Sleep Deprivation in the Intensive Care Unit (ICU) Patients

Learning resource for nursing staff within ICU which contains information regarding the importance of sleep for patients to promote the recovery and healing process.

Learning resource for staff within ICU which contains information regarding the importance of sleep for patient to promote recovery and healing process

Learning objectives

  • Understanding the importance of adequate sleep in the ICU patients
  • Understanding the physiological effects of inadequate sleep for ICU patients
  • Raising the awareness among staff member about sleep deprivation in ICU and apply the knowledge into their practice
  • Nursing staff are able to develop strategy to promote sleep in ICU

Definition

Sleep is defined as a state of sensory and perceptive disconnection from the external environment which is periodic and reversible (Pisani, Friese, Gehlbach, Schwab, Weinhouse & Jones, 2015; Carley & Farabi, 2016)

 It is a complex physiologic condition which is vital for repair, health and well-being 

In critically ill patients, sleep quality and quantity vary distinctly between individuals, therefore it is essential to have a sound understanding of normal sleep in order to recognise abnormalities within the ICU 

The prevalence of sleep deprivation during ICU admission has been reported to be more than 50%



(Kamdar, Needham & Collop, 2012; Bihari, McEvoy, Matheson, Kim, Woodman & Bersten, 2012)

Sleep cycles

Two types of sleep cycles

Rapid Eye Movement (REM)

  • Rapid eye movement along with increase activity in parts of the brain especially cerebral cortex which is responsible for learning, thinking and processing information
  • Research shown that lack of REM sleep would effect ability to learn information and skills that were shown prior to sleep
  • Consist of 25% of sleep time which occurs between 70-90 minutes post sleep
  • Muscle movement is inhibited during this period
  • Increased activity in the brain could result in dreaming
  • Referred to as ”active sleep” because the neuron activities are similar to the state of being fully awake


(Carley & Farabi, 2016; Aboalayon, Faezipour, Almuhammadi & Moslehpour, 2016)


Non-Rapid Eye Movement (Non-REM)

  • Stage 1- Light sleep where the experience of starting to fall asleep occurs, easy to be woken, slow movement of the eyes and decrease in muscle activity (ref).
  • Stage 2- No movement of the eyes, slower brain waves, decrease in heart rate as the body is getting ready for deep sleep.
  •  Stage 3-  Deep sleep where the restoration of the body occurs, growth hormones are released and the level of thyroid stimulating hormone (TSH) is decreased

Recommended sleep hours

It is recommended that adults receive 7-9 hours of sleep a night which will help the body to reach a maximum restorative period (National Sleep Foundation, 2017)

The importance of sleep for ICU patient

  • To improve recovery and healing process
  • To decrease episodes of delirium and improve cognitive function
  • Sleep promotes the ability to resist infection
  • Decrease in length of stay (LOS) in ICU
  • To reduce adverse events
  • Sleep and rest is as important as any medical treatment especially for brain injury patients


(Tembo & Parker, 2009; Nesbitt & Goode, 2014; Pisani et al., 2015)


Physiological effects of inadequate sleep

  • Increased noradrenaline and cortisol levels - sleep deprivation is deemed as a stressor which is related to an increase of cortisol levels
  • Decrease in growth hormone levels - the release of growth hormone is relatively high during stage 3 of sleep
  • An increase in insulin resistance - an increase in cortisol levels and other pro-inflammatory hormone could cause insulin sensitivity
  • Inspiratory muscles weaken
  • Irritability, emotional distress and anxiety

(Calhoun & Harding, 2010; Mesarwi, Polak, Jun & Polotsky, 2013; Kamdar, Needham & Collop, 2012; Wright, Drake, Frey, Fleshner, Desouza, Gronfier & Czeisler, 2015)

  • Delirium
  • Cause individual to be more sensitive to pain
  • Decrease in blood pressure control - Continuous lack of sleep will increase the stress level and inability of the circulating blood to control stress hormones combined with an unstable nervous system would cause hypertension and other cardiovascular morbidities
  • Disruption to circadian rhythm - Natural 24-hour body clock or sleep/wake cycle.
  • Increased level of aggression

