A Nap with the Scalpel

17. September 2008

Whoever does not give his or her brain some rest on a regular basis has to be aware of blackouts. There are various ways to achieve longer "mileage": Coffee, power pills or even better the "cat-nap"? But in general there is always this one question: Just how dangerous is overfatigue in the OR?

OR scrub, face mask and gloves and perhaps some Modafinil or Donepezil – just to be on the safe side. But then again – why not? At the beginning of the year a group of English surgeons at the London Imperial College initiated a discussion about the following: Shouldn’t surgeons with long working hours rather trust the effects of "Mama’s little wake-up helpers" than make mistakes in the OR? "Patients feel more and more the differences between good and bad surgical performance", Oliver Warren writes in his article in the Journal of Surgical Results. Warren continues that perhaps they soon might start asking whether physicians trust in means of "cognitive enhancement" or not, and if not – why. In California, reports the study made in 2006, tired-out physicians profited from Modafinil if they had to complete hours for further education the following day.

Remembering of false information

In Germany, working time regulations for hospital personnel are often just a piece of paper. According to a survey they are not complied with in more than half of the German hospitals. What remains is the snatching of brain power pills if after another two nightshifts, the seminar or a difficult surgery is still pending? “In the OR all fatigue just falls off” some frequent operators claim and completely rely on the reserve capacities of their central nervous system. But science says this only applies to a certain limit. Just recently, “Nature” reported about new results by the group of the Luebeck Sleep Researcher Jan Born. After a sleepless night, the brain simulates memories of events that never took place. The test persons were supposed to remember terms concerning a super-topic given to them before. The sleep-deprived were absolutely sure about their self-invented terms even after they had caught up on the sleep deficit. After according doses of coffee, the number of hits decreased by ten percent. The neurologists remember: The caffeine develops its effect in the prefrontal cortex – exactly where the brain differentiates between reality and fantasy.

Little sleep – risk for the heart

What happens in the brain of overfatigue shift workers shows the work of the sleep researcher Matthew Walker in Berkeley/California. After 25 hours without sleep, his test persons reacted to repellent pictures with three times stronger activity of the amygdala compared to control. The almond-sized part of the brain processes feelings. The prefrontal cortex controls the activities of the amygdala and averts over-dimensional emotional releases.The connections of those two regions were accordingly low active in test persons with a sleep deficit, but a lot stronger to autonomous centers at the brain stem. Who’s marvelled now about the statistics saying that people sleeping less with a lack of emotional control more frequently head for a heart attack and often die from it. In general the brain activity does not decrease due to a lack of sleep. Just the control processes of various functions do not work as usual. In May another study was published in the Journal of Neuroscience about view on the brains of people with enough sleep and those without via magnetic resonance. While a good night’s rest helps to compensate those little instants of negligence quickly, the picture is a different one with a deficit. Especially with difficult “see-understand-act” tasks, the processor stutters time and again. It seems that the central control fights against the required phase of regeneration. The danger particularly for physicians and truckers: Reactions after a lack of sleep are not much different from the normal ones. But the frequency of blackouts is a lot higher.

Rest is best

Whether Modafinil & friends can help the brain to run smoothly without any long-term troubles currently is being discussed and researched. Many surgeons forgo coffee and tea to avoid shivering hands. Sam Daetwyler at the Wake-Forest-University in North Carolina/USA increases the performance of the memory of overfatigue rhesus macaques by spray doses of the sleep hormone Orexin-A, a possibility which might be of interest as preparation for surgeries.
But it would be even better to give the brain some rest. Reinhard Pietrowsky of the Duesseldorf University reported a few weeks ago in the Journal of Sleep Research that even a break of six minutes is enough to considerably increase the performance during tasks requiring concentration.

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