Effects of deep sedation on sleep in critically ill medical patients on mechanical ventilation

Effect of inhaled aromatherapy on sleep quality in critically ill patients: A systematic review and network meta-analysis

AIM

This study aimed to compare the effect of inhaled aromatherapy using various essential oils on the sleep quality of critically ill patients.

BACKGROUND

Inhalation of essential oils significantly promotes the physiological and psychological health of patients in intensive care units (ICUs). However, research identifying and ranking the effects of different essential oils on the sleep quality of critically ill patients is lacking.

DESIGN

This study followed the PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of Health Care Interventions (PRISMA-NMA) guidelines.

METHODS

A comprehensive search of five databases (Embase, MEDLINE, the Cochrane Library, CINAHL and PsycINFO) was conducted from their inception to March 15, 2023 (with an additional eligible study included dated August 14, 2023). Google Scholar was used as a supplementary method. Frequentist NMA was used to determine the effects of various essential oils. Certainty of evidence (CoE) was assessed using Confidence in Network Meta-Analysis (CINeMA).

RESULTS

A total of 11 trials involving 690 critically ill patients were included in the analysis. The NMA of inhaled aromatherapy revealed that the combination of lavender, Matricaria recutita, and neroli essential oils (ratio 6:2:0.5) resulted in the most significant improvement in sleep quality compared to usual care, followed by Rosa damascene, peppermint, Citrus aurantium, pure sunflower oil and lavender oil alone. The overall CoE for the results was rated as low.

CONCLUSIONS

The results of this study indicate that a combination of lavender, Matricaria recutita and neroli essential oils significantly positively affected sleep quality among critically ill patients. Despite the low quality of evidence, inhaled aromatherapy is non-invasive and easy to use.

RELEVANCE TO CLINICAL PRACTICE

Inhaled aromatherapy can effectively improve sleep quality among critically ill patients.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution applies to this work.

STUDY REGISTRATION

The study protocol was registered to the PROSPERO International Prospective Register of Systematic Reviews (protocol number CRD42023433194).

Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review

Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.

Sleep and critical illness: a review

Critical illness and stays in the Intensive Care Unit (ICU) have significant impact on sleep. Poor sleep is common in this setting, can persist beyond acute critical illness, and is associated with increased morbidity and mortality. In the past 5 years, intensive care clinical practice guidelines have directed more focus on sleep and circadian disruption, spurring new initiatives to study and improve sleep complications in the critically ill. The global SARS-COV-2 (COVID-19) pandemic and dramatic spikes in patients requiring ICU level care also brought augmented levels of sleep disruption, the understanding of which continues to evolve. This review aims to summarize existing literature on sleep and critical illness and briefly discuss future directions in the field.

Effect of a music intervention on anxiety in adult critically ill patients: a multicenter randomized clinical trial

BACKGROUND

Previous studies show positive effect of music on reducing anxiety, pain, and medication requirement. Anxiety has become a more pertinent issue in the intensive care unit (ICU) since wakefulness is preferred according to recent guidelines. Nevertheless, evidence on the effect of music in ICU patients is scarce. Therefore, we studied the effect of music intervention on anxiety in ICU patients.

METHODS

A multicenter randomized clinical trial was conducted between August 2020 and December 2021 in ICU's at an academic medical centre and two regional hospitals. Adult critically ill patients were eligible when hemodynamically stable and able to communicate (Richmond agitation-sedation scale (RASS) of at least - 2). Patients in the intervention arm were offered music twice daily during three days for at least 30 min per session. Patients in the control group received standard care. The primary outcome was anxiety level assessed with the visual analogue scale for anxiety [VAS-A; range 0-10] twice daily (morning and evening). Secondary outcomes included; 6-item state-trait anxiety inventory (STAI-6), sleep quality, delirium, heart rate, mean arterial pressure, pain, RASS, medication, ICU length of stay, patients' memory and experience of ICU stay.

RESULTS

94 patients were included in the primary analysis. Music did not significantly reduce anxiety (VAS-A in the intervention group; 2.5 (IQR 1.0-4.5), 1.8 (0.0-3.6), and 2.5 (0.0-3.6) on day 1, 2, and 3 vs. 3.0 (0.6-4.0), 1.5 (0.0-4.0), and 2.0 (0.0-4.0) in the control group; p > 0.92). Overall median daily VAS-A scores ranged from 1.5 to 3.0. Fewer patients required opioids (21 vs. 29, p = 0.03) and sleep quality was lower in the music group on study day one [5.0 (4.0-6.0) vs. 4.5 (3.0-5.0), p = 0.03]. Other outcomes were similar between groups.

