Don’t Wake the Bear: Sleep Disruption in the ICU and How ...
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Don’t Wake the Bear: Sleep Disruption in the ICU and How Nurses Can Help Makayla Cordoza, PhD, RN, CCRN-K Postdoctoral Fellow University of Pennsylvania NTI 2021 C60M343 https://stock.adobe.com/search?k=bear+roar 1
Transcript of Don’t Wake the Bear: Sleep Disruption in the ICU and How ...
PowerPoint PresentationDon’t Wake the Bear: Sleep Disruption in the
ICU and How
Nurses Can Help
Postdoctoral Fellow
• Discuss consequences of disrupted sleep
• Causes of sleep disruption in the ICU
• Interventions to promote sleep and circadian alignment
2
3
Humans operate on a ~24h (23h 56min) day.
Our circadian rhythm is entrained to a day and night period.
Photo source: Clocking in: chronobiology in rheumatoid arthritis
Kleitman, & Engelmann. J Appl Phys; 1953.
Circadian development over infancy
5
6
Sato, et al. Front Physiol (2014). 7
Arendt. Endotext (2011)
8
9
Sleep is a biologic necessity. It is not optional. Failure to achieve adequate sleep
in the 24h day can result in negative short and long-term health outcomes.
Recommend 7-9h sleep per 24h
Watson, et al. SLEEP; 2015
Sleep should optimally be: • Continuous
• Cycle to enable deep and restorative sleep
• Sufficient in duration
• 72 yo F
• Scheduled for open thoracic AVR, going to be admitted to ICU
immediately post-surgery
• Rates her sleep quality as “good”
• No sleep disorders
• Normally goes to bed ~1000, wakes up ~0530
12
• ~65min Stage 3/4 sleep (15%)
W S1 S2 S3 REM
13
• Can be of adequate duration
• Not of high quality
• Not restorative
Devlin et al. Crit Care Med (2018); Elliott et al. Crit Care (2013)
15
• Baseline poor sleep quality
• Use of sleep-promoting medications
disease, sleep apnea, restless legs syndrome, insomnia, obesity, etc.
Devlin et al. Crit Care Med (2018)
16
Illness/Injury/Insult
Boone, et al. PLOS ONE (2012); Grima, et al. Neural Repair (2016)
17
Medications/Interventions
Benzodiazepines May ↑ TST
Analgesics (at higher doses) ↓ TST, REM, SWS, SE
Propofol Suppress REM, worsen SQ
Dexmedetomidine ↓ REM, SL/ Some evidence of ↑ SQ
Haloperidol ↓ wakefulness & SL
Amioderone Nightmares
Antibiotics (quinolone) Worsen SQ
Pisani, et al. AJRCCM (2015); Weinhouse. Crit Care Clin (2008); Romagnoli et al. Sleep Med (2020)
19
Cont tube feeding
Devlin et al. Crit Care Med (2018); Bihari et al. J Clin Sleep Med (2012); Tamburri et al. AJCC (2004)
20
Enteral Feeding
Jobanputra et al. Front Neurol (2020); Ichimaru. ASPEN (2018); Schuler & Hope. Int Funct Med Nut Therapy (2020)
• Feeding patterns directly affect the circadian clock
• Continuous delivery of energy is not in alignment with our biologic rhythms
21
Psychologic/Physiologic
Pain & discomfort
Difficulty breathing
Environment
23
Environment
24
Environment
Boone, et al. PLOS ONE (2012); Grima, et al. Neural Repair (2016)
25
Environment
Boone, et al. PLOS ONE (2012); Grima, et al. Neural Repair (2016)
Lighting
• Bright
• Continuous
disrupt melatonin
• Returned to ICU @1520 (~6h surgery)
• VS: BP 135/66, HR 67 NRS, RR 16 @30%, SpO2 100%
• Had a-line, pacer wires, PA catheter, chest tubes, SCDs in addition to usual
monitoring equipment
• Started on amiodarone @1 mg/6h after 150mg bolus
• Other medications: • hydromorphone 1 mg/hr PRN • Vancomycin and cefazolin • Acetaminophen 650 Q4h PRN
27
• Inter-individual differential effects and vulnerabilities to sleep disruption on biology and behavior
28
