Sleep in the intensive care unit

Abstract

Purpose of reviewSleep is particularly important for critically ill patients. Here, we review the latest evidence on how sleep and circadian disruption in the intensive care unit (ICU) affects physiology and clinical outcomes, as well as the most recent advances in sleep and circadian rhythm promoting interventions including therapeutics. Recent findingsOn a molecular level, clock genes dysrhythmia and altered immunity are clearly linked, particularly in sepsis. Melatonin may also be associated with insulin sensitivity in ICU patients. Clinically, changes in sleep architecture are associated with delirium, and sleep-promoting interventions in the form of multifaceted care bundles may reduce its incidence. Regarding medications, one recent randomized controlled trial (RCT) on melatonin showed no difference in sleep quality or incidence of delirium. SummaryFurther investigation is needed to establish the clinical relevance of sleep and circadian disruption in the ICU. For interventions, standardized protocols of sleep promotion bundles require validation by larger multicenter trials. Administratively, such protocols should be individualized to both organizational and independent patient needs. Incorporating pharmacotherapy such as melatonin and nocturnal dexmedetomidine requires further evaluation in large RCTs.

Part II: Case series: Acute agitation, delirium, and sleep management

“…Nonpharmacologic management is the most common approach to sleep optimization in the ICU 43 . These interventions include keeping the lights on in the ICU during the day and diming lights at night 96 . Noise in the ICU consistently exceeds the WHO recommended level for sleep 91 .…”

“…Results showed a significant reduction in delirium during the intervention period. Currently, many of the sleep‐promoting bundles do not incorporate sleep medications, but several ongoing studies are assessing the use of melatonin 96 …”

“…Currently, the routine use of melatonin agonists cannot be recommended in the ICU. Research is warranted to assess the incorporation of these therapies into a multicomponent, sleep bundle 96 …”

“…43 These interventions include keeping the lights on in the ICU during the day and diming lights at night. 96 Noise in the ICU consistently exceeds the WHO recommended level for sleep. 91 A recent prospective, RCT in patients admitted to the surgical ICU found the use of ear plugs and eyeshades to be associated with significant improvements in sleep quality.…”

Light, sleep and circadian rhythm in critical illness

“…Sleep architecture is divided into distinct stages: nonrapid eye movement (N) stages 1, 2, 3 and rapid eye movement (REM). Each sleep stage has its own unique electroencephalographic (EEG) characteristic(s) and arousal threshold [3]. Sleep duration, timing, continuity, regularity, sleep-wake cycling, and quality of wakefulness all constitute sleep health [4 & ].…”