CONCLUSIONS

Anxiety levels in this ICU population were low, and music during 3 days did not decrease anxiety. This study indicates that efficacy of music is context and intervention-dependent, given previous evidence showing decreased anxiety. Trial registration Netherlands Trial Register: NL8595, Registered, 1 April 2020.

CLINICALTRIALS

gov ID: NCT04796389, Registered retrospectively, 12 March 2021.

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.

The effect of music on delirium, pain, sedation and anxiety in patients receiving mechanical ventilation in the intensive care unit

OBJECTIVES

To examine the effects of music for patients under mechanical ventilation support in the intensive care unit on their delirium, pain, sedation, and anxiety.

RESEARCH METHODOLOGY/DESIGN

A single-blind, randomized, controlled trial.

SETTING

The study was conducted with delirium positive patients between August 2020 and September 2021 in the medical/surgical intensive care unit of a university hospital in Turkey.

METHODS

The study sample was selected through a simple and stratified randomization method; patients who met the inclusion criteria were assigned to the music, noise reduction or control group. The data were collected by using a Confusion Assessment Method for the ICU (CAM-ICU), CAM-ICU-7, Critical Care Pain Observation Tool (CPOT), Richmond Agitation-Sedation Scale (RASS), Facial Anxiety Scale (FAS), PRE-DELIRIC model, and Glasgow Coma Scale (GCS). The interventions were repeated twice a day for five days.

RESULTS

A total of 36 patients were included, with 12 patients in each group. Significant decreases were found in the severity of delirium and pain and the level of sedation and anxiety in the music compared to the other groups (p < 0.05). The number of patients with delirium and the number of days with mechanical ventilation was found to be significantly lower in the music group compared to the other groups (p < 0.05).

CONCLUSION

Music intervention may be used as a nursing intervention to control delirium, pain, need for sedation and anxiety in intensive care unit patients. However, additional studies with larger sample is needed to validate findings.

The effect of preoperative sleep quality on the target plasma concentration of propofol and postoperative sleep in patients undergoing painless gastroscopy

BACKGROUND

This study aims to investigate the effect of preoperative sleep quality on the target plasma concentration of propofol and postoperative sleep in patients undergoing painless gastroscopy.

METHODS

Ninety-three outpatients aged 45 to 64 years with body mass index (BMI) of 18.5-30 kg/m² and ASA grades of I or II, who underwent painless gastroscopy, were selected. All patients were evaluated by the Athens insomnia scale (AIS) before the painless gastroscopy. The patients were divided into two groups according to the AIS score evaluated before painless gastroscopy: normal sleep group (group N, AIS score < 4 points, 47 cases) and sleep disorder group (group D, AIS score > 6 points, 46 cases). The target-controlled infusion (TCI) of propofol (Marsh model) was used for general anesthesia, the Bispectral index (BIS) was used to monitor the depth of anesthesia, and the BIS was maintained between 50 and 65 during the painless gastroscopy. The target plasma concentration (Cp) of propofol was recorded when the patient's eyelash reflex disappeared (T1), before the painless gastroscopy (T2), at the time of advancing the gastroscope (T3) and during the painless gastroscopy (T4), and the infusion rate per body surface area of propofol was calculated. The patient's AIS score was followed up by telephone at day 1, day 3, 1 week, and 1 month after the painless gastroscopy to assess the postoperative sleep of the patient. The occurrence of adverse reactions during the painless gastroscopy was recorded; the patient's satisfaction and the endoscopist's satisfaction with the anesthesia effect were compared between the two groups.

RESULTS

Compared with group N, the Cp at each time point and the infusion rate per body surface area of propofol in group D was increased significantly (P < 0.05); compared with the AIS scores before the painless gastroscopy, the AIS scores of the two groups of patients were significantly increased day 1 after the painless gastroscopy (P < 0.05); there were no significant differences in the AIS scores of the two groups at day 3, 1 week, and 1 month after the painless gastroscopy (P > 0.05). There were no statistically significant differences in the occurrence of adverse reactions and the patient's satisfaction and the endoscopist's satisfaction with the anesthesia effect between the two groups (P > 0.05).

