Advertisement

Sleep in the intensive care unit

  • Sairam Parthasarathy
  • Martin J. Tobin
Chapter

Abstract

Abnormalities of sleep are extremely common in critically ill patients, but the mechanisms are poorly understood. About half of total sleep time occurs during the daytime, and circadian rhythm is markedly diminished or lost. Judgments based on inspection consistently overestimate sleep time and do not detect sleep disruption. Accordingly, reliable polygraphic recordings are needed to measure sleep quantity and quality in critically ill patients. Critically ill patients exhibit more frequent arousals and awakenings than is normal, and decreases in rapid eye movement and slow wave sleep. The degree of sleep fragmentation is at least equivalent to that seen in patients with obstructive sleep apnea. About 20% of arousals and awakenings are related to noise, 10% are related to patient care activities, and the cause for the remainder is not known; severity of underlying disease is likely an important factor. Mechanical ventilation can cause sleep disruption, but the precise mechanism has not been defined. Sleep disruption can induce sympathetic activation and elevation of blood pressure, which may contribute to patient morbidity. In healthy subjects, sleep deprivation can decrease immune function and promote negative nitrogen balance. Measures to improve the quantity and quality of sleep in critically ill patients include careful attention to mode of mechanical ventilation, decreasing noise, and sedative agents (although the latter are double-edged swords).

