Impact of Sleep Deprivation in the Neurological Intensive Care Unit: A Narrative Review

Reporting on Neurological Decline as Identified by Hourly Neuroassessments

ABSTRACT

BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

Effect of prolonged sedation with dexmedetomidine, midazolam, propofol, and sevoflurane on sleep homeostasis in rats

BACKGROUND

Sleep disruption is a common occurrence during medical care and is detrimental to patient recovery. Long-term sedation in the critical care setting is a modifiable factor that affects sleep, but the impact of different sedative-hypnotics on sleep homeostasis is not clear.

METHODS

We conducted a systematic comparison of the effects of prolonged sedation (8 h) with i.v. and inhalational agents on sleep homeostasis. Adult Sprague-Dawley rats (n=10) received dexmedetomidine or midazolam on separate days. Another group (n=9) received propofol or sevoflurane on separate days. A third group (n=12) received coadministration of dexmedetomidine and sevoflurane. Wakefulness (wake), slow-wave sleep (SWS), and rapid eye movement (REM) sleep were quantified during the 48-h post-sedation period, during which we also assessed wake-associated neural dynamics using two electroencephalographic measures: theta-high gamma phase-amplitude coupling and high gamma weighted phase-lag index.

RESULTS

Dexmedetomidine-, midazolam-, or propofol-induced sedation increased wake and decreased SWS and REM sleep (P<0.0001) during the 48-h post-sedation period. Sevoflurane produced no change in SWS, decreased wake for 3 h, and increased REM sleep for 6 h (P<0.02) post-sedation. Coadministration of dexmedetomidine and sevoflurane induced no change in wake (P>0.05), increased SWS for 3 h, and decreased REM sleep for 9 h (P<0.02) post-sedation. Dexmedetomidine, midazolam, and coadministration of dexmedetomidine with sevoflurane reduced wake-associated phase-amplitude coupling (P≤0.01). All sedatives except sevoflurane decreased wake-associated high gamma weighted phase-lag index (P<0.01).

CONCLUSIONS

In contrast to i.v. drugs, prolonged sevoflurane sedation produced minimal changes in sleep homeostasis and neural dynamics. Further studies are warranted to assess inhalational agents for long-term sedation and sleep homeostasis.

Impacts of Different Noise Environments on Polysomnographic Monitoring Parameters and Sleep Quality Among Hospitalized Patients

BACKGROUND

Excessive noise levels may decrease patients' sleep quality and increase the risk of sleep disorders in patients. Given that only a few studies have been conducted on noise levels and sleep quality in hospitalized patients, this study investigated the effects of different noise environments on polysomnographic parameters and sleep in hospitalized patients. It also analyzed the factors associated with patients' sleep quality.

METHODS

A sample of 244 cases of hospitalized patients were retrospectively selected from March 2020 to March 2023. A total of 122 patients without ward noise reduction treatment were set as the control group. A total of 122 patients who were treated with ward noise reduction were set as the observation group. The polysomnographic monitoring parameters and sleep conditions levels were compared between the two groups, after which logistic regression was used to analyze the relevant factors that affected patients' sleep.

RESULTS

The incidence of noise level, rapid eye movement stage (R) phase proportion, nonrapid eye movement stage 1 (N1) phase proportion, and poorer sleep quality all had higher levels in the control group than in the observation group. In comparison, nonrapid eye movement stage 2 (N2) phase proportion, total sleep time (TST), and sleep efficiency (SE) were all lower than those in the observation group (P < 0.05). Regression analysis revealed that the need for surgery, having diabetes mellitus, higher noise level and low N2 percentage levels were all associated factors affecting the sleep quality of patients.

CONCLUSION

Environments with higher levels of noise can lead to patients' poorer sleep quality. Thus, it is necessary to actively implement noise management measures to avoid higher noise levels and maintain good sleep quality among patients.

Sleep Deprivation and Its Consequences

OBJECTIVE

This article reviews the clinical, cognitive, behavioral, and physiologic consequences of sleep deprivation in relation to general neurology practice.

LATEST DEVELOPMENTS

Despite being one of the most common sleep problems in modern society, the role of sleep deprivation is underrecognized and underestimated in clinical medicine and general neurology practice. The recognition, diagnosis, and management of sleep deprivation in neurologic practice have only recently received close attention. The consequences of sleep deprivation involve all aspects of general neurology practice, including individuals with neurologic disease, neurologists, communities, and health care systems. The identification and timely management of sleep deprivation symptoms may help to improve symptoms of underlying primary neurologic disorders.