CONCLUSION

The preoperative sleep disturbance will increase the Cp and the infusion rate per body surface area of propofol in patients undergoing painless gastroscopy. Propofol only affects the patients' sleep for day 1 after the painless gastroscopy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100045332) on 12/04/2021.

Sleep cycle in children with severe acute bronchopneumonia during mechanical ventilation at different depths of sedation

BACKGROUND

To investigate the characteristics of sleep cycle in children with severe acute bronchopneumonia treated with invasive mechanical ventilation at different sedation depths.

METHODS

We included 35 pediatric patients with severe acute bronchopneumonia treated using mechanical ventilation in Pediatric Intensive Care Unit of Shengjing Hospital of China Medical University. They were divided into deep sedation group (n = 21; ramsay score 5-6) and light sedation group (n = 14; ramsay score3-4) based on sedation depth achieved during mechanical ventilation. Long-term video electroencephalography (EEG) monitoring was performed within the first 24 h after starting mechanical ventilation and after weaning from mechanical ventilation and discontinuing sedatives and analgesics. The results were analyzed and compared with those of normal children to analyze changes in sleep cycle characteristics at different sedation depths and mechanical ventilation stages.

RESULTS

There were 29 cases altered sleep architecture. The deep sedation group had a significantly higher incidence of sleep architecture altered, total sleep duration, and non-rapid eye movement sleep-1 (NREM-1) loss incidence than the light sedation group. Moreover, the deep sedation group had a significantly lower awakening number and rapid eye movement sleep (REM) percentage than the light sedation group. The sleep cycle returned to normal in 27 (77%) patients without NREM-1 or REM sleep loss.

CONCLUSIONS

Deep sedation during mechanical ventilation allows longer total sleep duration, fewer awakenings, and an increased deep sleep proportion, but sleep architecture is severely altered. After weaning from mechanical ventilation and sedative discontinuation, lightly sedated children exhibit better sleep recovery.

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.

Sleep Assessment in Critically Ill Adults: Established Methods and Emerging Strategies

Sleep is a biological mandate with an integral role in optimizing functions that maintain psychological and physical health. During critical illness, however, sleep may be disrupted at best and elusive at worst. Sleep improvement efforts and research endeavors evaluating interventions to improve sleep in critically ill adults are hampered by limited methods available to measure sleep in this setting. This narrative review summarizes available modalities for sleep assessment in the ICU, describes new ICU sleep assessment methods under development, and highlights features of the ideal ICU sleep measurement tool.

DATA SOURCES

The most relevant literature and author experiences were assessed for inclusion from PubMed and textbooks.

STUDY SELECTION

The authors selected studies for inclusion by consensus.

DATA EXTRACTION

The authors reviewed each study and selected appropriate data for inclusion by consensus.

DATA SYNTHESIS

Currently available tools to measure sleep in critically ill adults have important flaws. Subjective measurements are limited by recall bias, the inability of many patients to communicate, and poorly correlate with objective measures when completed by surrogates. Actigraphy does not consider the effects of sedating medications or myopathy leading to an over estimation of sleep time. Polysomnography, the gold standard for sleep assessment, is limited by interpretation issues and practical application concerns. Single and multiple channel electroencephalogram devices offer real-time physiologic data and are more practical to use than polysomnography but are limited by the scope of sleep-specific information they can measure and poorly characterize the circadian system.

CONCLUSIONS

A measurement tool that offers real-time sleep and circadian assessment and is practical for broad application in the ICU does not exist. Newer sleep assessment devices have shown promise in measuring physiologic data in real time; when used in combination with other assessment modalities, and analyzed by computational techniques, they may revolutionize sleep monitoring in the ICU.

Study protocol for a multicentre randomised controlled trial studying the effect of a music intervention on anxiety in adult critically ill patients (The RELACS trial)

INTRODUCTION

Anxiety is common in critically ill patients and has likely become more prevalent in the recent decade due to the imperative of the recent Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients (PADIS) to use low levels of sedation and strive for wakefulness. However, management of anxiety has not been included in the PADIS guidelines, and there is lack of evidence to treat it in spite of its growing importance. Administration of sedative and analgesic medication is often chosen to reduce anxiety, especially when associated with agitation. Sedatives are associated with prolonged mechanical ventilation, delirium and muscle wasting and are therefore preferably minimised. Previous studies have suggested positive effects of music interventions on anxiety in the critically ill. Therefore, we aim to study the effect of music intervention on anxiety in adult critically ill patients.

