Sleep on the ward in intensive care unit survivors: a case series of polysomnography

Effectiveness of sound and darkness interventions for critically ill patients' sleep quality: A systematic review and component network meta-analysis

BACKGROUND

Noise and lighting are prime factors of poor sleep quality in critically ill patients, which impair recovery and increase the risk of delirium or complications.

AIM

To identify and rank the effectiveness of sound and darkness interventions on the sleep quality of critically ill patients.

STUDY DESIGN

This systematic review and component network meta-analysis was based on the Preferred Reporting Items for Systematic Reviews incorporating the Network Meta-Analyses (PRISMA-NMA) Statement. The Embase, MEDLINE, Cochrane CENTRAL, CINAHL, Airiti Library, and Google Scholar databases were searched from inception to August 10, 2021, for randomized controlled trials (RCTs) on sound and darkness interventions targeting critically ill patients' sleep quality. We applied standard and component NMA to determine the effects of interventions. The certainty of evidence was evaluated using the Cochrane risk-of-bias tool (V.2.0) and the online Confidence in Network Meta-Analysis (CINeMA) application.

RESULTS

Twenty-four RCTs with 1507 participants who used combined interventions constituting seven competing interventions were included in the standard NMA. The combination of earplugs, eye masks, and music; eye masks alone; earplugs combined with eye masks; and music alone had beneficial intervention effects. The combination of earplugs, eye masks, and music was the best intervention, and these components had no interaction effect. An eye mask had the best relative effect, followed by music, quiet time, and earplugs.

CONCLUSIONS

This study provides clinical evidence of the effectiveness of using eye masks, music, and earplugs to improve sleep quality in critically ill patients. We also recommend future research using bedtime music, nocturnal eye masks, and quiet time, which had the best relative effects on sleep quality.

RELEVANCE TO CLINICAL PRACTICE

This study provides recommendations for interventions that nurses can use to improve critically ill patients' sleep quality.

What are the sleep characteristics among early kidney transplant recipients? An objective and subjective measurement from China

OBJECTIVE

To evaluate the sleep quality by self-reported questionnaires and polysomnography (PSG) among early kidney transplant recipients (KTRs) and to further explore their correlation.

DESIGN

This was a prospective and cross-sectional analysis of the sleep characteristics among early kidney transplant recipients through an objective and subjective measurement.

PARTICIPANTS

Patients with end stage renal disease on the transplant waiting list and after kidney transplantation were from a major organ transplantation center in Southern China (n = 83).

PRIMARY AND SECONDARY OUTCOME MEASUREMENTS

Objective outcomes: PSG, noise and light. Subjective outcomes: demographic and clinical questionnaires, self-reported pain and Richards Campbell sleep questionnaire (RCSQ). After agreement with the informed consent, participants first completed demographic and clinical questionnaires, then worn the PSG within 5-10 days after kidney transplantation. Both noise, light and self-reported pain were monitored during sleep. After completion of PSG, the RCSQs were filled out next morning.

RESULTS

A total of 298 patients were recruited and 83 participants were finally analyzed. The total RCSQ mean score was 51.0±18.9mm. The prevalence of poor sleep quality among early KTRs was 45.1%. Most of PSG characteristics were significantly correlated with their corresponding RCSQ items. And the total RCSQ scores were significantly correlated with the number of awakenings, the N2 percentage and the total sleep time (r = 0.79, 0.47 and 0.40, P<0.05) respectively. Noise was a statistically significant factor affecting the subjective sleep quality.

CONCLUSIONS

The sleep quality in early KTRs measured by both PSG and RCSQ exhibits consistency with each other. Sleep disruption always remains a substantial problem and is affected by self-reported noise among early KTRs. The RCSQ is easily applicable and interpretable so that it can be used for future daily clinical practice.