Keywords

Sleep Critical illness Mechanical ventilation Artificial respiration Arousal 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Bellow S (2000) Ravelstein. Penguin, New York, pp 208Google Scholar
  2. 2.
    Hilton BA (1976) Quantity and quality of patients' sleep and sleep-disturbing factors in a respiratory intensive care unit. J Adv Nurs 1:453–468PubMedCrossRefGoogle Scholar
  3. 3.
    Aurell J, Elmqvist D (1985) Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care. BMJ 290:1029–1032PubMedCrossRefGoogle Scholar
  4. 4.
    Gottschlich MM, Jenkins ME, Mayes T, Khoury J, Kramer M, Warden GD, Kagan RJ (1994) The 1994 Clinical Research Award. A prospective clinical study of the polysomnographic stages of sleep after burn injury. J Burn Care Rehabil 15:486–492PubMedCrossRefGoogle Scholar
  5. 5.
    Cooper AB, Thornley KS, Young GB, Slutsky AS, Stewart TE, Hanly PJ (2000) Sleep in critically ill patients requiring mechanical ventilation. Chest 117:809–818PubMedCrossRefGoogle Scholar
  6. 6.
    Freedman NS, Gazendam J, Levan L, Pack AI, Schwab RJ (2001) Abnormal sleep/wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit. Am J Respir Crit Care Med 163:451–457PubMedGoogle Scholar
  7. 7.
    Valente M, Placidi F, Oliveira AJ, Bigagli A, Morghen I, Proietti R, Gigli GL (2002) Sleep organization pattern as a prognostic marker at the subacute stage of post-traumatic coma. Clin Neurophysiol 113:1798–1805PubMedCrossRefGoogle Scholar
  8. 8.
    Gabor JY, Cooper AB, Crombach SA, Lee B, Kadikar N, Bettger HE, Hanly PJ (2003) Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care Med 167:708–715PubMedCrossRefGoogle Scholar
  9. 9.
    Johns MW, Large AA, Masterton JP, Dudley HA (1974) Sleep and delirium after open heart surgery. Br J Surg 61:377–381PubMedCrossRefGoogle Scholar
  10. 10.
    Orr WC, Stahl ML (1977) Sleep disturbances after open heart surgery. Am J Cardiol 39:196–201PubMedCrossRefGoogle Scholar
  11. 11.
    Broughton R, Baron R (1978) Sleep patterns in the intensive care unit and on the ward after acute myocardial infarction. Electroencephalogr Clin Neurophysiol 45:348–360PubMedCrossRefGoogle Scholar
  12. 12.
    Knill RL, Moote CA, Skinner MI, Rose EA (1990) Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week. Anesthesiology 73:52–61PubMedCrossRefGoogle Scholar
  13. 13.
    Edwards GB, Schuring LM (1993) Pilot study: validating staff nurses' observations of sleep and wake states among critically ill patients, using polysomnography. Am J Crit Care 2:125–131PubMedGoogle Scholar
  14. 14.
    Aaron JN, Carlisle CC, Carskadon MA, Meyer TJ, Hill NS, Millman RP (1996) Environmental noise as a cause of sleep disruption in an intermediate respiratory care unit. Sleep 19:707–710PubMedGoogle Scholar
  15. 15.
    Parthasarathy S, Tobin MJ (2002) Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 166:1423–1429PubMedCrossRefGoogle Scholar
  16. 16.
    Richards KC, Anderson WM, Chesson AL Jr, Nagel CL (2002) Sleep-related breathing disorders in patients who are critically ill. J Cardiovasc Nurs 17:42–55PubMedCrossRefGoogle Scholar
  17. 17.
    Krachman SL, D'Alonzo GE, Criner GJ (1995) Sleep in the intensive care unit. Chest 107:1713–1720PubMedCrossRefGoogle Scholar
  18. 18.
    Woods NF (1972) Patterns of sleep in postcardiotomy patients. Nurs Res 21:347–352PubMedCrossRefGoogle Scholar
  19. 19.
    Helton MC, Gordon SH, Nunnery SL (1980) The correlation between sleep deprivation and the intensive care unit syndrome. Heart Lung 9:464–468PubMedGoogle Scholar
  20. 20.
    Tweedie IE, Bell CF, Clegg A, Campbell IT, Minors DS, Waterhouse JM (1989) Retrospective study of temperature rhythms of intensive care patients. Crit Care Med 17:1159–1165PubMedCrossRefGoogle Scholar
  21. 21.
    Kong KL, Willatts SM, Prys-Roberts C, Harvey JT, Gorman S (1990) Plasma catecholamine concentration during sedation in ventilated patients requiring intensive therapy. Intensive Care Med 16:171–174PubMedCrossRefGoogle Scholar
  22. 22.
    Hurel D, Loirat P, Saulnier F, Nicolas F, Brivet F (1997) Quality of life 6 months after intensive care: results of a prospective multicenter study using a generic health status scale and a satisfaction scale. Intensive Care Med 23:331–337PubMedCrossRefGoogle Scholar
  23. 23.
