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University of Technology Sydney, Australia and Northern Sydney and Central Coast Area Health Service, St. Leonards, NSW 2067, Australia
Department of Respiratory and Sleep Medicine, University of Sydney and the Royal North Shore Hospital, Australia
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 2 July 2010
Received in revised form 24 October 2010
Accepted 26 November 2010
Background: Sleep is essential for well-being and recovery from illness. The critically ill are
in signicant need of sleep but at increased risk of sleep loss and disruption.
Objectives: To determine the quality and duration of sleep experienced by adults who are
patients in intensive care units and factors affecting their sleep.
Design: An integrative approach was used for this literature review in order to explore the
available evidence on this topic, which has yet to be fully investigated.
Data sources: PubMed, CINAHL, Psychinfo, the Australian Digital Theses Program and
ProQuest Dissertations and Theses (Interdisciplinary) databases were searched for studies
conducted about sleep in adult intensive care units. Manual searches of papers identied
from this search were performed to nd additional studies.
Review methods: Data related to the quality and duration of sleep along with study design,
sample size and intensive care context were extracted, evaluated and summarised.
Results: Total sleep time is normal or reduced with signicant fragmentation. Light sleep is
prolonged and deep and rapid eye movement sleep are reduced. The most likely factors
affecting sleep quality are high sound levels, frequent interventions and medications. Data
obtained from polysomnography are supported by patient self reports. Considerable
variation in data exists between patients and studies affecting generalizability. Existing
criteria for staging sleep may be inadequate for quantifying sleep in intensive care
patients.
Conclusions: There is evidence that intensive care patients sleep is signicantly disrupted.
Alternative methods of quantifying sleep for intensive care patients may be required. Few
large observational or interventional studies have used polysomnography and simultaneous recordings of intrinsic and extrinsic disruptive factors. These studies are required in
order to improve sleep for intensive care patients.
2010 Elsevier Ltd. All rights reserved.
Keywords:
Sleep
Intensive care
Literature review
Nursing
Adult
Sleep disruption
* Corresponding author. Tel.: +61 2 9411 6362; fax: +61 2 9439 8418.
E-mail address: rmelliot@nsccahs.health.nsw.gov.au (R. Elliott).
0020-7489/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2010.11.006
385
data from sleep studies in ICU are presented using the older
Rechtschaffen and Kales (R and K) criteria (1968) as the
recent American Academy of Sleep Medicine (AASM)
criteria (Iber et al., 2007), which merge stages 3 and 4,
have not yet been widely adopted. The R and K and AASM
criteria describe waveform congurations and frequencies
and arousals over 30 s intervals (standard epochs).
Both R and K and AASM criteria require sleep
monitoring using a polysomnograph (PSG) (EEG, electrooculography (EOG) and electromyography (EMG)). Sleep
data derived from PSG provide measures of TST/SEI, time in
Stages 14 and REM sleep, and arousals and arousal indices
(number per hour of sleep). Despite being technically
challenging and presenting limitations when assessing
sleep in ICU patients, PSG remains the gold standard of
measuring sleep in this context.
Other objective methods of measuring sleep include
actigraphy and Bispectral index (BIS) monitoring. Actigraphy utilises a movement sensor incorporated in a
device usually worn on the wrist. Actigraphy tends to
overestimate the quantity of sleep in ICU patients as they
are often immobile and it provides little information about
the quality of sleep (i.e. sleep stages) (Bourne et al., 2007).
BIS monitoring (commonly used to assess the depth of
anaesthesia) has also been used to attempt to record sleep
in the ICU patient, but specic algorithms for sleep have
not yet been developed and sleep data derived from the BIS
have limited value (Bourne et al., 2007).
Subjective measures of sleep include questionnaires
incorporating visual analogue and likert scales, for example
the Richards Campbell Sleep Questionnaire (RCSQ), the Sleep
in the Intensive Care Unit Questionnaire (SICQ) and the
Verran/Snyder Halpern (VSH) Sleep Scale (Snyder-Halpern
and Verran, 1987). The RCSQ and VSH were validated against
the PSG showing a moderate correlation of r = 0.58 between
total RCSQ score and PSG (Richards et al., 2000) and patients
were shown to be able to reliably report mid-sleep
awakenings >4 min using the VSH (when compared to
PSG) (Fontaine, 1989). However self report instruments have
limitations for ICU patients: they require a degree of
cognitive acumen and sufcient memory to be completed
accurately. For example Bourne et al. (2007) reported that
20% of patients were unable to complete the RCSQ mainly
because they were delirious and Frisk and Nordstrom (2003)
estimated that 50% of ICU patients were not sufciently
conscious or orientated to complete the RCSQ.
Nurse assessment instruments have also been validated
against PSG, for example the Echols Sleep Behaviour
Observation Tool (EBOT) (Echols, 1968) and the Nurses
Observation Checklist (Edwards and Schuring, 1993).