An Automated Algorithm for Determining Sleep Using Single-Channel Electroencephalography to Detect Delirium: A Prospective Observational Study in Intensive Care Units

The relationship between polysomnography-based objective sleep and delirium in the intensive care unit (ICU) is inconsistent across studies, suggesting limitations in manually determining the sleep stage of critically ill patients. We objectively measured 24-h sleep using a single-channel electroencephalogram (SleepScope [SS]) and an under-mattress sleep monitor (Nemuri SCAN [NSCAN]), both of which have independent algorithms that automatically determine sleep and wakefulness. Eighteen patients (median age, 68 years) admitted to the ICU after valvular surgery or coronary artery bypass grafting were included, and their sleep time was measured one day after extubation. The median total sleep times (TSTs) measured by SS (TST-SS) and NSCAN were 548 (48−1050) and 1024 (462−1257) min, respectively. Two patients with delirium during the 24-h sleep measurement had very short TST-SS of 48 and 125 min, and the percentage of daytime sleep accounted for >80% in both SS and NSCAN. This preliminary case series showed marked sleep deprivation and increased rates of daytime sleeping in ICU patients with delirium. Although data accuracy from under-mattress sleep monitors is contentious, automated algorithmic sleep/wakefulness determination using a single-channel electroencephalogram may be useful in detecting delirium in ICU patients and could even be superior to polysomnography.

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.

Effects of nursing interventions to improve inpatients' sleep in intensive and non-intensive care units: Findings from an umbrella review

AIM

This review aimed to synthesise the available reviews on the effects of nursing interventions on sleep quality among patients hospitalised in intensive care and non-intensive care units.

BACKGROUND

Poor sleep quality is a common fact in hospitalised patients. Nurses can contribute to the improvement of patients' sleep quality and duration.

DESIGN

A review of intervention reviews was carried out and reported following the PRISMA guidelines and checklist.

METHODS

We systematically searched for reviews published from January 2009 to December 2019 in PubMed, CINAHL Plus, Scopus, Institute for Scientific Information Web of Science, Joanna Briggs Database of Systematic Reviews and Cochrane Central Register of Controlled Trials databases. Searches were repeated at 24 November 2020 to include the most recent evidence. A narrative synthesis of the results was conducted.

RESULTS

Nine reviews (representing 109 original papers) met the selection criteria and were included for critical appraisal. Overall, nursing interventions and sleep quality were poorly defined. We grouped the interventions into 3 categories (environmental, barrier and internal interventions) to provide a more comprehensive overview and examine effects of nursing interventions on inpatients sleep quality. Inconsistent results were obtained and low quality of the original articles was reported, making it difficult to establish absolute conclusions.

CONCLUSION

The impact of environmental changes on patients' sleep was positive but inconclusive, while use of earplugs and eye masks, music and acupuncture generally showed positive results with moderate quality of evidence, and no harmful effects were reported.

Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit

We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.

Administration of pharmacological sleep aids prior to, during and following critical illness

BACKGROUND

Sleep in the intensive care unit (ICU) is frequently disturbed and this may have a detrimental effect on recovery.

AIMS

To determine use of pharmacological sleep aids in critically ill patients prior to, during and after ICU admission.

METHODS

We conducted a single-centre period prevalence study of all adult patients admitted to a university-associated adult medical-surgical Intensive Care Unit (ICU) for more than two nights in a three-month period ending September 2019. The major outcome of interest was the proportion of ICU patients who had a pharmacological sleep aid administered prior to, during and after ICU admission. Associations of selected patient variables with sleep aid prescription in the ICU were summarized both as unadjusted univariable comparisons, and as adjusted effect estimates returned by a multivariable logistic regression model.

RESULTS

During the study period, 370 patients met all eligibility criteria. A pharmacological sleep aid was identified prior to hospital admission in 34 patients (9%) and in 62 patients (17%) during ICU admission. Of the 340 ICU survivors, 292 remained in the same hospital. Of these, 96 (33%) received a pharmacological sleep aid at least once during their post-ICU general hospital ward stay. Pre-hospital sleep aid use, male sex, longer ICU admission and higher APACHE III scores were associated with sleep aid prescription in the ICU.

CONCLUSIONS

Pharmacological sleep aids are administered frequently in the ICU with administration increasing substantially after ICU discharge. This article is protected by copyright. All rights reserved.

Cross-cultural adaptation of the Richards-Campbell Sleep Questionnaire for intensive care unit inpatients in Brazil: internal consistency, test-retest reliability, and measurement error

STUDY OBJECTIVES

To perform the cross-cultural adaptation of the Richards-Campbell sleep questionnaire (RCSQ) to Portuguese-Brazil and to eval its internal consistency, test-retest reliability, and measurement error in intensive care unit (ICU) inpatients.

