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The Impact of Sedatives  on Sleep in the ICU       Kyle A. Amelung, Pharm.D. Candidate           Barnes-Jewish Hospital, S...
Patient CaseCC: Acute chest pain and back painHPI: LZ is a 78yo WM with a history of a type A ascending  aortic dissection...
Past HistoryMedical:                        Surgical: Ischemic Stroke (10/3/11)      Type A ascending aortic Polycythem...
Home Medications   Lisinopril 10mg PO daily for HTN/CKD   Doxazosin 4mg PO HS for HTN   Metoprolol tartrate (IR) 25mg B...
Course of ICU Stay10/21 Tx to SICU on NE 36, fentanyl,                   11midazolam, and sodium bicarbonate           20...
Course of ICU Stay10/23 ~300ml out of chest tube Lactate 1.4 Midazolam to 0, then back on later in the evening Phenyle...
Course of ICU Stay10/25 Extubated  6L NC K at 3.1, repleted Chest tube to water seal Tube feeds at goal Midazolam an...
Course of ICU Stay10/27 Eszopiclone increased to 3mg CAM-ICU [+] Cardiology medications titrated 3L NC WBC 12.9, Tmax...
10/28 Physical Exam   Tmax: 37.2oC                   Ht: 67”   HR: 69-96 bpm                  Wt: 70 kg (IBW: 66.1 kg)...
10/28 Laboratory Values151 111 38            1463.3 28 2.14                         9.5                  13.6          238...
10/28 Inpatient MedicationsScheduled:                                    PRN:*Aspirin 325mg PO daily for CV prophylaxis   ...
ICU Problem List1. Type B Aortic Aneurysm Rupture       S/p repair and currently controlled. Heparin for anticoagulant th...
ICU Problem List3. Delirium/Sleep Hygiene        Patient is experiencing abnormalities in sleep hygiene and         repor...
ICU Problem List5. Electrolyte Disturbances       Patient has chronic hypokalemia for which he takes a KCl supplement,   ...
ICU Problem List8. Depression     Diagnosed as an outpatient. Correctly treated with an SSRI.       Monitor mood.9. Glauc...
The Impact of Sedatives  on Sleep in the ICU       Kyle A. Amelung, Pharm.D. Candidate           Barnes-Jewish Hospital, S...
Objectives Explain the normal sleep cycle and  changes in critical illness Describe the barriers to healthy  sleep regim...
Sleep Cycle        Sleep                          Description                       %        Stage                        ...
Differences in ICU Patients                                     Parameter                                 Changes         ...
Clinical Effects of Sleep Deprivation       • Increased blood pressure       • Mood changes       • Elevated metabolic rat...
Relation with Delirium             Weinhouse et al. Bench-to-bedside review: delirium in ICU patients -             import...
Barriers to Sleep in the ICU          60% of ICU patients  Poor sleep or sleep deprivationStaff estimations of sleep qual...
Sedatives The sedative-sleep relationship is complex    The functions of sleep are unknown    Sleep and sedation have s...
GABAA Agonists First line recommendation in sedation guidelines, but only a  limited number of studies on their effects o...
GABAA Agonists       Propofol                MOA – also binds to GABAA but at a different site,                and alloste...
Treggiari-Venzi et al., 1996Overnight sedation with midazolam or propofol in the ICU: effects on sleep quality, anxiety an...
Treggiari-Venzi et al., 1996Methods: Bolus + continuous gtt from 2200 to 0600 for 5  consecutive nights, Infusion adjust...
Treggiari-Venzi et al., 1996                                 Quality of Sleep (10 = best)                              Mid...
2     Agonist     Dexmedetomidine        MOA – acts centrally at the locus coeruleus to agonize 2 receptors         G-pro...
Corbett et al., 2005Dexmedetomidine does not improve patient satisfaction when  compared with propofol during mechanical v...
Corbett et al., 2005Methods:    All patients underwent induction with propofol    Post-bypass, patients were randomized ...
Corbett et al., 2005                            Dexmedetomidine              Propofol                                (n=43...
DA-5HT2 AntagonistsTypicals (1st Gen.) – Haloperidol    MOA – 5HT2A, 5HT2C, DA antagonist;    however, sedative effects du...
GABAA Agonists           “Z-drugs” – Eszopiclone, Zolpidem       MOA – Unknown completely, but thought to involve GABAA-re...
Patient Case Revisited        10/21: Midazolam began for sedation10/25: Midazolam discontinued and patient extubated;Perio...