Causes of sleep deprivation in ICU

  • Noise levels in the ICU is often high such as staff conversation within ICU, equipment/monitors sounds and other alarms are also loud and frequent
  • Lights staying on late into the night can cause disruption of the circadian rhythm and inhibit the release of melatonin
  • Losing a sense of day/night time as well as non-familiar environment
  • Mechanical ventilator- dysynchrony, ventilation mode, endotracheal tube (ETT), suctioning and positioning are very uncomfortable for patient    
  • Multiple arousals and lack of deep sleep (Stage 3)
  • Anxiety and stress due to unfamiliar environment
  • Inability to speak with ETT



(Tembo & Parker, 2009; Kamdar, Needham & Collop, 2012; Bihari et al., 2012; Owens, Truong-Giang Huynh & Netzer, 2017) 

  • Medications- Sedation used in ICU on most ventilated patients have a significant effect on sleep which prevents REM and inhibits deep sleep therefore can lead to delirium.
  • Increased disruption with staff providing cares 24-hours a day such as patient assessments, personal hygiene, administering medications as well as adjusting the equipment and monitors
  • Increased in stimulants from visitors and family
  • Pain would cause wakefulness- uncontrollable pain would result in a decrease of quality and quantity of sleep
  • Patients’ medical and physical health as well as psychological conditions are all risk factors that could result in sleep deprivation

Promoting sleep in ICU

  • Promoting safe visiting hours within the ICU- Most facilities promote family-centred care where family are involved in the patient’s care to improve patient’s health outcomes therefore “open visitation” is encouraged to minimise anxiety and stress for family. However, an excessive amount of regular visitation raises concerns for the health staff as it can intensify patients’ physiological stress, hindering nursing care and increase emotional and physical stress for families. Research shows that visiting hours for ICU patients should be limited based on their needs with time, duration and number of visitors
  • If able, reducing the noise and lights such as alarms and monitors during the night time would cause less disturbances



(Kamdar, Needham & Collop, 2012; Wright et al., 2015; Khaleghparast, Joolaee, Ghanbari, Maleki, Peyrovi & Bahrani, 2016; McFeely, 2016; Owens, Truong-Giang Huynh & Netzer, 2017) 

  • Bundle the cares and interaction to minimise patient disturbance
  • Providing patients with non-pharmacology intervention such as masks, earplugs, white noise and relaxation technique will improve sleep quality and quantity
  • Promoting wakefulness during daytime and daylight to maintain “sleep-wake” cycle
  • If necessary the use of medications that will facilitate deep and restorative sleep for patients
  • Encouraging quiet times and reducing unnecessary noise within the ICU has shown improvement in sleep
  • Educate family and visitors of the importance of rest time for patients to achieve better outcomes and accelerate recovery time

Definition of sleep

Sleep is defined as a state of and perceptive from the external which is periodic and 

How many non-REM sleep stages are there?

  • 2
  • 3
  • 4
  • 5

What are the recommendation hours of sleep for an adult person

  • 5-6 Hours
  • 10-12 Hours
  • 5-7 Hours
  • 7-9 Hours

Which of the following is not a correct statement regarding the importance of adequate sleep in ICU?

  • Sleep promotes the ability to resist infection
  • Sleep improves recovery and healing process
  • Too much sleep can increase the risk of developing diabetes
  • Adequate sleep decreases episodes of delirium and improves cognitive function

Some physiological effects of inadequate sleep are

  • Weakening of inspiratory muscles, decrease in cortisol levels, decrease in aggression level and emotional distress
  • An increase in pain sensitivity, weakening of inspiratory muscles, delirium and poor blood pressure control
  • Decrease in cortisol levels, increase in aggression level, decrease in irritability and delirium
  • Decrease in insulin resistance, weakening of inspiratory muscles, anxiety and emotional distress

True or False

  • Increased brain activity is similar to the state of wakefulness, characteristic of non-REM sleep

True or False

  • In general, REM sleep consist of 45% of total sleep time

What environmental factors can cause sleep deprivation in ICU (there may be more than one answer)

  • Lights
  • Loud noise
  • Medication
  • Patient's medical condition

Other possible causes of sleep deprivation in ICU

  • Pain
  • Inability to speak with ETT
  • Anxiety and stress due to unfamiliar environment
  • Co-morbidity
  • All of the above