METHODS AND DESIGN

A multicentre randomised controlled trial was designed to study the effect of a music intervention on the level of anxiety experienced by adult patients admitted to the intensive care unit (ICU). One hundred and four patients will be included in three centres in the Netherlands. Patient recruitment started on 24-08-2020 and is ongoing in three hospitals. The primary outcome is self-reported anxiety measured on the visual analogue scale. Secondary outcomes include anxiety measured using the six-item State-Trait Anxiety Inventory, sleep quality, agitation and sedation level, medication requirement, pain, delirium, complications, time spend on mechanical ventilation, physical parameters and ICU memory and experience.

ETHICS AND DISSEMINATION

The Medical Ethics Review Board of Erasmus MC University Medical Centre Rotterdam, The Netherlands, has approved this protocol. The study is being conducted in accordance with the Declaration of Helsinki. Results of this trial will be published in peer-reviewed scientific journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04796389.

Music intervention for sleep quality in critically ill and surgical patients: a meta-analysis

OBJECTIVE

Sleep disruption occurs frequently in hospitalised patients. Given the potential of music intervention as a non-pharmacological measure to improve sleep quality, we aimed to assess and quantify current literature on the effect of recorded music interventions on sleep quality and quantity in the adult critical care and surgical populations.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, MEDLINE Ovid, Cochrane Central, Web of Science and Google Scholar.

ELIGIBILITY CRITERIA FOR STUDIES

Randomised controlled trials assessing the effect of music on sleep quality in critically ill and surgical patients.

METHODS

The electronic databases were systematically searched from 1 January 1981 to 27 January 2020. Data were screened, extracted and appraised by two independent reviewers. Primary outcomes were sleep quality and quantity, assessed with validated tools. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Random effects meta-analysis was performed, and pooled standardised mean differences (SMDs) with 95% CIs were reported.

RESULTS

Five studies (259 patients) were included in qualitative (risk of bias) and quantitative analysis (meta-analysis). Pooled data showed a significant effect of recorded music on subjective sleep quality in the critical care and surgical population (SMD=1.21 (95% CI 0.50 to 1.91), p<0.01, excluding one non-English study; SMD=0.87 (95% CI 0.45 to 1.29), p<0.01). The SMD of 1.21 corresponded to a 27.1% (95% CI 11.2 to 42.8) increase in subjective sleep quality using validated questionnaires. A significant increase in subjective sleep quantity of 36 min was found in one study. Objective measurements of sleep assessed in one study using polysomnography showed significant increase in deeper sleep stage in the music group.

CONCLUSIONS

Recorded music showed a significant improvement in subjective sleep quality in some critical care and surgical populations. Therefore, its use may be relevant to improve sleep, but given the moderate potential for bias, further research is needed.

PROSPERO REGISTRATION NUMBER

CRD42020167783.

The clinical value of comprehensive nursing intervention in preventing ventilator-associated pneumonia

OBJECTIVE

The aim of the present study was to evaluate the clinical value of comprehensive nursing intervention in preventing ventilator-associated pneumonia (VAP).

METHODS

Eligible 116 patients who received mechanical ventilation in our hospital from June 2018 to December 2019 were equally randomized into a control group and an observation group. The observation group adopted comprehensive nursing while conventional nursing was adopted in the control group accordingly. The mechanical ventilation time, hospitalization time, VAP incidence, psychological status, quality of life and nursing satisfaction were compared.