Summary        • Sedative use in the ICU is both a cause and potential          treatment for sleep disruption.        • S...
Proposed Algorithm for  Optimal Sleep in the ICU       Have barriers to sleep been minimized?                             ...
The Impact of Sedatives  on Sleep in the ICU       Kyle A. Amelung, Pharm.D. Candidate           Barnes-Jewish Hospital, S...
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The Impact Of Sedatives On Sleep In The Icu

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November 2011

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The Impact Of Sedatives On Sleep In The Icu

  1. 1. The Impact of Sedatives on Sleep in the ICU Kyle A. Amelung, Pharm.D. Candidate Barnes-Jewish Hospital, SICU Preceptor: Lee P. Skrupky, Pharm.D., BCPS November 9, 2011
  2. 2. Patient CaseCC: Acute chest pain and back painHPI: LZ is a 78yo WM with a history of a type A ascending aortic dissection s/p repair in 2006 with a chronic residual 5cm aortic dissection which was being followed by his physician. LZ presented on 10/21/11 from an OSH with sudden, severe, non-radiating chest and back pain. A chest X-ray and MRI revealed no evidence of rupture. While in the MRI scanner, LZ suddenly experienced a dramatic increase in pain and hypertension, followed by vomiting and hypotension. An emergent CT scan with contrast showed evidence of a type B aneurysm rupture with a left hemothorax and LZ subsequently underwent an emergent TEVAR with complication and was then transferred to the SICU.
  3. 3. Past HistoryMedical: Surgical: Ischemic Stroke (10/3/11)  Type A ascending aortic Polycythemia/Thrombocytosis dissection s/p repair (2006) Diastolic Heart Failure  L nephrectomy (2006) CKD  Cholecystectomy Hypertension Hyperlipidemia Social : Hypokalemia  [-] Tobacco (60 PY history) Depression  [-] EtOH Glaucoma  [-] Illicit Drugs Skin Cancer  Retired Banker Bladder Cancer  Lives with wife Renal Cell Carcinoma Allergies: NKDA
  4. 4. Home Medications Lisinopril 10mg PO daily for HTN/CKD Doxazosin 4mg PO HS for HTN Metoprolol tartrate (IR) 25mg BID for HTN Furosemide 80mg PO qAM + 40mg qPM for HTN Atorvastatin 20mg PO daily for HLD Escitalopram 10mg PO daily for mood Brimonidine 0.1% 1 gtt OU daily for glaucoma Latanoprost 0.005% 1 gtt OU HS for glaucoma Aspirin 81mg PO daily for CV prophylaxis Vitamin D 50000 IU PO weekly for supplement KCl 20mEq PO BID for supplement Docusate 100mg PO daily PRN for constipation
  5. 5. Course of ICU Stay10/21 Tx to SICU on NE 36, fentanyl, 11midazolam, and sodium bicarbonate 20.8 198 Perioperative cefazolin 33.3 SCVO2 74.5% Lactate 8.6 Vasopressin 0.04, Phenylephrine 1510/22 Chest tube placed, ~1500ml of bloody fluid drained Moving all extremities, not following commands NE at 12 Lactate 5.6 Troponin 0.27 MV with volume control at 18 / 580 / 60% / 5; Failed BEST Lipid Panel: Cholesterol 62, TG 108, LDL 22, HDL 18,
  6. 6. Course of ICU Stay10/23 ~300ml out of chest tube Lactate 1.4 Midazolam to 0, then back on later in the evening Phenylephrine 5 MV at 18 / 580 / 40% / 7.5 WBC 14, Tmax 38.3oC; Blood [-] x2 Home glaucoma medications added10/24 ~110ml out of chest tube Midazolam 0.5, fentanyl 50 CAM-ICU [+] Vasopressors weaned to 0; home antihypertensives added MV at 18 / 580 / 40% / 5; Failed BEST HgbA1c 6.1% WBC 12.2, Tmax 38.4oC; Urine, Tracheal Aspirate [-]; UA WNL TTE - Inferior-posterior hypokinesis; LVEF 40-45%
