Sleep and nursing care activities in an intensive care unit

Optimal nocturnal care for pressure injury prevention in the care environment: A scoping review

AIM

Nursing care activities conducted at night tend to disturb their sleep, but to our knowledge, no nocturnal care protocols for pressure injury prevention have been established. This scoping review aimed to map the nocturnal care for pressure injury prevention and propose nocturnal care recommendations that have a reduced impact on the patient's care environment.

METHODS

Literature databases were searched and two independent researchers screened the articles according to the inclusion criteria and extracted the data. The inclusion criteria were original articles/case studies, studies involving human subjects, and studies on nocturnal care for the prevention of pressure injuries.

RESULTS

Eight met the inclusion criteria, three studies focused on bedding and five on care activities. Parasympathetic activity was more likely to be maintained or enhanced when an automatic repositioning function was used. Additionally, the time to sleep resumption was significantly shorter when repositioning was performed during deep sleep than during shallow sleep. Significantly fewer awakenings in response to light or sound occurred when incontinence care was provided to awake patients than when it was performed regularly. Moreover, some studies have highlighted the usefulness of the small change method and the 30° side-lying position for repositioning.

CONCLUSION

Using a mattress with an automated turning function, providing care during wakefulness or deep sleep, and using repositioning methods with small positional changes may be effective in reducing the impact on patient's care environment. Further research is needed to determine nocturnal care for pressure injury prevention with less impact on the patient's care environment.

The effects of eye masks and earplugs on sleep quality, anxiety, fear, and vital signs in patients in an intensive care unit: A randomised controlled study

In intensive care units, environmental factors like loud noises and bright lights can cause fear, anxiety, changes in vital signs, and sleep disturbances. The aim of this study was to find out how using earplugs and eye masks during the night affected sleep quality, anxiety, fear, and vital signs of patients in an intensive care unit. A total of 70 patients, 35 in the intervention and 35 in the control group, were included in this randomised controlled study. While the patients in the intervention group were provided with earplugs and eye masks for 3 nights in addition to their routine care, only routine care was given to the patients in the control group. The 'Introductory Information Form', 'Visual Analogue Scale-Fear (VAS-F)', 'Visual Analogue Scale-Anxiety (VAS-A)', 'Vital Signs Monitoring Form', and 'Richards-Campbell Sleep Questionnaire' were used for data collection. It was found that the mean scores of VAS-F, VAS-A, heart rate, diastolic and systolic blood pressure of the intervention group decreased significantly after the intervention, while their sleep quality increased significantly. In this study, it was found that using earplugs and eye masks for patients in an intensive care unit during the night was effective in improving patients' sleep quality and reducing fear, anxiety, and problems in vital signs.

Effect of mini-dose dexmedetomidine supplemented intravenous analgesia on sleep structure in older patients after major noncardiac surgery: A randomized trial

STUDY OBJECTIVES

In previous studies, low-dose dexmedetomidine supplemented opioid analgesia improved sleep architecture but increased sedation level. Herein we tested the hypothesis that mini-dose dexmedetomidine supplemented analgesia improves sleep structure without increasing sedation.

METHODS

In this randomized trial, 118 older patients (≥65 years) following major noncardiac surgery were randomized to receive patient-controlled intravenous analgesia supplemented with either placebo or dexmedetomidine (median 0.02 μg kg^-1 h^-1) for up to 3 days. Polysomnogram was monitored from 9:00 p.m. on the day of surgery until 6:00 a.m. on the first day after surgery. Our primary outcome was the percentage of non-rapid eye movement stage 2 (N2) sleep. Secondary outcomes included other sleep structure parameters during the night of surgery and the sedation score during the first five postoperative days.

RESULTS

All 118 patients completed the study; of these, 85 were included in sleep structure analysis. Dexmedetomidine supplemented analgesia increased the percentage of N2 sleep (median difference, 10%; 95% CI, 1%-20%; P = 0.03). It also prolonged total sleep time (median difference, 78 min; 95% CI, 21 to 143; P = 0.01), increased sleep efficiency (median difference, 14%; 95% CI, 4%-26%; P = 0.01), decreased percentage of N1 sleep (median difference, -10%; 95% CI, -20% to -1%; P = 0.04), and lowered sleep fragmentation index (median difference, -1.6 times⋅h^-1; 95% CI, -3.7 to 0.1; P = 0.04). Sedation score within 5 days did not differ between the two groups.

