Sleep

Normal Stages of Sleep

  • xxx

Sleep in the Intensive Care Unit (ICU)

Effects of Intensive Care Unit Stay on Sleep Architecture

  • Abnormal Sleep-Wake Cycle
  • Decreased REM and Slow-Wave Sleep
  • Decreased Total Sleep Time/Decreased Sleep Efficiency
  • Increased Sleep Fragmentation
  • Prolonged REM Latency

Factors Contributing to Sleep Disruption in the Intensive Care Unit

  • Noise
  • Acute Illness: alters sleep architecture
  • Ambient Light Dyssynchronization
  • Mechanical Ventilation: mechanical ventilation is a well-known cause of sleep disruption
    • Mechanisms by Which Mechanical Ventilation May Disturb Sleep
      • Anxiety/Pain Induced by Ventilator
      • Overventilation: leading to apneas with arousals
      • Patient/Ventilator Asynchrony
      • Underventilation: leading to increased respiratory effort and arousals
    • Sleep Architecture is Highly Abnormal in Mechanically-Ventilated Patients, with No Effect with Choice of Ventilator Mode (2008) [MEDLINE]
      • Conscious, mechanically-ventilated patients have high degree of sleep fragmentation (frequent arousals), decreased total sleep time, short REM stage
      • The sleep efficiency in a medical population is reduced compared to a surgical one (40% v. 89%), which may partly explain the higher rate weaning failure seen in the medical population
  • Sedation/Analgesic Regimen
    • Risk Factors for Sleep Disruption in Mechanically Ventilated Patients in the Intensive Care Unit (Assessed in Preceding 24 hrs) (2000) [MEDLINE]
      • Acute Physiologic Score (APS) <13
      • Glasgow Coma Score (GCS) >10
      • Opiate Doses with Morphine Equivalent <10 mg/kg/h
      • Sedation Doses with Lorazepam Equivalent <10 mg/kg/h
    • Benzodiazepines Decrease Total Sleep and Suppress REM/N3 Sleep (see Benzodiazepines, [[Benzodiazepines]])
    • Diphenhydramine (Benadryl) Inhibits Histamine-Induced Wakefulness and Does Not Improve Polysomnographic Sleep Quality (see Diphenhydramine, [[Diphenhydramine]])
    • Trazodone (xxx) Subjectively Improves Sleep and Sleep Efficiency (But Polysomnographic Data are Limited) (see Trazodone, [[Trazodone]])
    • Opiates Provoke Nocturnal Awakenings, Suppress REM/N3 Sleep, and May Cause Central Sleep Apneas (see xxxx, [[xxxx]])
    • Demedetomidine (Precedex) Preserves the Day/Night Sleep Cycle, But Does Not Improve REM or Slow Wave Sleep (see Demedetomidine, [[Demedetomidine]]) [MEDLINE]
    • Propofol Decreases REM and Does Not Improve Sleep Efficiency or Fragmentation [MEDLINE]

Clinical Effects of Sleep Deprivation in the Intensive Care Unit

  • Cognitive Deficits: leading to ICU delirium
  • Decreased Insulin Sensitivity
  • Decreased Ventilatory Drive
  • Impaired Inspiratory Muscle Endurance
  • Impaired Immune Responses
    • Impaired Phagocytosis
    • Decreased NK Cell/Lymphocyte/Granulocyte Proliferation
    • Decreased Immune Response to Influenza Vaccination
  • Post-Traumatic Stress Disorder (PTSD) (see xxxx, [[xxxx]])

Measures to Reduce Sleep Disruption in the Intensive Care Unit

Decrease ICU Noise Levels

  • xxx

Clustering of Care Activities

  • Avoid Activities During Nocturnal Sleep Times

Early Mobilization

  • xxx

Ear Plugs

  • Trial of Ear Plugs in the ICU (2012)[MEDLINE]
    • Nocturnal Ear Plugs Decreased the Incidence of Confusion: beneficial effects appeared to be strongest within 48 hrs after admission
    • Patients Sleeping with Earplugs Developed Confusion Later than the Patients Sleeping Without Earplugs
    • After the First Night in the ICU, Patients Sleeping with Earplugs Reported a Better Perception of Sleep
  • Quality of Evidence is Low [MEDLINE]

Eye Masks

  • Some Data Suggest Benefit in Terms of Promoting Sleep and Decreasing Delirium: however, quality of evidence is low [MEDLINE]

Restoration of Natural Diurnal Lighting

  • Quiet Time Protocols

Minimization of Sedation

  • Daily Sedation Vacation Improves Polysomnographic Sleep Parameters in the ICU (2011) [MEDLINE]: daily sedation vacation increased the amount of slow wave sleep and REM

