Earplugs and eye masks: do they improve critical care patients’ sleep?

Disturbed sleep and sleep deprivation is common in patients in critical care settings. Noise and inappropriate use of light/dark cycles are two of the causes of sleep interruptions. The purpose of the study was to evaluate eye masks and earplugs to help control patients' exposure to noise and light within the critical care environment. An intervention study using a two group post-test quasi-experimental design of high dependency patients within a cardiothoracic critical care unit was undertaken by a group of critical care nurses. Sleep assessment rating scales and open-ended questions were used to obtain patients' reported experiences of their sleep. Patients self-selected into either an intervention or non-intervention group. Sixty-four patients consented to take part in the study, 34 patients tried the interventions earplugs and eye masks and many found they improved sleep. However, noise was still a factor preventing sleep for both groups of patients. Mixed reports were found with the interventions from very comfortable to very uncomfortable. At a cost of 2.50 pounds sterling/patient, earplugs and eye masks were a relatively cheap intervention with notable improvements for some critically ill patients. Further research is required with a larger sample size, plus an examination of both earplugs and eye masks separately. Offering patient's earplugs and eye masks to improve sleep should be considered as a matter of routine nursing practice, this should include time to show patients how to use and try them out for comfort.     

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.     

夜间降低噪音对ICU患者谵妄及睡眠质量的影响

目的：较高的噪音水平被认为可能诱导ICU患者睡眠障碍的发生。而睡眠障碍是增加重症患者谵妄发生的重要风险因素。危重病人的谵妄发生往往与各种临床不良预后相关呢。本研究假设通过降低夜间整体环境噪音水平,可以改善ICU患者的睡眠质量和谵妄发生率。方法：在成人外科重症监护病房进行序列研究。将干预前53例患者与干预后61例施夜间降音方案的患者进行比较。主要的观察指标是不同噪音环境下ICU患者睡眠质量与谵妄发生率的变化。分别采用谵妄筛查量表(ICDSC)和睡眠质量量表(RSCQ)测量。次要的观察指标是睡眠诱导或镇静药物的使用。结果：干预前后谵妄发生率有显著差异（分别为11.3% 和27.9%, p=0.03）。睡眠质量评分改善（分别为64.3±13.0和57.6±11.26,p<0.01）。干预后使用睡眠诱导药物的患者比例减少（分别为15.1%和32.8%, p=0.03）。结论：采用夜间降音方案后,ICU患者的谵妄发生率降低,且睡眠质量得到改善。     

Effects of nonpharmacological interventions on sleep improvement and delirium prevention in critically ill patients: A systematic review and meta-analysis

ObjectiveSleep disturbance and delirium are common problems experienced by critically ill patients in the intensive care unit (ICU). These interrelated issues increase the length of stay in the ICU but might also negatively affect long-term health outcomes. The objective of this study was to identify the nonpharmacological interventions provided to improve sleep or prevent delirium in ICU patients or both and integrate their effect sizes.Review methodsThis study was a registered systematic review and meta-analysis. We searched MEDLINE, CINAHL, EMBASE, Web of Science, and Cochrane Library from their inception until December 2021. We included randomised controlled trials and nonrandomised controlled trials-(RCT) that provided nonpharmacological interventions and reported sleep or delirium as outcome variables. Studies not published in English or whose full text was not available were excluded. The quality of the evidence was assessed with version 2 of the Cochrane risk-of-bias tool for RCTs and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I).ResultsThe systematic review included 118 studies, and the meta-analysis included 100 studies. Overall nonpharmacological interventions had significant effects on subjective sleep quality (standardised mean difference = 0.30, 95% confidence interval [CI] = 0.05 to 0.56), delirium incidence (odds ratio = 0.62, 95% CI = 0.53 to 0.73), and delirium duration (standardised mean difference = −0.68, 95% CI = −0.93 to −0.43). In individual interventions, aromatherapy, music, and massage effectively improved sleep. Exercise, family participation, information giving, cognitive stimulation, bright light therapy, architectural intervention, and bundles/protocols effectively reduced delirium. Light/noise blocking was the only intervention that ensured both sleep improvement and delirium prevention.ConclusionsOur results suggest nonpharmacological interventions improve sleep and prevent delirium in ICU patients. We recommend that ICU nurses use nonpharmacological interventions that promote person–environment compatibility in their clinical practice. The results of our review can guide nurses in adopting interventions related to sleep and delirium.Prospero reference numberCRD42021230815     

剥夺性睡眠后自然睡眠脑电图在癫痫诊断中的意义

目的：探讨剥夺睡眠后自然睡眠脑电图对癫痫的诊断价值。方法：对86例临床诊断癫痫患进行常规及剥夺睡眠脑电描记，并进行随访。结果：本组86例癫痫患间歇期常规脑电图异常率为26．5％(23／86)，剥夺睡眠脑电图异常率为77．9％(67／86)，剥夺睡眠脑电图能够较明确提示癫痫病人发作类型，指导临床用药，并与非癫痫发作进行鉴别。结论：剥夺睡眠脑电图痫样放电检出率显提高，对癫痫的诊断与鉴别诊断有重要的参考价值。     

