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John Hunter Hospital, Manning Base Rural Referral Hospital, Hunter New England Area Health Service
Abstract
Objectives:
To review the literature on the detrimental effects of disordered sleep in Intensive Care Unit (ICU) patients;
To identify the causative factors and immunological consequences of disturbed sleep and strategies to diminish their
effects;
To appraise the drugs frequently used within the ICU for the purposes of sedation in relation to their detrimental effect on sleep.
In light of the evidence reviewed in this work, recommendations to extend the scope and address the limitations of
current nursing and medical practice and beliefs are made.
Method: A review of the literature was undertaken. A search of online journal databases for qualitative and quantitative
studies on sleep deprivation published from 2000 to present was undertaken.
Findings: Sleep is an essential function for survival in humans. Sleep disturbances are common in critically ill patients and
contribute to morbidity. Patients are known to have disturbed sleep patterns during their time in the ICU, irrespective of
their diagnoses.
Conclusion: Factors implicated in contributing to sleep deprivation in the ICU include light, frequent disturbances and
activity, and unfamiliar setting and anxiety. Although controversial mechanical ventilation is implicated as a factor in abnormal sleep patterns so are the use of sedatives and analgesics. Nurses are pivotal in implementing strategies to promote
sleep, recognising conditions which predispose patients to sleep disturbances and advocating for patients regarding the
appropriate use of pharmacological modalities that are known to hinder sleep.
Key Words: Intensive Care, Nursing activity, Sleep deprivation, Sleep.
INTRODUCTION
For over two decades sleep disturbance in critically ill patients
has been a recognised phenomenon (Cooper, Thornley, Young,
Slutsky, Stewart & Hanly, 2000). A sequela of sleep deprivation in the critically ill is a host of psychneuroimmunological
and physical consequences that can prove to be fatal.
Nursing activities in addition to routine administration of
sedative and therapeutic drugs as well as drug use prior to
hospitalisation have been implicated in contributing to this
occurrence. (Parthasarathy & Tobin, 2006; elik, ztekin,
Akyolcu & sever, 2005; Bourne & Mills, 2004; Mistraletti,
Donatelli & Carli, 2005; Society of Critical Care Medicine &
American Society of Health-System Pharmacists, 2002). Despite this knowledge sleep deprivation remains an issue in
critically ill patients.
This review addresses the concept of sleep and the detrimental
effects of disordered sleep in the ICU patient. Immunological
consequences of disordered sleep are reviewed. The causative
factors specific to disturbed sleep in the ICU in conjunction
with strategies to diminish the effects are reviewed.
Drugs frequently used within the ICU for the purposes of sedation are appraised in relation to their detriment to sleep.
From the evidence reviewed in this work, recommendations
are made to address the limitations and extend the scope of
current nursing and medical practices and beliefs.
SEARCH STRATEGY
This review examines modern approaches to foundational
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work on sleep deprivation in the ICU. The search range included the OVID and ProQuest online journal database and
the search engine METASearch. A total of seven search terms
were used related to sleep deprivation in the ICU, and to melatonin and its role in sleep and psychoneuroimmunology. The
publication years searched spanned 2000 to the present with
exceptions occurring for particularly relevant work because it
built the framework upon which current investigations rest.
Authoritative institutional websites such as the Fellowship
of the Royal College of Anaesthetists were also reviewed. An
objective assessment of the impact of the research was considered prior to inclusion of the work. The search methodology was limited to the OVID and ProQuest journal databases.
Only English or English translation articles were included.
Additionally the review was limited by the search terms and
years.
FINDINGS
The Need for Sleep
Sleep is a basic function for survival in humans and one third
of each persons life is spent asleep (Patel, Chipman, Carlin,
& Shade, 2008; De Gennaro, 2008). Sleep disturbances are
common in critically ill patients and contribute to morbidity
(Bourne & Mills, 2004). It is known that patients in the ICU
irrespective of their diagnosis have disturbed sleep patterns
during their time spent in ICU and up to one week following
(Orwelius, Nordlund, Nordlund, Edll-Gustafsson & Sjberg,
2008). An investigation of adult mechanically ventilated ICU
patients conducted by Cooper, Thornley, Young, Slutsky,
Stewart & Hanly (2000) concluded that none of the study participants demonstrated normal sleep patterns.