Avoidance of Medications Which Suppress Slow-Wave Sleep and REM

Use of Sleep-Promoting Medications That Do Not Suppress Slow-Wave Sleep and REM

  • Gaboxadol (xxx) (see Gaboxadol, [[Gaboxadol]])
  • Melatonin (see Melatonin, [[Melatonin]]): antioxidant and sleep-promoting properties -> needs further study
  • Zolpidem (Ambien) (see Zolpidem, [[Zolpidem]]): GABA A receptor agonism -> might improve sleep in the ICU, but data are limited
  • Zopiclone (xxx) (see Zopiclone, [[Zopiclone]])

Multimodal Strategies to Enhance Sleep in the Intensive Care Unit

  • Multi-Faceted Trial of Sleep-Promoting Interventions in the ICU (2013) [MEDLINE]
    • Interventions Led to Significant Improvement in Perceived Nighttime Noise
    • Interventions Led to Significant Improvement in Daily Delirium/Coma-Free Status
    • Interventions Led to Non-Significant Improvement in Perceived Sleep Quality

Other Therapies

  • Music Therapy: needs further study
  • Back Massage: needs further study
  • Aromatherapy: needs further study

References

  • The relationship of postoperative delirium with psychoactive medications. JAMA. 1994;272:1518-1522
  • Sleep in the intensive care unit. Chest 1995; 107:1713
  • The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114:541-548
  • Sleep in critically ill patients requiring mechanical ventilation. Crit Care Med. 1999;27:2609-2615
  • Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Respir Crit Care Med. 1999;159:1155-1162
  • Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Chest. 2000;117:809-818
  • Sleep in critically ill patients requiring mechanical ventilation. Chest. 2000;117:809-818 [MEDLINE]

  • Delirium in an intensive care unit: a study of risk factors. Intensive Care Med. 2001;27:1297-1304

  • Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care Med. 2003;167:708-715
  • Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753-1762
  • Sleep in the intensive care unit. Intens Care Med 2004; 30:197
  • Sleep in the critically ill patient. Sleep 2006; 29:707
  • Quantity and quality of sleep in the surgical intensive care unit: Are our patients sleeping? J Trauma 2007;63:1210
  • Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007;33:66-73 [MEDLINE]
  • Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated ICU patients. Intensive Care Med. 2007;33:1148-1154
  • Patient-ventilator interaction and sleep in mechanically ventilated patients: pressure support versus proportional assist ventilation. Crit Care Med. 2007;35:1048-1054
  • Quantity and quality of sleep in the surgical intensive care unit: are our patients sleeping? J Trauma. 2007;63:1210-1214
  • Mechanical ventilation: let us minimize sleep disturbances. Curr Opin Crit Care. 2007 Feb;13(1):20-6 [MEDLINE]
  • Prevalence and risk factors for development of delirium in surgical and trauma ICU patients. J Trauma. 2008;65:34-41
  • Sleep and recovery from critical illness and injury: a review of theory, current practice, and future directions. Crit Care Med. 2008;36:697-705
  • Sleep quality in mechanically ventilated patients: comparison of three ventilatory modes. Crit Care Med. 2008;36:1749-1755 [MEDLINE]

  • Delirium in the intensive care unit. Crit Care. 2008;12(suppl 3):S3 [MEDLINE]

  • Indian J Chest Dis Allied Sci 2008; 50: 151-162

  • Effect of daily sedative interruption on sleep stages of mechanically ventilated patients receiving midazolam by infusion. Anaesth Intensive Care 2011;39:392–400 [MEDLINE]

  • Sleep quality of mechanically ventilated patients sedated with dexmedetomidine. Intensive Care Med 2012;38: 1982–9 [MEDLINE]

  • Effects of propofol on sleep quality in mechanically ventilated critically ill patients: a physiological study. Intensive Care Med 2012;38:1640–6 [MEDLINE]

  • The effect of earplugs during the night on the onset of delirium and sleep perception: A randomized controlled trial in intensive care patients. Crit Care 2012;16:R73 [MEDLINE]

  • The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med 2013;41:800-809 [MEDLINE]

  • Non-pharmacological interventions for sleep promotion in the intensive care unit. Cochrane Database Syst Rev. 2015 Oct 6;10:CD008808. doi: 10.1002/14651858.CD008808.pub2 [MEDLINE]

  • Sleep Loss and Circadian Rhythm Disruption in the Intensive Care Unit. Clin Chest Med. 2015 Sep;36(3):419-29. doi: 10.1016/j.ccm.2015.05.008. Epub 2015 Jun 29 [MEDLINE]