Consequences of sleep disruption: Mood, alertness, and performance
Van Dongen et al. SLEEP (2003); Dres et al. Am J Respir Crit Care Med (2019)
29
(IL-1, IL-6, TNF-a, CRP)
• Impaired recovery/healing
• Insulin resistance
Meier-Ewert et al. J Am Col Card (2004); Buxton et al. ADA (2010); Donga et al. J Clin Endocrinol Metab (2010)
30
• Digestion and microbiome
• Impaired muscle recovery and strength
Jeddi et al. Arq Bras Card (2015); Ogawa et al. SLEEP (2003)
31
Baseline
• TST= 7.2h
• SE= 89%
• Normal sleep physiology • ~86 min REM (20%) • ~65min Stage 3/4 sleep (15%)
ICU Sleep Study
Baseline Sleep Study
• TST= 2.5h
• SE= 12%
• Normal sleep physiology • 0 min REM • ~8min Stage 3/4 sleep (5%)
32
• Difficult to determine in routine clinical practice
• If able, subjectively ask patients about sleep
• DO NOT assume a patient with their eyes closed is sleeping
• Consider sleep deprivation and poor quality sleep as a factor in the differential diagnosis of ICU problems
33
• 6mo before and after QI project in a neurosurgical ICU
• Institute quiet time 2h twice daily
Goeren et al. CCN (2018) 35
Instituting quiet times
• RCT of N=56 ICU patients
Knauert. BMJ Open Respir Res (2019) 36
Sound masking/blocking • N=14 healthy volunteers
• Simulated ICU noise night
Hu et al. Crit Care (2010) 37
Sound masking/blocking
Stanchina et al. Sleep Med (2005); Smith et al. Sleep Med Reviews (2021)
• Overall evidence is low for use of WNM
• More rigorous research with objective sleep
measures and detailed noise descriptions,
including sound pressure level, frequency
weighting, noise location, noise type (e.g.,
pink, white, broadband), background noise,
exposure-response relationships, and
recommendations for the use of WNMs are
justifiable
https://www.mhealth.org/blog/2016/july-2016/innovative-lighting-system-will-promote-healing-at-masonic-childrens-hospital; https://www.inquirer.com/philly/health/the-era-of-circadian-lighting-in-health-care-is-dawning-20180627.html; https://www.nultylighting.co.uk/blog/blue-light-considerations-lighting-design/
• Massage, foot reflexology, music, acupressure, aromatherapy
• Sleep hygiene
• Decrease sedation
• Increase activity
• A-F bundles
Effect of
Effect of
Effect of
However… • Recent retrospective study (N=232) showed patients who received
melatonin for at least 48h had significantly less ICU delirium compared to the no melatonin group
• Recent placebo-RCT of N=203 patients who received 10mg melatonin q night for 7 consecutive nights had significantly better sleep quality
• 45.8% and 34.4% of participants in the melatonin and placebo groups had very good sleep (RR 1.33; 95% CI 0.94–1.89), whereas 3.1% and 14.6% had very poor sleep (RR 0.21; 95% CI 0.06–0.71), respectively
• Small study (N=20) using dexmedetomidine (maintain RASS -1 to -2) in non-intubated patients
• Significantly longer sleep duration, and better efficiency in the dex group
Baumgartner et al. Pharmacotherapy (2019); Gandolfi et al. CCM (2020); Lu et al. Medicine (2017) 47
Bottom line: How can we support Marerly Davthan to achieve optimal sleep in the ICU? Multi-modal strategy
• Quiet
• Limits non-urgent clinical care overnight • Clusters care overnight when able • Consider delaying morning labs
• Circadian entrained lighting systems • No bright lights overnight if possible
• Consider sound/light-masking strategies • Ear plugs/eye masks
• Increase mobility, promote “normal” day/night behaviors
• When providing holistic care, don’t forget about sleep!!!