CONCLUSIONS

Supplementing intravenous analgesia with mini-dose dexmedetomidine improved sleep structure without increasing sedation in older patients recovering from major surgery.

CLINICAL TRIALS

www.

CLINICALTRIALS

gov (NCT03117790), registered 2 April 2017.

Monitoring of nighttime EEG slow-wave activity during dexmedetomidine infusion in patients with hyperactive ICU delirium: An observational pilot study

BACKGROUND

The disturbance of sleep has been associated with intensive care unit (ICU) delirium. Monitoring of EEG slow-wave activity (SWA) has potential in measuring sleep quality and quantity. We investigated the quantitative monitoring of nighttime SWA and its association with the clinical evaluation of sleep in patients with hyperactive ICU delirium treated with dexmedetomidine.

METHODS

We performed overnight EEG recordings in 15 patients diagnosed with hyperactive delirium during moderate dexmedetomidine sedation. SWA was evaluated by offline calculation of the C-Trend Index, describing SWA in one parameter ranging 0 to 100 in values. Average and percentage of SWA values <50 were categorized as poor. The sleep quality and depth was clinically evaluated by the bedside nurse using the Richards-Campbell Sleep Questionnaire (RCSQ) with scores <70 categorized as poor.

RESULTS

Nighttime SWA revealed individual sleep structures and fundamental variation between patients. SWA was poor in 67%, sleep quality (RCSQ) in 67%, and sleep depth (RCSQ) in 60% of the patients. The category of SWA aligned with that of RCSQ-based sleep quality in 87% and RCSQ-based sleep depth in 67% of the patients.

CONCLUSION

Both, SWA and clinical evaluation suggested that the quality and depth of nighttime sleep were poor in most patients with hyperactive delirium despite dexmedetomidine infusion. Furthermore, the SWA and clinical evaluation classifications were not uniformly in agreement. An objective mode such as practical EEG-based solution for sleep evaluation and individual drug dosing in the ICU setting could offer potential in improving sleep for patients with delirium.

Sleep assessment in critically ill adults: A systematic review and meta-analysis

PURPOSE

To systematically review sleep evaluation, characterize sleep disruption, and explore effects of sleepdisruption on outcomes in adult ICU patients.

MATERIALS AND METHODS

We systematically searched databases from May 1969 to June 2021 (PROSPERO protocol number: CRD42020175581). Prospective and retrospective studies were included studying sleep in critically ill adults, excluding patients with sleep or psychiatric disorders. Meta-regression methods were applied when feasible.

RESULTS

132 studies (8797 patients) were included. Fifteen sleep assessment methods were identified, with only two validated. Patients had significant sleep disruption, with low sleep time, and low proportion of restorative rapid eye movement (REM). Sedation was associated with higher sleep efficiency and sleep time. Surgical versus medical patients had lower sleep quality. Patients on ventilation had a higher amount of light sleep. Meta-regression only suggested an association between total sleep time and occurrence of delirium (p < 0.001, 15 studies, 519 patients). Scarce data precluded further analyses. Sleep characterized with polysomnography (PSG) correlated well with actigraphy and Richards Campbell Sleep Questionnaire (RCSQ).

CONCLUSIONS

Sleep in critically ill patients is severely disturbed, and actigraphy and RCSQ seem reliable alternatives to PSG. Future studies should evaluate impact of sleep disruption on outcomes.

Lessons Learned from Extracorporeal Membrane Oxygenation Use During the COVID-19 Pandemic

With the rise of the coronavirus disease 2019 (COVID-19) respiratory pandemic, there has been an increased need to consider the use of extracorporeal membrane oxygenation (ECMO) technology. In the early phases of the pandemic, adults constituted most of the critically ill patients, and ECMO management strategies were developed for use in this population. During the course of the pandemic, there has been a rise in the number of critically ill children infected with COVID-19. Although ECMO has been used in the care of pediatric patients for more than half a century, it has been challenging to apply the lessons learned from adult patients with COVID-19 directly to critically ill children for whom ECMO is under consideration. This article reviews ECMO technology and highlights a number of important changes in pediatric ECMO regarding those patients infected with COVID-19. [Pediatr Ann. 2022;51(7):e281-e285.].