ESSENTIAL POINTS

This article emphasizes complexities related to the identification and evaluation of sleep deprivation in general neurology practice and describes the consequences of sleep deprivation. By recognizing sleep deprivation in patients with neurologic conditions, the neurologist can provide comprehensive care and contribute to improved clinical and neurologic outcomes.

Characterization of sound pressure levels and sound sources in the intensive care unit: a 1 week observational study

Background

Exposure to elevated sound pressure levels within the intensive care unit is known to negatively affect patient and staff health. In the past, interventions to address this problem have been unsuccessful as there is no conclusive evidence on the severity of each sound source and their role on the overall sound pressure levels. Therefore, the goal of the study was to perform a continuous 1 week recording to characterize the sound pressure levels and identify negative sound sources in this setting.

Methods

In this prospective, systematic, and quantitative observational study, the sound pressure levels and sound sources were continuously recorded in a mixed medical-surgical intensive care unit over 1 week. Measurements were conducted using four sound level meters and a human observer present in the room noting all sound sources arising from two beds.

Results

The mean 8 h sound pressure level was significantly higher during the day (52.01 ± 1.75 dBA) and evening (50.92 ± 1.66 dBA) shifts than during the night shift (47.57 ± 2.23; F(2, 19) = 11.80, p < 0.001). No significant difference was found in the maximum and minimum mean 8 h sound pressure levels between the work shifts. However, there was a significant difference between the two beds in the based on location during the day (F(3, 28) = 3.91, p = 0.0189) and evening (F(3, 24) = 5.66, p = 0.00445) shifts. Cleaning of the patient area, admission and discharge activities, and renal interventions (e.g., dialysis) contributed the most to the overall sound pressure levels, with staff talking occurring most frequently.

Conclusion

Our study was able to identify that continuous maintenance of the patient area, patient admission and discharge, and renal interventions were responsible for the greatest contribution to the sound pressure levels. Moreover, while staff talking was not found to significantly contribute to the sound pressure levels, it was found to be the most frequently occurring activity which may indirectly influence patient wellbeing. Overall, identifying these sound sources can have a meaningful impact on patients and staff by identifying targets for future interventions, thus leading to a healthier environment.

Sleep during and following critical illness: A narrative review

Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.

Reassessing hourly neurochecks

Following acute brain injury, frequent neurological examinations ("neurochecks") are commonly prescribed and form the cornerstone of many care protocols and guidelines (e.g., for intracranial hemorrhage). While these assessments are intended to identify and mitigate secondary injury, they may unintentionally contribute to additional injury related to neurocheck-associated sleep disruption. Data are lacking to define patterns of neurological decline following acute brain injury, as are data to define the short- and long-term consequences (e.g., neuropsychological sequelae) of frequent and prolonged neurochecks. A critical need exists for rigorous evaluation of neurocheck practices, perceptions, benefits and risks, along with interventions to optimize neurocheck frequency and duration.

YT521-B homology domain containing 1 ameliorates mitochondrial damage and ferroptosis in sleep deprivation by activating the sirtuin 1/nuclear factor erythroid-derived 2-like 2/heme oxygenase 1 pathway

In sleep deprivation (SD) models, ferroptosis is increased. SIRT1 alleviates cognitive impairment in SD, and SIRT1/NRF2/HO1 pathway depresses ferroptosis in different diseases. Moreover, YTHDC1 can regulate SIRT1 mRNA stability. Therefore, our study explored effects of the YTHDC1/SIRT1/NRF2/HO1 axis on neuronal damage and ferroptosis in SD. The SD mouse model was established through a modified multi-platform water environment method and a cell model of ferroptosis was constructed with Erastin, followed by gain- and loss-of-function assays. In mice, the cognitive impairment and CLOCK and BMAL1 levels in hippocampal tissues were assessed. In cells, viability was measured. In mice and cells, mitochondrial ultrastructure, the content of reactive oxygen species (ROS), malondialdehyde (MDA), glutathione (GSH), and iron, and the expression of GPX4 and ACSL4 were detected. The potential relationships among YTHDC1, SIRT1, and NRF2 were analyzed. SD mice had downregulated YTHDC1, SIRT1, NRF2, and HO1 protein expression in hippocampal tissues and increased ferroptosis. Mechanically, SIRT1 activated the NRF2/HO1 pathway through deacetylation, and YTHDC1 increased SIRT1 mRNA stability. YTHDC1 overexpression diminished mitochondrial damage, the content of ROS, iron, and MDA, and the expression of ACSL4 while enhancing GSH contents and GPX4 expression in hippocampal tissues of SD mice and Erastin-induced HT22 cells. Additionally, YTHDC1 overexpression elevated viability in Erastin-induced HT22 cells. SIRT1 or NRF2 overexpression ameliorated Erastin-induced mitochondrial damage and ferroptosis in HT22 cells. Silencing SIRT1 abolished the impact of YTHDC1 overexpression on SD mice and Erastin-induced HT22 cells. Collectively, YTHDC1 ameliorates mitochondrial damage and ferroptosis after SD by activating the SIRT1/NRF2/HO1 pathway.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Sleep of Intensive Care Patients: A Qualitative Study Based on Experiences of Nurses

