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Sagun E, Akyol A, Kaymak C. Chrononutrition in Critical Illness. Nutr Rev 2024:nuae078. [PMID: 38904422 DOI: 10.1093/nutrit/nuae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
Circadian rhythms in humans are biological rhythms that regulate various physiological processes within a 24-hour time frame. Critical illness can disrupt the circadian rhythm, as can environmental and clinical factors, including altered light exposure, organ replacement therapies, disrupted sleep-wake cycles, noise, continuous enteral feeding, immobility, and therapeutic interventions. Nonpharmacological interventions, controlling the ICU environment, and pharmacological treatments are among the treatment strategies for circadian disruption. Nutrition establishes biological rhythms in metabolically active peripheral tissues and organs through appropriate synchronization with endocrine signals. Therefore, adhering to a feeding schedule based on the biological clock, a concept known as "chrononutrition," appears to be vitally important for regulating peripheral clocks. Chrononutritional approaches, such as intermittent enteral feeding that includes overnight fasting and consideration of macronutrient composition in enteral solutions, could potentially restore circadian health by resetting peripheral clocks. However, due to the lack of evidence, further studies on the effect of chrononutrition on clinical outcomes in critical illness are needed. The purpose of this review was to discuss the role of chrononutrition in regulating biological rhythms in critical illness, and its impact on clinical outcomes.
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Affiliation(s)
- Eylul Sagun
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, 06100, Turkey
| | - Asli Akyol
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, 06100, Turkey
| | - Cetin Kaymak
- Gülhane Faculty of Medicine, Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara Training and Research Hospital, Intensive Care Unit, Ankara, 06230, Turkey
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Perry H, Alight A, Wilcox ME. Light, sleep and circadian rhythm in critical illness. Curr Opin Crit Care 2024:00075198-990000000-00175. [PMID: 38841914 DOI: 10.1097/mcc.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Sleep and circadian disruption (SCD) are associated with worse outcomes in the ICU population. We discuss sleep, circadian physiology, the role of light in circadian entrainment and its possible role in treating SCD, with special attention to the use of light therapies and ICU design. RECENT FINDINGS The American Thoracic Society recently published an official research statement highlighting key areas required to define and treat ICU SCD. Recent literature has been predominantly observational, describing how both critical illness and the ICU environment might impair normal sleep and impact circadian rhythm. Emerging consensus guidance outlines the need for standardized light metrics in clinical trials investigating effects of light therapies. A recent proof-of-concept randomized controlled trial (RCT) showed improvement in delirium incidence and circadian alignment from ICU room redesign that included a dynamic lighting system (DLS). SUMMARY Further investigation is needed to define the optimal physical properties of light therapy in the ICU environment as well as timing and duration of light treatments. Work in this area will inform future circadian-promoting design, as well as multicomponent nonpharmacological protocols, to mitigate ICU SCD with the objective of improving patient outcomes.
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Affiliation(s)
- Heather Perry
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta
| | - Athina Alight
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta
| | - M Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
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Melone MA, Becker TC, Wendt LH, Ten Eyck P, Patel SB, Poston J, Pohlman AS, Pohlman M, Miller A, Nedeltcheva A, Hall JB, Van Cauter E, Zabner J, Gehlbach BK. Disruption of the circadian rhythm of melatonin: A biomarker of critical illness severity. Sleep Med 2023; 110:60-67. [PMID: 37541132 DOI: 10.1016/j.sleep.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 08/06/2023]
Abstract
Circadian dysrhythmias occur commonly in critically ill patients reflecting variable effects of underlying illness, ICU environment, and treatments. We retrospectively analyzed the relationship between clinical outcomes and 24-h urinary 6-sulfatoxymelatonin (aMT6s) excretion profiles in 37 critically ill patients with shock and/or respiratory failure. Nonlinear regression was used to fit a 24-h cosine curve to each patient's aMT6s profile, with rhythmicity determined by the zero-amplitude test. From these curves we determined acrophase, amplitude, phase, and night/day ratio. After assessing unadjusted relationships, we identified the optimal multivariate models for hospital survival and for discharge to home (vs. death or transfer to another facility). Normalized aMT6s rhythm amplitude was greater (p = 0.005) in patients discharged home than in those who were not, while both groups exhibited a phase delay. Patients with rhythmic aMT6s excretion were more likely to survive (OR 5.25) and be discharged home (OR 8.89; p < 0.05 for both) than patients with arrhythmic profiles, associations that persisted in multivariate modelling. In critically ill patients with shock and/or respiratory failure, arrhythmic and/or low amplitude 24-h aMT6s rhythms were associated with worse clinical outcomes, suggesting a role for the melatonin-based rhythm as a novel biomarker of critical illness severity.
