Anesth Pain Med.  2024 Apr;19(2):125-133. 10.17085/apm.23038.

How does circadian rhythm affect postoperative pain after pediatric acute appendicitis surgery?

• Cekci FC
• Sargin M
• Siki FO

• KMID: 2555249
• DOI: http://doi.org/10.17085/apm.23038

Abstract

Background
Pain intensity has been reported to fluctuate throughout the day in various clinical situations. This study aimed to evaluate the relationship between postoperative pain and circadian rhythm after pediatric acute appendicitis surgery.
Methods
Two hundred patients, aged 6–18 years, undergoing acute appendicitis surgery were included in this prospective observational study. The patients were divided into four groups according to the time they underwent surgery: the night group, 01:01–07:00; morning group, 07:01–13:00; afternoon group, 13:01–19:00; and evening group, 19:01–01:00. Intraoperative and postoperative vital signs, postoperative 24-h Wong–Baker Faces Pain Rating Scale (FACEs) scores, and the amount of analgesic required were recorded.
Results
A total of 186 patients were analyzed in the study. There was no statistically significant difference in the demographic characteristics of the patient groups. Additionally, no differences were observed in intraoperative and postoperative vital signs among the four groups. However, patients in the night group had significantly higher FACEs values than those in the other groups at each time point (1st, 3rd, 6th, and 12th h) up to 12 h (P = 0.007, P = 0.023, P = 0.048, and P = 0.003, respectively). The amount of analgesic required in the night group was statistically higher than in the other groups until 12 h (P = 0.002, P < 0.001, P = 0.002, and P = 0.004, respectively).
Conclusion
A relationship was found between acute appendicitis operations performed at night (01:01 to 07:00) under general anesthesia and circadian rhythm in children. We believe that considering circadian time in the relief of postoperative pain would be beneficial.

Keyword

Circadian rhythm; Pediatric; Appendectomy; Postoperative; Pain; Analgesia

Reference

1. Golombek DA, Rosenstein RE. Physiology of circadian entrainment. Physiol Rev. 2010; 90:1063–102.

2. Bruguerolle B, Labrecque G. Rhythmic pattern in pain and their chronotherapy. Adv Drug Deliv Rev. 2007; 59:883–95.

3. Chassard D, Bruguerolle B. Chronobiology and anesthesia. Anesthesiology. 2004; 100:413–27.

4. Hagenauer MH, Crodelle JA, Piltz SH, Toporikova N, Ferguson P, Booth V. The modulation of pain by circadian and sleep-dependent processes: a review of the experimental evidence. Women in Mathematical Biology: Research Collaboration Workshop. In : Layton A, Miller L, editors. Knoxville: Springer International Publishing;2017. p. 1–21.

5. Kim MJ, Chung JW, Kho HS, Park JW. The circadian rhythm variation of pain in the orofacial region. J Oral Med Pain. 2015; 40:89–95.

6. Campagna S, Sperlinga R, Milo A, Sannuto S, Acquafredda F, Saini A, et al. The circadian rhythm of breakthrough pain episodes in terminally-ill cancer patients. Cancers (Basel). 2018; 11:18.

7. Bellamy N, Sothern RB, Campbell J. Aspects of diurnal rhythmicity in pain, stiffness, and fatigue in patients with fibromyalgia. J Rheumatol. 2004; 31:379–89.

8. Bellamy N, Sothern RB, Campbell J, Buchanan WW. Circadian rhythm in pain, stiffness, and manual dexterity in rheumatoid arthritis: relation between discomfort and disability. Ann Rheum Dis. 1991; 50:243–8.

9. Dekkers JC, Geenen R, Godaert GLR, Doornen LJP, Bijlsma JWJ. Diurnal courses of cortisol, pain, fatigue, negative mood, and stiffness in patients with recently diagnosed rheumatoid arthritis. Int J Behav Med. 2000; 7:353–71.

10. Brainard J, Gobel M, Bartels K, Scott B, Koeppen M, Eckle T. Circadian rhythms in anesthesia and critical care. medicine: potential importance of circadian disruptions. Semin Cardiothorac Vasc Anesth. 2015; 19:49–60.

11. Park S, Chi SI, Seo KS, Kim HJ. Circadian variation of IV PCA use in patients after orthognathic surgery - a retrospective comparative study. J Dent Anesth Pain Med. 2015; 15:141–6.

12. Vieira WS, Hidalgo MP, Torres Ida S, Caumo W. Biological rhythms of spinal-epidural labor analgesia. Chronobiol Int. 2010; 27:865–78.

