1
|
Singh G, Nguyen C, Kuschner W. Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review. J Intensive Care Med 2024:8850666241255345. [PMID: 38881385 DOI: 10.1177/08850666241255345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.
Collapse
Affiliation(s)
- Gaurav Singh
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Christopher Nguyen
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Ware Kuschner
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
2
|
Silverstein BH, Parkar A, Groenhout T, Fracz Z, Fryzel AM, Fields CW, Nelson A, Liu T, Vanini G, Mashour GA, Pal D. Effect of prolonged sedation with dexmedetomidine, midazolam, propofol, and sevoflurane on sleep homeostasis in rats. Br J Anaesth 2024; 132:1248-1259. [PMID: 38071152 DOI: 10.1016/j.bja.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/23/2023] [Accepted: 11/01/2023] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Sleep disruption is a common occurrence during medical care and is detrimental to patient recovery. Long-term sedation in the critical care setting is a modifiable factor that affects sleep, but the impact of different sedative-hypnotics on sleep homeostasis is not clear. METHODS We conducted a systematic comparison of the effects of prolonged sedation (8 h) with i.v. and inhalational agents on sleep homeostasis. Adult Sprague-Dawley rats (n=10) received dexmedetomidine or midazolam on separate days. Another group (n=9) received propofol or sevoflurane on separate days. A third group (n=12) received coadministration of dexmedetomidine and sevoflurane. Wakefulness (wake), slow-wave sleep (SWS), and rapid eye movement (REM) sleep were quantified during the 48-h post-sedation period, during which we also assessed wake-associated neural dynamics using two electroencephalographic measures: theta-high gamma phase-amplitude coupling and high gamma weighted phase-lag index. RESULTS Dexmedetomidine-, midazolam-, or propofol-induced sedation increased wake and decreased SWS and REM sleep (P<0.0001) during the 48-h post-sedation period. Sevoflurane produced no change in SWS, decreased wake for 3 h, and increased REM sleep for 6 h (P<0.02) post-sedation. Coadministration of dexmedetomidine and sevoflurane induced no change in wake (P>0.05), increased SWS for 3 h, and decreased REM sleep for 9 h (P<0.02) post-sedation. Dexmedetomidine, midazolam, and coadministration of dexmedetomidine with sevoflurane reduced wake-associated phase-amplitude coupling (P≤0.01). All sedatives except sevoflurane decreased wake-associated high gamma weighted phase-lag index (P<0.01). CONCLUSIONS In contrast to i.v. drugs, prolonged sevoflurane sedation produced minimal changes in sleep homeostasis and neural dynamics. Further studies are warranted to assess inhalational agents for long-term sedation and sleep homeostasis.
Collapse
Affiliation(s)
- Brian H Silverstein
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA
| | - Anjum Parkar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Trent Groenhout
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Zuzanna Fracz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Anna M Fryzel
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Amanda Nelson
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Tiecheng Liu
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Giancarlo Vanini
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA; Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA; Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA
| | - Dinesh Pal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA; Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA; Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
3
|
Langnas E, Maze M. Clinical Use of Adrenergic Receptor Ligands in Acute Care Settings. Handb Exp Pharmacol 2024. [PMID: 38177400 DOI: 10.1007/164_2023_705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
In this chapter, we review how ligands, both agonists and antagonists, for the major classes of adrenoreceptors, are utilized in acute care clinical settings. Adrenergic ligands exert their effects by interacting with the three major classes of adrenoceptors. Adrenoceptor agonists and antagonists have important applications, ranging from treatment of hypotension to asthma, and have proven to be extremely useful in a variety of clinical settings of acute care from the operating room to the critical care environment. Continued research interpreting the mechanisms of adrenoreceptors may help the discovery of new drugs with more desirable clinical profiles.
Collapse
Affiliation(s)
- Erica Langnas
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA.
- Center for Cerebrovascular Research, UCSF, San Francisco, CA, USA.
| |
Collapse
|
4
|
Eschbach E, Wang J. Sleep and critical illness: a review. Front Med (Lausanne) 2023; 10:1199685. [PMID: 37828946 PMCID: PMC10566646 DOI: 10.3389/fmed.2023.1199685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023] Open
Abstract
Critical illness and stays in the Intensive Care Unit (ICU) have significant impact on sleep. Poor sleep is common in this setting, can persist beyond acute critical illness, and is associated with increased morbidity and mortality. In the past 5 years, intensive care clinical practice guidelines have directed more focus on sleep and circadian disruption, spurring new initiatives to study and improve sleep complications in the critically ill. The global SARS-COV-2 (COVID-19) pandemic and dramatic spikes in patients requiring ICU level care also brought augmented levels of sleep disruption, the understanding of which continues to evolve. This review aims to summarize existing literature on sleep and critical illness and briefly discuss future directions in the field.