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Affiliation(s)
- Marie-Anne Melone
- Department of Pulmonary, Thoracic Oncology and Respiratory Intensive Care, Rouen University Hospital, Univ Rouen, F-76000, Rouen, France; CETAPS EA3832, Research Center for Sports and Athletic Activities Transformations, University of Rouen Normandy, F-76821, Mont-Saint-Aignan, France.
| | - Taylor C Becker
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Linder H Wendt
- Institute of Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | - Patrick Ten Eyck
- Institute of Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | - Shruti B Patel
- Department of Internal Medicine, Loyola University of Chicago, Chicago, IL, USA
| | - Jason Poston
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Anne S Pohlman
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Annette Miller
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Jesse B Hall
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Eve Van Cauter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Joseph Zabner
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Brian K Gehlbach
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA; Department of Neurology, University of Iowa, Iowa City, IA, USA
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Knauert MP, Ayas NT, Bosma KJ, Drouot X, Heavner MS, Owens RL, Watson PL, Wilcox ME, Anderson BJ, Cordoza ML, Devlin JW, Elliott R, Gehlbach BK, Girard TD, Kamdar BB, Korwin AS, Lusczek ER, Parthasarathy S, Spies C, Sunderram J, Telias I, Weinhouse GL, Zee PC. Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2023; 207:e49-e68. [PMID: 36999950 PMCID: PMC10111990 DOI: 10.1164/rccm.202301-0184st] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.
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Rault C, Heraud Q, Ragot S, Frat JP, Thille AW, Drouot X. A real-time automated sleep scoring algorithm to detect refreshing sleep in conscious ventilated critically ill patients. Neurophysiol Clin 2023; 53:102856. [DOI: 10.1016/j.neucli.2023.102856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
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Actigraphy-based sleep and activity measurements in intensive care unit patients randomized to ramelteon or placebo for delirium prevention. Sci Rep 2023; 13:1450. [PMID: 36702822 PMCID: PMC9879948 DOI: 10.1038/s41598-023-28095-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 01/12/2023] [Indexed: 01/27/2023] Open
Abstract
Patients in the ICU often sleep poorly for various reasons, which may predispose to delirium. We previously conducted a clinical trial in which we tested the efficacy of ramelteon, a melatonin-receptor agonist used to treat insomnia, versus placebo, in preventing ICU delirium in patients who underwent elective pulmonary thromboendarterectomy (PTE) surgery. Here we examine sleep, activity, and circadian patterns, measured with actigraphy, to understand changes in these metrics with our intervention and in those with and without delirium. Participants wore wrist actigraphy devices while recovering post-operatively in the ICU. For sleep analysis, we extracted total sleep time and sleep fragmentation metrics over the 22:00 to 06:00 period nightly, and daytime nap duration from the daytime period (0:600 to 22:00) for each participant. For activity analyses, we extracted the following metrics: total daytime activity count (AC), maximum daytime AC, total nighttime AC, and maximum nighttime AC. Next, we performed a nonparametric circadian analysis on ACs over each 24-h day and extracted the following: interdaily stability (IS), intra-daily variability (IV), relative amplitude (RA), and low and high periods of activity (L5 and M10) as well as their start times. These metrics were compared between patients who received ramelteon versus placebo, and between patients who became delirious versus those who did not develop delirium. We additionally made comparisons between groups for daytime and nighttime light levels. No differences in sleep, activity, circadian metrics or light levels were found between drug groups. Delirious patients, when compared to those who were never delirious, had a lower IS (0.35 ± 0.16 vs. 0.47 ± 0.23; P = 0.006). Otherewise, no differences in IV, L5, M10, or RA were found between groups. L5 and M10 activity values increased significantly over the post-extubation for the whole cohort. No differences were found for daytime or nighttime light levels between groups. Overall, ramelteon did not impact sleep or circadian metrics in this cohort. Consistent with clinical experience, delirious patients had less inter-daily stability in their rest-activity rhythms. These data suggest that actigraphy might have value for individual assessment of sleep in the ICU, and for determining and detecting the impact of interventions directed at improving sleep and circadian activity rhythms in the ICU.Trial registration: REGISTERED at CLINICALTRIALS.GOV: NCT02691013. Registered on February 24, 2016 by principal investigator, Dr. Robert L. Owens.
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Mansour W, Knauert M. Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients. Clin Chest Med 2022; 43:287-303. [PMID: 35659026 PMCID: PMC9177053 DOI: 10.1016/j.ccm.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Wissam Mansour
- Department of Internal Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University School of Medicine, 1821 Hillandale Road, Suite 25A, Durham, NC 27705, USA
| | - Melissa Knauert
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA.
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Poole J, Kitchen GB. Circadian regulation of innate immunity in animals and humans and implications for human disease. Semin Immunopathol 2022; 44:183-192. [PMID: 35169890 PMCID: PMC8853148 DOI: 10.1007/s00281-022-00921-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/03/2022] [Indexed: 01/19/2023]
Abstract
Circadian rhythms are 24-h oscillating variations in physiology generated by the core circadian clock. There is now a wide body of evidence showing circadian regulation of the immune system. Innate immune cells contain the molecular circadian clock which drives rhythmic responses, from the magnitude of the inflammatory response to the numbers of circulating immune cells varying throughout the day. This leads to rhythmic presentation of disease clinically, for example the classic presentation of nocturnal asthma or the sudden development of pulmonary oedema from acute myocardial infarction first thing in the morning.