  7. 7. Course of ICU Stay10/25 Extubated  6L NC K at 3.1, repleted Chest tube to water seal Tube feeds at goal Midazolam and fentanyl discontinued Brief AFib noted Periods of delirium and agitation at night WBC 10, Tmax 38oC10/26 Eszopiclone 2mg HS ordered for sleep hygiene WBC 11.5, Tmax 37.4oC CK 1347 ECG - QTc 461 PT 15.8, INR 1.21
  8. 8. Course of ICU Stay10/27 Eszopiclone increased to 3mg CAM-ICU [+] Cardiology medications titrated 3L NC WBC 12.9, Tmax 37.2oC10/28 Mag (2.3) and Ca (8.2) supplementation for ~3 beats of PVCs Chest X-ray – mild, but increasing atelectasis CAM-ICU [+] 2L NC
  9. 9. 10/28 Physical Exam Tmax: 37.2oC  Ht: 67” HR: 69-96 bpm  Wt: 70 kg (IBW: 66.1 kg) MAP: 76-102 RR: 25-30 bpm  Net Fluid Balance: -1900 ml O2sat: 96-100% on 2L NC  24-hour UO: 2500 mlNeuro: RASS 0, CAM-ICU [+], AAO x2Cardiac: RRRPulmonary: CTAB; Chest tube placedAbdomen: Soft, non-tender without masses; Sutured RLQ and LLQ incisionsOther: Decreased vision
  10. 10. 10/28 Laboratory Values151 111 38 1463.3 28 2.14 9.5 13.6 238 23.8 Ca: 8.2 Mg: 2.3 Phos: 3.4
  11. 11. 10/28 Inpatient MedicationsScheduled: PRN:*Aspirin 325mg PO daily for CV prophylaxis Insulin lispro SS*Lisinopril 10mg PO BID for HTN/CKD Glucose/glucagon IV/IM/POHydralazine 25mg PO QID for HTN Magnesium, Potassium IV *Docusate 100mg PO BIDAmlodipine 10mg PO daily for HTN*Metoprolol tartrate 25mg PO QID for HTN Relevant Past Meds:*Furosemide 60mg IV BID for edema Fentanyl 10/21-25*Atorvastatin 20mg PO daily for HLD Midazolam 10/21-25*Escitalopram 10mg PO daily for mood*Brimonidine 0.1% 1 gtt OU daily for glaucoma*Latanoprost 0.005% 1 gtt OU HS for glaucoma*KCl 40mEq PO daily for replacementHeparin 5000 units SQ TID for DVT prophylaxisEszopiclone 3mg PO HS for sleep hygiene *Home Medication
  12. 12. ICU Problem List1. Type B Aortic Aneurysm Rupture  S/p repair and currently controlled. Heparin for anticoagulant therapy which is appropriate for this vascular surgery patient.  Monitor CBC daily for decreasing platelets (HIT), decreasing H/H, and other signs/symptoms of bleeding. PTT should also be measured intermittently to monitor proper anticoagulation.2. Hemodynamic Instability/Vasodilatory Shock  Patient was on vasopressor therapy which was needed for hypotension control s/p surgery. No evidence of infection rules out sepsis. Vasopressin 0.04 was appropriately added to decrease ectopy of high dose NE. Currently, he is being followed by his home cardiologist who has placed him on an ACE-I, DHP-CCB, BB, and vasodilator which are appropriate for his chronic hypertensive condition.  Diastolic HF plays a role in this problem and is being monitored, previous EF 40-45%. Fluid administration being monitored.  Monitoring of his BP and HR are essential while s/p vascular surgery. BMP should be monitored to watch for hyperkalemia, increases in BUN (ACE-I) and peripheral edema (CCB).
  13. 13. ICU Problem List3. Delirium/Sleep Hygiene  Patient is experiencing abnormalities in sleep hygiene and reports not being able to sleep at night. CAM-ICU [+]. Signs of delirium such as not following through on thoughts or knowing where he is. Etiology includes past BZD use, critical illness, and ICU conditions.  Eszopiclone added for sleep hygiene (and dose increased) which is appropriate to maintain a healthy sleep cycle and promote recovery.  Monitor sleep habits and CAM-ICU twice a day.4. Respiratory Failure  Patient intubated for 4 days s/p surgery. Recent ABGs not drawn, but patient is now extubated and is saturating adequately on 2L NC.  Monitor oxygen saturation, RR, and dyspnea.