BACKGROUND

Intensive care patients experience a high rate of poor sleep quality. As the sleep quality is improved with nursing practices, patients' recovery and the length of stay in the intensive care unit (ICU) may be positively influenced, and patients may benefit from treatment and care at the highest level. Therefore, it is important to explore the experiences and evaluation of nurses working in ICUs.

OBJECTIVES

This study was carried out to explore the experiences and evaluations of ICU nurses about patients' sleep.

METHODS

The study is a qualitative study conducted in a descriptive phenomenological design. The data were collected using the individual in-depth interview method with the semistructured interview form. Thematic analysis was performed to analyze the data. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used.

RESULTS

The analysis revealed 4 main themes, which are (1) importance of sleep, (2) evaluation of sleep, (3) reasons for poor sleep, and (4) sleep promotion interventions.

CONCLUSIONS

This study revealed that nurses are aware of the importance of sleep; however, they do not evaluate sleep and try to improve sleep quality only based on their own knowledge and experience rather than on evidence-based approaches. However, their interventions are not sufficient and they are restricted because of physical conditions and intensive care procedures.

Optimizing Sleep and Circadian Health in the NeuroICU

Purpose of Review

This article introduces fundamental concepts in circadian biology and the neuroscience of sleep, reviews recent studies characterizing circadian rhythm and sleep disruption among critically ill patients and potentially links to functional outcomes, and draws upon existing literature to propose therapeutic strategies to mitigate those harms. Particular attention is given to patients with critical neurologic conditions and the unique environment of the neuro-intensive care unit.

Recent Findings

Circadian rhythm disruption is widespread among critically ill patients and sleep time is reduced and abnormally fragmented. There is a strong association between the degree of arousal suppression observed at the bedside and the extent of circadian disruption at the system (e.g., melatonin concentration rhythms) and cellular levels (e.g., core clock gene transcription rhythms). There is a paucity of electrographically normal sleep, and rest-activity rhythms are severely disturbed. Common care interventions such as neurochecks introduce unique disruptions in neurologic patients. There are no pharmacologic interventions proven to normalize circadian rhythms or restore physiologically normal sleep. Instead, interventions are focused on reducing pharmacologic and environmental factors that perpetuate disruption.

Summary

The intensive care environment introduces numerous potent disruptors to sleep and circadian rhythms. Direct neurologic injury and neuro-monitoring practices likely compound those factors to further derange circadian and sleep functions. In the absence of direct interventions to induce normalized rhythms and sleep, current therapy depends upon normalizing external stimuli.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

Independent Predictors of In-Hospital Mortality in Elderly and Non-elderly Adult Patients Undergoing Emergency Admission for Hemorrhoids

Background

The study explored determinants of mortality of admitted emergently patients with the primary diagnosis of hemorrhoids, during the years 2005-2014.

Methods

Demographics, clinical data, and outcomes were obtained from the National Inpatient Sample, 2005-2014, in elderly (65+ years) and non-elderly adult patients (18-64 years) with hemorrhoids who underwent emergency admission. Multivariable logistic regression model with backward elimination was used to identify predictors of mortality.

Results

25 808 adult and 26 978 elderly patients were included. Female patients consisted of 42.5% and 59.3% in adult and elderly, respectively. 42 (.2%) adults died, of which 50% were female and 125 (.5%) elderly patients died, of which 60% were female. Mean (SD) age of the adult patients was 47.8 (11) years and in elderly patients was 78.7 (8) years. 82.2% and 85.7% had internal hemorrhoids in adult and elderly patients, respectively. 9326 (36.1%) adult and 7282 (27%) elderly patients underwent an operation. In the final multivariable logistic regression model for adult patients with operation, delayed operation and invasive diagnostic procedures increased the odds of mortality, whereas in elderly patients, delayed operation and frailty index were the risk factors of mortality. In both adults and elderly with no operation, increased hospital length of stay (HLOS) significantly increased the odds of mortality, and undergoing an invasive diagnostic procedure significantly decreased the odds of mortality.