Although nurses in the Edwards and Schuring (1993) study
correctly assessed the sleep/wake state 82% of the time,
others report that nurse assessment overestimates the
quantity of sleep and provides limited information regarding sleep quality (Aurell and Elmqvist, 1985; Beecroft et al.,
2008; Bourne et al., 2007; Richardson et al., 2007b).
2. Objectives
This review was performed to assess what is already
known about the sleep experienced by adult intensive care
386
Table 1
24 h polysomnograph recordings in ICU patients.
Number of patients
and ICU context
Stage 1 and 2
(approx. %)
Stage 3 and 4
(approx. %)
REM
(approx. %)
Details/comments
Aurell and
Elmqvist (1985)
Descriptive
9, surgical
(Stage 1 excluded)
00:5803:48
3799
04
<16
20, medical
and surgical
Disrupted sleep:
1015
Atypical sleep: 45
Disrupted sleep: 10
Atypical sleep: 4
Mean arousals/hour
Disrupted sleep: 2025
Atypical sleep: 58
Risk of sleep disruption
associated with lower doses
of morphine and lorazepam,
lower severity of illness and
GCS 10
Edell-Gustafsson
et al. (1999)
Descriptive
38, cardiothoracic
(pre-op, n = 37,
post-op, n = 36,
home, n = 34)
Pre-op 07:01
Post-op 08:03
Home 7:28
Night:
Stage 1:
Stage 2:
Day:
Stage 1:
Stage 2:
Night:
Stage 3 and 4
718
Day:
Stage 3 and 4
613
Night:
017
Day:
010
Recording started
within 2 h postoperatively
and continued until ICU
discharge or 83 h (24 h
monitoring)
Nurses rated sleep every
5 min
Isolation room
Muscle relaxants, sedatives
and opioids used. Some
patients comatose
All mechanically ventilated
Patients divided into
groups; atypical sleep
(n = 5), disrupted sleep
(n = 8) and coma (n = 7).
No recognisable sleep data
for coma group
Light sedation only
Comparison of sleep of
38 patients at three
time points; 24 h
pre-operatively, 48 h 3 h
after surgery and for 24 h
1 month after surgery
(at home)
Mechanically ventilated
patients (n = 20).
Intermittent sedation used
in eight patients (14 none)
Unscorable data for ve
with/prior to developing
sepsis. Fourteen 24 h
recordings; eight patients
studied for 48 h. No patients
had consolidated sleep
Five mechanically
ventilated patients, 13
received opioids and 3
sedatives
Sleep was signicantly
disrupted
All patients mechanically
ventilated six received
benzodiazepines
1130
5562
1538
4762
22 (nal 17),
medical
08:48 (1:4219:24)
Stage 1: 59
Stage 2 26
16, surgical
8:16
Stage 1 and 2:
96
Stage 3 and 4:
1
No correlation between
sedation and sleep disruption.
Seven patients,
(six healthy
volunteers),
Med/surg
Patients
6:12
Patients
Stage 1: 19
Stage 2: 64
Patients
Stage 3 and 4
3
Patients
14
Arousals 10/h
Awakenings 11/h
50% of sleep during day
387
388
Table 1 (Continued )
Number of patients
and ICU context
Stage 1 and 2
(approx. %)
Stage 3 and 4
(approx. %)
REM
(approx. %)
Details/comments
18; medical
1018
Stage 1:
520
Stage 2:
2857
Stages 3 and 4:
3149
IS: 3, NMBA/CS:
(not detectable)
Hilton (1976)
Descriptive
9, respiratory
First 24 h: 05:20
Second 24 h: 05:48
(00:0613:20)
5, surgical
(cardiothoracic)
24 h postoperative
14
First 24 h:
Stage 3: 0.7
Stage 4: 0.1
Second 24 h:
Stage 3: 14
Stage 4: 4.5
Not stated
First 24 h:
3.6
Second 24 h:
6.0
First 24 h:
Stage 1: 49
Stage 2: 41
Second 24 h:
Stage 1: 32
Stage 2: 43
Not stated
Four patients
had none,
one patient
had nine
Table 2
Overnight polysomnography (PSG) in ICU patients.
