Preoperative Sleep Quality and Postoperative Outcomes in Breast Surgery

This prospective, single-center observational study examined the association between preoperative sleep quality and postoperative outcomes in women undergoing elective breast cancer surgery. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), with scores ≤5 indicating good sleep quality and scores >5 indicating poor sleep quality.

The primary outcome was the systemic immune-inflammation index (SII), calculated from routine blood counts obtained 24 hours after surgery. Postoperative SII was compared between sleep-quality groups, accounting for preoperative SII and relevant clinical and surgical characteristics. Secondary outcomes included change in SII from baseline, pain intensity during the first 45 minutes in the post-anesthesia care unit (PACU), opioid consumption, rescue analgesic requirement, and length of hospital stay. Pain was assessed using a 10-cm visual analogue scale on PACU arrival and at 15, 30, and 45 minutes. Opioid consumption included morphine and tramadol administered during the final 20 minutes of surgery and the first 45 minutes in the PACU, expressed as intravenous morphine equivalents.

No treatment was assigned by the study protocol. Anesthetic and analgesic management followed routine clinical practice.

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Detailed Description:

This prospective observational study was conducted at Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital in Ankara, Turkey, among women undergoing elective breast cancer surgery under general anesthesia. Procedures included lumpectomy or mastectomy, with axillary dissection when clinically indicated. The study examined whether preoperative sleep quality was associated with postoperative systemic immune-inflammation index (SII), immediate postoperative pain, and analgesic use.

Preoperative sleep quality was assessed using the validated Turkish version of the Pittsburgh Sleep Quality Index (PSQI). The total score ranges from 0 to 21, with higher scores indicating poorer sleep quality. Patients were classified as having good sleep quality (PSQI ≤5) or poor sleep quality (PSQI >5). Demographic characteristics, comorbidities, oncological history, surgical characteristics, and perioperative clinical data were recorded prospectively.

The primary outcome was SII measured 24 hours after surgery, calculated as platelet count × neutrophil count / lymphocyte count. Preoperative SII was calculated using the same formula. The primary analysis compared postoperative SII between sleep-quality groups, adjusting for baseline SII and clinical and surgical covariates. Change in SII, calculated as postoperative minus preoperative SII, was a secondary outcome.

Pain intensity was assessed using a 10-cm visual analogue scale (VAS), anchored at "no pain" and "worst imaginable pain." Patients marked their pain intensity on the line; the distance from the zero anchor was measured and rounded to the nearest whole centimeter. Assessments were performed on arrival in the post-anesthesia care unit (PACU) and at 15, 30, and 45 minutes. Maximum VAS was defined as the highest score across the four scheduled assessments. The pain assessor was unaware of patients' PSQI scores and sleep-quality groups.

Anesthetic and analgesic management followed routine clinical practice, with no treatment assigned by the study protocol. Intravenous morphine or tramadol was administered for postoperative analgesia during the final 20 minutes of surgery. Rescue analgesia consisted of intravenous morphine or tramadol when the PACU VAS score was ≥4; drug selection and dosing were determined by the treating anesthesiologist. Scheduled pain assessments continued after rescue treatment. No regional blocks or surgical local anesthetic infiltration were performed.

Total opioid consumption comprised morphine and tramadol administered during the final 20 minutes of surgery and the first 45 minutes in the PACU. Intravenous tramadol doses were converted to intravenous morphine equivalents using a factor of 0.1 and added to the administered morphine dose. Fentanyl used for induction and remifentanil used for maintenance were excluded from this measure. Rescue analgesic requirement was defined as receipt of at least one rescue opioid dose during the PACU observation period. Subsequent ward pain and analgesic use were not assessed. Length of hospital stay was also recorded.

Secondary analyses evaluated PSQI total score as a continuous predictor of postoperative SII, maximum VAS, total opioid consumption, and rescue analgesic requirement. Adjustment variables included age, body mass index, ASA physical status III, chronic disease burden, chemotherapy within the previous year, axillary dissection, and operation duration. Breast surgery type was added to the models during manuscript revision. Preoperative SII was included only in the postoperative SII models. Individual covariate-outcome associations were interpreted as exploratory.