METHODS

The study enrolled 113 inpatients at medical/surgical ICU in Curitiba, Brazil. The RCSQ was first translated to Portuguese-Brazil according to the principles of good practice for the translation and cultural adaptation process for patient-reported outcomes and then applied in 30 inpatients. The final version (RCSQ-PT-Br) was applied to measure content validity (83 inpatients, 47 men [56.6%], 60.4 ± 14.2 years), and test-retest reliability and measurement error (a subset of 53 inpatients). Internal consistency of the RCSQ-PT-Br was estimated using Cronbach's a; test-retest reliability (2 independent rates) was assessed using the single measurement, absolute agreement, two-way random effects model (ICC_2,1).

RESULTS

Group-average RCSQ-PT-Br total score was 46.9 ± 26.7 (range 3.4-98.8). The RCSQ-PT-Br total score showed good content internal consistency (Cronbach's α = 0.850 95%CI = [0.789-0.897]) and excellent test-retest reliability (ICC_2,1 = 0.840 95% CI = [0.739-0.904]). Measurement error was low (standard error of mean = 11 mm, mean difference = 30 mm).

CONCLUSIONS

The RCSQ-PT-Br is a valid and reliable instrument to evaluate the sleep of patients hospitalized in the ICU in Brazil.

Temperature rhythms and ICU sleep: the TRIS study

BACKGROUND

Core body temperature (CBT) patterns associated with sleep have not been described in the critically ill. This study aimed to characterize night-time sleep and its relationship to CBT in ICU patients.

METHODS

A prospective study was performed in a 27-bed tertiary adult intensive care unit of 20 mechanically ventilated patients in the weaning stage of their critical illness. The study assessed sleep by polysomnography (PSG) during the evening between 21:00-7:00 hours, nursing interventions using the Therapeutic Intervention Scoring System (TISS), illness severity using SOFA and APACHE II scores and CBT 24-hour pattern.

RESULTS

Patients were awake for approximately half the study period (45.04%, IQR 13.81-77-17) with no REM (0%, IQR 0-0.04%) and median arousals of 19.5/hour (IQR 7.1-40.9). The 24-hour CBT had a rhythmic pattern in 13 (65%) patients with a highly variable phase of median peak time at 17:35 hours (IQR 12:40-19:39). No significant associations were found between CBT rhythmicity, sleep stages, sleep EEG frequency density, illness severity scores or TISS on the day of PSG. There was no relationship between time awake and CBT rhythmicity (P=0.48) or CBT peak time (P=0.82). The relationship between circadian rhythms and sleep patterns in the critically ill is complex.

CONCLUSIONS

Patients recovering in ICU commonly have CBT loss of rhythmicity or a significant phase shift with loss of normal night-time patterns of sleep architecture. Appropriate care plans to promote sleep and circadian rhythm require further investigation of contributing factors such as environment, clinical care routines, illness type and severity.

Nighttime Sleep Duration Is Associated With Length of Stay Outcomes Among Older Adult Survivors of Critical Illness

BACKGROUND

Older adults who required mechanical ventilation while in an intensive care unit (ICU) require adequate sleep throughout recovery from critical illness. Poor post-ICU sleep quality may contribute to worsening impairments in physical, cognitive, or psychological status after critical illness, known as post-ICU syndrome. Previous research has evaluated post-ICU sleep with qualitative or mixed methods (eg, interviews, questionnaires). We proposed measurement of sleep with actigraphy. We hypothesized that nighttime sleep is associated with length of stay (LOS).

OBJECTIVES

The aims of this study were to describe sleep quality of previously mechanically ventilated older adults recently transferred out of ICU and explore relationships between sleep duration and LOS outcomes.

METHODS

We enrolled 30 older adults, 65 years and older, within 24 to 48 hours after ICU discharge. We collected actigraphy data on post-ICU sleep duration (total sleep time [TST]) and sleep fragmentation (wake time after sleep onset) over 2 consecutive nights. We explored associations between TST and LOS (in days) outcomes using multivariate regression.