Patients’ sleep in an intensive care unit—patients’ and nurses’ perception

The main purpose of this study was to describe how patients treated in an intensive care unit (ICU) perceive their sleep and to compare patients' and nurses' perceptions of the patients' sleep. The study also determined the percentage of patients in the ICU who were able to fill in the Richard Campell Sleep Questionnaire (RCSQ). This instrument consists of six items and utilises a visual analogue scale (VAS). The results of five of the RCSQ questions are used to calculate a total sleep score, ranging between 0 and 100 (0=the worst possible sleep, 100=the best sleep).Approximately half of the patients were able to answer the RCSQ (n=31). The patients' rating of their sleep varied widely (total sleep score: range 0-97, mean 45.5). Patients who had received hypnotics or sedatives during the night (n=12) had a significantly lower total sleep score (mean=31.6) than the rest of the patients (mean 54.3; P=0.037).On comparing the patients' and the nurses' perceptions of the patients' sleep, no significant difference between the groups was seen. This indicates that nurses can use the RCSQ to assess the sleep of patients who are unable to report their sleep themselves.     

The effects of total and REM sleep deprivation on laser-evoked potential threshold and pain perception

We investigated the effects of total and rapid eye movement (REM) sleep deprivation on the thermal nociceptive threshold and pain perception using the objective laser-evoked potential (LEP) and the subjective visual analogue scale (VAS). Twenty-eight male adult volunteers were assigned into Control (CTRL), Total (T-SD), and REM (REM-SD) Sleep Deprivation groups. The T-SD and REM-SD volunteers were totally or selectively deprived of sleep for 2 and 4 consecutive nights, respectively. Pain parameters were measured daily during the experimental period. Volunteers were stimulated on the back of the hand by blocks of 50 diode laser pulses. Intensities increased between successive blocks, ranging from nonnoxious to noxious levels, and the LEP threshold was identified based on the evoked-response onset. Both the LEP threshold and VAS ratings were significantly increased after the second night of T-SD. No significant variations were observed in the REM-SD group, suggesting a predominant role for slow wave sleep rather than selective REM-SD in pain perception. Also, for both sleep-deprived groups, the mean values of the LEP threshold and VAS ratings showed a gradual increase that was proportional to the SD deprivation time, followed by a decrease after 1 night of sleep restoration. These findings demonstrate a hyperalgesic modification to pain perception (as reflected by the augmented VAS) and a concomitant increase in the LEP threshold following T-SD, an apparently contradictory effect that can be explained by differences in the ways that attention affects these pain measurements.     

Repeated sleep‐quality assessment and use of sleep‐promoting interventions in ICU

To describe sleep quality using repeated subjective assessment and the ongoing use of sleep‐promoting interventions in intensive care. It is well known that the critically ill experience sleep disruption while receiving treatment in the intensive care unit. Both the measurement and promotion of sleep is challenging in the complex environment of intensive care unit. Repeated subjective assessment of patients' sleep in the intensive care unit and use of sleep‐promoting interventions has not been widely reported. An observational study was conducted in a 58‐bed adult intensive care unit. Sleep quality was assessed using the Richards‐Campbell Sleep Questionnaire (RCSQ) each morning. intensive care unit audit sleep‐promoting intervention data were compared to data obtained prior to the implementation of a sleep guideline. Patients answered open‐ended questions about the facilitators and deterrents of their sleep in intensive care unit. The sample (n = 50) was predominately male (76%) with a mean age: 62.6±16.9 years. Sleep quality was assessed on 2 days or more for 21 patients. The majority of patients (98%) received sleep‐promoting interventions. Sleep quality had not improved significantly since the guideline was first implemented. The mean Richards‐Campbell Sleep Questionnaire score was 47.9±24.1 mm. The main sleep deterrents were discomfort and noise. Frequently cited facilitators were nothing (i.e. nothing helped) and analgesia. The Richards‐Campbell Sleep Questionnaire was used on repeated occasions, and sleep‐promoting interventions were used extensively. There was no evidence of improvement in sleep quality since the implementation of a sleep guideline. The use of the Richards‐Campbell Sleep Questionnaire for the subjective self‐assessment of sleep quality in intensive care unit patients and the implementation of simple‐promoting interventions by intensive care unit clinicians is both feasible and may be the most practical way to assess sleep in the intensive care unit context.     