  14. 14. ICU Problem List5. Electrolyte Disturbances  Patient has chronic hypokalemia for which he takes a KCl supplement, which is appropriate. This medication is being continued for his low inpatient K levels. LZ also currently has hypernatremia which is seen as a free water deficit of about 3.3 liters. Crystalloids and FW flushes should be continued. BMP should be monitored daily.6. Acute Kidney Injury + CKD  Patient has underlying Stage 3/4 CKD, baseline SCr of 1.8-2.0. Treated, in part, with an ACE-I, which is appropriate. Current AKI possibly due to hypoperfusion 2/2 vasodilator shock and/or imaging contrast. Bicarb drip started appropriately and fluids/vasopressors administered as above. Monitor SCr, BUN, urine output daily.7. Hyperlipidemia  Currently treated with an HMG-CoA reductase inhibitor (statin) which is appropriate. Dose should be decreased from 20mg to 10mg, as recent lipid panel should low HDL and LDL much lower than goal of <70. Monitor FLP in 3 months, then every 6 months.
  15. 15. ICU Problem List8. Depression  Diagnosed as an outpatient. Correctly treated with an SSRI. Monitor mood.9. Glaucoma  Treated as an outpatient with topical medications to decrease pressure, which are appropriate. Current decrease in vision could be due to recent vasopressor administration. Monitor for worsening vision. If needed, consider an ophthalmology consult.10. Health Maintenance/Prophylaxis  Aspirin for stoke/CV prophylaxis is appropriate s/p stroke.  Administer influenza vaccine at discharge.
  16. 16. The Impact of Sedatives on Sleep in the ICU Kyle A. Amelung, Pharm.D. Candidate Barnes-Jewish Hospital, SICU Preceptor: Lee P. Skrupky, Pharm.D., BCPS November 9, 2011
  17. 17. Objectives Explain the normal sleep cycle and changes in critical illness Describe the barriers to healthy sleep regimens for patients in an ICU, focusing on sedative use Understand clinical outcomes after sleep deprivation Discuss the effects of sedatives on the natural sleep pattern
  18. 18. Sleep Cycle Sleep Description % Stage Defined: A periodic, reversible Stage 1 Light sleep 2-5% state of cognitive and sensory (N1) disengagement from the external Stage 2 Light sleep 45-55% environment (N2) Deep sleep; restoration; SWS anabolic; 15-20% (N3) promoted by GABA Greatest cardiac and REM respiratory 20-25% variability; catabolicKamdar et al. Sleep Deprivation in Critical Illness: Its Role in Physical Hardin KA. Sleep in the ICU: potential mechanismsand Psychological Recovery. J Intensive Care Med. 2011 Feb 7. Web. and clinical implications. Chest. 2009 Jul;136(1):284-94.
  19. 19. Differences in ICU Patients Parameter Changes SWS Decreased Decreased  Adaptive/Protective REM mechanism? May be equivalent, but distributed Total Hours across the 24h day REM Rebound May affect critically ill patients more Patients with acute illness require Need more total sleep time for recoveryKamdar et al. Sleep Deprivation in Critical Illness: Its Role in Physical Hardin KA. Sleep in the ICU: potential mechanismsand Psychological Recovery. J Intensive Care Med. 2011 Feb 7. Web. and clinical implications. Chest. 2009 Jul;136(1):284-94.
  20. 20. Clinical Effects of Sleep Deprivation • Increased blood pressure • Mood changes • Elevated metabolic rate All possibly elevated during • Immune system disruption times of critical illness. • Hyperalgesia • Decreased mentation Salas RE and CE Gamaldo. Adverse effects of sleep deprivation in the ICU. Crit Care Clin. 2008 Jul;24(3):461-76, v-vi.
  21. 21. Relation with Delirium Weinhouse et al. Bench-to-bedside review: delirium in ICU patients - importance of sleep deprivation. Crit Care. 2009;13(6):234.
  22. 22. Barriers to Sleep in the ICU 60% of ICU patients  Poor sleep or sleep deprivationStaff estimations of sleep quality/quantity are inaccurate ~25% of the time • Baseline sleep insufficiency/disorder • Medical Illness • Pain • Environmental factors • Staff-patient interactions • Mechanical ventilation • Medications • Medication withdrawal Salas RE and CE Gamaldo. Adverse effects of sleep deprivation in the ICU. Crit Care Clin. 2008 Jul;24(3):461-76, v-vi.
  23. 23. Sedatives The sedative-sleep relationship is complex  The functions of sleep are unknown  Sleep and sedation have some similarities, but many differences. Overall, sedatives may have both [+] and [-] effects on patients’ sleep and ICU quality of life.
