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Why Won’t My Patient Sleep!
The Intensive Care patient will often lie awake at night, eyes wide open, clearly with no intention of sleeping. So why won’t the intensive care patient sleep? Perhaps we need to understand what happens during normal sleep and take it from there…..
Stages of sleep
Sleep is divided into non-rapid eye movement and rapid eye movement phases. The non-rapid eye movement stage is further divided into three different stages. The third of these, stage N3, is significant for its role in restorative processes.
Rapid eye movement sleep occupies 20% to 25% of the total sleep period. The brain is highly active in this period is associated with dreaming.
The circadian rhythms which drive the sleep wake cycle is regulated by adenosine and melatonin. One helps us sleep the other helps us keep awake.
What happens during sleep?
During sleep there is a loss of compensatory responses, such as shivering and sweating. The body temperature reaches its lowest point during the latter part of sleep and then rises prior to awakening.
Voluntary control of respiration is lost during sleep. Moving from being awake to the early phases of sleep is marked by a reduction in minute volume. Due to relaxation of upper respiratory muscles, increased airway resistance, and diminished central respiratory drive hypoventilation can occur which will increase arterial PCO2 levels.
During non-rapid eye movement sleep increased parasympathetic tone causes a decreased blood pressure, heart rate and systemic vascular resistance.
There is more variability during rapid eye movement sleep. There may be bursts of vagal activity and along with decreased sympathetic tone there may be bradyarrhythmias and sinus pauses.
Growth hormone and prolactin peak during sleep. Cortisol levels are also at their lowest level after sleep onset. Thyroid stimulating hormone is inhibited during sleep and will increase with sleep deprivation.
Sleep in ICU
Patients in intensive care commonly report poor sleep quality and surveys of survivors have shown that sleep deprivation ranks among the top three major sources of anxiety and stress during their stay in intensive care.
50% of their sleep will occur during daytime hours, and the average approximately 41 sleep periods per 24 hours each one lasting approximately 15 minutes. They commonly go through the first two stages of sleep without then moving onto the latter stage and rapid eye movement sleep. In other words they have broken light sleep without the restorative stages needed.
Causes of sleep disruption.
Noise– staff conversations, alarms, telephones and televisions are commonly quoted as being the causes of the noise within the intensive care unit. The recommendation is for maximum hospital noise levels of 45 dB during the day and 35 dB at night. Commonly however both daytime and night time noise levels routinely exceed 80 dB.
Patient care activities– patients in intensive care may experience 40 to 60 interruptions each night due to activities such as patient assessments, vital signs and is, equipment adjustment and medication administration to name a few.
Light– intensive care survivors have reported that light is less disruptive than noise and patient care activities. However it is known that nocturnal melatonin secretion in intensive care patients can be suppressed, causing further difficulties in sleeping.
Mechanical ventilation– the patient that is ventilated as compared to the patient that isn’t is more likely to suffer from sleep deprivation. This is due to factors such as increased ventilatory effort, abnormal gas exchange, and patient ventilator dysynchrony. Other factors may include endotracheal tube discomfort, ventilator alarms, suctioning, positioning, and frequent assessments.
Pic courtesy AJC1
Medications-some commonly used medications in intensive care can have profound effects on sleep quantity and quality. The sedation we use with many of the patients in intensive care is also disruptive to sleep. For example opiates such as fentanyl and morphine inhibit rapid eye movement sleep, profoundly suppress the latter stages of non-rapid eye movement sleep and can provoke awakening at night. Benzodiazepines and opiates are also associated with delirium in critically ill patients.
Propofol suppresses the latter stages of non rapid eye movement sleep whereas dexmedetomidine has been shown to enhance this stage of sleep in a rat model.
Psychological consequences of sleep deprivation in critically ill patients.
Delirium– delirium is associated with patient mortality, increase cost and length of stay and long-term cognitive impairment. It is possibly difficult to say whether sleep deprivation directly contributes to delirium but circadian rhythm disturbance, sedating medications and opiates contribute to both delirium and sleep disruption.
Psychiatric disturbances– survivors of critical illness often experience frightening flashbacks, nightmares, anxiety, and mood disturbances related to their intensive care stay.
Post-traumatic stress disorder has been shown in 10% to 39% of intensive care unit survivors during their first year after the intensive care unit stay. Post-traumatic stress disorder symptoms have been present in up to 45% of those discharged and is still present in 24% at 8 years after intensive care unit discharge.