McKenna et al. Crit Care (2018)
48
• Addressing the environment • Quiet space, especially during the night
• Providing circadian-entrained lighting
• Promoting normal sleep and wake behaviors
• e.g. mobility, sleep hygiene
associated-with-cognitive-impairment-in-icu-survivors/
49
Photo: Wellness Wednesday Guide: Sleep; Dangers of Sleep Deprivation - Health and Safety; SIESTA project reduces inpatient sleep interruptions
50
Nurses Can Help
Postdoctoral Fellow
• Discuss consequences of disrupted sleep
• Causes of sleep disruption in the ICU
• Interventions to promote sleep and circadian alignment
2
3
Humans operate on a ~24h (23h 56min) day.
Our circadian rhythm is entrained to a day and night period.
Photo source: Clocking in: chronobiology in rheumatoid arthritis
Kleitman, & Engelmann. J Appl Phys; 1953.
Circadian development over infancy
5
6
Sato, et al. Front Physiol (2014). 7
Arendt. Endotext (2011)
8
9
Sleep is a biologic necessity. It is not optional. Failure to achieve adequate sleep
in the 24h day can result in negative short and long-term health outcomes.
Recommend 7-9h sleep per 24h
Watson, et al. SLEEP; 2015
Sleep should optimally be: • Continuous
• Cycle to enable deep and restorative sleep
• Sufficient in duration
• 72 yo F
• Scheduled for open thoracic AVR, going to be admitted to ICU
immediately post-surgery
• Rates her sleep quality as “good”
• No sleep disorders
• Normally goes to bed ~1000, wakes up ~0530
12
• ~65min Stage 3/4 sleep (15%)
W S1 S2 S3 REM
13
• Can be of adequate duration
• Not of high quality
• Not restorative
Devlin et al. Crit Care Med (2018); Elliott et al. Crit Care (2013)
15
• Baseline poor sleep quality
• Use of sleep-promoting medications
disease, sleep apnea, restless legs syndrome, insomnia, obesity, etc.
Devlin et al. Crit Care Med (2018)
16
Illness/Injury/Insult
Boone, et al. PLOS ONE (2012); Grima, et al. Neural Repair (2016)
17
Medications/Interventions
Benzodiazepines May ↑ TST
Analgesics (at higher doses) ↓ TST, REM, SWS, SE
Propofol Suppress REM, worsen SQ
Dexmedetomidine ↓ REM, SL/ Some evidence of ↑ SQ
Haloperidol ↓ wakefulness & SL
Amioderone Nightmares
Antibiotics (quinolone) Worsen SQ
Pisani, et al. AJRCCM (2015); Weinhouse. Crit Care Clin (2008); Romagnoli et al. Sleep Med (2020)
19
Cont tube feeding
Devlin et al. Crit Care Med (2018); Bihari et al. J Clin Sleep Med (2012); Tamburri et al. AJCC (2004)
20
Enteral Feeding
Jobanputra et al. Front Neurol (2020); Ichimaru. ASPEN (2018); Schuler & Hope. Int Funct Med Nut Therapy (2020)
• Feeding patterns directly affect the circadian clock
• Continuous delivery of energy is not in alignment with our biologic rhythms
21
Psychologic/Physiologic
Pain & discomfort
Difficulty breathing
Environment
23
Environment
24
Environment
Boone, et al. PLOS ONE (2012); Grima, et al. Neural Repair (2016)
25
Environment
Boone, et al. PLOS ONE (2012); Grima, et al. Neural Repair (2016)
Lighting
• Bright
• Continuous
disrupt melatonin
• Returned to ICU @1520 (~6h surgery)
• VS: BP 135/66, HR 67 NRS, RR 16 @30%, SpO2 100%
• Had a-line, pacer wires, PA catheter, chest tubes, SCDs in addition to usual
monitoring equipment
• Started on amiodarone @1 mg/6h after 150mg bolus
• Other medications: • hydromorphone 1 mg/hr PRN • Vancomycin and cefazolin • Acetaminophen 650 Q4h PRN
27
• Inter-individual differential effects and vulnerabilities to sleep disruption on biology and behavior
28
Consequences of sleep disruption: Mood, alertness, and performance
Van Dongen et al. SLEEP (2003); Dres et al. Am J Respir Crit Care Med (2019)
29
(IL-1, IL-6, TNF-a, CRP)
• Impaired recovery/healing
• Insulin resistance
