Sleep in Critical Care :What Do We Know About The Issue?

Ebru Ortaç ErsoyHacettepe University

Medical Intensive Care Unit

Sleep:

• Sleep is a naturally occurring periodic, reversible state of cognitive and sensory disengagement from the external environment, from which a person can be aroused by sensory stimulation

Sleep Stages

• Non-rapid eye movement (NREM)

• Rapid eye movement (REM)

NREM

• N1• N2• N3

REM

• EEG activation

• EMG athony

• Rapid eye movement

• dreams

REM

• ‘Arousal’:– 3 sec<TİME<15 sec

• ‘Awakening’

Sleep– Awaikening

Monitorisation of sleep

• Polisomnography: Gold standart• Actigraphy• BİS??• Subjective assesments

Sleep in ICU

• Sleep deprivation and fragmentations

• Difficulty in starting sleep

• Abnormal sleep pattern (reduced deep sleep)

• Reduced Total sleep time

• 50% of sleep occurs at daytime. JOURNAL OF INTENSİVE CARE MED 2014

Sleep in ICU

HR,BPM

3 05 07 09 011 01 3 01 5 01 7 01 9 0

Sp O2 ,%

5 0

6 0

7 0

8 0

9 0

1 0 0

Sta g e

N3

N2

N1

R

W

CA,s e c

0

1 0

2 0

OA,s e c

0

1 0

2 0

MA,s e c

0

1 0

2 0

HYPO,s e c

0

1 0

2 0

1 5 :2 4 :3 0 1 7 :0 0 1 8 :0 0 1 9 :0 0 2 0 :0 0 2 1 :0 0 2 2 :0 0 2 3 :0 0 0 0 :0 0 0 1 :0 0 0 2 :0 0 0 3 :0 0 0 4 :0 0 0 5 :0 0 0 6 :0 0 0 7 :0 0 0 8 :0 0

HR,BPM

3 05 07 09 011 01 3 01 5 01 7 01 9 0

Sp O2 ,%

5 0

6 0

7 0

8 0

9 0

1 0 0

Sta g e

N3

N2

N1

R

W

CA,s e c

0

1 0

2 0

OA,s e c

0

1 0

2 0

MA,s e c

0

1 0

2 0

HYPO,s e c

0

1 0

2 0

1 5 :2 4 :3 0 1 7 :0 0 1 8 :0 0 1 9 :0 0 2 0 :0 0 2 1 :0 0 2 2 :0 0 2 3 :0 0 0 0 :0 0 0 1 :0 0 0 2 :0 0 0 3 :0 0 0 4 :0 0 0 5 :0 0 0 6 :0 0 0 7 :0 0 0 8 :0 0

Factors effecting sleep

1. ICU

2. Severity of disease, drugs

3. Mechanical ventilation

Bozulmuş Uyku

Sağlık çalışanları/girişimler

AğrıIŞIK

İLAÇLAR Gürültü Anksiyete

Factors effecting sleep in ICU

Freedman ve ark, 1999

1 2

3

22

Noise

• Noise levels<30 dB during night, <40dB during day

• Mean noise levels: 53-70dB, max. 102 dB. WHO, 1999

Gürültü

Bentley et al. Perceived noise in surgical wards and an intensive care area: an objective analysis. BMJ

Freedman ,et al.Abnormal sleep/wake cycles and the effect of environmental noiseon sleep disruption in the intensive care unit. Am J Respir Crit CareMed 2001;Gabor Jet al. Contribution of theintensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care Med

Noise

• Arousal • Awakining

Noise

• Ventilator alarms• Telephones• Staff speakings

Light

• Effects *Cirkadien rythm, *Melatonin excretions

• Length of stay• Emotional stress• Disease severity

Co morbidities

Co morbidities

• Chronic Cardiopulmonary diseases• Sleep diseases• Pain

Severity of disease

Patients with high APACHE II

*Increased Arousal index , *decreased sleep time, *decreased SWS time Gabor et al. Am J Respir Crit Care Med2003 Parthasarathy S, Tobin MJ. Am J Respir and Crit Care Med 2003

Sleep in Sepsis

• Increased Non –REM .• Decreased REM azalır.• Increased TNFα,IL-8• EEG changes• Decreased melatonin secretion

Sleep in Sepsis

• Melatonin theraphy may be useful for protecting patients from sepsis

• Gitto E, et al. Melatonin reduces oxidativestress In surgical neonates. J Pediatr Surg 2004;39:184-189.• Sener G, et al. Melatonin protects againstoxidative organ Injury In a rat model of sepsis. Surg Today2005;35:52-59.

Sleep and mechanical ventilation

• Endotracheal tube or mask,• Ventilator mode settings

Meyer ve ark, 1997

• PSV vs ACV• 11 patient• One night ACV,PSV ve PSV+dead space

PSV vs ACV

Parthasarathy ve Tobin, 2002

37

Uyku bölünmesi (Arousal+uyanma/saat)

Uyku etkinliği%

Parthasarathy ve Tobin, 2002

PSV vs ACV

• Mechanical ventilator modes can effect sleep

Drugs

• Sleep time, • Sleep fragmentation,• sleep quality can be effected by drugs.

• Dexmedetomidine should be selected instead of BDZ

Maldonado et al. 2004

Uyku Deprivasyonunun Sonuçları

Is it possible to improve sleep in ICU?

• Management of diseases• Avoiding from noise and light• Mechanical ventiltor modes• Decreasing patient care activities• Massage • Music• Melatonin ?

•noise ↓ ear plugs closed doors visit time regulations •Light off at 10 pm •decrease patient care activities at night

•Pain and anxitety↓ •drugs ↓ •BDZ •short acting drugs MELATONİN??

Melatonin

Sleep prophilaxis??

Sleep prophilaxis??

• Ventilator strategies

Only patients ??

• Relatives?• Staff?

• ????

thanks...