Some methods to promote sleep in the ICU are

  • Divide cares evenly throughout shift, leave lights on all night so staff can monitor patient, reduce unnecessary noise
  • Bundle cares, reduce unnecessary noise, have loud casual conversation with staff across the unit, promote wakefulness during daytime to maintain “sleep-wake” cycle
  • Bundle cares, minimise patient stimulation during rest periods, promote wakefulness during daytime to maintain “sleep-wake” cycle
  • Divide cares evenly throughout shift, reduce unnecessary noise, leave lights on all night so staff can monitor patient

The End

Thank You

References

References

Aboalayon, K. A. I., Faezipour, M., Almuhammadi, W. S., & Moslehpour, S. (2016). Sleep Stage Classification Using EEG Signal Analysis: A Comprehensive Survey and New Investigation. Entropy, 18(9), 1–31.

Bihari, S., Doug McEvoy, R., Matheson, E., Kim, S., Woodman, R. J., & Bersten, A. D. (2012). Factors Affecting Sleep Quality of Patients in Intensive Care Unit. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine, 8(3), 301–307. https://doi.org/10.5664/jcsm.1920

Calhoun, D. A., & Harding, S. M. (2010). Sleep and Hypertension. Chest, 138(2), 434–443. https://doi.org/10.1378/chest.09-2954

Carley, D. W., & Farabi, S. S. (2016). Physiology of Sleep. Diabetes Spectrum, 29(1), 5–9. https://doi.org/10.2337/diaspect.29.1.5

Kamdar, B. B., Needham, D. M., & Collop, N. A. (2012). Sleep Deprivation in Critical Illness: Its Role in Physical and Psychological Recovery. Journal of Intensive Care Medicine, 27(2), 97–111. https://doi.org/10.1177/0885066610394322

Khaleghparast, S., Joolaee, S., Ghanbari, B., Maleki, M., Peyrovi, H., & Bahrani, N. (2016). A Review of Visiting Policies in Intensive Care Units. Global Journal of Health Science, 8(6), 267–276. https://doi.org/10.5539/gjhs.v8n6p267

McFeely, J. (2016). Patients Rarely Sleep in the ICU. Critical Care Alert, 24(3), 17–19.

Mesarwi, O., Polak, J., Jun, J., & Polotsky, V. Y. (2013). Sleep disorders and the development of insulin resistance and obesity. Endocrinology and Metabolism Clinics of North America, 42(3), 617–634. https://doi.org/10.1016/j.ecl.2013.05.001

National Sleep Foundation Recommends New Sleep Times. (n.d.). Retrieved September 6, 2017, from https://sleepfoundation.org/press-release/national-sleep-foundation-recommends-new-sleep-times

Nesbitt, L., & Goode, D. (2014a). Nurses perceptions of sleep in the intensive care unit environment: A literature review. Intensive and Critical Care Nursing, 30(4), 231–235. https://doi.org/10.1016/j.iccn.2013.12.005

Owens, R. L., Truong-Giang Huynh, & Netzer, G. (2017). Sleep in the Intensive Care Unit in a Model of Family-Centered Care. AACN Advanced Critical Care, 28(2), 171–178. https://doi.org/10.4037/aacnacc2017393

Pisani, M. A., Friese, R. S., Gehlbach, B. K., Schwab, R. J., Weinhouse, G. L., & Jones, S. F. (2015). Sleep in the Intensive Care Unit. American Journal of Respiratory and Critical Care Medicine, 191(7), 731–738. https://doi.org/10.1164/rccm.201411-2099CI

Tembo, A. C., & Parker, V. (2009). Factors that impact on sleep in intensive care patients. Intensive and Critical Care Nursing, 25(6), 314–322. https://doi.org/10.1016/j.iccn.2009.07.002

Visiting a patient in the ICU. (2017). Retrieved September 6, 2017, from http://www.intensivecarefoundation.org.au/visiting-a-patient-in-the-icu/

Wright, K. P., Drake, A. L., Frey, D. J., Fleshner, M., Desouza, C. A., Gronfier, C., & Czeisler, C. A. (2015). Influence of sleep deprivation and circadian misalignment on cortisol, inflammatory markers, and cytokine balance. Sleep, Brain, Behavior, and Immunity, 47, 24–34. https://doi.org/10.1016/j.bbi.2015.01.004