Stress systems exacerbate the inflammatory response after corneal abrasion in sleep-deprived mice via the IL-17 signaling pathway

Sleep deprivation (SD) has a wide range of adverse health effects. However, the mechanisms by which SD influences corneal pathophysiology and its post-wound healing remain unclear. This study aimed to examine the basic physiological characteristics of the cornea in mice subjected to SD and determine the pathophysiological response to injury after corneal abrasion. Using a multi-platform water environment method as an SD model, we found that SD leads to disturbances of corneal proliferative, sensory, and immune homeostasis as well as excessive inflammatory response and delayed repair after corneal abrasion by inducing hyperactivation of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis. Pathophysiological changes in the cornea mainly occurred through the activation of the IL-17 signaling pathway. Blocking both adrenergic and glucocorticoid synthesis and locally neutralizing IL-17A significantly improved corneal homeostasis and the excessive inflammatory response and delay in wound repair following corneal injury in SD-treated mice. These results indicate that optimal sleep quality is essential for the physiological homeostasis of the cornea and its well-established repair process after injury. Additionally, these observations provide potential therapeutic targets to ameliorate SD-induced delays in corneal wound repair by inhibiting or blocking the activation of the stress system and its associated IL-17 signaling pathway.

Sleep, anxiety, depression, and stress in critically ill patients: a descriptive study in a Portuguese intensive care unit

BACKGROUND

Sleep disorders are common among patients admitted to intensive care units (ICUs). This study aimed to assess the perceptions of sleep quality, anxiety, depression, and stress reported by ICU patients and the relationships between these perceptions and patient variables.

METHODS

This cross-sectional study used consecutive non-probabilistic sampling to select participants. All patients admitted for more than 72 hours of ICU hospitalization at a Portuguese hospital between March and June 2020 were asked to complete the "Richard Campbell Sleep Questionnaire" and "Anxiety, depression, and Stress Assessment Questionnaire." The resulting data were analyzed using descriptive statistics, Pearson's correlation coefficient, Student t-tests for independent samples, and analysis of variance. The significance level for rejecting the null hypothesis was set to α ≤0.05.

RESULTS

A total of 52 patients admitted to the ICU for at least 72 hours was recruited. The mean age of the participants was 64 years (standard deviation, 14.6); 32 (61.5%) of the participants were male. Approximately 19% had psychiatric disorders. The prevalence of self-reported poor sleep was higher in women (t[50]=2,147, P=0.037) and in participants with psychiatric problems, although this difference was not statistically significant (t[50]=-0.777, P=0.441). Those who reported having sleep disorders before hospitalization had a worse perception of their sleep.

CONCLUSIONS

Sleep quality perception was worse in female ICU patients, those with psychiatric disorders, and those with sleep alterations before hospitalization. Implementing early interventions and designing nonpharmacological techniques to improve sleep quality of ICU patients is essential.

Relationship between noise levels and intensive care patients' clinical complexity: An observational simulation study

BACKGROUND

Noise pollution in intensive care units is a relevant problem, associated with psychological and physiological consequences for patients and healthcare staff. Sources of noise pollution include medical equipment, alarms, communication tools, staff activities, and conversations.

AIMS

To explore the cumulative effects of noise caused by an increasing number and type of medical devices in an intensive care setting on simulated patients with increasing clinical complexity. Secondly, to measure medical device alarms and nursing activities' sound levels, evaluating their role as potentially disruptive noises.

STUDY DESIGN

Observational simulation study (reported according to the STROBE checklist). Using an electronic sound meter, the sound levels of an intensive care room in seven simulated clinical scenarios were measured on a single day (09 March 2022), each featuring increasing numbers of devices, hypothetically corresponding to augmented patients' clinical complexity. Secondly, noise levels of medical device alarms and specific nursing activities performed at a distance of three meters from the sound meter were analysed.

RESULTS

The empty room's mean baseline noise level was 37.8 (±0.7) dBA; among the simulated scenarios, noise ranged between 45.3 (±1.0) and 53.5 (±1.5) dBA. Alarms ranged between 76.4 and 81.3 dBA, while nursing tasks (closing a drawer, opening a saline bag overwrap, or sterile packages) and speaking were all over 80 dBA. The noisiest activity was opening a sterile package (98 dBA).

CONCLUSION

An increased number of medical devices, an expression of patients' higher clinical complexity, is not a significant cause of increased noise. Some specific nursing activities and conversations produce higher noise levels than medical devices and alarms. This study's findings suggest further research to assess the relationships between these factors and to encourage adequate noise reduction strategies.

RELEVANCE TO CLINICAL PRACTICE

Excessive noise level in the intensive care unit is a clinical issue that negatively affects patients' and healthcare providers' well-being. The increase in baseline room noise from medical devices is generally limited. Typical nursing tasks and conversations produce higher noise levels than medical devices and alarms. These findings could be helpful to raise awareness among healthcare professionals to recognize noise sources. The noisiest components of the environment can be modified by staff behaviour, promoting noise reduction strategies and improving the critical care environment.

Sleep in the intensive and intermediate care units: Exploring related factors of delirium, benzodiazepine use and mortality

AIM OF THE STUDY

The primary purpose was to examine sleep difficulties and delirium in the Intensive and Intermediate Care Unit. Secondarily, factors impacting night-time sleep duration and quality, mortality, and the impact of benzodiazepine use on sleep outcomes were investigated.

MATERIALS AND METHODS

This retrospective study encompassed data from 323 intensive and intermediate care unit admissions collected in the Netherlands, spanning from November 2018 to May 2020. Sleep quality was measured using the Richards-Campbell Sleep Questionnaire. Night-time sleep duration was nurse-reported. We investigated associations of these sleep outcomes with age, sex, length-of-stay, natural daylight, disease severity, mechanical ventilation, benzodiazepine use, and delirium using Generalized Estimating Equations models. Associations with one-year post-discharge mortality were analyzed using Cox regression.

RESULTS

Night-time sleep duration was short (median 4.5 hours) and sleep quality poor (mean score 4.9/10). Benzodiazepine use was common (24 % of included nights) and was negatively associated with night-time sleep duration and quality (B = -0.558 and -0.533, p <.001). Delirium and overnight transfers were negatively associated with sleep quality (B = -0.716 and -1.831, p <.05). The day-to-night sleep ratio was higher in the three days before delirium onset than in non-delirious individuals (p <.05). Age, disease severity and female sex were associated with increased one-year mortality. Sleep quality was negatively, but not-significantly, associated with mortality (p =.070).

CONCLUSIONS

Night-time sleep in the critical care environment has a short duration and poor quality. Benzodiazepine use was not associated with improved sleep. Sleep patterns change ahead of delirium onset.

IMPLICATIONS FOR CLINICAL PRACTICE

Consistent sleep monitoring should be part of routine nursing practice, using a validated instrument like the Richards-Campbell Sleep Questionnaire. Given the lack of proven efficacy of benzodiazepines in promoting sleep in critical care settings, it is vital to develop more effective sleep treatments that include non-benzodiazepine medication and sleep hygiene strategies.