Conclusion

In all operated patients, increased time to operation and undergoing an invasive diagnostic procedure were the risk factors for mortality. On the other hand, in non-operated emergency hemorrhoids patients, increased age and increased HLOS were the risk factors for mortality while undergoing an invasive diagnostic procedure decreased the odds of mortality.

Practices and Patterns of Hourly Neurochecks: Analysis of 8,936 Patients With Neurological Injury

BACKGROUND

Patients experiencing acute neurological injury often receive hourly neurological assessments ("neurochecks") to capture signs of deterioration. While commonly utilized in the intensive care unit (ICU) setting, little is known regarding practices (i.e., variations by age and ordering services) and patterns (i.e., duration and post-discontinuation plans) of hourly neurochecks. To inform future quality improvement intervention efforts, we performed an analysis of hourly neurochecks using an electronic health record-based dataset.

STUDY DESIGN AND METHODS

Our 75-month retrospective dataset consisted of all health system ICU patients who received hourly neurochecks. Variables included age, admission diagnosis category, ordering provider, post-discontinuation order, and discharge destination. Multivariable Cox regression was used to evaluate factors associated with hourly neurocheck duration.

RESULTS

We evaluated 9,513 first admission hourly neurocheck orders in 8,936 patients. The trauma, neurosurgery, and neurocritical care services were responsible for 4,067 (43%), 2,071 (22%) and 1,697 (18%) hourly neurocheck orders, respectively. Median (interquartile range) hourly neurocheck duration was 1.09 (0.69, 2.35) days, and was greater than 3 and 7 days, respectively, for 1,773 (19%) and 640 (7%) patients. Median hourly neurocheck duration ranged from 0.87 (0.65, 1.68) to 1.60 (0.83, 2.97) days for neurosurgical and non-neurological ICU services, respectively. Upon discontinuation, 2,225 (23%) of hourly neurochecks were transitioned to no neurochecks.

CONCLUSION

Substantial differences exist between ICU services and practice patterns surrounding hourly neurochecks. Understanding these differences will help inform intervention efforts aimed at streamlining hourly neurocheck practices and outcomes for patients with acute neurological injury.

Sleep after Traumatic Brain Injury

Sleep disturbances are common after traumatic brain injury of all levels of severity, interfere with acute and long-term recovery, and can persist for years after injury. There is increasing evidence of the importance of sleep in improving brain function and recovery. Noticing and addressing sleep disturbances are important aspects of nursing care, especially for the prevention or early recognition of delirium. Nonpharmacologic interventions can improve sleep. Teaching about the importance of sleep after traumatic brain injury, promoting sleep hygiene, and multidisciplinary approaches to addressing sleep problems and improving sleep are important for recovery from traumatic brain injury.

The Effect of Using Eye Masks and Earplugs on Intensive Care Patients Quality of Sleep and Vital Signs

ABSTRACT

BACKGROUND: Intensive care unit (ICU) patients with severe health problems experience a high rate of sleep deprivation that harms their psychological and physiological health. Environmental factors are considered to be the greatest cause of sleep deprivation in the ICU, and noise and light are leading among these factors. This study aimed to investigate the effect of eye masks and earplugs on the sleep quality and vital signs of conscious ICU patients. METHODS: This study used a quasi-experimental, in similar groups, pretest-posttest design with a control group. The Richards-Campbell Sleep Questionnaire (RCSQ) was used to collect data, and vital signs were recorded every 2 hours. On day 1, standard care was provided to the experimental group (n = 32), and they were provided with eye masks and earplugs on day 2. The control group (n = 32) was provided with standard care on both days. Chi-square, t, and McNemar and McNemar-Bowker tests were used to analyze the data. Multiple regression analysis was used for predictive analysis. RESULTS: The RCSQ mean (SD) pretest and posttest scores were 50.21 (16.02) and 68.50 (17.57), respectively, for the experimental group and 55.34 (16.62) and 49.03 (15.53), respectively, for the control group. In the experimental group, the posttest RCSQ score was significantly higher than the pretest RCSQ score (P < .01). No differences in vital signs were observed in the control group. All the vital signs were found to be similar in the experimental group, except for the mean daily pulse rate. CONCLUSION: The use of earplugs and eye masks may help reduce sleep deprivation. Eye masks and earplugs can be used by nurses to improve the sleep quality of patients in ICUs.