    Freedman NS, Kotzer N, Schwab RJ (1999) Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Respir Crit Care Med 159:1155–1162PubMedGoogle Scholar
  24. 24.
    Simini B (1999) Patients' perceptions of intensive care. Lancet 354:571–572PubMedCrossRefGoogle Scholar
  25. 25.
    Treggiari-Venzi M, Borgeat A, Fuchs-Buder T, Gachoud JP, Suter PM (1996) Overnight sedation with midazolam or propofol in the ICU: effects on sleep quality, anxiety and depression. Intensive Care Med 22:1186–1190PubMedCrossRefGoogle Scholar
  26. 26.
    Walder B, Francioli D, Meyer JJ, Lancon M, Romand JA (2000) Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels. Crit Care Med 28:2242–2247PubMedCrossRefGoogle Scholar
  27. 27.
    Shilo L, Dagan Y, Smorjik Y, Weinberg U, Dolev S, Komptel B, Shenkman L (2000) Effect of melatonin on sleep quality of COPD intensive care patients: a pilot study. Chronobiol Int 17:71–76PubMedCrossRefGoogle Scholar
  28. 28.
    Olson DM, Borel CO, Laskowitz DT, Moore DT, McConnell ES (2001) Quiet time: a nursing intervention to promote sleep in neurocritical care units. Am J Crit Care 10:74–78PubMedGoogle Scholar
  29. 29.
    Topf M, Thompson S (2001) Interactive relationships between hospital patients' noise-induced stress and other stress with sleep. Heart Lung 30:237–243PubMedCrossRefGoogle Scholar
  30. 30.
    Nelson JE, Meier DE, Oei EJ, Nierman DM, Senzel RS, Manfredi PL, Davis SM, Morrison RS (2001) Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med 29:277–282PubMedCrossRefGoogle Scholar
  31. 31.
    Mundigler G, Delle-Karth G, Koreny M, Zehetgruber M, Steindl-Munda P, Marktl W, Ferti L, Siostrzonek P (2002) Impaired circadian rhythm of melatonin secretion in sedated critically ill patients with severe sepsis. Crit Care Med 30:536–540PubMedCrossRefGoogle Scholar
  32. 32.
    McKinley S, Nagy S, Stein-Parbury J, Bramwell M, Hudson J (2002) Vulnerability and security in seriously ill patients in intensive care. Intensive Crit Care Nurs 18:27–36PubMedCrossRefGoogle Scholar
  33. 33.
    Parthasarathy S, Tobin MJ (2003) Is sleep disruption related to severity of critical illness (abstract)? Am J Respir Crit Care Med 167:A968Google Scholar
  34. 34.
    Guilleminault C, Partinen M, Quera-Salva MA, Hayes B, Dement WC, Nino-Murcia G (1988) Determinants of daytime sleepiness in obstructive sleep apnea. Chest 94:32–37PubMedCrossRefGoogle Scholar
  35. 35.
    Young GB, Bolton CF, Austin TW, Archibald YM, Gonder J, Wells GA (1990) The encephalopathy associated with septic illness. Clin Invest Med 13:297–304PubMedGoogle Scholar
  36. 36.
    Trachsel L, Schreiber W, Holsboer F, Pollmacher T (1994) Endotoxin enhances EEG alpha and beta power in human sleep. Sleep 17:132–139PubMedGoogle Scholar
  37. 37.
    Prior PF (1985) EEG monitoring and evoked potentials in brain ischaemia. Br J Anaesth 57:63–81PubMedCrossRefGoogle Scholar
  38. 38.
    Riker RR, Fraser GL, Simmons LE, Wilkins ML (2001) Validating the sedation agitation scale with the bi-spectral index and visual analog scale in adult ICU patients after cardiac surgery. Intensive Care Med 27:853–858PubMedCrossRefGoogle Scholar
  39. 39.
    Kress JP, Pohlman AS, Hall JB (2002) Sedation and analgesia in the intensive care unit. Am J Respir Crit Care Med 166:1024–1028PubMedCrossRefGoogle Scholar
  40. 40.
    Kress JP, Pohlman AS, O'Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477PubMedCrossRefGoogle Scholar
  41. 41.
    Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK (2002) The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166:1338–1344PubMedCrossRefGoogle Scholar
  42. 42.
    Ramsay MA, Savege TM, Simpson BR, Goodwin R (1974) Controlled sedation with alphaxalone-alphadolone. BMJ 2:656–659PubMedCrossRefGoogle Scholar
  43. 43.
    Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway SA Jr, Murray MJ, Peruzzi WT, Lumb PD (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30:119–141PubMedCrossRefGoogle Scholar
  44. 44.
    Wauquier A (1993) EEG and neuropharmacology. In: Niedermeyer E and Da Silva FL (eds) Elelctroencephalography. Basic principles, clinical applications, and related fields. Willliams and Wilkins, Baltimore, pp 619–629Google Scholar
  45. 45.
    Sebel PS, Bovill JG, Wauquier A, Rog P (1981) Effects of high-dose fentanyl anesthesia on the electroencephalogram. Anesthesiology 55:203–211PubMedCrossRefGoogle Scholar