The effect of lavender and bergamot oil applied via inhalation on the anxiety level and sleep quality of surgical intensive care unit patients

OBJECTIVE

Due to numerous stressors in intensive care, common psychosocial problems arise in patients. Among these, decreased anxiety and sleep quality are observed. This study aims to determine the effect of lavender and bergamot oil applied by inhalation on anxiety and sleep quality in surgical intensive care unit patients.

METHODS

Fifty-four patients hospitalized in the intensive care unit of a hospital in Istanbul, Turkey, were included in this study. They were randomly divided into three groups (Lavender, Bergamot, Control). Intervention groups were exposed to 3 drops of lavender oil or bergamot oil on pillows for 20 min, which were then placed 10 cm away from the patient's head. This intervention was applied for two nights. The patients' sleep quality and anxiety level were evaluated using the "State-Trait Anxiety Inventory (STAI)" and "Richard-Campbell Sleep Scale (RCSS)." Data were analyzed using Chi-square, independent t-test, One-way ANOVA tests.

RESULTS

According to our results, anxiety scores significantly decreased in the lavender and bergamot groups. Sleep quality scores significantly increased (p = <0.001). The control group showed lower sleep quality scores.

CONCLUSION

Lavender and bergamot oil inhalation appeared effective in reducing anxiety and improving sleep quality in surgical intensive care unit patients.

The effects of ergonomic sleep mask use on sleep quality and comfort in intensive care patients

This study was conducted to determine the effects of the use of ergonomic sleep mask on sleep quality and comfort in intensive care patients. This randomised controlled experimental study was completed with 128 surgical intensive care patients (control = 64, experimental = 64). During the second night of their stay in the unit, ergonomic sleep masks were given to the patients in the experimental group, and earplugs and eye masks were given to the patients in the control group. A Patient information form, Visual analogue scale for discomfort, and the Richard-Campbell sleep questionnaire were used to collect data. While 51.6% of the patients were female, the mean age of the patients was 63.87 ± 14.94 years. The highest rates of patients had undergone cardiovascular surgery (28.9%) and general anaesthesia (57.8%). It was determined that the sleep quality of the patients in the experimental group was statistically and clinically significantly higher after the intervention (50.86 ± 21.46 vs 37.64 ± 14.97, t = -5.355, Cohen's d = 0.450, p < 0.001). Likewise, the patients who used ergonomic sleep masks had a statistically significantly lower mean VAS for Discomfort score, and their comfort level was higher (p < 0.001), but the difference was not clinically significant (Cohen's d = 0.208). The results of this study showed that the use of ergonomic sleep masks in surgical intensive care patients had a more positive effect on both the sleep quality and comfort levels of patients compared with earplugs and eye masks. The use of an ergonomic sleep mask is recommended in the early period to facilitate sleep and rest in surgical intensive care patients.

Effects of immersive virtual reality on sensory overload in a random sample of critically ill patients

Background

Sensory overload and sensory deprivation have both been associated with negative health outcomes in critically ill patients. While there is a lack of any clear treatment or prevention strategies, immersive virtual reality is a promising tool for addressing such problems, but which has not been repetitively tested in random samples. Therefore, this study aimed to determine how critically ill patients react to repeated sessions of immersive virtual reality.

Methods

This exploratory study was conducted in the mixed medical-surgical intermediate care unit of the University Hospital of Bern (Inselspital). Participants (N = 45; 20 women, 25 men; age = 57.73 ± 15.92 years) received two immersive virtual reality sessions via a head-mounted display and noise-canceling headphones within 24 h during their stay in the unit. Each session lasted 30-min and showed a 360-degree nature landscape. Physiological data were collected as part of the participants' standard care, while environmental awareness, cybersickness, and general acceptance were assessed using a questionnaire designed by our team (1 = not at all, 10 = extremely).

Results

During both virtual reality sessions, there was a significant negative linear relationship found between the heart rate and stimulation duration [first session: r(43) = -0.78, p < 0.001; second session: r(38) = -0.81, p < 0.001] and between the blood pressure and stimulation duration [first session: r(39) = -0.78, p < 0.001; second session: r(30) = -0.78, p < 0.001]. The participants had a high comfort score [median (interquartile range {IQR}) = 8 (7, 10); mean = 8.06 ± 2.31], did not report being unwell [median (IQR) = 1 (1, 1); mean = 1.11 ± 0.62], and were not aware of their real-world surroundings [median (IQR) = 1 (1, 5); mean = 2.99 ± 3.22].

Conclusion

The subjectively reported decrease in environmental awareness as well as the decrease in the heart rate and blood pressure over time highlights the ability of immersive virtual reality to help critically ill patients overcome sensory overload and sensory deprivation. Immersive virtual reality can successfully and repetitively be provided to a randomly selected sample of critically ill patients over a prolonged duration.

Sleep and critical illness: a review

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.

The effect of music on sleep in hospitalized patients: A systematic review and meta-analysis

Sleep is often severely disturbed in hospitalized patients due to multiple factors such as noise, pain, and an unfamiliar environment. Since sleep is important for patient recovery, safe strategies to improve sleep in hospitalized patients are warranted. Music interventions have been found to improve sleep in general, and the aim of this systematic review is to assess the effect of music on sleep among hospitalized patients. We searched 5 databases to identify randomized controlled trials evaluating the effect of music interventions on sleep in hospitalized patients. Ten studies including a total of 726 patients matched the inclusion criteria. The sample sizes ranged from 28 to 222 participants per study. The music interventions varied in how the music was chosen as well as duration and time of day. However, in most studies, participants in the intervention group listened to soft music for 30 minutes in the evening. Our meta-analysis showed that music improved sleep quality compared to standard treatment (standardized mean difference 1.55 [95% CI 0.29-2.81], z = 2.41; p = 0.0159). Few studies reported other sleep parameters, and only one study used polysomnography for objective sleep measurement. No adverse events were reported in any of the trials. Hence, music may constitute a safe and low-cost adjunctive intervention to improve sleep in hospitalized patients. Prospero registration number: CRD42021278654.

Hospitalized Patients' Sleep Quality Compared Between Multioccupancy Rooms and Single-Patient Rooms

OBJECTIVES

To evaluate patients' sleep quality in a former hospital with two-and four-bedded rooms compared to a new hospital that incorporated evidence-based design features, including exclusively single-patient rooms (SPRs).

BACKGROUND

Hospitalized patients often report poor sleep quality due to both patient-related factors and hospital environmental factors. It is unclear if staying in an SPR in a hospital designed as a healing environment is associated with better sleep quality.

METHODS

In a before-after study, sleep quality, duration, and efficiency over 72 hr were measured with a sleep diary, GENEActiv accelerometer, and the Richards-Campbell Sleep Questionnaire (RCSQ) with scores ranging from 0 to 100, with higher scores reflecting better sleep. Participants were either staying alone in the former hospital with two-and four-bedded rooms (Group 1), sharing a room with one to three fellow patients (Group 2), or staying alone in a newly designed hospital with 100% SPRs (Group 3).

RESULTS

We included 17 patients in Group 1, 32 patients in Group 2, and 56 patients in Group 3. Univariable linear mixed model analysis, controlling for night number, revealed that the RCSQ total score was lowest in Group 2 compared to the other two groups. In the multivariable analysis, the RCSQ score was also the lowest in Group 2, with a significant effect from covariate "use of night medication."