Collapse
Affiliation(s)
- Erin Eschbach
- Division of Pulmonary, Critical Care, and Sleep, Mount Sinai Hospital, New York, NY, United States
| | | |
Collapse
|
5
|
Showler L, Ali Abdelhamid Y, Goldin J, Deane AM. Sleep during and following critical illness: A narrative review. World J Crit Care Med 2023; 12:92-115. [PMID: 37397589 PMCID: PMC10308338 DOI: 10.5492/wjccm.v12.i3.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/13/2023] [Accepted: 03/22/2023] [Indexed: 06/08/2023] Open
Abstract
Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.
Collapse
Affiliation(s)
- Laurie Showler
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Jeremy Goldin
- Sleep and Respiratory Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Adam M Deane
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| |
Collapse
|
6
|
Ala-Kokko T, Erikson K, Koskenkari J, Laurila J, Kortelainen J. Monitoring of nighttime EEG slow-wave activity during dexmedetomidine infusion in patients with hyperactive ICU delirium: An observational pilot study. Acta Anaesthesiol Scand 2022; 66:1211-1218. [PMID: 36053891 DOI: 10.1111/aas.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 07/21/2022] [Accepted: 07/28/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The disturbance of sleep has been associated with intensive care unit (ICU) delirium. Monitoring of EEG slow-wave activity (SWA) has potential in measuring sleep quality and quantity. We investigated the quantitative monitoring of nighttime SWA and its association with the clinical evaluation of sleep in patients with hyperactive ICU delirium treated with dexmedetomidine. METHODS We performed overnight EEG recordings in 15 patients diagnosed with hyperactive delirium during moderate dexmedetomidine sedation. SWA was evaluated by offline calculation of the C-Trend Index, describing SWA in one parameter ranging 0 to 100 in values. Average and percentage of SWA values <50 were categorized as poor. The sleep quality and depth was clinically evaluated by the bedside nurse using the Richards-Campbell Sleep Questionnaire (RCSQ) with scores <70 categorized as poor. RESULTS Nighttime SWA revealed individual sleep structures and fundamental variation between patients. SWA was poor in 67%, sleep quality (RCSQ) in 67%, and sleep depth (RCSQ) in 60% of the patients. The category of SWA aligned with that of RCSQ-based sleep quality in 87% and RCSQ-based sleep depth in 67% of the patients. CONCLUSION Both, SWA and clinical evaluation suggested that the quality and depth of nighttime sleep were poor in most patients with hyperactive delirium despite dexmedetomidine infusion. Furthermore, the SWA and clinical evaluation classifications were not uniformly in agreement. An objective mode such as practical EEG-based solution for sleep evaluation and individual drug dosing in the ICU setting could offer potential in improving sleep for patients with delirium.
Collapse
Affiliation(s)
- Tero Ala-Kokko
- Division of Intensive Care Medicine, Research Group of Surgery, Anesthesiology, and Intensive Care Medicine, Oulu University Hospital and Medical Research Center, Oulu, Finland
| | - Kristo Erikson
- Division of Intensive Care Medicine, Research Group of Surgery, Anesthesiology, and Intensive Care Medicine, Oulu University Hospital and Medical Research Center, Oulu, Finland
| | - Juha Koskenkari
- Division of Intensive Care Medicine, Research Group of Surgery, Anesthesiology, and Intensive Care Medicine, Oulu University Hospital and Medical Research Center, Oulu, Finland
| | - Jouko Laurila
- Division of Intensive Care Medicine, Research Group of Surgery, Anesthesiology, and Intensive Care Medicine, Oulu University Hospital and Medical Research Center, Oulu, Finland
| | - Jukka Kortelainen
- Physiological Signal Analysis Team, Center for Machine Vision and Signal Analysis, University of Oulu and Medical Research Center, Oulu, Finland.,Cerenion Oy, Oulu, Finland
| |
Collapse
|
7
|
Kakar E, Priester M, Wessels P, Slooter AJC, Louter M, van der Jagt M. Sleep assessment in critically ill adults: A systematic review and meta-analysis. J Crit Care 2022; 71:154102. [PMID: 35849874 DOI: 10.1016/j.jcrc.2022.154102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 06/14/2022] [Accepted: 06/18/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE To systematically review sleep evaluation, characterize sleep disruption, and explore effects of sleepdisruption on outcomes in adult ICU patients. MATERIALS AND METHODS We systematically searched databases from May 1969 to June 2021 (PROSPERO protocol number: CRD42020175581). Prospective and retrospective studies were included studying sleep in critically ill adults, excluding patients with sleep or psychiatric disorders. Meta-regression methods were applied when feasible. RESULTS 132 studies (8797 patients) were included. Fifteen sleep assessment methods were identified, with only two validated. Patients had significant sleep disruption, with low sleep time, and low proportion of restorative rapid eye movement (REM). Sedation was associated with higher sleep efficiency and sleep time. Surgical versus medical patients had lower sleep quality. Patients on ventilation had a higher amount of light sleep. Meta-regression only suggested an association between total sleep time and occurrence of delirium (p < 0.001, 15 studies, 519 patients). Scarce data precluded further analyses. Sleep characterized with polysomnography (PSG) correlated well with actigraphy and Richards Campbell Sleep Questionnaire (RCSQ). CONCLUSIONS Sleep in critically ill patients is severely disturbed, and actigraphy and RCSQ seem reliable alternatives to PSG. Future studies should evaluate impact of sleep disruption on outcomes.
