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
- Mechanisms by Which Mechanical Ventilation May Disturb Sleep
- 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]
- Risk Factors for Sleep Disruption in Mechanically Ventilated Patients in the Intensive Care Unit (Assessed in Preceding 24 hrs) (2000) [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
- Avoidance of Antihistamines (Diphenhydramine, etc) (see H1-Histamine Receptor Antagonists, [[H1-Histamine Receptor Antagonists]])
- Avoidance of Benzodiazepines (see Benzodiazepines, [[Benzodiazepines]])
- Avoidance of Opiates (see Opiates, [[Opiates]])
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
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Sleep in critically ill patients requiring mechanical ventilation. Chest. 2000;117:809-818 [MEDLINE]
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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
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Sleep quality in mechanically ventilated patients: comparison of three ventilatory modes. Crit Care Med. 2008;36:1749-1755 [MEDLINE]
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Delirium in the intensive care unit. Crit Care. 2008;12(suppl 3):S3 [MEDLINE]
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Effect of daily sedative interruption on sleep stages of mechanically ventilated patients receiving midazolam by infusion. Anaesth Intensive Care 2011;39:392–400 [MEDLINE]
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Sleep quality of mechanically ventilated patients sedated with dexmedetomidine. Intensive Care Med 2012;38: 1982–9 [MEDLINE]
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Effects of propofol on sleep quality in mechanically ventilated critically ill patients: a physiological study. Intensive Care Med 2012;38:1640–6 [MEDLINE]
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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]
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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]
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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]