Introduction:
Sleep deprivation is a dangerous yet frequent condition among patients in intensive care units (ICUs). Lack of sleep is linked to emotional distress and has been postulated to weakened immune systems, cognitive issues, muscle issues, aberrant breathing patterns, and prolonged mechanical ventilation. Critically sick individuals are more likely to experience fragmented sleep, decreased restorative sleep, and frequent nocturnal awakenings. Noise, light, patient-ventilator dyssynchrony, pharmaceutical side effects, and frequent care activities are all factors that contribute to sleep deprivation in the intensive care unit.
What Characteristics Does Sleep Deprivation Have?
Inadequate sleep duration or poor sleep quality may contribute to sleep deprivation. Critically ill patients and healthy adults often get about the same total sleep. However, critically ill individuals may have a decrease in subjective quality of sleep. In addition, compared to healthy individuals, these patients have more fragmented sleep, sleep during the day, and extended periods of light sleep. Mechanical ventilation may worsen the circadian cycle and sleep fragmentation, but the impacts still need to be thoroughly shown in the available research. Although there is debate over delirium's general effect on sleep, it may also alter circadian rhythm cycles.
The amount and quality of sleep in the ICU (intensive care unit) have been examined in several studies using polysomnography, and it has been discovered that although patients occasionally get some restorative sleep, it is frequently fragmented. The most significant disturbances are observed with losses in deep and rapid eye movement (REM) sleep periods, regarded as the most refreshing.
How to Measure Sleep in the ICU?
Sleep measuring in critically sick patients remains a significant impediment to large-scale studies on ICU-related sleep disruptions. The gold standard and most popular method of measuring sleep is polysomnography, which records electroencephalograms (EEG), electromyograms (EMG), and electrooculograms (EOG) simultaneously. This method requires complicated equipment, trained operators, and expert interpretation. PSG is, therefore, expensive and logistically challenging. Since common ICU drugs and conditions like sepsis, shock, hepatic encephalopathy, and renal failure are linked to altered EEG patterns, PSG interpretation in the ICU is particularly challenging.
Actigraphy and the BIS (bispectral index) have been researched as more practical methods for measuring objective sleep in ICU patients than PSG. Actigraphy uses an automated wristwatch to analyze patient motion to gauge the length of time spent asleep and awake. Actigraphy is frequently recommended as a minimally invasive, low-cost alternative to other sleep-wake measuring techniques.
However, it has been demonstrated that 24-hour actigraphy in critically ill patients consistently overestimates total sleep time compared to PSG. Actigraphy's inability to distinguish between sleep and motionless wakefulness in primarily immobile, bedridden ICU patients is likely to cause this difference.
The measurement of sleep may also be done using subjective survey tools. The Richards-Campbell Sleep Questionnaire (RCSQ), a 5-question assessment evaluated against PSG, is the most extensively used tool. The RCSQ might be a practical choice for measuring perceived sleep on a large scale throughout the ICU as an element of regular medical care and quality initiatives for improvement.
What Contributes to Disturbed Sleep in the Intensive Care Unit?
Several frequent factors, such as underlying sleeping disorders, medical diseases, and psychological issues, can disturb hospitalized patients' sleep. Additionally, modifiable elements like light, noise, contact with healthcare providers, and drugs can interrupt sleep in critically sick patients. The severity of the sickness and mechanical ventilation are two additional reasons that can disturb sleep.
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Noise: ICUs frequently experience loud noise levels. ICU patients frequently complain about noise as a major sleep disruptor, and the most frequent causes are staff talks, notifications, overhead pages, phone systems, and televisions.
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Patient-Care Procedures: Each night, patient-care activities may cause 40 to 60 disruptions for ICU patients. These tasks include phlebotomy, radiography, wound management, transportation, bathing, vital sign evaluations, device adjustments, prescription delivery, and patient assessments.
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Light: The synchronization of the circadian cycle depends critically on light. Sleep disruption requires light levels of 1500 lux, and melatonin release suppression requires light levels of 100 to 500 lux. Although ICU survivors have indicated that light is less bothersome to sleep compared to noise and patient care activities, light may disturb ICU patients' sleep.
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Ventilation Equipment: Mechanical ventilation has been linked to sleep disruption. Patients who use mechanical ventilation have less restful sleep, less efficient sleep, and more daytime sleep than their non ventilated counterparts. The subjective level of daytime sleepiness has dramatically increased in patients getting mechanical breathing.
What Are the Effects of Inadequate Sleep on Critically Ill Patients?
Both immediate and long-term effects have been linked to sleep deprivation in ICU patients. Lack of sleep can negatively affect the immune system, cognitive function, delirium, emotional discomfort, musculoskeletal issues, and respiratory irregularities. These changes may result in delayed weaning periods, poor tolerance to noninvasive breathing techniques, poor glucose control in both diabetics and non-diabetics, elevated anxiety, and elevated pain perception.
The link between lack of sleep and delirium is very significant in the ICU context. The majority of ICU patients, especially those who are old and on mechanical ventilation, may have both inadequate sleep and delirium. Delirium is independently linked to patient mortality, extended stay, higher expense, and long-term cognitive decline. Circadian rhythm and melatonin levels are disturbed by sleep loss. Studies have shown that these disturbances can cause delirium to manifest. Increasing melatonin supplies might, despite the debate, help these populations experience delirium less frequently.
How Is Sleep Deprivation Managed in the ICU?
Various strategies have been put forth to combat sleep loss in the ICU. Once preventive measures have failed, the next best course of action is early issue identification and management. Due to the multidimensional nature of sleep deprivation, it is vital to begin a tailored treatment plan as soon as feasible using clinical judgment and broad medical principles. Goal-directed nursing care should be a part of a sleep hygiene practice. Some individuals may benefit from pharmaceutical treatments, which could include the use of clinically relevant pain medications and sleep aids.
Non-medication Approaches:
There are a number of non-medication strategies for treating sleep deficiency. Improved patient sleep patterns may be the outcome of sleep hygiene practices.30 Increasing the patient's activity and energy use across the day, enhancing movement via earlier progressive mobility initiatives, deliberately differing the intensity of light in the environment during the day versus night, grouping nighttime care activities, and reducing noise are just a few examples of specific sleep hygiene interventions. It could be beneficial to play calming music an hour before bed. However, little research supports the use of music as a regular sleep deprivation remedy.
Pharmacological Approach:
Patients and families frequently ask for pharmacological treatments to aid sleep in the intensive care unit. Clinicians may feel under pressure to administer a pharmaceutical intervention, but they should be aware of the risks involved. Numerous sleep aids have adverse side effects and might worsen delirium in individuals needing critical care.
Melatonin has drawn a lot of attention among medicinal solutions to sleep loss. One hour before bed, melatonin is commonly taken orally. It has been demonstrated to positively affect the immune system, oxidant activity, and neuroprotection, in addition to helping regulate circadian rhythm.
Conclusion:
In the ICU, sleep deprivation is a serious issue. Sleep deprivation assessment is made difficult by aspects of critical illness and hampered by a lack of sufficient research on the validity and reliability of affordable assessment tools. The best way to handle a lack of sleep in the ICU is prevention. Multifaceted management strategies should include sleep hygiene practices, nursing care plans that promote sleep, and proper medication schedules.