CONCLUSION

Self-reported sleep quality of hospitalized patients in a hospital with 100% SPRs designed as a healing environment was slightly better than that of patients staying in multioccupancy rooms with fellow patients.

Sleep in neurointensive care patients, and patients after brain tumor surgery

BACKGROUND

Severely brain injured patients treated in the neuro intensive care unit (NICU) are usually sedated. Sedation may affect not only the ability to sleep, but also the EEG rhythms used to identify sleep.

AIM

The aims were: To study if sleep patterns could be identified in the severely brain injured and sedated patients in the NICUTo study if sleep patterns could be identified in patients the night after brain tumor surgery in the neurointermediate care unit (NIMCU)To search for risk factors for not being able to sleep after brain tumor surgery.

STUDY DESIGN

Two populations were included; one with patients affected by severe brain injury and one with patients who had undergone planned brain tumor surgery. This was a quantitative observational study using EEG. Eligible neurointensive care patients for this study had to be suffering from a neurosurgical condition (for example subarachnoid haemorrhage, acute subdural hematoma, intracerebral haemorrhage and meningitis), have affected consciousness and age over 18 years. Thirty-seven patients were included from NICU. Ninety-eight patients, with a suspected glioma (WHO grade II-IV) planned for surgery were also included.

RESULTS

Neuro intensive care patients, sedated and treated in ventilator, showed no EEG sleep patterns at all. After brain tumor surgery, sleep occurred in 74% of the patients, despite frequent wake-up tests. The patients with sleep patterns were on average 8 years younger, p = 0.03.

CONCLUSIONS

Patients with severe brain injury are at risk of having no sleep when treated at the NICU, whereas after brain tumor surgery, sleep occurs in three-fourths of the patients. Further studies and new methods are warranted to identify sleep and investigate how the loss of sleep affects these patients and how sleep disturbances can be managed.

Sleep during and following critical illness: A narrative review

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.

Critical Care Rehabilitation of the Burn Patient

Despite the fact that modern burn care has significantly reduced the mortality associated with severe burn injuries, the rehabilitation and community reintegration of survivors continues to be a challenge. An interprofessional team approach is essential for optimal outcomes. This includes early occupational and physical therapy, beginning in the intensive care unit (ICU). Burn-specific techniques (edema management, wound healing, and contracture prevention) are successfully integrated into the burn ICU. Research demonstrates that early intensive rehabilitation of critically ill burn patients is safe and effective. Further work on the physiologic, functional, and long-term impact of this care is needed.

Improve sleep in critically ill patients: Study protocol for a randomized controlled trial for a multi-component intervention of environment control in the ICU

INTRODUCTION

In critically ill patients, sleep and circadian rhythms are greatly altered. These disturbances have been associated with adverse consequences, including increased mortality. Factors associated with the ICU environment, such as exposure to inadequate light and noise levels during the day and night or inflexible schedules of daily care activities, have been described as playing an essential role in sleep disturbances. The main objective of this study is to evaluate the impact of the use of a multifaceted environmental control intervention in the ICU on the quantity and quality of sleep, delirium, and post-intensive care neuropsychological impairment in critically ill patients.

METHODS

This is a prospective, parallel-group, randomized trial in 56 critically ill patients once they are starting to recover from their acute illness. Patients will be randomized to receive a multifaceted intervention of environmental control in the ICU (dynamic light therapy, auditory masking, and rationalization of ICU nocturnal patient care activities) or standard care. The protocol will be applied from enrollment until ICU discharge. Baseline parameters, light and noise levels, polysomnography and actigraphy, daily oscillation of plasma concentrations of Melatonin and Cortisol, and questionnaires for the qualitative evaluation of sleep, will be assessed during the study. In addition, all patients will undergo standardized follow-up before hospital discharge and at 6 months to evaluate neuropsychological impairment.

DISCUSSION

This study is the first randomized clinical trial in critically ill patients to evaluate the effect of a multicomponent, non-pharmacological environmental control intervention on sleep improvement in ICU patients. The results will provide data about the potential synergistic effects of a combined multi-component environmental intervention in ICU on outcomes in the ICU and long term, and the mechanism of action.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT. Registered on January 10, 2023. Last updated on 24 Jan 2023.

A nomogram model for assessing predictors and prognosis of postoperative delirium in patients receiving acute type A aortic dissection surgery

BACKGROUND

Postoperative delirium (POD) complicates the postoperative course. There is limited information on POD-related risk factors (RFs) and prognosis in patients with acute type A aortic dissection (ATAAD) after modified triple-branched stent graft implantation (MTBSG) surgery.

METHODS

We retrospectively examined consecutive ATAAD patients who received MTBSG surgery in our hospital between January 2013 and December 2019. We employed univariate and multivariate analyses to identify stand-alone RFs for POD. A nomogram was next generated to estimate POD occurrence. The primary outcome was the development of POD, and the secondary outcomes were intensive care unit (ICU) and hospital stays, hospitalization costs, and in-hospital and follow-up mortality.

RESULTS

We selected 692 patients, of whom 220 experienced POD (31.8%). Based on our analysis, the following factors enhanced the likelihood of POD development: alcohol consumption (p < 0.001), acute physiology and chronic health evaluation II score (p = 0.023), serum total bilirubin (p = 0.007), stage 3 acute kidney injury (p < 0.001), serum interleukin-6 (p = 0.031), post-operative analgesics usage (p = 0.015), and ventilation duration (p = 0.008). POD patients had significantly longer ventilator times (p = 0.003), ICU stays (p < 0.001), and hospital stays (p = 0.038), together with increased hospitalization costs (p < 0.001) and in-hospital mortality (p = 0.019). However, POD was not a RF for mortality during follow-up (log-rank p = 0.611).

CONCLUSIONS

We demonstrated a strong link between POD and poor prognosis in ATAAD patients. We also constructed a prognosis estimator model which will benefit early management guidance to minimize the incidence of POD.

Effectiveness of aromatherapy on anxiety and sleep quality among adult patients admitted into intensive care units: A systematic review

PURPOSE

This review aims to evaluate the effectiveness of aromatherapy on anxiety and sleep quality among adult patients admitted to an intensive care unit.

MATERIALS AND METHODS

A systematic search for published and unpublished studies across nine databases and sources were conducted. Randomised Controlled Trials and Controlled Clinical Trials, which assessed the effectiveness of aromatherapy on anxiety and sleep quality among intensive care unit patients, were included in this review. Only studies that used aromatherapy as a single intervention were included. Narrative synthesis was conducted across all outcomes due to high heterogeneity across studies.

RESULTS

A total of 26 studies involving 2176 participants across six countries were included in this review. Most studies had an overall high risk of bias. Publication bias was detected in the studies. Findings have shown that aromatherapy may be effective in reducing anxiety based on the low GRADE certainty of evidence, and improving sleep quality based on the very low GRADE certainty of evidence. Inconsistencies in findings were also observed.

CONCLUSION

Aromatherapy might be beneficial on anxiety and sleep quality among intensive care unit patients, however, the level of evidence is very low, based on the low quality of studies. Considerations can be made to incorporate aromatherapy into existing interventions that improve anxiety and sleep quality in the intensive care unit. Due to inconsistencies in findings, further research can be done to investigate and strengthen these evidence.

