Anaesthesia, 1993, Volume 48, page 527-529

Peri-operative nightmares in surgical patients

J. Brimacombe, MB, ChB, FRCA, A. G. Macfie, MB, ChB, FRCA, Senior Registrars, Royal Perth Hospital,
Wellington Street, Perth 6001, Australia.

Summary
A questionnaire was designed which made specific enquiries about peri-operative nightmares and general enquiries regarding
peri-operative hallucinations, sleep disturbance and pain. The questionnaire was completed by four groups of patients. Groups I
and 2 comprised patients who had undergone elective cardiac surgery and major noncardiac surgery respectively. Group 3
comprised patients undergoing day surgery. Group 4 consisted of 100 randomly selected patients who had undergone minor
elective surgery to the upper or lower limbs during the preceding 2 years, half of whom had received regional and halfgeneral
anaesthesia. Two hundred and seventy-one completed questionnaires were analysed. In all, 18.5% of patients had experienced at
least one nightmare during the postoperative week and and the highest incidence (27.9%) was found in group 1. Nightmares
occurred most commonly on the fourth postoperative night and did not correlate with disturbed sleep, hallucinations or any other
symptom recorded. Patients in group I reported the highest incidences of disturbed sleep (54.8%) and hallucinations (12.5%).

Key words
Anaesthesia; general.
Memory; dreams.

Acute pain is perhaps the greatest source of misery for
most patients in the postoperative period. However, other
problems can cause distress. Surgery and anaesthesia may
result in severe disruption of nocturnal sleep [I] and a study
of sleep patterns in 12 patients following major surgery
showed an increased incidence of distressing dreams and
vivid nightmares from the third postoperative night [2].
The aim of the present study was to determine the
incidence of nightmares and sleep disruption in the peri-
operative period in a wider range of patients to assess the
extent of this problem.
Methods
Ethics committee approval was obtained for this study. A
questionnaire was designed which made specific enquiries
about peri-operative nightmares and general enquiries
regarding peri-operative hallucinations, sleep disturbance
and pain. An abbreviated version of the questionnaire is
shown in Table 1.
The questionnaire was distributed to four groups of
patients. Group 1 comprised 104 patients who had under-
gone cardiac surgery. Group 2 consisted of 53 patients who
had undergone major noncardiac surgery. Both groups
were interviewed by one of the authors on the 7th post-
operative day. Group 3 comprised 67 patients undergoing
day surgery who were given a questionnaire in a sealed
envelope. They were not informed about the nature of the
questionnaire and were asked to open and complete it one
week later. Group 4 consisted of 100 randomly selected
patients who had undergone minor surgery to the upper or
lower limb during the preceding 2 years, half of whom had
received regional and half general anaesthesia. A question-
naire was posted to them, and they were asked to complete
and return it.
A nightmare was defined as a terrifying dream or a
dream from which the patient awoke with severe anxiety or
symptoms such as palpitations or sweating. All other
information was obtained from the patient’s notes and
included age, sex, duration of operation, anaesthetic drugs
and technique, postoperative problems, postoperative anal-
gesia, previous general anaesthetics and, for the cardiac
patients, cross-clamp time, bypass time, time spent in the
intensive care unit and total duration of tracheal
intubation.
Statistical analysis of results was undertaken using the
Chi-squared test with Yates’ correction. Statistical signifi-
cance was taken at p < 0.05.
Results
A total of 271 completed questionnaires were analysed (104
cardiac inpatients, 53 noncardiac inpatients, 57 day cases
and 57 postal surveys). The response rate to the inpatient
Table 1. The questionnaire.
I Before you knew you required an operation did you ever
have nightmares? How often? Did they wake you? Did
you have difficulty sleeping at that time? How
severe-worrying, frightening, absolutely horrifying?
2 After you knew you required an operation, did you have
nightmares? (as per q I )
3 On the night before your operation, did you have a
nightmare? (as per q I )
4 Can you remember having any dreams or nightmares
during the operation?
5 Can you remember feeling any discomfort or pain during
the operation?
6 Did you have any nightmares in the week following the
operation? How many? When? (as per q I)
I Did you have a lot of pain after the operation?
8 Did you have any hallucinations after the operation?
9 Has your pattern of sleep been improved or disturbed since
the operation? What reasons?
10 Were you happy with the outcome of the surgery?
I1 Did you find the experience of going to hospital and having
an operation emotionally traumatic?
12 Were you happy with the standard of care whilst you were
in hospital?