Author (s) (Year)
Design
Number of
patients and
ICU context
Total sleep
time (h)
Stages 1 and 2
(approx. %)
Details/comments
6
Respiratory
05:25
Stage 1: 14
Stage 2: 43
17
Medical
Not stated
12
Med/surg
03:06
(medians reported)
Protocol A:
PAVhigh: 12
PShigh 10
Protocol B:
PAVhigh: 4
PShigh: 2
Stage 3 and 4:
0.15
Protocol A:
PAVhigh: 1
PShigh none
Protocol B:
PAVhigh: 2
PShigh 20
0.4
Arousals
Protocol A: 47/h
Protocol B: 812/h
Periodic breathing associated
with increased sleep disruption
Protocol A:
PAVhigh: 87
PShigh 90
Protocol B:
PAVhigh: 94
PShigh: 78
Stage 1:
20
Stage 2:
74
13, Med/surg
PAV: 05:34
PSV: 05:14
Not stated
Not stated
Not stated
Arousals
PAV: 16/h
PSV: 9/h
Patient-ventilator asynchrony
associated with arousals
Broughton and
Baron (1978)
Descriptive
12, Cardiology
05:39
45
26
10
Awakenings
20, SEI 78
Angina lead to sleep disruption
Stage 1: 8
Stage 2: 63
19
10
Fontaine (1989)
Descriptive
Parthasarathy and
Tobin (2002)
Clinical trial
15, medical
05:14
(Medians
reported)
Richards (1998)
Clinical trial
17, cardiac
C = 04:17
R = 04:32
BM = 05:19
5462
811
59
Richards and
Bairnsfather (1988)
Descriptive
10, medical
04:45
Stage 1: 16
Stage 2: 35
Stage 3: 3
Stage 4: <1
389
390
Table 2 (Continued )
Stages 3 and 4 REM
(approx. %)
(approx. %)
Details/comments
05:48
27, medical
(8 had abnormal (Medians reported
on 19 patients)
PSG)
Stage 1 and 2: 71
22
20, Medical
Both groups: 51
Number of
patients and
ICU context
Roche Campo
et al. (2010)
Descriptive
Total sleep
time (h)
AC: 03:37
PS: 03:48
(% total recording
time shown)
*
Richards Campbell Sleep Questionnaire (RCSQ) is an instrument specically developed to allow critical care patients to subjectively report on their sleep. The RCSQ comprises 5 visual analogue scales 100 mm in
length (0 is poor and 100 excellent). Patients are required to mark the lines. The total score is the average of the measurements of the 5 scales.
Table 3
Methods other than PSG used to record sleep in ICU patients.
Author(s) (Year)
Design
Number of patients
and ICU context
Results
Comments
24, general
BIS monitoring/actigraphy/hourly
nurse observation/Richards
Campbell (RCSQ)* over night
(22:0007:00 h)
Brown and
Scott, 1998
Clinical trial
Stages 1 and 2
(approx. %)
203, general
Frisk and
Nordstrom (2003)
Descriptive
31, surgical
32, general
Knapp-Spooner
and Yarcheski (1992)
Descriptive
24, cardiac
(coronary by-pass
surgery)
104, surgical
27, general
379 (patients
observed),
neurocritical care
Trial of melatonin
All patients tracheostomised and
weaning from mechanical ventilation.
Sedatives discontinued 12 h prior to
sleep monitoring. Polysomnography
would have strengthened this study
391
392
Table 3 (Continued )
Number of patients
and ICU context
Results
Comments
Richardson
et al. (2007a)
Clinical trial
64, high
dependency/
cardiothoracic ICU
Richardson
et al. (2007b)
Clinical trial
82 patients and 82
nurses, general
Neurosurgical
Cardiothoracic
Richardson (2003)
Clinical trial
14, respiratory
(And six ward
patients)
8, respiratory
(And six ward
patients)
Treggiari-Venzi
et al. (1996)
Clinical trial
40, surgical
Author(s) (Year)
Design
*
Richards Campbell Sleep Questionnaire (RCSQ) is an instrument specically developed to allow critical care patients to subjectively report on their sleep. The RCSQ comprises 5 visual analogue scales 100 mm in
length (0 is poor and 100 excellent). Patients are required to mark the lines. The total score is the average of the measurements of the 5 scales.
y
The Verran/Snyder Halpern (VSH) Sleep Scale contained 15 Visual analogue items (100 mm line) measuring three concepts; sleep disturbance, effectiveness and supplementation. Patients are required to mark
the lines. The range of scores are; 0700 for disturbance, 0600 for effectiveness and 0400 for supplementation. Higher scores reect higher disturbance, effectiveness and supplementation.
Ugras and
ztekin (2007)
O
Descriptive
84, neurosurgical
393
[()TD$FIG]
394
Records excluded,
n= 83 (duplicates, n=
46, not
studies/relevant n
=37)
Studies included in
integrated review, n=42
Fig. 1. MOOSE owchart for the integrated review.
Table 4
Summary of the nature of the quality and duration of sleep in ICU patients (measured with polysomnography).
Parameter
Details
Duration of sleep
Little or no sleep
Quality of sleep
Poor
Awakenings
Frequent
Daytime sleepiness
Evident
Themes emerging
Attribute sleep disruption to noise,
from patient reports intrusive treatments, thirst etc.
Approximately 30% of recovering
ICU patients remember not being able to sleep
395
396
397
398
399
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