IMPLICATION FOR CLINICAL PRACTICE

This review has demonstrated that aromatherapy may have benefits on anxiety and sleep quality. Despite uncertain evidence, aromatherapy may still be considered as a complementary or alternative option to improve anxiety and sleep quality among intensive care patients as it is relatively safe, cost-effective and easy to implement (Buckle, 2014). However, proper training by a professional clinical aromatherapist is needed to ensure there is screening of patients for suitability, proper technique for administering aromatherapy, safe handling of essential oils and monitoring for adverse events (Farrar & Farrar, 2020).

Remimazolam besylate for the sedation of postoperative patients undergoing invasive mechanical ventilation in the ICU: a prospective dose‒response study

This single-center study aimed to determine the effective dose and safety of remimazolam besylate for the sedation of postoperative patients undergoing invasive mechanical ventilation in the intensive care unit (ICU). Mechanically ventilated patients admitted to the ICU after surgery were included. The Narcotrend index (NTI) was used to assess the depth of sedation, and the Richmond Agitation-Sedation Scale (RASS) score was also recorded. Remimazolam besylate was administered initially at a loading dose of 0.02 mg/kg, followed by a gradual increase of 0.005 mg/kg each time until the targeted depth of sedation was achieved (NTI 65-94). A maintenance dose of remimazolam besylate was administered starting at 0.2 mg/kg/h, followed by increments or subtractions of 0.05 mg/kg/h each time until a satisfactory depth of sedation was achieved and maintained for at least 30 min. The demographic data, anesthesia, surgery types, hemodynamics and respiratory parameters were recorded. Adverse events and adverse drug reactions were monitored for safety. Twenty-three patients were eventually included in this study covering a period of 1 year. A satisfactory depth of sedation was achieved by a single intravenous infusion of remimazolam besylate at a loading dose of 0.02-0.05 mg/kg followed by a maintenance dose of 0.20-0.35 mg/kg/h. There were no significant changes in hemodynamic and respiratory parameters within 10 min after the administration of remimazolam besylate. In addition, a significant correlation was observed between the NTI and the RASS score for assessing sedation (r = 0.721, P < 0.001). The NTI showed a predictive probability for a RASS score of 0.817. Remimazolam besylate was effective for mild/moderate sedation of invasively mechanically ventilated postoperative patients in the ICU while maintaining excellent respiratory and hemodynamic stability. The NTI can be used as a good tool for the objective evaluation of the depth of sedation and agitation.

Sleep assessment in critically ill adults: A systematic review and meta-analysis

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.

The effect of music therapy on the anxiety, depression and sleep quality in intensive care unit patients: A protocol for systematic review and meta-analysis

BACKGROUND

Music therapy serves as a non-pharmacological intervention for a variety of disorders with promising results. However, the effect of music therapy on improving anxiety, depression, and sleep quality in intensive care unit (ICU) patients remains unclear. This meta-analysis aims to evaluate the effect of music therapy on improving anxiety, depression, and sleep quality in ICU patients, thus providing evidences to support music therapy as a novel complementary alternative therapy.

METHODS

Randomized controlled trials (RCTs) reporting the efficacy of music therapy on improving anxiety, depression and sleep quality in ICU patients published before January 2022 will be searched in online databases, including the PubMed, the Cochrane Library, Web of Science, Embase, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Database, and WanFang Database. Literature screening, data extraction, and evaluation of risk of bias will be independently performed by two investigators. Meta-analysis will be performed using Stata 14.0 software.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will provide reliable evidence-based evidence for the effect of music therapy on anxiety, depression, and sleep quality in ICU patients.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/EXAZ6.

Family Presence and Sleep in the Intensive Care Unit

Sleep is a vital component of health and healing. Hospitalized patients need sleep in order to overcome their illness, and family members of those patients also need restorative sleep. Nurses can assist with both patient's and family member's abilities to obtain nonfragmented sleep. Education is important for families to understand the importance of sleep, and nurses can also supply families with simple comfort measures such as ear plugs, eye masks, and a comfortable sleep location.

Very-Short-Term Sleep Deprivation Slows Early Recovery of Lymphocytes in Septic Patients

Sleep plays an important role in immune function. However, the effects of very-short-term sleep deprivation on the early recovery of immune function after sepsis remain unclear. This study was conducted in the intensive care unit to investigate the effects of 2 consecutive days of sleep deprivation (SD) on lymphocyte recovery over the following few days in septic patients who were recovering from a critical illness. The patients' self-reports of sleep quality was assessed using the Richards–Campbell Sleep Questionnaire at 0 and 24 h after inclusion. The demographic, clinical, laboratory, treatment, and outcome data were collected and compared between the good sleep group and poor sleep group. We found that 2 consecutive days of SD decreased the absolute lymphocyte count (ALC) and ALC recovery at 3 days after SD. Furthermore, post-septic poor sleep decreased the plasma levels of atrial natriuretic peptide (ANP) immediately after 2 consecutive days of SD. The ANP levels at 24 h after inclusion were positively correlated with ALC recovery, the number of CD3⁺ T cells, or the number of CD3⁺ CD4⁺ cells in the peripheral blood on day 5 after inclusion. Our data suggested that very-short-term poor sleep quality could slow down lymphocyte recovery over the following few days in septic patients who were recovering from a critical illness. Our results underscore the significance of very-short-term SD on serious negative effects on the immune function. Therefore, it is suggested that continuous SD or several short-term SD with short intervals should be avoided in septic patients.

A Systematic Review of Risk Factors for Sleep Disruption in Critically Ill Adults

OBJECTIVES

Numerous risk factors for sleep disruption in critically ill adults have been described. We performed a systematic review of all risk factors associated with sleep disruption in the ICU setting.

DATA SOURCES

PubMed, EMBASE, CINAHL, Web of Science, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews.

STUDY SELECTION

English-language studies of any design published between 1990 and April 2018 that evaluated sleep in greater than or equal to 10 critically ill adults (> 18 yr old) and investigated greater than or equal to 1 potential risk factor for sleep disruption during ICU stay. We assessed study quality using Newcastle-Ottawa Scale or Cochrane Risk of Bias tool.

DATA EXTRACTION

We abstracted all data independently and in duplicate. Potential ICU sleep disruption risk factors were categorized into three categories based on how data were reported: 1) patient-reported reasons for sleep disruption, 2) patient-reported ratings of potential factors affecting sleep quality, and 3) studies reporting a statistical or temporal association between potential risk factors and disrupted sleep.

DATA SYNTHESIS

Of 5,148 citations, we included 62 studies. Pain, discomfort, anxiety/fear, noise, light, and ICU care-related activities are the most common and widely studied patient-reported factors causing sleep disruption. Patients rated noise and light as the most sleep-disruptive factors. Higher number of comorbidities, poor home sleep quality, home sleep aid use, and delirium were factors associated with sleep disruption identified in available studies.

CONCLUSIONS

This systematic review summarizes all premorbid, illness-related, and ICU-related factors associated with sleep disruption in the ICU. These findings will inform sleep promotion efforts in the ICU and guide further research in this field.

