COMMENTARY

The Latest on Sleep in the ICU

New Research Sheds Light on How Medication May Help Critically Ill Patients Get a Better Night's Sleep

Aaron B. Holley, MD

Disclosures

October 20, 2014

Introduction

Sleep and normal circadian rhythms are known to be disturbed during ICU admissions. There are several causes for poor sleep quality in the critically ill, including the effects of the underlying illness, the need for continuous mechanical ventilation, and the use of various sedative medications.

Given the well-documented relationship between sleep and recovery from illness, it is reasonable to assume that poor sleep quality adversely affects outcomes in critical illness. That being said, overcoming the barriers to quality sleep that exist in the ICU is easier said than done.

New Research

In the past month, two new articles have been published on managing sleep in the ICU. The first compared using dexmedetomidine (Precedex™) at night vs no medication.[1] All patients were intubated and monitored by EEG for 3 nights and 2 days (a total of 57 hours). The investigators found important improvements in sleep efficiency and an increase in stage 2 sleep on the nights when dexmedetomidine was used. The drug did not increase time in stage 3 or REM sleep. On nights when patients received dexmedetomidine, sleep tended to be consolidated to the nighttime period.

In a second article,[2] investigators randomly assigned elderly patients to receive either ramelteon (Rozerem®), a melatonin agonist, or a placebo each night. They found a dramatic decrease in delirium rates (3% vs 32%; P = .003) in favor of the patients who received the study drug. The reduction remained significant after adjustment for factors known to increase the incidence of delirium.

As one might expect, both studies had limitations. Still, both add significantly to the literature. The fact that dexmedetomidine consolidated sleep and preserved normal sleep architecture is an important finding, as many other continuous sedatives cause diffuse EEG slowing that is not consistent with any sleep stage. It would have been more impressive if patients had been able to enter stage 3 and REM sleep while receiving the drug, but that might be too much to ask when they're intubated and receiving narcotics.

Conclusion

Delirium in the ICU is associated with a number of adverse outcomes. If using ramelteon can truly reduce rates, it could be an important tool for treating the critically ill. The ramelteon study included only elderly patients, none of whom were intubated, so drug performance in a "sicker" population remains uncertain. In addition, although the authors hypothesized several pathways through which a melatonin agonist might affect delirium rates, it's difficult to attribute the reduction to the drug because it did not affect reported sleep quality or duration.

These studies are an important step in the right direction. In order to optimize sleep in the ICU, we need to learn more about it. Our knowledge has increased incrementally over the past 5-10 years; hopefully, studies like these will continue to be published.

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