  24. 24. GABAA Agonists First line recommendation in sedation guidelines, but only a limited number of studies on their effects on sleep.Benzodiazepines – Midazolam, Lorazepam MOA – activate GABAA at the hypothalamus, enhancing the CNS inhibitory system  psychomotor depression  [+]  Decrease in sleep latency and awakenings, increase sleep time efficiency  [-]  Increase Stage II NREM, decreased SWS and REM Weinhouse GL and PL Watson. Sedation and sleep disturbances in the ICU. Crit Care Clin. 2009 Jul;25(3):539-49, ix.
  25. 25. GABAA Agonists Propofol MOA – also binds to GABAA but at a different site, and allosterically enhances receptor activity +/- Endocannabinoid receptors?  No definite effect on REM  [+]  The normal homeostatic control of sleep may occur during use; Decrease in sleep latency and increase in total sleep time  [-]  SWS suppression  Positive animal dataKamdar et al. Sleep Deprivation in Critical Illness: Its Role in Physical Weinhouse GL and PL Watson. Sedation and sleep disturbancesand Psychological Recovery. J Intensive Care Med. 2011 Feb 7. Web. in the ICU. Crit Care Clin. 2009 Jul;25(3):539-49, ix.
  26. 26. Treggiari-Venzi et al., 1996Overnight sedation with midazolam or propofol in the ICU: effects on sleep quality, anxiety and depression Treggiari-Venzi M, Borgeat A, Fuchs-Buder T, Gachoud JP, Suter PM. Intensive Care Med. 1996 Nov;22(11):1186-90.Design  Open, comparative prospective, randomized study in one SICU Inclusions Exclusions Trauma or elective orthopedic, Long term sedative or thoracic or abdominal surgery psychotropic medication use Expected ICU stay 5+ days Alcohol abuse Non-intubated Neurologic disorder, head trauma
  27. 27. Treggiari-Venzi et al., 1996Methods: Bolus + continuous gtt from 2200 to 0600 for 5 consecutive nights, Infusion adjusted to sedation level of Ramsay 3 Morphine to all patients No patients received other BZDs or psychotropic medications Hospital Anxiety and Depression (HAD) Scale used 6h post-infusionPatient Demographics: Midazolam (n=13) Propofol (n=19) Age (years) 41 +/- 16 48 +/- 17 Weight (kg) 70.1 +/- 8.4 71.4 +/- 8.2 APACHE II 14.5 +/- 4.1 13.5 +/- 4.5
  28. 28. Treggiari-Venzi et al., 1996 Quality of Sleep (10 = best) Midazolam Propofol Day 1 6.3 +/- 3.4 6.5 +/- 3.3 Day 3 6.3 +/- 3.2 6.6 +/- 2.9 Day 5 7.2 +/- 2.9 7.2 +/- 2.3Conclusions: (1) Sleep quality tended to improve during the study in the two groups, but the change didn’t reach statistical significance. (2) The beneficial effects of sedation on sleep quality were comparable for the two medications.Limitations: Small study sample Limited length of follow up  results 2/2 decrease in post-op pain? Patients were not intubated Relatively low APACHE II scores Only studied the sedatives in overnight sedation
  29. 29. 2 Agonist Dexmedetomidine MOA – acts centrally at the locus coeruleus to agonize 2 receptors  G-proteins and second messengers  inhibition of AC and decrease in cAMP  hyperpolarization  suppression of neuronal firing and decreased NE release  [+]  Increase in SWS; Decreased sleep latency; clinically, more closely resemble natural sleep than with GABAA agonists  [-]  Increase in Stage II, Decrease in REM  Its role in improving sleep in the ICU is still undefined.Kamdar et al. Sleep Deprivation in Critical Illness: Its Role in Physical Weinhouse GL and PL Watson. Sedation and sleep disturbancesand Psychological Recovery. J Intensive Care Med. 2011 Feb 7. Web. in the ICU. Crit Care Clin. 2009 Jul;25(3):539-49, ix.