Collapse
Affiliation(s)
- Ellaha Kakar
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | | | | | - Arjen J C Slooter
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - M Louter
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - M van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| |
Collapse
|
8
|
|
9
|
Ueno Y, Sato K, Momota K, Sato H, Nakano Y, Akimoto Y, Nunomura T, Tane N, Itagaki T, Oto J. The quality and quantity of sleep on dexmedetomidine during high-flow nasal cannula oxygen therapy in critically ill patients. THE JOURNAL OF MEDICAL INVESTIGATION 2022; 69:266-272. [DOI: 10.2152/jmi.69.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Yoshitoyo Ueno
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1, Kuramoto, Tokushima, 770-8503, Japan
| | - Koji Sato
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1, Kuramoto, Tokushima, 770-8503, Japan
| | - Kazuki Momota
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1, Kuramoto, Tokushima, 770-8503, Japan
| | - Hiroki Sato
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1, Kuramoto, Tokushima, 770-8503, Japan
| | - Yuki Nakano
- Emergency and Critical Care Medicine, Tokushima Prefectural Miyoshi Hospital, 815-2, Ikeda-cho Shima, Miyoshi, 778-8503, Japan
| | - Yusuke Akimoto
- Emergency and Critical Care Medicine, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Toshiyuki Nunomura
- Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1, Kuramoto, Tokushima, 770-8503, Japan
| | - Natsuki Tane
- Emergency and Critical Care Medicine, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Taiga Itagaki
- Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1, Kuramoto, Tokushima, 770-8503, Japan
| | - Jun Oto
- Emergency and Critical Care Medicine, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| |
Collapse
|
10
|
DI Filippo A, Romagnoli S. Dexmedetomidine: the most versatile and multitasking of anesthetics. Minerva Anestesiol 2021; 87:968-970. [PMID: 34036774 DOI: 10.23736/s0375-9393.21.15825-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Alessandro DI Filippo
- Division of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy -
| | - Stefano Romagnoli
- Division of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
| |
Collapse
|
11
|
Carlson G, Curtis A. To Sleep, or Not to Sleep, that Is the Question. Crit Care Nurs Clin North Am 2021; 33:213-217. [PMID: 34023087 DOI: 10.1016/j.cnc.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Sleep disruptions occur in the intensive care unit (ICU), and pharmacologic and nonpharmacologic interventions can help minimize the effects. A structured quality improvement plan will ensure successful implementation and sustainability of a sleep protocol in the ICU.
Collapse
Affiliation(s)
- Glenn Carlson
- Division of Critical Care and Pulmonary Medicine, Bronson Battle Creek, Battle Creek, MI 49107, USA.
| | - Alyssa Curtis
- Bronson Battle Creek, Battle Creek, MI 49107, USA. https://twitter.com/alyssacurtis33
| |
Collapse
|
12
|
Review of Pharmacologic Sleep Agents for Critically Ill Patients. Crit Care Nurs Clin North Am 2021; 33:145-153. [PMID: 34023082 DOI: 10.1016/j.cnc.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sleep is a dynamic restorative process that is frequently disrupted in critically ill patients. Inadequate sleep can contribute to delirium and impaired healing. The etiology is multifactorial and practitioners often use a combination of nonpharmacologic and pharmacologic therapies to promote a healthy sleep cycle. There are many pharmacologic agents that may be used to promote sleep, and they display varying degrees of efficacy and safety. The selection of agent(s) should be based on patient- and disease-specific factors. All members of the treatment team can aid in assessing and optimizing sleep for critically ill patients.
Collapse
|