Sleep of the critically ill and the influencing factors

Transcription

1 Sleep of the critically ill and the influencing factors Marita Ritmala-Castrén RN, MNSc, CNS Helsinki University Hospital, Operative department, Finland Professor Helena Leino-Kilpi, RN, PhD University of Turku, Department of Nursing and Health sciences

2 Search and results Medline, CINAHL, PsycINFO Sleep (any of below) sleep$ Sleep Disorders "sleep enhancement (iowa nic) * "Sleep Pattern Disturbance (NANDA) * AND Assessment (any of below) Monitoring, Physiologic assess$ adj5 sleep$ monitor$ adj5 sleep$ measur$ adj5 sleep$ qualit$ adj5 sleep$ question$ adj5 sleep$ sleep scale polysomnograp$ actigraph$ actometr$ bispectral index AND Critical care (any of below) acute disease catastrophic illness critical illness Emergencies critical care intensive care Intensive Care Units critically ill severely ill Adult, no brain injury/surgery, no sedation studies 36 articles described sleep in an ICU and/or factors influencing it

3 Multifactorial model of sleep Redeker & Hedges 2002 J Cardiovasc Nurs

4 Normal sleep Non-REM sleep Light sleep Deep sleep N1 N2 N3 Time Kryger et al 2005

5 SLEEP of the critically ill Quantity mean 5,3-18,9 h/24 h mean 1-6 h/night Continuity awakenings 2,4-76/h Diurnal timing if intubated, ~50 % day sleep Depth Friese et al Lippincott Williams & Wilkins Deep sleep (N3) mean 2-46 % of total sleep time (TST) REM sleep mean 0-20 % of TST

6 Environmental/situational influences - ILLNESS Sleep indicators in EEG disappear in sepsis (Freedman et al 2001) Vivid dreams, hallucinations with Guillan-Barré syndrome (Cochen et al 2005) No correlation with APACHE II or III (Bourne et al 2008; Calvete Vasques et al 2000; Freedman et al 2001; Hardin et al 2006) pos/neg culture results (Hardin et al 2006) P-crea (Nicholson et al 2001) Medical vs surgical illness (Nicholson et al 2001) Type of surgery (Nicolas et al 2002) Diagnosis (Scotto et al 2009)

7 Environmental/situational influences HOSPITAL ENVIRONMENT Noise perceived as the most or 2nd most disrupting in 5 studies staff talking and alarms the worst Noise causes % of arousals/ awakenings (Bosma et al 2007) Other disrupting matters heat (Calvete Vasquez et al 2000) uncomfortable bed (Calvete Vasquez et al 2000; de Haro Marin et al 1999) Quiet time reduces noise and light levels and increases the amount of observed sleep (Olson et al 2001) Light is not perceived disturbing

8 Environmental/situational influences - TREATMENT Nursing care explain 7,1 % arousals/ awakenings (Gabor et al 2003) Vital signs, phlebotomy most disturbing (Freedman et al 1999) Ventilator settings Apneas, ineffective breathing efforts explain 10 % arousals/awakenings (Cabello et al 2008) Proportional assist ventilation better than pressure support (less asynchrony) (Bosma et al 2007) PAV with load adjustable gain factors, PS no difference (Alexopoulou et al 2007) Assist control vent improves sleep efficiency and decreases awakenings vs PS (Parthasarathy & Tobin 2002) ACV, apsv, cpsv no difference (Cabello et al 2008)

9 Environmental/situational influences TREATMENT (cont.) Perceived disturbing ET tube, NONinv ventilation, pleural drains (Calvete Vasquez et al 2000) Need to urinate (de Haro Marin 1999) No correlation ICU stay (5 studies) use of benzodiazepines or narcotics (Friese et al 2007; Hardin et al 2006; Nicholson et al 2001; Richards 1998) analgesics and sedatives promote N1 and N2 sleep, decrease N3 and REM sleep (Hilton 1976) not receiving hypnotics -> felt they slept better (Frisk & Nordström 2003), but opioid analgesics provide better sleep than non-opioids (Nicolas et al 2002) use of sympatomimetics (Nicholson et al 2001) vent/no vent (Nicholson et al 2002) with perceived sleep quality (Freedman et al 1999)

10 Environmental/situational influences TREATMENT (cont.) Improve sleep (?) Back massage (p = 0,06) (Richards 1998) Relaxation (p = 0,06) (Richards 1998) Relaxation with guided imagery (stat sign?) (Richardson 2003) Eye masks (no stat tests) ( Richardson et al 2007) Earplugs make patients to fall asleep easier, experience less waking and tossing and turning, sleep more deeply, for longer periods, and awake more satisfied and refreshed (Scotto 2009) Melatonin may improve induction of sleep (Shilo et al 2000)

11 Endogenous influences AGE no difference, 6 studies < 50 years old -> report more disturbances (Higgins 1998) GENDER no difference, 5 studies men respond to relaxation/quided imagery immediately, women need repetition (stat sig?) (Richardson 2003) BASELINE HEALTH STATUS no data

12 Primary sleep disorders No significant correlation (Calvete Vasquez et al 2000; Richards 1998) Sleep related breathing disorders present in almost half of the participants with cardiovascular disease (Richards et al 2002)

13 Cardiovascular disease Heart failure (EF < 50 or history of CHF) more common among pts who had apnea (Pathasarathy & Tobin 2002) No sleep associated dysrythmias (Richards et al 1996)

14 Symptoms PAIN disturbance perceived 4,48 (scale 1-10) (Calvete Vasquez et al 2000) prevented from sleeping 3rd night in ICU (de Haro Marin et al 1999) FATIGUE No data DYSPNEA No data COUGH (not in the model) prevented from sleeping 2nd and 3rd night in ICU (de Haro Marin et al 1999) TEMPERATURE (not in the model) No correlation (Hardin et al 2006)

15 Emotional distress Anxiousness, fear - disturbance perceived 2,48 (scale 1-10) (Calvete Vasquez et al 2000) Preoccupation with illness or family matters prevented from sleeping 3rd night in ICU (de Haro Marin et al 1999)

16 Summary? Noise Disturbing! Sleep promoting treatments????? Other symptoms??? Redeker & Hedges 2002 J Cardiovasc Nurs

17 Some final thoughts... We know patients do not sleep well in an ICU sleep is important even to healthy people We do not know how to effectively help patients to sleep what/how to remove disturbing factors (except noise) how to promote sleep But we can use common sence (Honkus 2003)

18 Thank you!