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Low blood-oxygen levels were found to be the distinguishing factor that affected executive control-related neural activity and cognitive performance when exercise was performed in low-oxygen conditions

Tsukuba, Japan—When physically demanding activities are performed at high altitude or in other low-oxygen environments, excellent coordination, judgment, and decision-making are important. In some cases, such as when mountaineering, these capabilities may be the difference between life and death.

What is executive function and why is it important? Executive functions control and coordinate other brain functions, like memory, emotions, and movement control, to enable more complex behaviors—for example, learning, planning, judgment, and decision-making.

In a study published this month in Scientific Reports, researchers at the University of Tsukuba showed that reductions in neural activity in brain regions responsible for executive control-related cognitive functions and cognitive performance during exercise in low-oxygen conditions could be prevented by maintaining oxygen saturation.

Demonstrating causality—that the decreases in neural activity and performance are caused by low oxygen availability to brain tissue—is not straightforward because of the complexity exhibited by the brain and all its functions. Yet the University of Tsukuba research team have done just that. “We compared the effects of hypoxic conditions in which blood oxygen levels is reduced with those in which blood oxygen levels remains stable during exercise,” says senior author Professor Hideaki Soya. “By doing this, we isolated low oxygen saturation as a factor for decreased neural activity and decreased performance.”

Neural activity in the prefrontal cortex was measured with functional near-infrared spectroscopy to show change in oxygenated hemoglobin (i.e., oxygen usage from regional blood supply). Cognitive performance was assessed using Stroop interference, which is the difference in completion time (or number of errors) between neutral and incongruent trials. In incongruent trials, the color of the text must be identified when, for example, the word red is written in green. In neutral trials, only the color of a swatch must be identified.

“When blood oxygen levels remained stable during exercise, the Stroop effect was not as pronounced,” says senior author Dr. Genta Ochi. “In the brain region of interest—the left dorsolateral prefrontal cortex—there was less of a decrease in activation from the neutral to the incongruent trial.”

The study suggests that oxygen supply is important for maintaining cognitive function during exercise in low-oxygen environments. Furthermore, regions of the brain with newer (from an evolutionary point of view), less critical functions may be lower priority than those responsible for functions that keep us alive. Thus, the effects of cognitive fatigue must be taken into account when physical activities that require judgment and critical thinking are performed in low-oxygen environments.

A review at this year’s Euroanaesthesia congress in Milan, Italy (4-6 June) on the potentially lethal effects of fatigue on doctors and nurses themselves, and its impact on the quality of their clinical work and judgement and therefore patient safety, will be given by Consultant Anaesthetist Dr Nancy Redfern of Newcastle Hospitals NHS Foundation Trust, Newcastle, UK. She will conclude that due to these risks, “healthcare should have formal risk management systems like those required by law in every other safety-critical industry”.

She will also recommend that all doctors and nurses need 20-minute power naps during night shifts to keep patients safe (and make their own journeys home after work safer), and also recommend that no doctor or nurse does more than 3 consecutive night shifts.

Dr Redfern will discuss evidence from various sources including surveys from the joint Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine fatigue working group, published in the journal Anaesthesia, that showed around half of trainee doctors, consultants and nurses had experienced either an accident or a near miss driving home after a night shift. Indeed, research has shown driving after being awake for 20 hours or more and at the body’s circadian low point (in the night or very early morning when it most needs sleep) is as dangerous as driving with blood alcohol levels above the legal limit. And workers who drive home after a 12-hour shifts are twice as likely to crash as those working 8-hour shifts. 

A ‘sleep debt’ begins building after 2 or more nights of restricted sleep, and it takes at least 2 nights of good sleep to recover from this. Cognitive function is impaired after 16-18 hours awake leading to a deterioration in the medical worker’s ability to interact effectively with patients and colleagues.  “When fatigue sets in, we in the medical and nursing team are less empathic with patients and colleagues, vigilance becomes more variable, and logical reasoning is affected, making it hard to calculate, for example, the correct doses of drugs a patient needs,” explains Dr Redfern. “We find it hard to think flexibility, or to retain new information which make it difficult to manage quickly changing emergency situations.  Our mood gets worse, so our teamwork suffers.  Hence, everything that makes us and our patients safe is affected.”

She will discuss how fatigue induces spontaneous, unrecognised uncontrolled ‘sleep lapses’ or ‘microsleeps’, which means driving home tired is the most dangerous thing a healthcare practitioner does.  Evidence around short 20-minute power naps in improving staff and patient safety will be presented and ways of building this into night shift work discussed.

There is work going on at many levels to address the impact of fatigue. The European Society of Anaesthesiology and Intensive Care (ESAIC) (that hosts Euroanaesthesia) is working on producing guidelines for night working, while the Association of Anaesthetists has an active #fightfatigue campaign. The European Board of Anaesthesiology and the European Patient Safety Foundation are also active in this area, and Dr Redfern notes that several European countries are leading the way with action, including the UK, Romania, The Netherlands and Portugal.*

Dr Redfern explains: “We hope in the end that regulators will recognise that healthcare workers have the same physiology as employees in every other safety-critical industry and require formal fatigue risk management as part of its overall approach to patient and staff safety.”

She concludes: “We need to change the way we manage night shifts to mitigate the effects of fatigue.  Those working shifts must ensure everyone gets a power nap, and that we support each other to remain safe and vigilant when we work through the night.  Staffing schedules should allow sufficient time between shifts for proper rest, and no-one should do more than 3 night shifts in a row.”