KTA VP Sleep in the ICU

Putting the Pieces Back Together; Un-fracturing Sleep for the Critically Ill
November 26, 2014
Vininder Bains, ICU Nurse, Vancouver General Hospital

Webinar recording: http://www.inspirenet.ca/sites/default/files/docs/virtual_podium_sleep-20141126_1906-1.mp4

More information about the Virtual Podium initiative: http://www.inspirenet.ca/KT-Invitation-Virtual-Podium


Natural restorative sleep has a specific architecture; it consists of 6 to 8 hours of nocturnal consecutive sleep. A person cycles from light sleep, to deep and rapid eye movement (REM) sleep every 90 to 120 minutes, with 20% to 25% of the night spent in REM sleep. This architecture is achieved by the co-ordination of 2 separate processes; the circadian rhythm and Process S, also known as the homeostatic process (Patel, Chipman, Carlin, & Shade, 2008). Circadian rhythm is controlled by the cyclic interplay of a several neurotransmitters such as dopamine, serotonin, norepinephrine, melatonin acetylcholine and histamine (Patel et al., 2008). Process S is influenced by how long you have been awake; it affects the duration and depth of sleep (Patel et al., 2008). If you are awake for long periods, process S will allow you to sleep longer, and more deeply than usual to recover.

Sleep also has a purpose; it allows us to recover and restore normal function. Sleep deprivation has been known to impair immune function, alter cognition, reduce pain tolerance, contribute to delirium, slow wound healing, glucose intolerance, cause hypertension and hemodynamic instability (Tembo & Parker, 2009). The most crucial need for efficient sleep is during an illness, and yet this is the time when a person is least likely to achieve it.

Instead sleep, for any hospital patient, is very disrupted.  Sleep disruption is worst for the critically ill patient. In the ICU, it consisting of many 3 to 15 minute micro-naps, 50% of sleep occurs during the day, and because of the fragmented pattern of sleep, patients spend as little as 0-8% of their sleep in the REM state (Elliott, McKinley, Cistulli, & Fien, 2013). The effects of prolonged sleep deprivation have long term affects, contributing to sleep disturbances, which persists many months after discharge.

There are also many environmental factors that we as health care workers can impact to promote or prevent sleep. One study reported in only 9 out of 147 nights, did ICU patients receive a 2-3 hour block of undisturbed time at night to sleep (Tamburri, DiBrienza, Zozula, & Redeker, 2004). Other research indicate average noise levels in ICU is 53dB to 65dB (Patel et al., 2008) which far exceed the recommendation of less than 35dB to promote sleep. (Agency, 1974)

Today sleep in the Intensive Care Unit (ICU) is as woefully inadequate and highly fractured today as it was when it was first researched 40 years ago (Elliott et al., 2013) Will we make a difference?

Agency, US Environmental Protection. (1974). Information on levels of environmental noise requisite to protect public health and welfare with an adequate margin of safety: Proceedings of the Conference on Noise as a Public Health Problem, March 1974. Paper presented at the Conference on Noise as a Public Health Problem, Washington DC.

Elliott, R., McKinley, S., Cistulli, P., & Fien, M. (2013). Characterisation of sleep in intensive care using 24-hour polysomnography: an observational study. Crit Care, 17(2), R46. doi: 10.1186/cc12565

Patel, M., Chipman, J., Carlin, B. W., & Shade, D. (2008). Sleep in the intensive care unit setting. Crit Care Nurs Q, 31(4), 309-318; quiz 319-320. doi: 10.1097/01.cnq.0000336816.89300.41

Tamburri, L. M., DiBrienza, R., Zozula, R., & Redeker, N. S. (2004). Nocturnal care interactions with patients in critical care units. Am J Crit Care, 13(2), 102-112; quiz 114-105.

Tembo, A. C., & Parker, V. (2009). Factors that impact on sleep in intensive care patients. Intensive Crit Care Nurs, 25(6), 314-322. doi: 10.1016/j.iccn.2009.07.002

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