A Meta-analysis of Sleep-promoting Interventions During Critical Illness

Abstract

Background Sleep quality and quantity are severely reduced in critically ill patients receiving mechanical ventilation with potential for adverse consequences. Our objective was to synthesize the randomized controlled trials (RCTs) that measured the efficacy of sleep-promoting interventions on sleep quality and quantity in critically ill patients. Methods We included RCTs that objectively measured sleep with electroencephalography or its derivatives and excluded observational studies and those that measured sleep by subjective reports. The research was performed according to PRISMA guidelines. Results Of 6,022 studies identified, 13 studies met eligibility criteria involving 296 critically-ill patients. Eight trials looked at different modes of mechanical ventilation as sleep interventions, and the remaining five involved pharmacological, non-pharmacological, or environmental interventions. Meta-analysis of the studies revealed that sleep-promoting interventions improved sleep quantity (pooled standardized mean of differences [SMD] 0.37, 95%CI: 0.05, 0.69; P=0.02) and sleep quality through reduction in sleep fragmentation (SMD −0.31; 95%CI −0.60, −0.01; P=0.04). Subgroup analysis revealed that timed-modes of ventilation improved sleep quantity when compared to spontaneous-modes of ventilation (SMD 0.45, 95%CI 0.10, 0.81; P=0.01). Non-mechanical ventilation interventions tended to improve sleep quantity (SMD 0.65; 95%CI; −0.03, 1.33; P=0.06) and tended to reduce sleep fragmentation (SMD −0.29; 95% CI −0.61, 0.03; P=0.07). Conclusions The synthesized evidence suggests that both mechanical ventilation and non-mechanical ventilation-based therapies improve sleep quantity and quality in critically ill patients but the clinical significance is unclear. In the future, adequately-powered multi-center RCTs involving pharmacological interventions to promote sleep in critically ill patients are warranted.

Clinical practices to promote sleep in the ICU: A multinational survey

“…interventions that might improve quality and quantity of sleep in critically ill patients [26] such as decreasing monitor alarm volume, turning off room lights, closing ICU room doors to reduce noise, earplugs or decreasing frequency of nursing interventions at night [19,20,27]. This may be due to context specific factors such as an open ICU layout (common in Mediterranean countries), or lower versus higher nurse to patient ratios of 1:1 (frequently 1:1 in Scandinavian countries, Canada and the UK, whereas in 1:2 in the Netherlands, and 1:3 or 1:4 in France or Italy).…”

Perceptions and Practices Regarding Sleep in the Intensive Care Unit. A Survey of 1,223 Critical Care Providers

“…Complex and costly environmental interventions cannot be justified without high-level evidence to justify the cost (28,36). Additionally, complex environmental interventions cannot be instituted on an individual level (1,32,47).…”

“…As part of these efforts, interventions to promote sleep in the ICU have gained particular interest and are therefore strongly recommended in recent clinical practice guidelines of the Society of Critical Care Medicine (SCCM) (27). Moreover, recent meta-analyses suggest that sleep-promoting interventions may improve sleep quantity and quality in critically ill patients (28).…”

The reliability of the Czech version of the Richards-Campbell Sleep Questionnaire

“…The environmental factors comprise noise, light and nursing interventions (Pisani et Rittayamai et al, 2016;Tembo and Parker, 2009). In order to achieve and maintain a maximum level of sleep quality, effort is made to implement organisational measures -sleep promoting strategies (Elliott and McKinley, 2014;Hu et al, 2015;Norton et al, 2015;Poongkunran et al, 2015). The method of its evaluation in critically ill patients is an important limitation in the evaluation of the effectiveness of these measures.…”