeine Studies have shown positive effects of slow release caffeine on vigilance and cognitive performance (Beaumont, 2001)

    37. Good Sleep Habits Use a pre-sleep routine to provide cues for relaxation and sleep Avoid negative sleep cues in the bed and bedroom Have a light snack or drink if hungry or thirsty Avoid caffeine intake at least 3 hrs before bed Avoid exercise within 2-3 hrs of bedtime

    38. Follow a 30-min “toss-and-turn” rule such that if you are unable to fall asleep in 30 min, get out of bed, engage in some sleep promoting activity, return to bed when ready Use relaxation techniques Try to get 8 hrs of sleep in every 24 hr period (consider a supplement nap) Limit intake of ethanol or nicotine- containing products close to bedtime

    39. Other Drugs and Light Therapy Modafinil-schedule IV, nonamphetamine, alertness enhancing drug used in the treatment of narcolepsy (Caldwell, et al., 2000 & Buguet, et al., 1995) Melatonin-hormone produced by the pineal gland Light therapy-under investigation Modafinil-found to have significant alertness-promoting properties with fewer side effects and little effect on recovery sleep when compared with amphetamines. Melatonin-studies evaluating the efficacy of melatonin in shift workers have yielded mixed results Light therapy-implementation and timing of light therapy is complex ad has to be correctly applied to have the desired effectsModafinil-found to have significant alertness-promoting properties with fewer side effects and little effect on recovery sleep when compared with amphetamines. Melatonin-studies evaluating the efficacy of melatonin in shift workers have yielded mixed results Light therapy-implementation and timing of light therapy is complex ad has to be correctly applied to have the desired effects

    40. 80-Hour Work Week Standard: Duty hours must be limited to 80 hours per week, averaged over a 4-week period, inclusive of all in-house call activities.

    41. In-House Call Standard: In-house call must occur no more frequently than every 3rd night.

    42. Continuous Hours Standard: Continuous, on-site duty must not exceed 30 consecutive hours.

    43. Days Free Standard: Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call.

    44. Hours Off Between Duty Shifts Standard: Residents must be provided with a 10-hour time period between all daily duty periods and after in-house call.

    45. Objectives By the end of this session, participants will be able to: List 4 effects of sleep loss and fatigue List 2 warning signs of fatigue in others List 2 warning signs of fatigue in yourself Describe the most effective way of using naps to combat fatigue Describe the most effective way of using caffeine to combat fatigue

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