Depression among survivors is also very common and has been shown to be present in 28% of patients within the first year of intensive care unit discharge. In those that suffered from ARDS the prevalence of depression is a size 46% at one year and 23% at two years after discharge.
Many studies have demonstrated depressive symptoms and increase levels of fatigue anxiety and stress in healthy participants undergoing total or partial sleep restriction. Sleep disruptions in the critically ill patient may be contributing to post intensive care unit psychiatric disorders. This is possibly not that well understood at the moment.
Cognitive dysfunction-impairment of memory, attention, concentration, language, mental processing speed, visuospatial abilities and executive function have all been shown to have been affected following critical illness. Some of the causes are thought to include delirium and sedating medications.
Due to neuro cognitive dysfunction many intensive care unit survivors experience challenges with daily functioning, social isolation and difficulties returning to work.
Quality of life-health-related quality-of-life concerns one’s perception of overall well-being and incorporates measures of physical, mental, emotional, and social functioning. Critical illness is associated with long-term impairments in quality of life for many years after intensive care unit discharge chronically reduce sleep also leads to reductions in quality of life.
With all of this in mind it would seem important therefore to try to promote whatever we can to help the patient to sleep whilst in the vertical care department. How can we do this? What measures can we take? Do you already take measures in your department? If you do, how are you sure they make any difference?
Please feel free to add your comments below.
Reference
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Get in touch with Jonathan
I would love to hear from you so that we can start to work together.- Send an email to contact@criticalcarepractitioner.co.uk
- Use my voicemail service link to the right of this page
- Fill in contact form at the bottom of the page
The Content on the website is provided for FREE as is the podcast.
You could help support this work by going to Amazon via this link. This means that I will earn a small commission from any purchases you make with NO extra cost to yourself.
Thank you.
Amazon Link
| Podcast Link | Podcast Episode Name |
|---|---|
| CCP Podcast 001 | Introduction and Interview with Teresa Chinn from @WeNurses |
| CCP Podcast 002 | Twitter, Google Hang Outs and Speakpipe |
| CCP Podcast 003 | Interview with Robin Davies, Lead Resuscitation Officer |
| CCP Podcast 004 | Great Medical Podcasts to Listen To |
| CCP Podcast 005 | Chat with Ken Spearpoint |
| CCP Podcast 006 | Chat with David Barton |
| CCP Podcast 007 | Chat with Bethan Bishop |
| CCP Podcast 008 | Chat with Claire Flatt |
| CCP Podcast 009 | SMACC Me Hard! |
| CCP Podcast 010 | Cricoid Pressure: Do it? Do it right? Or do it at all? |
| CCP Podcast 011 | Social Media...Use it, don't abuse it! |
| CCP Podcast 012 | Get my feet to the floor...please! |
| CCP Podcast 013 | Mind and Body |
| CCP Podcast 014 | How Much Fluid? |
| CCP Podcast 015 | The Power of Practitioners? |
| CCP Podcast 016 | The Strong Arm of Eric...YouTube Learning. |
| CCP Podcast 017 | Simon is one of the First 2 Act |
| CCP Podcast 018 | Mechanical Ventilation... |
| CCP Podcast 019 | SepsisPAM analysed. Gav and Jonathan try to work it out! |
| CCP Podcast 020 | More Power to Practitioners |
| CCP Podcast 021 | Jesse's Show |
| CCP Podcast 022 | ACPs Education, Education, Education. |
| CCP Podcast 023 | Wash Your Mouth Out!! |
| CCP Podcast 024 | Mechanical Ventilation...the basics |
| CCP Podcast 025 | Teresa Gets A Gong! |
| CCP Podcast 026 | Crew Resource Management...What? |
| CCP Podcast 027 | Crew Resource Management Continued |
| CCP Podcast 028 | James DuCanto Talks Intubation |