13. Qiu Q, Xu Y, Tan Y, Sun C, Liang Y, Zhang N, et al. Comparison of the postoperative in-hospital versus at-home recovery quality and circadian rhythm status in preschool kids after adenotonsillectomy: a cohort and observational study. Transl Pediatr. 2023; 12:645–54.

14. Labrecque G, Karzazi M, Vanier MC. Biological rhythms in pain and analgesia. Physiology and pharmacology of biological rhythms. In : Redfern PH, Lemmers B, editors. New York: Springer-Verlag;1997. p. 83–90.

15. Vacas S, Kurien P, Maze M. Sleep and anesthesia – common mechanisms of action. Sleep Med Clin. 2013; 8:1–9.

16. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. N Engl J Med. 2010; 363:2638–50.

17. Pöllmann L. Duality of pain demonstrated by the circadian variation in tooth sensitivity. Chronobiology 1982–1983. In : Haus E, Kabat H, editors. Basel: Karger;1984. p. 225–8.

18. Labrecque G, Vanier MC. Biological rhythms in pain and in the effects of opioid analgesics. Pharmacol Ther. 1995; 68:129–47.

19. Petrovsky N, McNair P, Harrison LC. Diurnal rhythms of pro-inflammatory cytokines: regulation by plasma cortisol and therapeutic implications. Cytokine. 1998; 10:307–12.

20. Novak CM, Albers HE. Novel phase-shifting effects of GABAA receptor activation in the suprachiasmatic nucleus of a diurnal rodent. Am J Physiol Regul Integr Comp Physiol. 2004; 286:820–5.

21. Mihara T, Kikuchi T, Kamiya Y, Koga M, Uchimoto K, Kurahashi K, et al. Day or night administration of ketamine and pentobarbital differentially affect circadian rhythms of pineal melatonin secretion and locomotor activity in rats. Anesth Analg. 2012; 115:805–13.

22. Auvil-Novak SE, Novak R, Smolensky MH, Kavanagh JJ, Kwan JW, Wharton JT. Twenty-four hour variation in selfadministration of morphine sulfate and hydromorphone by post-surgical gynecologic cancer patients. Ann Rev Chronopharmacol. 1988; 5:343–6.

23. Boom M, Grefkens J, Van Dorp E, Olofsen E, Lourenssen G, Aarts L, et al. Opioid chronopharmacology: İnfluence of timing of infusion on fentanyl’s analgesic efficacy in healthy human volunteers. J Pain Res. 2010; 21:183–9.

24. Anastasopoulou‐Sampani D, Sampanis E, Karargiris G. The need for analgesia in elective cholecystectomies influenced by the time of day the operation is performed. Acta Anaesthesiol Scand. 1996; 40:955.

25. Ollagnier M, Decousus H, Cherrah Y, Levi F, Mechkouri M, Queneau P, et al. Circadian changes in the pharmacokinetics of oral ketoprofen. Clin Pharmacokinet. 1987; 12:367–78.

26. Clench J, Reinberg A, Dziewanowska Z, Ghata J, Smolensky M. Circadian changes in the bioavailability and effects of indomethacin in healthy subjects. Eur J Clin Pharmacol. 1981; 20:359–69.

27. Guissou P, Cuisinaud G, Llorca G, Lejeune E, Sassard J. Chronopharmacokinetic study of a prolonged release form of indomethacin. Eur J Clin Pharmaco. 1983; 24:667–70.

28. Halsas M, Hietala J, Veski P, Jürjenson H, Marvola M. Morning versus evening dosing of ibuprofen using conventional and time-controlled release formulations. Int J Pharm. 1999; 189:179–85.

29. Boggio JC, Valtorta SE, Sánchez S, Mckellar Q. Chronobiological variations of indomethacin pharmacokineticparameters in sheep. J Vet Pharmacol Ther. 2001; 24:261–5.

30. Aviram J, Shochat T, Pud D. Pain perception in healthy young men is modified by time-of-day and is modality dependent. Pain Med. 2015; 16:1137–44.

31. Junker U, Wirz S. Review article: chronobiology: influence of circadian rhythms on the therapy of severe pain. J Oncol Pharm Pract. 2010; 16:81–7.

32. Cutolo M. Circadian rhythms and rheumatoid arthritis. Joint Bone Spine. 2019; 86:327–33.

33. Schiessl C, Schestag I, Griessinger N, Sitt R, Zernikow B. [Zirkadianer Rhythmus des PCA-gesteuerten Opioidver-brauchs bei Kindern mit chemotherapiebedingter Mukositis]. Schmerz. 2009; 23:7–19. German.

34. Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain. Clin J Pain. 2012; 28:819–41.