Immunological Consequences
Inadequate sleep induces a state of catabolism and impaired
cellular and humoral immunity, which in turn may lead to
delayed healing and increased susceptibility to infection
(Bourne & Mills, 2004; Gabor, Cooper, & Hanly, 2001). Sleep
deprivation has been reported to increase circulating levels of
inflammatory markers such as IL-6, tumour necrosis factor,
Respiratory Dysfunction
Gabor, Cooper & Hanly (2001) and Olson, Borel, Laskowitz,
Moore, and McConnell (2001) report that consequences of
sleep disturbance in ICU patients can cause respiratory dysfunction, noted by decreased respiratory muscle endurance
following 30 hours of sleep deprivation and as a consequence
potentially prolonging the need for mechanical ventilatory
support. In addition there are reports of decreased ventilatory
responsiveness to hypercapnia and development of increased
upper airway compliance (Bourne & Mills, 2004; Gabor, Cooper& Hanly, 2001).
Systems Breakdown
Sleep is a critical restorative process, with important circadian variations in protein synthesis and cellular division being present with peak activity occurring during sleep (Patel,
Chipman, Carlin & Shade, 2008). Experimental animal studies
inducing sleep deprivation have been associated with major
physical abnormalities including development of gastric ulcers, internal haemorrhage, pulmonary oedema, and systemic
bacterial invasion (Patel, Chipman, Carlin & Shade, 2008).
Everson and Toth (2000) report bacterial translocation and its
sequelae provide the mechanism by which sleep deprivation
is detrimental to health. Previous experimental animal studies
inducing sleep deprivation illustrated gradual deterioration in
health culminating in fatal opportunistic facultative anaerobes
generally ascribed as being of gut origin, such as Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus agalactiae, and Corynebacterium jejeiku
(Everson & Toth, 2000). In isolation these organisms are not
associated with primary bacteraemia or life threatening consequence unless the host is immune-compromised (Everson
& Toth, 2000). Everson and Toth (2000) conducted animal experiments where the principal finding was early infection of
the mesenteric lymph nodes by bacteria translocated from the
intestine. This finding highlights the importance of instituting
early enteric nutrition in the ICU patient as opposed to total
parenteral nutrition due to reported mucosal atrophy and increased intestinal permeability, reflective of intestinal barrier
damage allowing for translocation of bacteria (Gatt, Reddy, &
Macfie, 2007).
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Administration of benzodiazepines or
narcotics
Use of rectal or bladder (Foley)
catheters
Visual or hearing impairment
Use of central venous catheters
Hypoglycemia or hyperglycemia
Hypothermia or fever
Use of physical restraints
Age > 70 years
Use of tube feeding or total parenteral
nutrition
Cardiogenic or septic shock
Serum urea nitrogen-creatinine
ratio >18
History of depression
History of cngestive heart failure
History of stroke or epilepsy
Drug overdose or use of illicit drugs
within preceding week
Transfer from nursing home
Alcohol abuse within preceding month
Malnutrition
Liver disease
Hypothyroidism or hyperthyroidism
Human immunodeficiency virus
infection
Excretion of Melatonin
Interestingly, urinary excretion of the melatonin metabolite,
6 - sulphatoxymelatonin is reported to exhibit marked abnormalities in septic patients when compared to non-septic patients in whom the secretion remains normal (Mundigler et
al. 2002). Equipped with this knowledge the nurse when caring for the septic patient should be aware they are more than
likely to be suffering sleep deprivation.
RECOMMENDATIONS
Nursing and medical staff need to be informed through
means of wider education on the importance and the physiological restorative benefits of sleep, especially in the critically
ill. There is a need for greater awareness of how routine care
activities are impinging upon sleep and the pharmacological
effects of therapeutic and sedative drugs routinely administered in the ICU.
CONCLUSION
It is imperative nursing and medical staff understand the im-
plications of sleep deprivation in critically ill patients. Furthermore nursing and medical staff need to be made aware of
factors implicated in contributing to sleep deprivation in the
ICU. It is crucial nurses receive education about this issue as
they are pivotal in implementing strategies to promote sleep,
recognise conditions which predispose patients to sleep disturbances and to advocate for patients in appropriate use of
pharmacological modalities that are known to hinder sleep.
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