Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement

Abstract

Background Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.

Nighttime medication administration and patient perception of sleep in the intensive care unit

“…Nighttime administration times and effect on patient perceived sleep were an endpoint of interest as some dosing schedules will result in sleep disruption. For example, a medication that is dosed more frequently than every 8 h will inevitably result in a “due” time during sleeping hours (assuming a standard 8 h of sleep) 2,5 …”

“…The circadian rhythm is an internal pathway that is heavily influenced by external stimuli, which can easily result in sleep–wake disruption 5 . Examples of external stimuli in the ICU may include noise, light, immobility, and interventions such as respiratory support, medication administrations, and general nursing care 4,6–11 .…”

“…Examples of external stimuli in the ICU may include noise, light, immobility, and interventions such as respiratory support, medication administrations, and general nursing care 4,6–11 . Awakenings are likely to negatively impact sleep quality due to inability to maintain rapid eye movement (REM) and other deep stages of sleep 1,5,8 . Disrupted sleep can lead to aberrant circadian rhythm and adverse effects such as nitrogen or metabolic imbalances, end organ injury, chemoreceptor alteration, and immune system dysfunction 5 .…”

“…Furthermore, patients with a new diagnosis of delirium are at an increased risk of longer length of stay compared to those without 21–29 . Although the precise mechanism is not known, a link between circadian rhythm abnormalities and delirium manifestation in ICU patients has been noted 5,6,25 . The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) in the ICU patient, therefore, recommend implementation of multicomponent bundles to improve sleep hygiene in order to mitigate delirium risk 6 …”

“…4 The circadian rhythm is an internal pathway that is heavily influenced by external stimuli, which can easily result in sleep-wake disruption. 5 Examples of external stimuli in the ICU may include noise, light, immobility, and interventions such as respiratory support, medication administrations, and general nursing care. 4,[6][7][8][9][10][11] Awakenings are likely to negatively impact sleep quality due to inability to maintain rapid eye movement (REM) and other deep stages of sleep.…”