Accepted 10 August 1992.

528 Forum

Table 2. Patient characteristics. the experience of having an operation emotionally trau-

Group I Group 2 Group 3 Group 4
Age; years
mean (SD) 60(11) 59 (14) 38 (14) 51 (20)
range 19-84 23-83 15-70 16-90
M:F 72:32 24:29 29:28 36:21
study was loo%, to the day case study 85% and to the
postal study 57%. Demographic data are shown in
Table 2.
Group 1 consisted of inpatients who had undergone
coronary artery bypass graft (CABG; 73 YO), valve surgery
(19Y0) or both ( 5 % ) . The noncardiac group had undergone
a variety of major surgery: general (49%), thoracic (1 1 YO),
gynaecological (4%), vascular (1 7%), urological (6%),
ENT (6%) and orthopaedics (2%).
The data regarding nightmares are displayed in Table 3.
In all, 24% of patients had experienced at least one night-
mare in the year preceding the date on which they dis-
covered that they would require surgery. The overall
incidence of nightmares on the night before surgery was
3%. However, 18.5% of patients experienced at least one
nightmare during the first postoperative week. Patients in
group I had significantly more nightmares in the first week
than those in groups 3 or 4 (p < 0.05). Nightmares
occurred in groups I , 2 and 3 most frequently on the fourth
postoperative day (mean 3.6, S D = 1.2). N o data relating
to the day on which nightmares occurred were deemed
reliable in group 4 because the mean period between the
postal survey and operation was 11.5 months (SD = 4.7).
The severity of nightmares was assessed crudely using a
simple scoring system and was found to be similar in all
groups.
Patients in group 4 had the same incidence of nightmares
several months after the operation as during the period
before they knew that surgery was required. There was no
significant difference in the incidence of peri-operative
nightmares between patients who had received regional
(5.8%) or general anaesthesia (8.6%).
On average, 84.5% of patients had received previous
general anaesthetics and 75.6% of patients denied finding
matic. Thc experience of undergoing surgery was found less
emotionally traumatic in groups 3 (19.3%) and 4 (20.2%)
than in group 1 (29.8%) or 2 (28.3%) (p < 0.01).
Severe pain was reported by fewer patients in group 1
(30.8%) than group 2 (49.1 YO), but not significantly less
than in group 3 (42. I YO)or group 4 (35.1 YO). The incidence
of postoperative hallucinations was significantly higher in
cardiac patients (12.5%) than in other patients (5.7%)
(p < 0.02:1.
Sleep d,lsturbance during the first postoperative week was
reported by 54.8% of patients in group 1 and 30.2% of
those in group 2. The reasons given in the order of
frequency were: uncomfortable bed (32.7%), pain from
wound (20.2%), noise (16.3%), non-wound pain (6.7%),
unfamiliarity with environment (3.8%), palpitations
(3.8%), sore throat (2.9%), nightmares (1 YO), too hot (1 YO),
too cold ( 1 Yo).
There was no statistically significant relationship
between the incidence of nightmares and any of the other
symptom!; recorded, notably pain or disturbed sleep
pattern or awareness. In group I , there was no correlation
with durztion of the operation, cross-clamp time, bypass
time, time: until the trachea was extubated or the time spent
in the inti:nsive care unit.
Discussiori
Profound disturbance of normal sleep patterns has been
noted in the first postoperative week after major
surgery [I]. Nightmares occur most frequently about the
middle of the first postoperative week, and were associated
with increased rapid eye movement (REM) activity in a
group of 12 patients following major surgery. Our study
has shown that sleep disruption is very common and that
18.5% of patients experience at least one nightmare during
the first postoperative week. This phenomenon may be a
response to the sleep deprivation experienced after surgery.
After sleep deprivation, there is an initial night of deep
sleep on the first night, but a significant rebound in
dreaming activity on the second night to greater than
baseline lavels [3]. The association between REM sleep and
normal dreaming has been demonstrated and may repre-

Table 3. The incidence of nightmares expressed as the number of patients (YOof group
total), and temporal relationship of nightmares in the peri.operative period expressed as
mean (SD),(range).