RESULTS

Subjects' mean TST was 7.55 ± 2.52 hours, and mean wake time after sleep onset was 2.26 ± 0.17 hours. In exploratory regression analyses, longer ICU LOS (β = 0.543, P < .001) and longer length of mechanical ventilation (β = 0.420, P = .028) were associated with greater post-ICU TST, after adjusting for potential confounding factors. Total sleep time was prospectively associated with total hospital LOS (β = 0.535, P < .001).

DISCUSSION

Older ICU survivors demonstrate greater sleep duration and worse sleep fragmentation. Poor sleep may contribute to longer LOS, secondary to post-ICU syndrome and sequelae. We recommend nursing interventions to promote sleep consolidation throughout transitions of care in the acute post-ICU recovery period.

Viability and validity of the bispectral index to measure sleep in patients in the intensive care unit

Objective

To investigate the viability of the bispectral index in the sleep evaluation of critically ill patients and to quantify the associations of sleep parameters measured by this index with the Richards-Campbell Sleep Questionnaire and environmental noise.

Methods

This was a cross-sectional observational study that evaluated critically ill adults with diseases of low or moderate severity. The following were measured: total sleep volume and time, deep sleep volume and time, continuous sleep volume and time, sleep onset latency, and environmental sound pressure level. The subjective perception of sleep was evaluated with the Richards-Campbell Sleep Questionnaire the morning after each night of observation.

Results

Patients had a low total sleep time (234 minutes), a predominance of superficial sleep stages, and little deep sleep (1.7 minutes). The total, deep, and continuous sleep volumes were 3,679, 9.4, and 3,143 (bispectral index units × minutes), respectively. The sleep latency was 94 minutes. The mean score of the Richards-Campbell Sleep Questionnaire was 57.9. Total sleep volume, total sleep time, and continuous sleep volume were weakly correlated with the Richards-Campbell Sleep Questionnaire depth of sleep domain score, overall sleep quality domain score, and total score. Total volume, total time, and continuous volume were moderately correlated with the occurrence of awakenings domain score.

Conclusion

The bispectral index is an instrument with limited viability to monitor the sleep of lucid patients and patients with low to moderate disease severity in the intensive care unit. Patients with higher total sleep volume, total sleep time, and continuous sleep volume had better overall sleep perception.

Circadian Hygiene in the ICU Environment (CHIE) study

Objective: To investigate the environment and care in the intensive care unit (ICU) and its relationship to patient circadian temperature disruption. Design: 30-day, prospective period prevalence study. Setting: 27-bed tertiary ICU. Participants: Patients expected to remain in the ICU for at least 24 hours. Main outcome measures: Temperature, relative humidity, light and sound intensity in the ICU; nursing interventions (using the Therapeutic Intervention Scoring System-28); and core body temperature of ICU patients. Results: Of 28 patients surveyed, 20 (71%) were mechanically ventilated. Median (interquartile range [IQR]) light intensity peaked at 07:00 at 165 (12-1218) lux with a trough at 23:00 of 15 (12-51) lux and was consistently < 100 lux between 21:00 and 06:00. Peak median (IQR) sound intensity was at 07:00 (62.55 [57.87-68.03] dB) while 58.84 (54.81-64.71) dB at 02:00. Ambient temperature and humidity varied with median (IQR) peaks of 23.11°C (22.74-23.31°C) at 16:00 and 44.07% (32.76-51.08%) at 11:00 and median troughs of 22.37°C (21.79-22.88°C) at 05:00 and 39.95% (31.53-47.95%) at 14:00, respectively. Disturbances to sleep during the night occurred due to care activities including linen changes (15 patients, 54%) and bathing (13, 46%). On the day before and the day of the study, 13 patients (47%) and 10 patients (36%), respectively, had a circadian rhythm on core body temperature without an association with illness severity, nursing intervention or environmental measures. Conclusions: The ICU has low light intensity with relative humidity and ambient temperature not aligned to normal human circadian timing. Noise levels are commonly equivalent to conversational speech while patient care procedures interrupt overnight sleep. The contribution of these factors to disrupted CBT rhythmicity is unclear.

Sleep and Circadian Rhythm in Critical Illness

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .