Cerrahi Sonrası Sirkadiyen Bozukluklar
Özet
Sirkadiyen ritimlerin bozulması uyku düzensizliklerine ve çeşitli postoperatif komorbiditelere yol açmaktadır. Cerrahi operasyonlar ve anestezikler (NMDA antagonistleri ve GABA agonistleri), suprakiazmatik çekirdek üzerindeki etkileriyle endojen sirkadiyen düzeni, melatonin üretimini ve kortizol salınımını bozmaktadır. Özellikle majör cerrahi sonrasında uyku yapısı ciddi şekilde etkilenmekte; ilk üç gecede yavaş dalga ve REM uykusu azalırken, üçüncü ve dördüncü gecelerde REM uykusunun geri tepmesi (rebound) gerçekleşmektedir. Bu durum, artan sempatik aktivite ve solunumsal düzensizliklerle birleşerek postoperatif miyokard iskemisi, deliryum, yorgunluk ve bilişsel işlev bozukluğu gibi kardiyovasküler ve genel morbidite risklerini maksimuma çıkarmaktadır. Endojen sirkadiyen ritim düzenleyici bir hormon olan melatoninin, postoperatif deliryumu önlemede ve uyku kalitesini artırmada etkili olduğu gösterilmiştir. Yapılan prospektif kohort çalışmalarında, sirkadiyen ritmin iskemi-reperfüzyona karşı miyokardiyal toleransı değiştirdiği ve öğleden sonra yapılan aort kapak replasmanı ameliyatlarının, sabah yapılanlara kıyasla majör olumsuz kardiyovasküler olay (MACE) insidansını ve perioperatif miyokard hasarını anlamlı derecede azalttığı tespit edilmiştir. Sonuç olarak, postoperatif sirkadiyen ritim ve uyku bozuklukları komplikasyonları artırdığından, tıbbi müdahalelerin hastaların endojen ritmine göre kronoterapi ilkeleriyle ayarlanması ve bu alanda daha detaylı çalışmaların yapılması büyük önem arz etmektedir.
Disruption of circadian rhythms leads to sleep disturbances and various postoperative comorbidities. Surgical procedures and anesthetics (NMDA antagonists and GABA agonists) disrupt the endogenous circadian order, melatonin production, and cortisol secretion through their effects on the suprachiasmatic nucleus. Especially after major surgery, sleep architecture is severely affected; slow-wave and REM sleep decrease during the first three nights, followed by a rebound of REM sleep on the third and fourth nights. This phenomenon, combined with increased sympathetic activity and respiratory instability, maximizes the risk of cardiovascular and general morbidities such as postoperative myocardial ischemia, delirium, fatigue, and cognitive dysfunction. Melatonin, an endogenous circadian regulator, has been shown to be effective in preventing postoperative delirium and improving sleep quality. Prospective cohort studies have demonstrated that circadian rhythms alter myocardial tolerance against ischemia-reperfusion, and aortic valve replacement surgeries performed in the afternoon significantly reduce the incidence of major adverse cardiovascular events (MACE) and perioperative myocardial injury compared to those performed in the morning. In conclusion, since postoperative circadian and sleep disruptions increase complications, it is of clinical importance to align surgical interventions with the patient's endogenous rhythm using chronotherapy principles, and further detailed studies are warranted.
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