Meier-Ewert et al. J Am Col Card (2004); Buxton et al. ADA (2010); Donga et al. J Clin Endocrinol Metab (2010)
30
• Digestion and microbiome
• Impaired muscle recovery and strength
Jeddi et al. Arq Bras Card (2015); Ogawa et al. SLEEP (2003)
31
Baseline
• TST= 7.2h
• SE= 89%
• Normal sleep physiology • ~86 min REM (20%) • ~65min Stage 3/4 sleep (15%)
ICU Sleep Study
Baseline Sleep Study
• TST= 2.5h
• SE= 12%
• Normal sleep physiology • 0 min REM • ~8min Stage 3/4 sleep (5%)
32
• Difficult to determine in routine clinical practice
• If able, subjectively ask patients about sleep
• DO NOT assume a patient with their eyes closed is sleeping
• Consider sleep deprivation and poor quality sleep as a factor in the differential diagnosis of ICU problems
33
• 6mo before and after QI project in a neurosurgical ICU
• Institute quiet time 2h twice daily
Goeren et al. CCN (2018) 35
Instituting quiet times
• RCT of N=56 ICU patients
Knauert. BMJ Open Respir Res (2019) 36
Sound masking/blocking • N=14 healthy volunteers
• Simulated ICU noise night
Hu et al. Crit Care (2010) 37
Sound masking/blocking
Stanchina et al. Sleep Med (2005); Smith et al. Sleep Med Reviews (2021)
• Overall evidence is low for use of WNM
• More rigorous research with objective sleep
measures and detailed noise descriptions,
including sound pressure level, frequency
weighting, noise location, noise type (e.g.,
pink, white, broadband), background noise,
exposure-response relationships, and
recommendations for the use of WNMs are
justifiable
https://www.mhealth.org/blog/2016/july-2016/innovative-lighting-system-will-promote-healing-at-masonic-childrens-hospital; https://www.inquirer.com/philly/health/the-era-of-circadian-lighting-in-health-care-is-dawning-20180627.html; https://www.nultylighting.co.uk/blog/blue-light-considerations-lighting-design/
• Massage, foot reflexology, music, acupressure, aromatherapy
• Sleep hygiene
• Decrease sedation
• Increase activity
• A-F bundles
Effect of
Effect of
Effect of
However… • Recent retrospective study (N=232) showed patients who received
melatonin for at least 48h had significantly less ICU delirium compared to the no melatonin group
• Recent placebo-RCT of N=203 patients who received 10mg melatonin q night for 7 consecutive nights had significantly better sleep quality
• 45.8% and 34.4% of participants in the melatonin and placebo groups had very good sleep (RR 1.33; 95% CI 0.94–1.89), whereas 3.1% and 14.6% had very poor sleep (RR 0.21; 95% CI 0.06–0.71), respectively
• Small study (N=20) using dexmedetomidine (maintain RASS -1 to -2) in non-intubated patients
• Significantly longer sleep duration, and better efficiency in the dex group
Baumgartner et al. Pharmacotherapy (2019); Gandolfi et al. CCM (2020); Lu et al. Medicine (2017) 47
Bottom line: How can we support Marerly Davthan to achieve optimal sleep in the ICU? Multi-modal strategy
• Quiet
• Limits non-urgent clinical care overnight • Clusters care overnight when able • Consider delaying morning labs
• Circadian entrained lighting systems • No bright lights overnight if possible
• Consider sound/light-masking strategies • Ear plugs/eye masks
• Increase mobility, promote “normal” day/night behaviors
• When providing holistic care, don’t forget about sleep!!!
McKenna et al. Crit Care (2018)
48
• Addressing the environment • Quiet space, especially during the night
• Providing circadian-entrained lighting
• Promoting normal sleep and wake behaviors
• e.g. mobility, sleep hygiene
associated-with-cognitive-impairment-in-icu-survivors/
49
Photo: Wellness Wednesday Guide: Sleep; Dangers of Sleep Deprivation - Health and Safety; SIESTA project reduces inpatient sleep interruptions
50