Updated Perspectives on the Management of Sleep Disorders in the Intensive Care Unit

Sleep disorders and circadian dysrhythmias are extremely prevalent in critically ill patients. Impaired sleep has a variety of etiologies, exhibits a wide range of negative effects and, moreover, might deteriorate the patient's prognosis. Despite a number of scientific findings and increased awareness, the importance of sleep optimization is still lower on the list of priories in the intensive care unit (ICU). The techniques of measuring and the evaluation of sleep quantity and quality are a great challenge in the ICU setting. The subjective and objective tools of sleep validation continue to suffer from deficiencies. Treatment approaches to improve the critically ill patient's sleep have focused on non-pharmacologic and pharmacologic strategies with some promising results. But pharmacological interventions alone could not provide sufficient patient benefit. Being aware and knowing of sleep problems and the beneficial effect of the necessary therapies in ICU patients requires greater acceptance. The application of available methods and the development of new methods to prevent sleep disorders in the ICU offer the potential to improve the critically ill patient's outcome.

A Systematic Review of Risk Factors for Sleep Disruption in Critically Ill Adults

OBJECTIVES

Numerous risk factors for sleep disruption in critically ill adults have been described. We performed a systematic review of all risk factors associated with sleep disruption in the ICU setting.

DATA SOURCES

PubMed, EMBASE, CINAHL, Web of Science, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews.

STUDY SELECTION

English-language studies of any design published between 1990 and April 2018 that evaluated sleep in greater than or equal to 10 critically ill adults (> 18 yr old) and investigated greater than or equal to 1 potential risk factor for sleep disruption during ICU stay. We assessed study quality using Newcastle-Ottawa Scale or Cochrane Risk of Bias tool.

DATA EXTRACTION

We abstracted all data independently and in duplicate. Potential ICU sleep disruption risk factors were categorized into three categories based on how data were reported: 1) patient-reported reasons for sleep disruption, 2) patient-reported ratings of potential factors affecting sleep quality, and 3) studies reporting a statistical or temporal association between potential risk factors and disrupted sleep.

DATA SYNTHESIS

Of 5,148 citations, we included 62 studies. Pain, discomfort, anxiety/fear, noise, light, and ICU care-related activities are the most common and widely studied patient-reported factors causing sleep disruption. Patients rated noise and light as the most sleep-disruptive factors. Higher number of comorbidities, poor home sleep quality, home sleep aid use, and delirium were factors associated with sleep disruption identified in available studies.

CONCLUSIONS

This systematic review summarizes all premorbid, illness-related, and ICU-related factors associated with sleep disruption in the ICU. These findings will inform sleep promotion efforts in the ICU and guide further research in this field.

Sleep-disrupting effects of nocturnal nursing interventions in intensive care unit patients: A systematic review

Patients staying in the intensive care unit (ICU) require constant monitoring and numerous nursing interventions performed as needed, irrespective of daytime or night-time. The disturbing effect of nocturnal nursing interventions and their contribution to sleep disruptions are unclear. The review analysed nocturnal nursing interventions, and their character, frequency and effects on sleep quality. The databases CINAHL, PubMed and Scopus were searched to identify and subsequently evaluate 19 studies (1,531 patients) meeting the algorithm used. Although nocturnal nursing interventions provided to ICU patients were frequent and varied, they were responsible for only a minority of observed sleep disruptions. The most frequent nocturnal intervention was Vital signs monitoring (Nursing Interventions Classification, 6,680). Implementation of sleep protocols, of which an integral part is clustering and planning of nocturnal interventions, appears to be effective. The review suggests that nursing interventions are not the main cause of sleep disruptions in the ICU. In an effort to improve the quality of sleep in ICU patients, other factors causing disturbance need to be addressed as well. The current trend is more careful planning of nursing care, clustering of interventions and minimizing nocturnal disruptions to allow patients at least one uninterrupted sleep cycle (90 min).

Promoting Sleep in the Intensive Care Unit

Introduction

Intensive care nurses face several challenges to facilitating sleep in their critically ill patients. With its high noise levels, hectic around-the-clock activity and constant artificial lights, the intensive care environment does not foster sleep. Intensive care unit patients have significant alterations in their sleep architecture with frequent awakenings and lighter sleep; up to 50% of this sleep also occurs during the daytime. Sleep loss increases the risk of developing delirium (especially in elderly patients) and immune system impairment, which prolongs healing. The aim of this article was to develop an evidence-based bundle of nursing care activities that promote adult intensive care patients’ sleep.