Use of music to enhance sleep and psychological outcomes in critically ill patients: a protocol for a systematic review and meta-analysis

INTRODUCTION

Music listening is used as a non-pharmacological intervention in various populations with positive results; however, evidence for its effect on sleep and psychological outcomes in critically ill patients remains unclear. It is essential to understand the impact of music listening for critically ill patients to optimise care and minimise the risk for harm. We will assess whether music listening improves sleep and psychological outcomes in critically ill patients.

METHODS AND ANALYSIS

We will systematically search scientific databases for relevant studies, including PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest, the Cochrane Central Register of Controlled Trials, China Biological Medicine Database, China National Knowledge Infrastructure Library, Wan fang databases, VIP Database for Chinese Technical Periodicals and the Chinese Clinical Trial Registry. Databases will be searched for articles published from inception to 10 June 2020. Music therapy journals and reference lists in some articles will be hand-searched. Grey literature will also be searched. We will include randomised and quasi-randomised controlled trials that used music listening to improve sleep and psychological outcomes in critically ill patients. The primary outcomes will be sleep-related outcomes, and secondary outcomes will be anxiety and depression scores and physiological outcomes. Two reviewers will independently verify study eligibility and methodological quality; disagreements will be resolved by a third reviewer or through discussion. The risk of bias will be independently determined using the Cochrane Risk of Bias Tool. The Consolidated Standards of Reporting Trials checklist will be used to examine the quality of included papers. Data will be extracted from eligible studies by two researchers. RevMan V.5.3 will be used for meta-analysis.

ETHICS AND DISSEMINATION

This work will review existing trial data and will not introduce new patient data or interventions; therefore, ethics committee approval is not required. We will disseminate this protocol in a related peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019147202.

Music intervention for sleep quality in critically ill and surgical patients: a meta-analysis

OBJECTIVE

Sleep disruption occurs frequently in hospitalised patients. Given the potential of music intervention as a non-pharmacological measure to improve sleep quality, we aimed to assess and quantify current literature on the effect of recorded music interventions on sleep quality and quantity in the adult critical care and surgical populations.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, MEDLINE Ovid, Cochrane Central, Web of Science and Google Scholar.

ELIGIBILITY CRITERIA FOR STUDIES

Randomised controlled trials assessing the effect of music on sleep quality in critically ill and surgical patients.

METHODS

The electronic databases were systematically searched from 1 January 1981 to 27 January 2020. Data were screened, extracted and appraised by two independent reviewers. Primary outcomes were sleep quality and quantity, assessed with validated tools. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Random effects meta-analysis was performed, and pooled standardised mean differences (SMDs) with 95% CIs were reported.

RESULTS

Five studies (259 patients) were included in qualitative (risk of bias) and quantitative analysis (meta-analysis). Pooled data showed a significant effect of recorded music on subjective sleep quality in the critical care and surgical population (SMD=1.21 (95% CI 0.50 to 1.91), p<0.01, excluding one non-English study; SMD=0.87 (95% CI 0.45 to 1.29), p<0.01). The SMD of 1.21 corresponded to a 27.1% (95% CI 11.2 to 42.8) increase in subjective sleep quality using validated questionnaires. A significant increase in subjective sleep quantity of 36 min was found in one study. Objective measurements of sleep assessed in one study using polysomnography showed significant increase in deeper sleep stage in the music group.

CONCLUSIONS

Recorded music showed a significant improvement in subjective sleep quality in some critical care and surgical populations. Therefore, its use may be relevant to improve sleep, but given the moderate potential for bias, further research is needed.

PROSPERO REGISTRATION NUMBER

CRD42020167783.

Review of Pharmacologic Sleep Agents for Critically Ill Patients

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.

Sleep and Activity Patterns Are Altered During Early Critical Illness in Mechanically Ventilated Adults

BACKGROUND

Mechanically ventilated (MV) patients in the intensive care unit (ICU) often experience disturbed sleep and profound inactivity.

OBJECTIVES

The aim of this study was to report 5 consecutive days' descriptive analyses on sleep efficiency (SE), total sleep time (TST), daytime activity ratio (DAR), and hourly activity counts among critically ill MV adults from 9 ICUs across 2 hospitals.

METHODS

A secondary analysis was undertaken from our parent National Institutes of Health-funded randomized controlled trial (NIH R01 NR016702). Subjects included 31 critically ill patients from multiple ICUs. Wrist actigraphy estimated SE and TST. Mean DAR, an indicator of altered sleep-wake cycles, was calculated. Continuous 24-hour activity counts over 5 consecutive days were summarized. Descriptive analyses were used.

RESULTS

A total of 31 subjects with complete actigraphy data were included. Mean age was 59.6 (SD, 17.3) years; 41.9% were male; 83.9% were White, and 67.7% were Hispanic/Latino; and the mean APACHE III (Acute Physiology and Chronic Health Evaluation III) severity of illness score was 74.5 (SD, 25.5). The mean nighttime SE and TST over the 5-day ICU period were 83.1% (SD, 16.14%) and 6.6 (SD, 1.3) hours, respectively. The mean DAR over the 5-day ICU period was 66.5% (SD, 19.2%). The DAR surpassed 80% on only 17.5% of subject days. The majority of subjects' activity level was low, falling below 1000 activity counts per hour.

CONCLUSION

Our study revealed poor rest-activity cycle consolidation among critically ill MV patients during the early ICU period. Future interventional studies should promote quality sleep at nighttime and promote mobilization during the daytime.

Development and Validation of a Clinical Prediction Model for Sleep Disorders in the ICU: A Retrospective Cohort Study

Background

Sleep disorders, the serious challenges faced by the intensive care unit (ICU) patients are important issues that need urgent attention. Despite some efforts to reduce sleep disorders with common risk-factor controlling, unidentified risk factors remain.

Objectives

This study aimed to develop and validate a risk prediction model for sleep disorders in ICU adults.

Methods

Data were retrieved from the MIMIC-III database. Matching analysis was used to match the patients with and without sleep disorders. A nomogram was developed based on the logistic regression, which was used to identify risk factors for sleep disorders. The calibration and discrimination of the nomogram were evaluated with the 1000 bootstrap resampling and receiver operating characteristic curve (ROC). Besides, the decision curve analysis (DCA) was applied to evaluate the clinical utility of the prediction model.

Results

2,082 patients were included in the analysis, 80% of whom (n = 1,666) and the remaining 20% (n = 416) were divided into the training and validation sets. After the multivariate analysis, hemoglobin, diastolic blood pressure, respiratory rate, cardiovascular disease, and delirium were the independent risk predictors for sleep disorders. The nomogram showed high sensitivity and specificity of 75.6% and 72.9% in the ROC. The threshold probability of the net benefit was between 55% and 90% in the DCA.

Conclusion

The model showed high performance in predicting sleep disorders in ICU adults, the good clinical utility of which may be a useful tool for providing clinical decision support to improve sleep quality in the ICU.

