Research Calls for Prioritization of Sleep in ICUs

Patients in the intensive care unit (ICU) are subject to constant observation and monitoring, but new research is shining a light on an issue that often gets neglected in the care of the sickest patients in the hospital: lack of sleep.

Two recent studies highlight the issue of sleep in the ICU. One examined sleep disruptions, the other, how hospital staff contribute to the problem.

Georg Nilius

The first study, a review article published in Nature and Science of Sleep, focused on the management of sleep disorders. Corresponding author Georg Nilius, M.D., of the Essen-Mitte Clinic in Germany, noted that sleep optimization is “still lower on the list of priorities in the intensive care unit.”

“There is no doubt that sleep is a basic physiological need and, in addition to a variety of functions, it is also indispensable for the regeneration and recovery of the body,” Nilius and colleagues wrote. “Numerous studies have demonstrated that patients in the intensive care unit (ICU) commonly experience sleep deprivation and sleep disturbances.”

The investigators said it is difficult to know exactly how prevalent sleep problems are among ICU because studies of the issue have had heterogeneous patient populations and different measurement methods. Even so, they observe that conditions of the ICU can replicate the effects of sleep disorders.

“Patient-related factors such as anxiety, pain, stress or disease-related organ dysfunction, in addition to external disturbing factors from the ward environment, affect not only sleep quality but also sleep quantity,” they wrote.

The second study, published in the August print edition of the Journal of Sleep Research, reviewed interruptions associated with monitoring and nursing the ICU.2 Corresponding author Hana Locihová, Ph.D., M.P.H., of the AGEL Research and Training Institute in the Czech Republic, and colleagues found that the majority of sleep interruptions were related to vital sign monitoring. Nocturnal nursing interventions were frequent and varied, though they represented a minority of sleep disruptions, the authors reported.

Because nighttime monitoring cannot be avoided in an ICU, one way to address the problem of sleep disruptions is by clustering interventions. Locihová and colleagues said existing evidence suggests these types of strategies can have a meaningful benefit.

“The current trend is more careful planning of nursing care, clustering of interventions and minimizing nocturnal disruptions to allow patients at least one uninterrupted sleep cycle [of 90 minutes],” they wrote.

Nilius, the author of the review article published in Nature and Science of Sleep, made a plea for hospital staff to be more aware of the effects of light and noise. Not only is darkness beneficial at night, but sufficient sunlight in rooms during the day can help coax the body’s circadian rhythms back into equilibrium, they said. Music interventions and ambient noise can also help.

Physicians should also be thoughtful about nutrition in the ICU, particularly for patients who are on feeding tubes. The investigators suggested continual nutrition may be detrimental to sleep patterns.

“It can be assumed that daytime nutrition with breaks attenuates circadian rhythm disturbances compared to continuous 24-hour application,” they said. “A daily mobilization during daytime may reinforce this potential.”

Nilius and colleagues said there are pharmacological approaches that can also help with sleep management, but they wrote that it is unlikely that pharmacological approaches alone could solve the problem. Part of the solution, they said, is awareness and acceptance that sleep needs to be a high priority in the ICU.

“The detection, management, and prevention of sleep disorders and circadian dysrhythmias would ideally be incorporated into daily interdisciplinary rounds,” they said, adding that larger studies could help determine the best methods for assessing and improving sleep for intensive-care patients.