Group I Group 2 Group 3 Group 4 Total

Nightmares on night before 2 2 3 I 8

operation (1.9%) (3.8%) (5.3%) (1.8%) (3.0%)
Nightmares during week after 29 10 7 4 50
operation (27.9%) (18.9%) (12.3%) (7.0%) (18.5%)
Commonest day after surgery 3.8 4.0 3.0
(1.0) (1.2) (1.3)
(1-7) (1-6) (1-5)

Table 4. The incidence of postoperative problems. Results are expressed as the number
of patients (YOof patients in group).

Group 1 Group 2 Group 3 Group 4 Total

Sleep improved 4 4 4 12
(3.8) (7.5) (7.0) (4.4)
Sleep disturbed 57 16 8 81
(54.8) (30.2) (14.0) (29.9)
Hallucinations 13 3 0 0 16
(12.5) (5.7) (0) (0) (5.9)
Severe pain 32 26 24 20 102
(30.8) (49.1) (42.1) (35.1) (37.6)

sent scanning movements as the dreamer watches the visual
events of a dream. After the initial suppression of all
aspects of sleep, including REM and slow wave sleep on
the first 2 or 3 postoperative nights, there is a recovery
associated with an increase in REM sleep to greater than
the pre-operative levels [2].
The causes of sleep disturbance after surgery may be due
to several factors including anaesthesia, the endocrine and
metabolic response to surgical trauma, pain or opioid
therapy, postoperative hypoxaemia, peri-operative fasting,
elevated body temperature or environmental factors.
In our study the highest incidence of nightmares, halluci-
nations and sleep disturbance occurred in patients who had
undergone cardiac surgery. Delirium and sleep disorders
are well recognised complications of open heart surgery.
However, Johns et al. [4] found that patients suffering from
delirium after cardiac surgery had sleep disruption and an
absence of REM sleep and concluded that special features
of cardiac surgery, such as cerebral hypoxia, were respons-
ible. Subclinical cerebral ischaemia suffered during cardio-
pulmonary bypass may result in behavioural changes and
subtle intellectual impairment [5,6]. The contribution of
this problem to the high incidence of nightmares, sleep
disturbance and hallucinations in the cardiac group is not
known, but no correlation was found with cross-clamp
time, intubation time or time in the intensive care unit.
Intensive care management following major surgery
nearly abolishes both REM and non-REM sleep [7]. Sleep
changes after minor surgery have been described; after
herniorrhaphy, these changes are similar to, but of a less
severe nature than, those associated with major surgery [8].
Morphine disrupts sleep in a dose-dependent fashion,
reducing sleep time, slow wave and REM sleep in volun-
teers without pain [9]. These changes are similar to those
found in the first week after upper abdominal surgery [I].
The influence of morphine on the disruption of normal
sleep patterns in the peri-operative period may be one of
the more important factors. This would account for the
increased incidence of disturbed sleep and nightmares in
the inpatient groups who had received opioid analgesia
after major cardiac and general surgery in our study.
Interestingly, the day case group, who received n o opioid
analgesia in the postoperative period, reported more severe
pain than the cardiac group, but had less disturbed sleep
and fewer nightmares.
General anaesthesia is not thought to play a major role
in sleep disturbance [8]. This was confirmed by the equal
incidence of nightmares in the general anaesthesia and
regional anaesthetic subgroups of our postal survey.
Isoflurane causes modest alterations in nocturnal sleep,
Forum 529
limited to the first postoperative night [ 101. Nightmares are
known to occur in response t o psychological stress and
dream disturbances may occur specifically in association
with the post-traumatic stress disorder [ 121. Admission to
hospital for major surgery is associated with many anxieties
and stresses and these may contribute to the production of
distressing dreams.
Distressing nightmares are a common occurrence during
the first postoperative week after major surgery. The cause
of these nightmares is probably multifactorial and further
research is required to determine the relative importances
of each factor. Sleep disruption and the resulting sleep
deprivation are associated commonly with nightmares and
may be important in their evolution.
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