  46. 46.
    Cropp AJ, Woods LA, Raney D, Bredle DL (1994) Name that tone. The proliferation of alarms in the intensive care unit. Chest 105:1217–1220PubMedCrossRefGoogle Scholar
  47. 47.
    Bentley S, Murphy F, Dudley H (1977) Perceived noise in surgical wards and an intensive care area: an objective analysis. BMJ 2:1503–1506PubMedCrossRefGoogle Scholar
  48. 48.
    Soutar RL, Wilson JA (1986) Does hospital noise disturb patients? BMJ 292:305PubMedCrossRefGoogle Scholar
  49. 49.
    Topf M, Davis JE (1993) Critical care unit noise and rapid eye movement (REM) sleep. Heart Lung 22:252–258PubMedGoogle Scholar
  50. 50.
    Topf M (1992) Effects of personal control over hospital noise on sleep. Res Nurs Health 15:19–28PubMedCrossRefGoogle Scholar
  51. 51.
    Woods NF, Falk SA (1974) Noise stimuli in the acute care area. Nurs Res 23:144–150PubMedCrossRefGoogle Scholar
  52. 52.
    Kahn DM, Cook TE, Carlisle CC, Nelson DL, Kramer NR, Millman RP (1998) Identification and modification of environmental noise in an ICU setting. Chest 114:535–540PubMedCrossRefGoogle Scholar
  53. 53.
    Wallace CJ, Robins J, Alvord LS, Walker JM (1999) The effect of earplugs on sleep measures during exposure to simulated intensive care unit noise. Am J Crit Care 8:210–219PubMedGoogle Scholar
  54. 54.
    Esteban A, Anzueto A, Alia I, Gordo F, Apezteguia C, Palizas F, Cide D, Goldwaser R, Soto L, Bugedo G, Rodrigo C, Pimentel J, Raimondi G, Tobin MJ (2000) How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 161:1450–1458PubMedGoogle Scholar
  55. 55.
    Mehta S, Hill NS (2001) Noninvasive ventilation. Am J Respir Crit Care Med 163:540–577PubMedGoogle Scholar
  56. 56.
    Meza S, Mendez M, Ostrowski M, Younes M (1998) Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol 85:1929–1940PubMedGoogle Scholar
  57. 57.
    Hotchkiss JR Jr, Adams AB, Stone MK, Dries DJ, Marini JJ, Crooke PS (2002) Oscillations and noise: inherent instability of pressure support ventilation? Am J Respir Crit Care Med 165:47–53PubMedGoogle Scholar
  58. 58.
    Gleeson K, Zwillich CW, White DP (1990) The influence of increasing ventilatory effort on arousal from sleep. Am Rev Respir Dis 142:295–300PubMedGoogle Scholar
  59. 59.
    Preas HL 2nd, Jubran A, Vandivier RW, Reda D, Godin PJ, Banks SM, Tobin MJ, Suffredini AF (2001) Effect of endotoxin on ventilation and breath variability: role of cyclooxygenase pathway. Am J Respir Crit Care Med 164:620–626PubMedGoogle Scholar
  60. 60.
    Issa FG, Sullivan CE (1983) Arousal and breathing responses to airway occlusion in healthy sleeping adults. J Appl Physiol 55:1113–1119PubMedGoogle Scholar
  61. 61.
    Rechtschaffen A, Gilliland MA, Bergmann BM, Winter JB (1983) Physiological correlates of prolonged sleep deprivation in rats. Science 221:182–184PubMedCrossRefGoogle Scholar
  62. 62.
    Rechtschaffen A, Bergmann BM, Everson CA, Kushida CA, Gilliland MA (1989) Sleep deprivation in the rat: X. Integration and discussion of the findings. Sleep 12:68–87PubMedGoogle Scholar
  63. 63.
    Bonnet MH (2000) Sleep deprivation. In: Kryger MH, Roth T, Dement WC (eds) Principles and practice of sleep medicine. Saunders, Philadelphia, pp 53–71Google Scholar
  64. 64.
    Jubran A, Van de Graaff WB, Tobin MJ (1995) Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 152:129–136PubMedGoogle Scholar
  65. 65.
    Tobin MJ, Jubran A, Laghi F (2001) Patient-ventilator interaction. Am J Respir Crit Care Med 163:1059–1063PubMedGoogle Scholar
  66. 66.
    Younes M (1994) Mechanisms of respiratory load compensation. In: Dempsey JA, Pack AI (eds) Regulation of breathing. Lung biology in health and disease. Vol. 79. Dekker, New York, pp 867–922Google Scholar
  67. 67.
    Dempsey JA, Skatrud JB (2001) Apnea following mechanical ventilation may be caused by nonchemical neurome-chanical influences. Am J Respir Crit Care Med 163:1297–1298PubMedGoogle Scholar
  68. 68.
    Younes M (2001) Apnea following mechanical ventilation may not be caused by neuromechanical influences. Am J Respir Crit Care Med 163:1298–1301PubMedGoogle Scholar
  69. 69.
    Leung RS, Bradley TD (2001) Sleep apnea and cardiovascular disease. Am J Respir Crit Care Med 164:2147–2165PubMedGoogle Scholar
  70. 70.