Hemodynamics Changes in the Phase Before, During, and After Sleep Based on Patients’ Sleep Quality in High Care Unit

BACKGROUND: Sleep is a human physiological need that must be fulfilled. Sleep disturbance is generally experienced by hospitalized patients and measured by sleep quality. Sleep disturbance can adversely affect hemodynamic parameters, physiological, and psychological outcome that contribute to the healing of patients. However, few literatures discussing the hemodynamic changes based on the patients’ sleep quality. AIM: The study aimed to describe the hemodynamic changes before, during, and after sleeping phases METHODS: This is an observational analytic quantitative study conducted between February and March 2019 and involved 45 patients. The samples were the conscious patients, aged between 18 and 60 years old (adult) and had been hospitalized for more than 2 days. The Richards-Campbell Sleep Questionnaire was utilized to measure the patients sleep quality, while hemodynamic values were observed by patients’ bedside monitor before, during and after sleep. Data analysis used the Friedman test to determine hemodynamic changes. RESULTS: The results showed that most respondents were female (75.6%), used oxygen (46.7%), sleep in supine position (55.6%), and average age of 35.47 (standard deviation [SD] = 9.581) years old. Patients’ sleep quality score was 44.27 (SD = 22.809), with the average days of treatment were 2.47 days (SD = 694). The average score of Hemodynamic Mean Arterial Pressure (MAP), Heart Rate (HR), and Oxygen saturation (SpO2) before sleeping was 97.64, 94.04, and 94.09, during sleeping was 89.87, 85.00, and 91.22 while after sleeping was 98.27, 97.56, and 97.89, respectively. There was a significant change in HR with p = 0.019, and there was no significant change in the MAP (p = 0.152) and SpO2 (p = 0.149) CONCLUSION: There were variations in hemodynamic score changes before, during, and after sleep, changes in MAP, HR, and SpO2 score within normal ranges. The high hemodynamic changes in the early phase, decrease during sleep, and rise again after sleep. HR is a hemodynamic parameter that significantly changes in those three phases. Monitoring of hemodynamic values in patients could be carried out in the before, during, and after sleep phases to determine the patients’ physiological and psychological condition so as to contribute the healing process.

Daytime-to-Nighttime Sleep Ratios and Cognitive Impairment in Older Intensive Care Unit Survivors

BACKGROUND

Sleep duration and proportion of daytime versus nighttime sleep may affect cognitive function in older patients in the transition out of the intensive care unit.

OBJECTIVE

To explore the relationship between the daytime-to-nighttime sleep ratio and cognitive impairment in older intensive care unit survivors.

METHODS

The study enrolled 30 older adults within 24 to 48 hours after intensive care unit discharge. All participants were functionally independent before admission and underwent mechanical ventilation in the intensive care unit. Actigraphy was used to estimate daytime (6 AM to 9:59 PM) and nighttime (10 PM to 5:59 AM) total sleep duration. Daytime-to-nighttime sleep ratios were calculated by dividing the proportion of daytime sleep by the proportion of nighttime sleep. The National Institutes of Health Toolbox Cognition Battery Dimensional Change Card Sort Test (DCCST) was used to assess cognition. Associations between sleep and cognition were explored using multivariate regression after adjusting for covariates.

RESULTS

The mean (SD) daytime sleep duration was 7.55 (4.30) hours (range, 0.16-14.21 hours), and the mean (SD) nighttime sleep duration was 4.99 (1.95) hours (range, 0.36-7.21 hours). The mean (SD) daytime-to-nighttime sleep ratio was 0.71 (0.30) (range, 0.03-1.10). Greater daytime sleep duration (β = -0.351, P = .008) and higher daytime-to-nighttime sleep ratios (β = -0.373, P = .008) were negatively associated with DCCST scores.

CONCLUSIONS

The daytime-to-nighttime sleep ratio was abnormally high in the study population, revealing an altered sleep/wake cycle. Higher daytime-to-nighttime sleep ratios were associated with worse cognition, suggesting that proportionally greater daytime sleep may predict cognitive impairment.

Sleep Deprivation in the Intensive Care Patient

TOPIC

Sleep deprivation in the intensive care unit setting.

CLINICAL RELEVANCE

The Society of Critical Care Medicine has identified sleep deprivation as a significant contributor to the development of delirium in adult patients in the intensive care unit. Thus, preventing and managing sleep deprivation is important in reducing the incidence of delirium in this patient population. A multifaceted and multidisciplinary approach to promoting sleep in the intensive care unit setting that includes sleep hygiene routines, nursing care plans, and appropriate medication regimens may improve patient outcomes, including reducing delirium.

PURPOSE OF ARTICLE

To review the current literature on sleep deprivation in the intensive care unit setting and present care guidelines in a concise format. This information may be helpful in the development of clinical tools and may guide future quality improvement projects aimed at reducing delirium through sleep promotion in critical care patients.

CONTENT COVERED

A review of current literature and national organization recommendations revealed consistent themes in addressing the problem of sleep deprivation in the intensive care unit. Modifiable and nonmodifiable risk factors included frequent care interactions, light, noise, medication effects, and preexisting sleep problems.

Challenges of Implementing the Choosing Wisely Guideline to Promote Sleep and Rest at Night for Hospitalized Patients

BACKGROUND

Evidence suggests that a lack of sleep among patients during hospitalization can impact their health and well-being.

LOCAL PROBLEM

On inpatient units, patients experience lack of sleep due to noise and multiple interruptions at night.

METHODS

A pilot intervention to support the initiative, "Don't wake the patient for routine care unless the patient's condition or care specifically requires it," was implemented on 3 units in 3 hospitals. All the 3 units had experienced patient concerns about lack of sleep at night.

INTERVENTIONS

Nurses implemented the project using a purposeful strategy of sleep masks, earplugs, noise detectors, and bundling care.

RESULTS

Positive experiences of those patients who participated in the sleep intervention.

CONCLUSIONS

There was multidisciplinary support to promote a better patient experience of nighttime sleep. The experiences across the 3 hospital units were positive for providers, patients, and patients' families.

The efficacy of nursing interventions on sleep quality in hospitalized patients: A systematic review of randomized controlled trials

OBJECTIVE

To determine the effect of interventions that could be performed by nurses to improve the sleep quality of hospitalized patients in acute and semi-acute units.

DESIGN

A systematic review of randomized controlled trials and narrative synthesis.

DATA SOURCES

Seven electronic databases (PubMed, CINAHL Plus, Scopus, ISI WoS, CENTRAL, PsycInfo, and Embase) were accessed on 20 May 2019 with a temporal limit of 10 years prior.

REVIEW METHODS

Original research studies of interventions that could be delivered by nurses to improve sleep quality during hospitalization in acute and semi-acute units were included. Study selection, data extraction, and risk of bias assessment were performed by two independent reviewers.

RESULTS

Seventeen studies met the inclusion criteria and were included in this review. The interventions carried out in the trials were classified into four categories of measurement: environmental, physical, behavioural, and combined. Fourteen studies obtained statistically significant improvements; two showed a blend of significant and non-significant improvements; and one reported non-significant results. However, only four trials of the seventeen were judged as having a low risk of bias.

CONCLUSIONS

Overall evidence about interventions that could be performed by nurses to improve perceived sleep quality in hospitalized patients was found to be positive, and no negative effects were reported. However, higher quality research using both subjective and objective measures is needed, in order to strengthen the evidence.

