COMMENTARY

Sleep Deprivation in the ICU

Marilyn W. Edmunds, PhD, CRNP; Laurie Scudder, MS, NP

Disclosures

December 31, 2009

Factors That Impact on Sleep in Intensive Care Patients

Tembo AC, Parker V
Intensive Crit Care Nurs. 2009;25:314-322

Study Summary

Over time, studies have shown that sleep is important in the critically ill for healing and survival; yet there is consistent evidence that patients in the intensive care unit do not get enough sleep.

This review explored research reports and other relevant literature that examined sleep disruption in the intensive care unit. The aim of the review was to identify factors consistently reported as contributing to sleep disturbance, strategies to assess and promote sleep, changes in sedation practices, and their implications on sleep-related outcomes for patients.

A literature search from Medline, CINAHL, Proquest, and psychinfo databases returned 22 articles that had been published since 2000, 8 of which were literature reviews, 5 were qualitative studies, and 9 were quantitative studies. Noise, pain and discomfort, modes of ventilation, drugs, and nurse interactions and procedures, have been cited as causes of sleep deprivation in critically ill patients. Intrinsic factors such as the severity of the underlying critical illness were noted to play a role in sleep disruptions.

The inability of nurses to accurately assess patients' sleep has also been cited as a concern. Polysomnography has been identified as the most effective way of assessing patients' sleep despite the difficulties associated with this tool. Some authors question the accuracy of sleep assessment by nurses, because nurses are reported to assess sleep merely through observation, which overestimates sleep duration and fails to account for sleep fragmentation.

Sleep deprivation impinges on recovery and ability to resist infection. It brings about neurologic problems such as delirium and agitation, and respiratory problems because it weakens upper airway muscles, thus prolonging the duration of ventilation and intensive care unit stay. Sleep deprivation may provoke posttraumatic stress disorder, withdrawal symptoms, depression, and continued sleep disruption. Sleep deprivation may reduce pain tolerance; increase fatigue in sympathetic nerve centers; increase sympathetic activity, leading to nocturnal high blood pressure; and blunt chemoreceptor responses promoting ineffective gas exchange.

The reviewers made recommendations covering clinical implications, implications for nurse practice/education, and suggestions for more research. Sleep deprivation can be reduced by the following measures:

  • Noise reduction;

  • Avoid/minimize use of sleep-inhibiting pharmacologic agents;

  • Facilitate uninterrupted adequate sleep time;

  • Ensure ventilator synchrony;

  • Encourage use of non-sleep-inhibiting drugs; and

  • Promote comfort and relaxation.

Implications for nurse practice and education were:

  • Incorporate into nursing education the importance of sleep, especially in critically ill patients, and proper sleep quality assessment techniques;

  • Specific focused sleep assessment using the right tools to accurately determine patients' sleep patterns;

  • Cluster nurse interventions so that unnecessary disruptions are avoided; and

  • Proper temperature regulation and noise reduction could help promote sleep.

Finally, more research is needed regarding proper and effective ways of monitoring and assessing quality of sleep in critically ill patients.

Viewpoint

Although clinicians give lip service to the need to allow acutely ill patients to sleep, the reality is that with very ill patients, few nursing personnel, and the demands of time, it is often difficult for the nurse to "cluster" care. Nursing education must do a better job of teaching nurses to care for their patients without disrupting their sleep. Is there a role for white noise machines, ear plugs, or other ways to reduce ambient and machine noise? How much does the light in intensive care units play in disrupting sleep? Clearly the problem of sleep disruption is recognized but is anyone really paying attention and doing anything about it?

Abstract

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