Sleep and delirium in ICU patients: a review of mechanisms and manifestations

Sleep deprivation and delirium are conditions commonly encountered in intensive care unit patients. Sleep in these patients is characterized by sleep fragmentation, an increase in light sleep, and a decrease of both slow wave sleep and rapid eye movement sleep. The most common types of delirium in this population are hypoactive and mixed-type. Knowledge about the mechanisms of sleep and delirium has evolved over time, but these phenomena are not yet well understood. What is known, however, is that different areas in the brainstem transmit information to the thalamus and cortex necessary for sleep–wake regulation. Delirium is related to an imbalance in the synthesis, release, and inactivation of some neurotransmitters, particularly acetylcholine and dopamine. The relationship between sleep deprivation and delirium has been studied for many years and has been viewed as reciprocal. The link between them may be ascribed to shared mechanisms. An imbalance in neurotransmitters as well as alteration of melatonin production may contribute to the pathogenesis of both phenomena. A better understanding of the mechanisms and factors that contribute to sleep deprivation and delirium can guide the development of new methods and models for prevention and treatment of these problems and consequently improve patient outcomes.     

The accuracy of simple,feasible alternatives to polysomnography for assessing sleep in intensive care: An observational study

BackgroundSleep disturbance is common in intensive care patients. Understanding the accuracy of simple, feasible sleep measurement techniques is essential to informing their possible role in usual clinical care.ObjectiveThe aim of the study was to investigate whether sleep monitoring techniques such as actigraphy (ACTG), behavioural assessments, and patient surveys are comparable with polysomnography (PSG) in accurately reporting sleep quantity and quality among conscious, intensive care patients.MethodsAn observational study was conducted in 20 patients admitted to the intensive care unit (ICU) for a minimum duration of 24 h, who underwent concurrent sleep monitoring via PSG, ACTG, nursing-based observations, and self-reported assessment using the Richards–Campbell Sleep Questionnaire.ResultsThe reported total sleep time (TST) for the 20 participants measured by PSG was 328.2 min (±106 min) compared with ACTG (362.4 min [±62.1 min]; mean difference = 34.22 min [±129 min]). Bland–Altman analysis indicated that PSG and ACTG demonstrated clinical agreement and did not perform differently across a number of sleep variables including TST, awakening, sleep-onset latency, and sleep efficiency. Nursing observations overestimated sleep duration compared to PSG TST (mean difference = 9.95 ± 136.3 min, p > 0.05), and patient-reported TST was underestimated compared to PSG TST (mean difference = −51.81 ± 144.1 7, p > 0.05).ConclusionsAmongst conscious patients treated in the ICU, sleep characteristics measured by ACTG were similar to those measured by PSG. ACTG may provide a clinically feasible and acceptable proxy approach to sleep monitoring in conscious ICU patients.     

睡眠剥夺对大鼠学习能力和海马乙酰胆碱含量的影响

目的研究不同持续时间睡眠剥夺(SD)对大鼠学习能力以及海马乙酰胆碱(Ach)含量的影响。方法采用小平台水环境法建立睡眠剥夺模型,以正常组作为对照,使用Y型迷宫测试不同持续时间睡眠剥夺对大鼠学习能力的影响,采用碱性羟胺比色法测定海马乙酰胆碱含量变化。结果与正常对照组相比,睡眠剥夺4 d、6 d组学习成绩明显降低,海马乙酰胆碱含量明显减少,睡眠剥夺2 d组学习成绩明显提高,海马乙酰胆碱含量无显著差异。结论睡眠剥夺导致的大鼠学习能力下降可能与其海马乙酰胆碱含量减少有关。     

非药物干预比较改善ICU患者睡眠质量效果的网状Meta分析

目的采用网状Meta分析方法评价非药物干预改善ICU患者睡眠质量的效果。方法计算机检索The Cochrane Library、PubMed、EMbase、Web of Science、CNKI、WanFang Data、VIP和CBM数据库,搜集非药物干预改善ICU患者睡眠质量效果的随机对照试验(RCT),检索时限均为建库至2018年12月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Stata 13.0软件进行网状Meta分析。结果共纳入12个RCT,包括1223例患者,涉及9种非药物干预方法(音乐疗法、综合护理干预、中医情志、音乐疗法+中医情志、中药枕疗法、耳穴压豆、眼罩+耳塞+音乐、眼罩+耳塞、常规护理)。针对匹兹堡睡眠质量指数(PSQI)的网状Meta分析结果显示:在改善ICU患者睡眠质量方面,眼罩+耳塞、眼罩、综合护理干预优于常规护理,其差异有统计学意义。结果排序图显示:眼罩+耳塞>眼罩>综合护理干预、音乐疗法+中医情志>中医情志>音乐疗法>常规护理。针对Richards-Campbell睡眠量表(RCSQ)的网状Meta分析结果显示:眼罩+耳塞+音乐、中药枕疗法、耳穴压豆优于常规护理,其差异有统计学意义。结果排序图显示:眼罩+耳塞+音乐>中药枕疗法>音乐疗法>耳穴压豆>常规护理。结论当前证据显示,在改善ICU患者睡眠质量方面,眼罩+耳塞、眼罩、综合护理干预、音乐疗法+中医情志都可能是有效的干预方式,建议未来开展更多非药物干预改善ICU患者睡眠质量效果的RCT。