Nurses' autonomy in sleep management improves patients' sleep quality: A cross-sectional study

BACKGROUND

The current literature indicates that intensive care (ICU) patients' sleep quality is generally poor, which is associated with serious physical and psychological consequences.

AIMS AND OBJECTIVES

To describe the practices nurses use to provide good-quality sleep to adult ICU patients and assess nurses' perceptions of patients' sleep quality and nurses' professional autonomy in sleep management.

DESIGN

A descriptive-correlational, cross-sectional study.

METHODS

A total of 232 ICU nurses from four hospitals in Poland were recruited. Data were collected between May and August 2019 using a previously developed questionnaire and analysed using descriptive statistics and non-parametric tests.

RESULTS

A total of 119 nurses took part in the study (response rate: 51%). On average, nurses rated patients' sleep quality as moderate (4.44 ± 2.23, scale 0-10). Most of the respondents (95.8%) said they did not use any sleep protocol. Various strategies to improve patients' sleep were used sporadically (2.64 ± 1.55, scale 1-5). The use of sleep quality assessment methods was positively correlated with patients' sleep quality (rho = 0.22, P = .02). Nurses' professional autonomy regarding sleep management was assessed as average (4.34 ± 2.43, scale 0-10) and was correlated with the patients' sleep quality (rho = 0.25, P < .01). Nurses who rated their autonomy in patients' sleep management more highly (rho = 0.29, P < .01) and more often influenced patients' sleep decisions (rho = 0.24, P < .01) used more methods to improve patients' sleep.

CONCLUSIONS

Strengthening the professional autonomy of ICU nurses and creating a reliable sleep assessment and improvement tool, which would describe strategies nurses can implement independently could increase sleep quality among ICU patients.

RELEVANCE TO CLINICAL PRACTICE

Addressing organizational problems, which hamper the patients' sleep management by ICU nurses could result in using more strategies to provide good-quality sleep to ICU patients. There is a need for clinical guidelines regarding patients' sleep management to help educate and guide nurses how to independently use sleep improvement methods.

Viability and validity of the bispectral index to measure sleep in patients in the intensive care unit

Objective

To investigate the viability of the bispectral index in the sleep evaluation of critically ill patients and to quantify the associations of sleep parameters measured by this index with the Richards-Campbell Sleep Questionnaire and environmental noise.

Methods

This was a cross-sectional observational study that evaluated critically ill adults with diseases of low or moderate severity. The following were measured: total sleep volume and time, deep sleep volume and time, continuous sleep volume and time, sleep onset latency, and environmental sound pressure level. The subjective perception of sleep was evaluated with the Richards-Campbell Sleep Questionnaire the morning after each night of observation.

Results

Patients had a low total sleep time (234 minutes), a predominance of superficial sleep stages, and little deep sleep (1.7 minutes). The total, deep, and continuous sleep volumes were 3,679, 9.4, and 3,143 (bispectral index units × minutes), respectively. The sleep latency was 94 minutes. The mean score of the Richards-Campbell Sleep Questionnaire was 57.9. Total sleep volume, total sleep time, and continuous sleep volume were weakly correlated with the Richards-Campbell Sleep Questionnaire depth of sleep domain score, overall sleep quality domain score, and total score. Total volume, total time, and continuous volume were moderately correlated with the occurrence of awakenings domain score.

Conclusion

The bispectral index is an instrument with limited viability to monitor the sleep of lucid patients and patients with low to moderate disease severity in the intensive care unit. Patients with higher total sleep volume, total sleep time, and continuous sleep volume had better overall sleep perception.

The CAM-ICU-7 and ICDSC as measures of delirium severity in critically ill adult patients

Background

In clinical practice, a dichotomous approach to delirium identification may no longer be relevant when existing delirium screening tools measure a range of scores. The objective of this study was to compare the Confusion Assessment Method for the Intensive Care Unit 7-item (CAM-ICU-7) and the Intensive Care Delirium Screening Checklist (ICDSC) as measures of the spectrum of delirium severity in critically ill adult patients.

Methods

In this cross-sectional study, 218 patients underwent 641 paired assessments by bedside nurses (ICDSC, as per usual care) and trained research assistants (CAM-ICU-7). Correlation between the CAM-ICU-7 and ICDSC scores was evaluated. Logistic regression was used to explore associations between CAM-ICU-7 or ICDSC score and length of ICU stay and mechanical ventilation (receipt, ≥96 hours).

Results

Delirium prevalence evaluated by the CAM-ICU-7 and ICDSC were 46.3% (95% CI:39.7–53.0) and 34.4% (95% CI:28.3–41.0). Prevalence of less than clinical threshold symptoms of delirium evaluated by the CAM-ICU-7 (score: 1–2) and ICDSC (score: 1–3) were 30.3% (95%CI:24.5–36.7) and 50.9% (95%CI:44.3–57.6). The CAM-ICU-7 and ICDSC had significant positive correlation (0.58, p<0.001). Agreement between the tools as measures of delirium was moderate (kappa = 0.51) and as measures of less than clinical threshold symptoms of delirium was fair (kappa = 0.21). Less than clinical threshold symptoms of delirium identified by the ICDSC, not CAM-ICU-7, were associated with prolonged length of ICU stay (≥7 days) in patients <65 years of age [Odds Ratio (OR) 9.2, 95% CI:2.5–34.0] and mechanical ventilation (receipt: OR 2.8, 95% CI:1.3–6.4; ≥96 hours: OR 6.6, 95% CI:1.9–22.9), when compared to patients with no delirium.

Conclusions

The CAM-ICU-7 and ICDSC are measures of the spectrum of delirium severity that are closely correlated. Less than clinical threshold symptoms of delirium measure by the ICDSC is a better predictor of outcomes, when compared with the CAM-ICU-7.

A key role of gut microbiota-vagus nerve/spleen axis in sleep deprivation-mediated aggravation of systemic inflammation after LPS administration

AIMS

Sleep deprivation (SD) correlates with exacerbated systemic inflammation after sepsis. However, the underlying mechanisms remain unclear. This study aimed to evaluate the roles and mechanisms of SD in inflammatory organ injury after lipopolysaccharide (LPS) administration.

MAIN METHODS

Mice were intraperitoneally injected with LPS followed by 3 consecutive days of SD. The pseudo germ-free (PGF) mice received fecal microbiota transplant by being gavaged with supernatant from fecal suspension of septic mice with or without SD. The subdiaphragmatic vagotomy (SDV) or splenectomy was performed 14 days prior to LPS injection or antibiotics administration.

KEY FINDINGS

Post-septic SD increased the plasma levels of interleukin (IL)-6 and tumor necrosis factor-α (TNF-α), reduced IL-10 plasma level, increased spleen weight, and promoted inflammatory injury of the lung, liver and kidney. The relative abundance of Proteobacteria and its subgroups were increased after post-septic SD. PGF mice transplanted with fecal bacteria from septic mice subjected to SD developed splenomegaly, systemic inflammation, organ inflammation and damage as their donors did. Intriguingly, SDV abolished the aggravated effects of SD on splenomegaly and inflammatory organ injury in septic mice received SD or in PGF mice transplanted with fecal bacteria from septic mice subjected to SD. Furthermore, splenectomy also abrogated the increase in IL-6 and TNF-α plasma levels and the decrease in IL-10 plasma level in PGF mice transplanted with fecal bacteria from septic mice subjected to SD.