Methods

A broad search was conducted in PubMed, CINAHL, Cochrane Library, and McMaster plus using search words and Medical Subject Headings terms, such as sleep, intensive care unit, intensive care, critical care nursing, sleep promotion, music, white noise, earplugs, pain relief, absence of pain, nonpharmacological intervention, and mechanical ventilation. Eight recommendations emerged from this review: reduce noise, use earplugs and eye masks, use music, promote a natural circadian rhythm, manage pain, use quiet time, cluster nursing care activities at night, and optimize ventilator modes.

Conclusion

Promoting sleep within this patient population needs to be a higher priority for intensive care nurses. Sleep should be a focus throughout the day and night, in order to sustain patients’ natural circadian rhythms. Novel research in this field could change the strength of these recommendations and add new recommendations to the bundle.

The role of melatonin and melatonin receptor agonist in the prevention of sleep disturbances and delirium in intensive care unit - a clinical review

AIM

The intensive care unit (ICU) environment contributes to the development of sleep disturbances. Sleep disturbances, sleep fragmentation, and multiple awakening episodes lead to the circadian rhythm disorder, which increases the risk of delirium. Melatonin and melatonin receptor agonist is widely used agent in the therapy of sleep disturbances. However, there is also some for its efficacy in ICU delirium. Enteral melatonin and ramelteon supplementation eliminates (partially) the delirium inducing factors.

METHODS

PubMed/MEDLINE, OVID, Embase, Cochrane Library, and Web of Science databases were searched using adequate key words. We reviewed the literature on the role of melatonin and ramelteon in the prevention of sleep disturbances and delirium in intensive care units and analysed the methods of melatonin therapy in an ICU setting. Review followed the PRISMA statement. A review written protocol was not drafted.

RESULTS

Originally 380 studies were searched in five scientific databases. After rejecting the duplicate results, 125 results were obtained. Finally, 10 scientific studies were included in the review. In selected articles, the leading topics analysed were the role of melatonin and ramelteon in the prevention of delirium and sleep disorders. In addition, the noted effect of therapy with these agents on reducing the ventilation time of mechanical time and the demand for psychoactive substances in the ICU environment.

CONCLUSION

Reduction of either the incidence or the severity of delirium course is possible by eliminating its risk factors. Risk factors are directly related to sleep disorders. To reduce the problem, therefore, a holistic approach to the source is necessary. The efficacy of melatonin therapy in an ICU setting requires confirmation in studies including a greater number of participants as the impact of melatonin on these factors is yet to be fully elucidated. However, the prognosis is predictive because this concept provides patients with a minimally invasive and natural form of therapy.

Development and daily use of a numeric rating score to assess sleep quality in ICU patients

PURPOSE

Insufficient sleep burdens critically ill patients, optimizing sleep may enhance patient's outcomes. Current assessment methods may unnecessary burden patients. Therefore, a single numeric rating score was validated for sleep assessment.

MATERIALS AND METHODS

First, two cross-sectional measurements on two separate days, from cooperative patients from 19 centers assessed their sleep sufficiency, the numeric rating score (NRS) and the Richards Campbell Sleep Questionnaire (RCSQ). Assessments were compared using a Bland Altman plot. A NRS cut-off was determined using regression analysis. Second, daily sleep assessment was implemented and monitored single center for a year.

RESULTS

Multicenter, 194 patients assessed sleep quality, of which 53% was rated as sufficient. Mean (±SD) difference between RCSQ and NRS-Sleep using Bland-Altman analysis was 0.25 (±1.21, 95% limits of agreement -2.12 to 2.62). The optimal cut-off was >5. Single center, 1603 patients ranked 4532 ICU nights of sleep, of which 71% was sufficient; median NRS was 6 [IQR 5-7].

CONCLUSIONS

A single numeric rating score for sleep is interchangeable for the RCSQ score for assessment of sleep quality. Optimal cut-off is >5. Use of a numeric rating score for sleep is a practical way to evaluate and monitor sleep as perceived by patients in daily ICU practice.

Impact of nurse-assisted patient turning at different sleep stages on the quality of subsequent sleep

BACKGROUND

Nursing care performed during sleep, including nurse-assisted patient turning, is one of the factors that deteriorates sleep quality but is necessary for pressure ulcer prevention. Thus, it is important to determine when nurseassisted patient turning has the least impact on sleep quality.

AIM

The aim of this study was to clarify the impact of nurseassisted patient turning at different sleep stages and to determine the optimal timing of this aspect during sleep.