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Affiliation(s)
- Joanna Poole
- Southmead Hospital, North Bristol Trust, Southmead Rd, Bristol, BS10 5NB, UK
| | - Gareth B Kitchen
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, M13 9PT, UK.
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK.
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Lindskov FO, Iversen HK, West AS. Clinical outcomes of light therapy in hospitalized patients - A systematic review. Chronobiol Int 2021; 39:299-310. [PMID: 34727798 DOI: 10.1080/07420528.2021.1993240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Light therapy and the effects on biological function have been known and investigated for decades. Light therapy is used to compensate for the lack of exposure to sunlight, which is thought to be linked to major depressive disorder with seasonal patterns. It is applied as sessions with bright light mimicking natural sunlight. Lack of bright light during daytime is not the only factor to maintain the circadian rhythm, also lack of exposure to bright light at night is important. A new modality called naturalistic light shows promise, mimicking daylight by dynamically changing intensity and wavelengths throughout the day. Evidence of clinical effects, besides bright light effects on depression, is still limited, especially in hospital populations, and present review aims to extract results of the effect of any optical light intervention on hospitalized patients. Through database search, 29 trials were included, of which 8 trials used a variation of naturalistic light. Trials were heterogeneous regarding designs, populations, interventions, methods and outcomes. In 14 out of 17 studies investigating sleep duration, quality and circadian alignment, along with decreased fatigue and improved mood in daytime, light therapy had a significant effect. Circadian rhythm and rhythmicity were affected as well. The effect on mood and cognition was inconsistent across studies. Trials showed more significant outcomes when conducted in non-intensive care units and with duration >5 days. Lux was reported in and compared across 24 studies and did not appear to be correlated to outcome, rather the distribution of wavelengths should be considered when conducting trials in the future. Of the 8 trials investigating naturalistic light, 4 trials had significant outcomes and 3 had adverse outcomes compared to one in the standard light regime. The overall effect of light therapy is beneficial, but evidence for the effect of naturalistic light is still insufficient to be recommended before other modalities. Future research in this area should be conducted in facilities where naturalistic light is installed, with a focus on the spectral distribution.
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Affiliation(s)
- Filippa O Lindskov
- Clinical Stroke Research Unit, Department of Neurology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Helle K Iversen
- Clinical Stroke Research Unit, Department of Neurology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anders S West
- Clinical Stroke Research Unit, Department of Neurology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Jobanputra AM, Scharf MT, Androulakis IP, Sunderram J. Circadian Disruption in Critical Illness. Front Neurol 2020; 11:820. [PMID: 32849248 PMCID: PMC7431488 DOI: 10.3389/fneur.2020.00820] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022] Open
Abstract
Circadian rhythms play a vital role in metabolic, hormonal, and immunologic function and are often disrupted in patients in the ICU. Circadian rhythms modulate the molecular machinery that responds to injury and illness which can impact recovery. Potential factors contributing to the alteration in circadian rhythmicity in intensive care unit (ICU) patients include abnormal lighting, noise, altered feeding schedules, extensive patient care interactions and medications. These alterations in circadian rhythms in ICU patients may affect outcomes and therefore, normalization of circadian rhythmicity in critically ill patients may be an important part of ICU care.
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Affiliation(s)
- Aesha M Jobanputra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Matthew T Scharf
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States.,Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Ioannis P Androulakis
- Biomedical Engineering Department, Rutgers University, Piscataway, NJ, United States.,Chemical and Biochemical Engineering Department, Rutgers University, Piscataway, NJ, United States.,Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Jag Sunderram
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Tan X, van Egmond L, Partinen M, Lange T, Benedict C. A narrative review of interventions for improving sleep and reducing circadian disruption in medical inpatients. Sleep Med 2018; 59:42-50. [PMID: 30415906 DOI: 10.1016/j.sleep.2018.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 12/28/2022]
Abstract
Sleep and circadian disruptions are frequently observed in patients across hospital wards. This is alarming, since impaired nocturnal sleep and disruption of a normal circadian rhythm can compromise health and disturb processes involved in recovery from illness (eg, immune functions). With this in mind, the present narrative review discusses how patient characteristics (sleep disorders, anxiety, stress, chronotype, and disease), hospital routines (pain management, timing of medication, nocturnal vital sign monitoring, and physical inactivity), and hospital environment (light and noise) may all contribute to sleep disturbances and circadian misalignment in patients. We also propose hospital-based strategies that may help reduce sleep and circadian disruptions in patients admitted to the hospital.
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Affiliation(s)
- Xiao Tan
- Department of Neuroscience, Sleep Research Laboratory, Uppsala University, Uppsala, Sweden.
| | - Lieve van Egmond
- Department of Neuroscience, Sleep Research Laboratory, Uppsala University, Uppsala, Sweden
| | - Markku Partinen
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland; VitalMed Research Center, Helsinki Sleep Clinic, Helsinki, Finland
| | - Tanja Lange
- Department of Rheumatology & Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Christian Benedict
- Department of Neuroscience, Sleep Research Laboratory, Uppsala University, Uppsala, Sweden.
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