Effect of Earplugs during The Night on The Onset of Delirium and Sleep Perceptiona: Randomised Controlled Trial in Intensive Care Patients

ABSTRACT

Van Rompaey B, Elseviers MM, Van Drom W, Fromont V, Jorens PG

INTRODUCTION: This study hypothesised that a reduction of sound during the night using earplugs could be beneficial in the prevention of intensive care delirium. Two research questions were formulated. First, does the use of earplugs during the night reduce the onset of delirium or confusion in the ICU? Second, does the use of earplugs during the night improve the quality of sleep in the ICU?

METHODS: A randomized clinical trial included adult intensive care patients in an intervention group of 69 patients sleeping with earplugs during the night and a control group of 67 patients sleeping without earplugs during the night. The researchers were blinded during data collection. Assignment was performed by an independent nurse researcher using a computer program. Eligible patients had an expected length of stay in the ICU of more than 24 hours, were Dutch- or English-speaking and scored a minimum Glasgow Coma Scale of 10. Delirium was assessed using the validated NEECHAM scale, sleep perception was reported by the patient in response to five questions.

RESULTS: The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception.

CONCLUSIONS: Earplugs may be a useful instrument in the prevention of confusion or delirium. The beneficial effects seem to be strongest within 48 hours after admission. The relation between sleep, sound and delirium, however, needs further research. (Crit Care. 2012 May 4;16(3):R73)

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Effect of Earplugs and Eye Mask on Nocturnal Sleep,Melatonin, and Cortisol in a Simulated Intensive Care Unit Environtment

ABSTRACT

Rong-fang Hu, Xiao-ying Jiang, Yi-ming Zeng, Xiao-yang Chen, You-hua Zhang

Introduction: Environmental stimulus, especially noise and light, is thought to disrupt sleep in patients in the intensive care unit (ICU). This study aimed to determine the physiological and psychological effects of ICU noise and light, and of earplugs and eye masks, used in these conditions in healthy subjects.

Methods: Fourteen subjects underwent polysomnography under four conditions: adaptation, baseline, exposure to recorded ICU noise and light (NL), and NL plus use of earplugs and eye masks (NLEE). Urine was analyzed for melatonin and cortisol levels. Subjects rated their perceived sleep quality, anxiety levels and perception of environmental stimuli.

Results: Subjects had poorer perceived sleep quality, more light sleep, longer rapid eye movement (REM) latency, less REM sleep when exposed to simulated ICU noise and light (P < 0.05). Nocturnal melatonin (P = 0.007) and cortisol secretion levels (P = 0.004) differed significantly by condition but anxiety levels did not (P = 0.06). Use of earplugs and eye masks resulted in more REM time, shorter REM latency, less arousal (P < 0.05) and elevated melatonin levels (P = 0.002).

Conclusions: Earplugs and eye masks promote sleep and hormone balance in healthy subjects exposed to simulated ICU noise and light, making their promotion in ICU patients reasonable. (Crit Care. 2010; 14(2): R66)

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Effect of daily sedative interruption on sleep stages of mechanically ventilated patients receiving midazolam by infusion

SUMMARY

J. OTO, K. YAMAMOTO, S. KOIKE, H. IMANAKA§, M. NISHIMURA

Daily sedative interruption (DSI) may reduce excessive sedation and shorten the duration of mechanical ventilation. It is not clear, however, how DSI affects sleep characteristics. For patients receiving mechanicalventilation, we compared the effect on sleep quality of DSI and continuous sedation (CS). Twenty-two mechanically ventilated patients who were receiving midazolam by infusion were randomly assigned to two groups, DSI (n=11) or CS (n=11). In the DSI group, sedatives were interrupted until the patients awoke and expressed discomfort, after which midazolam or opioids were administered intermittently as needed during the daytime (0600 to 2100 hours); during the night (2100 to 0600) midazolam was administered intravenouslyto maintain Ramsay sedation scale 4 to 5. In the CS group, the sedatives were titrated to obtain Ramsay sedation scale 4 to 5 throughout the day. The polysomnography of each patient was recorded continuously over a 24 hour period. Sleep stages were analysed using Rechtschaffen and Kales criteria. In the DSI group, the amount of stage 3 and 4 non-rapid eye movement sleep (slow wave sleep) was longer (6 vs 0 minutes, P=0.04) and rapid eye movement sleep was longer than in CS (54 vs 0 minutes, P=0.02). In the CS group, total sleep time during night-time was longer (8.7 vs 7.3 hours, P=0.047) and frequency of arousal was lower (2.2 vs 4.4 event/hour, P=0.03) than those in the DSI group. All mechanically ventilated patients demonstrated abnormal sleep architecture, but, compared with CS, DSI increased the amount of slow wave sleep and rapid eye movement sleep.