| CCP Podcast 029 | Mechanical Ventilation...Phases of the Breath |
| CCP Podcast 030 | SMACC it! |
| CCP Podcast 031 | Lifesaver to Lightsabre! |
| CCP Podcast 032 | Hello South Africa! |
| CCP Podcast 033 | Calling all students... |
| CCP Podcast 034 | Mechanical Ventilation...Types of breath |
| CCP Podcast 035 | 5 Tips for Better Presentations |
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| CCP Podcast 038 | WeNurses Tweet Chat About Advanced Practitioners |
| CCP Podcast 039 | Early Mobilisation- Get Them Moving! |
| CCP Podcast 040 | Why Won't We Change? |
| CCP Podcast 041 | PTSD in Critical Care |
| CCP Podcast 042 | What angle should I sit my patient at? |
| CCP Podcast 043 | Why won't my patient sleep? |
| CCP Podcast 044 | Helping the ITU patient sleep |
| CCP Podcast 045 | Simple Things to Help them Sleep |
| CCP Podcast 046 | PTSD in Critical Care II |
| CCP Podcast 047 | Advanced Critical Care Practitioner |
| CCP Podcast 048 | RSI- Which Drug? |
| CCP Podcast 049 | Central Venous Catheter- Which Needle? |
| CCP Podcast 050 | LeoPARDS Trial |
| CCP Podcast 051 | ICU Follow Up Clinics |
| CCP Podcast 052 | Chronic Critical Illness |
| CCP Podcast 053 | Nutrition Guidelines |
| CCP Podcast 054 | Nutrition Guidelines at ICSSOA 2016 |
| CCP Podcast 055 | Papers of the Month |
| CCP Podcast 056 | Got to help them cough |
| CCP Podcast 057 | Papers of the Month |
| CCP Podcast 058 | Early Mobilisation. Do we know it works? |
| CCP Podcast 059 | Surviving the ICU: The Patient Experience. |
| CCP Podcast 060 | My Critical Care Patient Can't Swallow! Why? |
| CCP Podcast 061 | Papers of the Month: March 2017 |
| CCP Podcast 062 | Escalate the Patient! |
| CCP Podcast 063 | The Two Jonnys Do Twitter: May 2017 |
| CCP Podcast 064 | Papers of the Month May 2017 |
| CCP Podcast 065 | ACCP Presentation- What, Why, How? |
| CCP Podcast 066 | The Two Jonnys Do Twitter: May 2017 (2) |
| CCP Podcast 067 | Papers of the Month June 2017 |
| CCP Podcast 068 | The Two Jonnys Do Twitter: June 2017 |
| CCP Podcast 069 | DasSMACC Day 1 |
| CCP Podcast 070 | DasSMACC Day 2 |
| CCP Podcast 071 | DasSMACC Day 3 |
| CCP Podcast 072 | The Two Jonnys Do Twitter: July 2017 |
| CCP Podcast 073 | Bariatric Surgery in the Management of the Obese Patient |
| CCP Podcast 074 | Lung Ultrasound with SonoPhysio |
| CCP Podcast 075 | ACP Conference October 2017 |
| CCP Podcast 076 | The Two Jonnys Septmber 2017 |
| CCP Podcast 077 | NCEPOD 2017 Acute NIV |
| CCP Podcast 078 | NCEPOD 2017 Acute NIV- A Discussion |
| CCP Podcast 079 | The Two Jonnys November 2017 |
| CCP Podcast 080 | Nitin does FICE….quickly! |
| CCP Podcast 081 | The Two Jonnys at ICSSOA 2017 (and Dave) |
| CCP Podcast 082 | FICE...Just Do It! |
| CCP Podcast 083 | Guidelines to Tracheal Intubation |
| CCP Podcast 084 | Audits on some ACCPs skills |
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| CCP Podcast 088 | Chat about NTI2018 |
| CCP Podcast 089 | Cath and Jonathan chat about BTS2018 |
| CCP Podcast 090 | Mechanical Ventilation with Thomas |
| CCP Podcast 091 | Practitioners Across The Pond |
| CCP Podcast 092 | Practicing Critical Care Like An Adult |
| CCP Podcast 093 | Recent research with Nicole Kupchik |
| CCP Podcast 094 | Magnesium for the win. |
| CCP Podcast 095 | More mechanical ventilation with Thomas |
| CCP Podcast 096 | Hyponatremia |
| CCP Podcast 097 | ERS Conference 2018 |
| CCP Podcast 098 | Bryan talks AKI |
| CCP Podcast 099 | Fluids- Part I |
| CCP Podcast 100 | The Two Jonnys Season Two |
| CCP Podcast 101 | Palliative Care in the ICU |
| CCP Podcast 102 | Dale Needham and Delirium |
| CCP Podcast 103 | Acute Right Heart Failure |
Get in touch with Jonathan
I would love to hear from you so that we can start to work together.- Send an email to contact@criticalcarepractitioner.co.uk
- Use my voicemail service link to the right of this page
- Fill in contact form at the bottom of the page