METHODS

The experiment, which consisted of healthy men in their 20s and 30s, was performed over four successive nights per subject. The first night was dedicated to environment adaptation, and the 2nd to the 4th nights were randomly assigned for shallow sleep intervention, deep sleep intervention, and non-intervention. On the intervention day, nurse-assisted patient turning was conducted twice. Overnight sleep conditions were measured by polysomnography (PSG). The PSG waveform transmitted to a tablet was analyzed in real time to determine the stage of sleep. The patient was turned when he entered the planned stage of sleep.

RESULTS

The study analyzed fourteen (14) subjects. Shallow sleep time, deep sleep time, and sleep resumption time after nurse-assisted patient turning were compared among the three groups of non-intervention day, shallow sleep intervention day and deep sleep intervention day. There was no significant difference in the shallow and deep sleep time among the three groups. However, sleep resumption time after nurse-assisted patient turning was significantly shorter on the deep sleep intervention day than on the shallow sleep intervention day (p = textbf 0.033).

CONCLUSIONS

This study has novelty in examining the impact of nurse-assisted patient turning performed at different sleep stages on subsequent sleep using objective indicators. The study suggested that a deep sleep state is the optimal timing of nurseassisted patient turning due to the short time to sleep resumption.

Sleep Deprivation in Intensive Care Unit - Systematic Review

Background

Sleep disturbances in intensive care unit (ICU) patients have been studied worldwide for over 30 years. Factors contributing to sleep disturbances are still being identified, and therapeutic procedures aimed at the mitigation of such ailments are consequently being developed.

Objectives

The aim of this study was to review the literature on sleep disturbances in intensive care unit patients.

Material and Methods

MEDLINE PubMed, OVID, Web of Science, and EBSCO databases have been searched using adequate keywords.

Results

Sleep disorders in ICUs were common among all of the analysed articles. Noise plays a significant role in sleep interruption (11.5 - 17% of awakenings). It was noted that the introduction of "white noise" into the ICU environment proved unsuccessful in reducing the magnitude of changing noise levels. Nursing care activities significantly disturb nocturnal rest, and 42.7 such procedures per every 12-hour night shift were registered. Aggregating nursing care interventions was suggested in order to reduce the number of stimuli experienced by the patient.

Conclusion

Changes in sleep structure developing during an ICU stay may significantly contribute to sleep disorders once the hospitalisation is over.

Quality of Sleep Among Intensive Care Unit Patients: A Literature Review

Investigating sleep disturbances among intensive care unit (ICU) patients and its serious consequences is considered a crucial issue for nurses. The need of sleep increases during hospitalization time to preserve energy for the healing process. Previous studies have demonstrated that sleep disturbance is one of the most common complaints of patients in the ICUs, with a prevalence of more than 50%. Although the total sleep time might be normal, the patients' sleep is fragmented and light in the intensive care settings. The main purpose of this review is to generate a clear view of what is known about sleep disturbances among ICU patients as well as to identify the gap in knowledge regarding this issue. This was done by describing, summarizing, clarifying, and evaluating well-selected previous studies about this topic. In addition, this concise review has focused on the prevalence of sleep disturbances in the ICU, factors contributing to poor quality of sleep among ICU patients, and the physiological effects of poor sleep on the patients' prognosis.

The need to support caregivers during pediatric bone marrow transplantation (BMT): A case report

ABSTRACTObjective:Pediatric bone marrow transplants represent a medically stressful, potentially traumatic experience for children and caregivers, and psychological support for parental caregivers is paramount to their long-term well-being. However, many medical centers do not have protocols in place to sustain caregiver well-being during these distressing experiences.

METHOD

We report on a case of a 10-month-old infant with Wiskott Aldrich Syndrome who was hospitalized for bone marrow transplantation.

RESULT

We describe the significant burden that fell upon caregivers during and after a bone marrow transplantation.

SIGNIFICANCE OF RESULTS

This case helped guide our suggestions to improve care for caregivers. Several logistical hurdles could be overcome to alleviate some of these burdens. We suggest that a child psychologist or psychiatrist should be on patient care teams and be attentive to parental stress, impairments, or impediments to self-care, and signs of emergency of mental illness in this setting of medical trauma. Additionally, promotion of sleep hygiene and linkage to support systems can maximize resiliency. Finally, we believe that hospital administrators should partner with clinicians to facilitate routine support during highly stressful transitions of care.