    Sin DD, Logan AG, Fitzgerald FS, Liu PP, Bradley TD (2000) Effects of continuous positive airway pressure on cardiovascular outcomes in heart failure patients with and without Cheyne-Stokes respiration. Circulation 102:61–66PubMedGoogle Scholar
  71. 71.
    Wellens HJ, Vermeulen A, Durrer D (1972) Ventricular fibrillation occurring on arousal from sleep by auditory stimuli. Circulation 46:661–665PubMedGoogle Scholar
  72. 72.
    Marin JM, Carrizo SJ, Kogan I (1998) Obstructive sleep apnea and acute myocardial infarction: clinical implications of the association. Sleep 21:809–815PubMedGoogle Scholar
  73. 73.
    Brooks D, Horner RL, Kozar LF, Render-Teixeira CL, Phillipson EA (1997) Obstructive sleep apnea as a cause of systemic hypertension. Evidence from a canine model. J Clin Invest 99:106–109PubMedCrossRefGoogle Scholar
  74. 74.
    Trinder J, Merson R, Rosenberg JI, Fitzgerald F, Kleiman J, Douglas Bradley T (2000) Pathophysiological interactions of ventilation, arousals, and blood pressure oscillations during Cheyne-Stokes respiration in patients with heart failure. Am J Respir Crit Care Med 162:808–813PubMedGoogle Scholar
  75. 75.
    Leuenberger U, Jacob E, Sweer L, Waravdekar N, Zwillich C, Sinoway L (1995) Surges of muscle sympathetic nerve activity during obstructive apnea are linked to hypoxemia. J Appl Physiol 79:581–588PubMedGoogle Scholar
  76. 76.
    Parthasarathy S, Laghi F, Jubran A, Tobin MJ (2002) Does ventilator mode influence blood pressure oscillations in critically ill patients (abstract)? Am J Respir Crit Care Med 165:A165Google Scholar
  77. 77.
    Cheshire K, Engelman H, Deary I, Shapiro C, Douglas NJ (1992) Factors impairing daytime performance in patients with sleep apnea/hypopnea syndrome. Arch Intern Med 152:538–541PubMedCrossRefGoogle Scholar
  78. 78.
    Spengler C, Shea S (2001) Sleep deprivation per se does not decrease the hypercapnic ventilatory response in humans. Am J Respir Crit Care Med 161:1124–1128Google Scholar
  79. 79.
    McGuire BE, Basten CJ, Ryan CJ, Gallagher J (2000) Intensive care unit syndrome: a dangerous misnomer. Arch Intern Med 160:906–909PubMedCrossRefGoogle Scholar
  80. 80.
    Irwin M, McClintick J, Costlow C, Fortner M, White J, Gillin JC (1996) Partial night sleep deprivation reduces natural killer and cellular immune responses in humans. FASEB J 10:643–653PubMedGoogle Scholar
  81. 81.
    Dinges DF, Douglas SD, Hamarman S, Zaugg L, Kapoor S (1995) Sleep deprivation and human immune function. Adv Neuroimmunol 5:97–110PubMedCrossRefGoogle Scholar
  82. 82.
    Dinges DF, Douglas SD, Zaugg L, Campbell DE, McMann JM, Whitehouse WG, Orne EC, Kapoor SC, Icaza E, Orne MT (1994) Leukocytosis and natural killer cell function parallel neurobehavioral fatigue induced by 64 hours of sleep deprivation. J Clin Invest 93:1930–1939PubMedCrossRefGoogle Scholar
  83. 83.
    Palmblad J, Petrini B, Wasserman J, Akerstedt T (1979) Lymphocyte and granulocyte reactions during sleep deprivation. Psychosom Med 41:273–278PubMedGoogle Scholar
  84. 84.
    Moldofsky H, Lue FA, Davidson JR, Gorczynski R (1989) Effects of sleep deprivation on human immune functions. FASEB J 3:1972–1977PubMedGoogle Scholar
  85. 85.
    Boyum A, Wiik P, Gustavsson E, Veiby OP, Reseland J, Haugen AH, Opstad PK (1996) The effect of strenuous exercise, calorie deficiency and sleep deprivation on white blood cells, plasma immunoglobulins and cytokines. Scand J Immunol 43:228–235PubMedCrossRefGoogle Scholar
  86. 86.
    Brown R, Pang G, Husband AJ, King MG (1989) Suppression of immunity to influenza virus infection in the respiratory tract following sleep disturbance. Reg Immunol 2:321–325PubMedGoogle Scholar
  87. 87.
    Scrimshaw NS, Habicht JP, Pellet P, Piche ML, Cholakos B (1966) Effects of sleep deprivation and reversal of diurnal activity on protein metabolism of young men. Am J Clin Nutr 19:313–319PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2009

Authors and Affiliations

  • Sairam Parthasarathy
    • 1
  • Martin J. Tobin
    • 2
  1. 1.Division of Pulmonary and Critical Care, Medicine E dward H ines Jr. Veterans A dministrative H ospitalLoyola University of C hicago S tritch S chool of Medicine RouteHinesUSA
  2. 2.Division of Pulmonary and critical care Medicine edward hines JrVa hospitalHinesUSA

Personalised recommendations