SIGNIFICANCE

Gut microbiota-vagus nerve axis and gut microbiota-spleen axis play key roles in modulating systemic inflammation induced by SD after LPS administration.

Dim light at night exacerbates stroke outcome

Circadian rhythms are endogenous biological cycles that synchronize physiology and behaviour to promote optimal function. These ~24-hr internal rhythms are set to precisely 24 hr daily by exposure to the sun. However, the prevalence of night-time lighting has the potential to dysregulate these biological functions. Hospital patients may be particularly vulnerable to the consequences of light at night because of their compromised physiological state. A mouse model of stroke (middle cerebral artery occlusion; MCAO) was used to test the hypothesis that exposure to dim light at night impairs responses to a major insult. Stroke lesion size was substantially larger among animals housed in dLAN after reperfusion than animals maintained in dark nights. Mice housed in dLAN for three days after the stroke displayed increased post-stroke anxiety-like behaviour. Overall, dLAN amplified pro-inflammatory pathways in the CNS, which may have exacerbated neuronal damage. Our results suggest that exposure to LAN is detrimental to stroke recovery.

Sleep-disrupting effects of nocturnal nursing interventions in intensive care unit patients: A systematic review

Patients staying in the intensive care unit (ICU) require constant monitoring and numerous nursing interventions performed as needed, irrespective of daytime or night-time. The disturbing effect of nocturnal nursing interventions and their contribution to sleep disruptions are unclear. The review analysed nocturnal nursing interventions, and their character, frequency and effects on sleep quality. The databases CINAHL, PubMed and Scopus were searched to identify and subsequently evaluate 19 studies (1,531 patients) meeting the algorithm used. Although nocturnal nursing interventions provided to ICU patients were frequent and varied, they were responsible for only a minority of observed sleep disruptions. The most frequent nocturnal intervention was Vital signs monitoring (Nursing Interventions Classification, 6,680). Implementation of sleep protocols, of which an integral part is clustering and planning of nocturnal interventions, appears to be effective. The review suggests that nursing interventions are not the main cause of sleep disruptions in the ICU. In an effort to improve the quality of sleep in ICU patients, other factors causing disturbance need to be addressed as well. 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 (90 min).

Desflurane anesthesia shifts the circadian rhythm phase depending on the time of day of anesthesia

Desflurane is one of the most frequently used inhalational anesthetics in clinical practice. A circadian rhythm phase-shift after general anesthesia with sevoflurane or isoflurane has been reported in mice, but few studies have reported this effect with desflurane. In the present study, we examined the rest/activity rhythm of mice by counting the number of running wheel rotations, and we found that desflurane anesthesia caused a phase shift in the circadian rhythm that was dependent on the time of day of anesthesia. We also found that desflurane anesthesia altered the relative mRNA expression of four major clock genes (Per2, Bmal, Clock, and Cry1) in the suprachiasmatic nucleus (SCN). These results are important for elucidating the effects of desflurane on the SCN, which is the master clock for the mammalian circadian rhythm. Further studies on the relationship between anesthesia and circadian rhythm may lead to the prevention and treatment of postoperative complications related to circadian rhythms.

Poor-sleep is associated with slow recovery from lymphopenia and an increased need for ICU care in hospitalized patients with COVID-19: A retrospective cohort study

Sleep is known to play an important role in immune function. However, the effects of sleep quality during hospitalization for COVID-19 remain unclear. This retrospective, single-center cohort study was conducted to investigate the effects of sleep quality on recovery from lymphopenia and clinical outcomes in hospitalized patients with laboratory-confirmed COVID-19 admitted to the West District of Wuhan Union Hospital between January 25 and March 15, 2020. The Richards-Campbell sleep questionnaire (RCSQ) and Pittsburgh Sleep Quality Index (PSQI) were used to assess sleep quality. The epidemiological, demographic, clinical, laboratory, treatment, and outcome data were collected from electronic medical records and compared between the good-sleep group and poor-sleep group. In all, 135 patients (60 in good-sleep group and 75 in poor-sleep group) were included in this study. There were no significant between-group differences regarding demographic and baseline characteristics, as well as laboratory parameters upon admission and in-hospital treatment. Compared with patients in the good-sleep group, patients in the poor-sleep group had lower absolute lymphocyte count (ALC) (day 14: median, 1.10 vs 1.32, P = 0.0055; day 21: median, 1.18 vs 1.48, P = 0.0034) and its reduced recovery rate (day 14: median, 56.91 vs 69.40, P = 0.0255; day 21: median, 61.40 vs 111.47, P = 0.0003), as well as increased neutrophil-to-lymphocyte ratio (NLR; day 14: median, 3.17 vs 2.44, P = 0.0284; day 21: median, 2.73 vs 2.23, P = 0.0092) and its associated deterioration rate (day 14: median, -39.65 vs -61.09, P = 0.0155; day 21: median, -51.40% vs -75.43, P = 0.0003). Nine [12.0%] patients in the poor-sleep group required ICU care (P = 0.0151); meanwhile, none of the patients in good-sleep group required ICU care. Patients in the poor-sleep group had increased duration of hospital stay (33.0 [23.0-47.0] days vs 25.0 [20.5-36.5] days, P = 0.0116) compared to those in the good-sleep group. An increased incidence of hospital-acquired infection (seven [9.3%] vs one [1.7%]) was observed in the poor-sleep group compared to the good-sleep group; however, this difference was not significant (P = 0.1316). In conclusion, poor sleep quality during hospitalization in COVID-19 patients with lymphopenia is associated with a slow recovery from lymphopenia and an increased need for ICU care.

Study protocol for a randomised controlled trial evaluating the effects of the orexin receptor antagonist suvorexant on sleep architecture and delirium in the intensive care unit

INTRODUCTION

Insomnia frequently occurs in patients admitted to an intensive care unit (ICU). Sleep-promoting agents may reduce rapid eye movement sleep and have deliriogenic effects. Suvorexant (Belsomra) is an orexin receptor antagonist with Food and Drug Administration (FDA) approval for the treatment of adult insomnia, which improves sleep onset and maintenance as well as subjective measures of quality of sleep. This trial will evaluate the efficacy of postoperative oral suvorexant treatment on night-time wakefulness after persistent sleep onset as well as the incidence and duration of delirium among adult cardiac surgical patients.

METHODS AND ANALYSIS

In this single-centre, randomised, double-blind, placebo-controlled trial, we will enrol 120 patients, aged 60 years or older, undergoing elective cardiac surgery with planned postoperative admission to the ICU. Participants will be randomised to receive oral suvorexant (20 mg) or placebo one time a day starting the night after extubation. The primary outcome will be wakefulness after persistent sleep onset. The secondary outcome will be total sleep time. Exploratory outcomes will include time to sleep onset, incidence of postoperative in-hospital delirium, number of delirium-free days and subjective sleep quality.

ETHICS AND DISSEMINATION

Ethics approval was obtained through the 'Committee on Clinical Investigations' at Beth Israel Deaconess Medical Center (protocol number 2019P000759). The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

This trial has been registered at clinicaltrials.gov on 17 September 2019 (NCT04092894).