RESULTS

The mechanical ventilation and hospitalization time in the observation group was shorter compared to that in the control group (P < 0.05). For the VAP incidence, the observation group exhibited a significantly lower level than the control group (3.44% vs 13.79%) (P < 0.05). SAS and SDS scores before intervention were not different between the groups (P > 0.05); after intervention, the scores in both groups decreased, and the scores of the former group were significantly lower than those of the latter group (P < 0.05). The quality of life scores before intervention did not show any significant difference (P > 0.05); after intervention, a significant increase of quality of life in the observation group was observed compared to the control group (P < 0.05). The nursing satisfaction rate in the observation group was found to be higher when compared with that in the control group (94.87% vs 81.03%, P < 0.05). After intervention, the oxygenation index, the ratio of alveolar arterial oxygen partial pressure difference to arterial oxygen partial pressure (P(A-a)DO₂/PaO₂), and oxygen partial pressure in both groups of patients were improved compared with those before intervention. After intervention, a significant increase in the oxygen partial pressure and oxygenation index was identified in the observation group compared with the control group, while the P(A-a)DO₂/PaO₂ was found to be in a lower level (P < 0.05).

CONCLUSION

Comprehensive nursing intervention can shorten the mechanical ventilation and hospitalization time, prevent the occurrence of VAP, ease the negative emotions of patients, and improve their quality of life as well as nursing satisfaction.

Family automated voice reorientation (FAVoR) intervention for mechanically ventilated patients in the intensive care unit: Study protocol for a randomized controlled trial

Delirium in the intensive care unit (ICU) affects up to 80% of critically ill, mechanically ventilated (MV) adults. Delirium is associated with substantial negative outcomes, including increased hospital complications and long-term effects on cognition and health status in ICU survivors. The purpose of this randomized controlled trial is to test the effectiveness of a Family Automated Voice Reorientation (FAVoR) intervention on delirium among critically ill MV patients. The FAVoR intervention uses scripted audio messages, which are recorded by the patient's family and played at hourly intervals during daytime hours. This ongoing orientation to the ICU environment through recorded messages in a voice familiar to the patient may enable the patient to more accurately interpret the environment and thus reduce risk of delirium. The study's primary aim is to test the effect of the FAVoR intervention on delirium in critically ill MV adults in the ICU. The secondary aims are to explore: (1) if the effect of FAVoR on delirium is mediated by sleep, (2) if selected biobehavioral factors moderate the effects of FAVoR on delirium, and (3) the effects of FAVoR on short-term and long-term outcomes, including cognition and health status. Subjects (n = 178) are randomly assigned to the intervention or control group within 48 h of initial ICU admission and intubation. The intervention group receives FAVoR over a 5-day period, while the control group receives usual care. Delirium-free days, sleep and activity, cognition, patient-reported health status and sleep quality, and data regarding iatrogenic/environmental and biobehavioral factors are collected.

Effects of deep sedation on sleep in critically ill medical patients on mechanical ventilation

Atypical EEG patterns not consistent with standard sleep staging criteria have been observed in medical intensive care unit (ICU) patients. Our aim was to examine the relationship between sleep architecture and sedation in critically ill mechanically ventilated patients pre- and post-extubation. We performed a prospective observational repeated measures study where 50 mechanically ventilated patients with 31 paired analyses were examined at an academic medical centre. The sleep efficiency was 58.3 ± 25.4% for intubated patients and 45.6 ± 25.4% for extubated patients (p = .02). Intubated patients spent 76.33 ± 3.34% of time in non-rapid eye movement (NREM) sleep compared to 64.66 ± 4.06% of time for extubated patients (p = .02). REM sleep constituted 1.36 ± 0.67% of total sleep time in intubated patients and 2.06 ± 1.09% in extubated patients (p = .58). Relative sleep atypia was higher in intubated patients compared to extubated patients (3.38 ± 0.87 versus 2.79 ± 0.42; p < .001). Eleven patients were sedated with propofol only, 18 patients with fentanyl only, 11 patients with fentanyl and propofol, and 10 patients had no sedation. The mean sleep times on "propofol", "fentanyl", "propofol and fentanyl," and "no sedation" were 6.54 ± 0.64, 4.88 ± 0.75, 6.20 ± 0.75 and 4.02 ± 0.62 hr, respectively. The sigma/alpha values for patients on "propofol", "fentanyl", "propofol and fentanyl" and "no sedation" were 0.69 ± 0.04, 0.54 ± 0.01, 0.62 ± 0.02 and 0.57 ± 0.02, respectively. Sedated patients on mechanical ventilation had higher sleep efficiency and more atypia compared to the same patients following extubation. Propofol was associated with higher sleep duration and less disrupted sleep architecture compared to fentanyl, propofol and fentanyl, or no sedation.