(Anaesth Intensive Care 2011; 39: 392-400)

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Contribution Of The Intensive Care Unit Environment To Sleep Disruption In Mechanically Ventilated Patients And Healthy Subjects

ABSTRACT

Gabor JY, Cooper AB, Crombach SA, Lee B, Kadikar N, Bettger HE, Hanly PJ.

Recent studies have challenged the traditional hypothesis that excessive environmental noise is central to the etiology of sleep disruption in the intensive care unit (ICU). We characterized potentially disruptive ICU noise stimuli and patient-care activities and determined their relative contributions to sleep disruption. Furthermore, we studied the effect of noise in isolation by placing healthy subjects in the ICU in both normal and noise-reduced locations. Seven mechanically ventilated patients and six healthy subjects were studied by continuous 24-hour polysomnography with time-synchronized environmental monitoring. Sound elevations occurred 36.5 +/- 20.1 times per hour of sleep and were responsible for 20.9 +/- 11.3% of total arousals and awakenings. Patient-care activities occurred 7.8 +/- 4.2 times per hour of sleep and were responsible for 7.1 +/- 4.4% of total arousals and awakenings. Healthy subjects slept relatively well in the typically loud ICU environment and experienced a quantitative, but not qualitative, improvement in sleep in a noise-reduced, single-patient ICU room. Our data indicate that noise and patient-care activities account for less than 30% of arousals and awakenings and suggest that other elements of the critically ill patient's environment or treatment should be investigated in the pathogenesis of ICU sleep disruption. (Am J Respir Crit Care Med. 2003 Mar 1;167(5):708-15)

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Common Sleep Problems In ICU: Heart Failure And Sleep-Disordered Breathing Syndromes

INTRODUCTION

Matthew T. Naughton, MD, FRACP

Heart failure and sleep-disordered breathing are important to the intensivist. Sleep is frequently the ‘‘stress’’ that destabilizes cardiac function and results in the symptoms that many patients develop that require admission to ICU. Sleep-related breathing disorders are intertwined with cardiovascular disease by virtue of their shared real estate (ie, the lungs) and common interacting cardiopulmonary physiology. The therapies that have been used to manage long-term obstructive sleep apnea–hypopnea syndrome (OSAHS) and hypoventilation disorders with various noninvasive ventilation (NIV) devices (bilevel positive airway pressure [PAP], continuous PAP [CPAP], volume-cycled portable devices) in the domiciliary setting have been used as the backbone in the development of comfortable, portable, and effective NIV devices that are used by intensivists and emergency physicians to manage acute cardiac and respiratory failure today. (Crit Care Clin. 2008 Jul;24(3):565-87, vii-viii. doi: 10.1016/j.ccc.2008.02.004)

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Clinical Review The Impact of Noise on Patients Sleep and The Effectiveness of Noise Reduction Strategies in Intensive Care Units

ABSTRACT

Xie H, Kang J, Mills GH.

Excessive noise is becoming a significant problem for intensive care units (ICUs). This paper first reviews the impact of noise on patients' sleep in ICUs. Five previous studies have demonstrated such impacts, whereas six other studies have shown other factors to be more important. Staff conversation and alarms are generally regarded as the most disturbing noises for patients' sleep in ICUs. Most research in this area has focused purely on noise level, but work has been very limited on the relationships between sleep quality and other acoustic parameters, including spectrum and reverberation time. Sound-absorbing treatment is a relatively effective noise reduction strategy, whereas sound masking appears to be the most effective technique for improving sleep. For future research, there should be close collaboration between medical researchers and acousticians. (Crit Care. 2009;13(2):208. doi: 10.1186/cc7154. Epub 2009 Mar 9)

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Clinical Review Sleep Measurement in Critical Care Patients: Research and Clinical Implication

ABSTRACT

Richard S Bourne, Cosetta Minelli, Gary H Mills, and Rosalind Kandler

Sleep disturbances are common in critically ill patients and have been characterised by numerous studies using polysomnography. Issues regarding patient populations, monitoring duration and timing (nocturnal versus continuous), as well as practical problems encountered in critical care studies using polysomnography are considered with regard to future interventional studies on sleep. Polysomnography is the gold standard in objectively measuring the quality and quantity of sleep. However, it is difficult to undertake, particularly in patients recovering from critical illness in an acute-care area. Therefore, other objective (actigraphy and bispectral index) and subjective (nurse or patient assessment) methods have been used in other critical care studies. Each of these techniques has its own particular advantages and disadvantages. We use data from an interventional study to compare agreement between four of these alternative techniques in the measurement of nocturnal sleep quantity. Recommendations for further developments in sleep monitoring techniques for research and clinical application are made. Also, methodological problems in studies validating various sleep measurement techniques are explored.

(Crit Care. 2007; 11(4): 226.)

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