  30. 30. Corbett et al., 2005Dexmedetomidine does not improve patient satisfaction when compared with propofol during mechanical ventilation.Corbett SM, Rebuck JA, Greene CM, Callas PW, Neale BW, Healey MA, Leavitt BJ. Crit Care Med. 2005 May;33(5):940-5. Design  Prospective, randomized study with questionnaire administration Inclusions Exclusions Non-emergent CABG patients Systolic BP <90 or HR <40 before requiring post-op MV administration Expected MV length <24 hours CrCl <30 ml/min, AST >183, or ALT >287 Need for neuromuscular blockade or epidural Obesity Alcohol or drug abuse or neurologic impairment
  31. 31. Corbett et al., 2005Methods:  All patients underwent induction with propofol  Post-bypass, patients were randomized to dexmedetomidine bolus+gtt or propofol bolus+gtt and titrated to Ramsay 5 for two hours, then Ramsay 3-4 (obtained q2 hours)Questionnaire:  Administered 24+ hours after extubation.  Modified Hewitt (1-10 scale), validated pre-study by interviewing 10 random CABG patients after extubation  Consistent, understood  Same investigator participated in all questionnaire administrations Similar in all reported characteristics (P >0.05): Sex Baseline SCr Alice at Discharge Age Morphine and midazolam requirements Weight SBP, MAP, HR, and CVP Length of anesthesia, surgery, MV, and ICU stay
  32. 32. Corbett et al., 2005 Dexmedetomidine Propofol (n=43) (n=46)How easy was it to sleep? 3.8 (1.0 – 5.3) 3.0 (1.0 – 5.3) P = 0.430How much did difficultyresting or sleeping upset 5.0 (1.0 - 7.8) 2.0 (1.0 - 5.0) P = 0.051you? 1=best; 10=worst Median (intraquartile range) Conclusions:  Authors  Propofol resulted in a more comfortable patient experience during MV with fewer sleep difficulties.  Personal  Many unaccounted for factors probably played a role; short MV possibly makes external validity diminish
  33. 33. DA-5HT2 AntagonistsTypicals (1st Gen.) – Haloperidol MOA – 5HT2A, 5HT2C, DA antagonist; however, sedative effects due to H1 antagonism  [+]  Increased total sleep time and possibly SWS  [-]  Increased sleep latency; Increased Stage II; ADRsAtypicals (2nd Gen.) – Olanzapine, Quetiapine MOA – 5HT2A >> DA antagonist; sedative effects due to H1 antagonism  Similar to haloperidol, but with less ADRs  [-]  At best, 30% sedation rate Very limited data Kamdar et al. Sleep Deprivation in Critical Illness: Its Role in Physical and Psychological Recovery. J Intensive Care Med. 2011 Feb 7. Web.
  34. 34. GABAA Agonists “Z-drugs” – Eszopiclone, Zolpidem MOA – Unknown completely, but thought to involve GABAA-receptor complexes at binding domains located close to the BZD binding site ( 1). While BZDs, non-selectively bind to and activate all BZD subtypes, these medications are thought to activate a smaller number of specific subtypes.  [+]  Decreased latency  [-]  Decreased REM, ADRsWinsky-Sommerer R. Role of GABAA receptors in the physiology and Weinhouse GL and PL Watson. Sedation and sleep disturbancespharmacology of sleep. Eur J Neurosci. 2009 May;29(9):1779-94. in the ICU. Crit Care Clin. 2009 Jul;25(3):539-49, ix.
  35. 35. Patient Case Revisited 10/21: Midazolam began for sedation10/25: Midazolam discontinued and patient extubated;Periods of delirium and agitation at night; CAM-ICU [+] 10/26: Eszopiclone 2mg given for sleep 10/27: Eszopiclone increased to 3mg
  36. 36. Summary • Sedative use in the ICU is both a cause and potential treatment for sleep disruption. • Sleep in the ICU should first be allowed to occur naturally by controlling pain and environmental factors. • There has never been a sedation algorithm studied specifically for its effects on sleep. • Guideline Recommendations: “Sleep promotion should include optimization of the environment and nonpharmacologic methods to promote relaxation with adjunctive use of hypnotics.” (B)Weinhouse GL and PL Watson. Sedation and sleep disturbances Jacobi et al. Clinical practice guidelines for the sustained use of sedatives andin the ICU. Crit Care Clin. 2009 Jul;25(3):539-49, ix. analgesics in the critically ill adult. Crit Care Med. 2002 Jan;30(1):119-41.
  37. 37. Proposed Algorithm for Optimal Sleep in the ICU Have barriers to sleep been minimized? Staff MechanicalPain Environmental Medications Interactions Ventilation Has patient been napping during the day? Does patient have an underlying sleep disorder? Home medication? Z-Drug
  38. 38. The Impact of Sedatives on Sleep in the ICU Kyle A. Amelung, Pharm.D. Candidate Barnes-Jewish Hospital, SICU Preceptor: Lee P. Skrupky, Pharm.D., BCPS November 9, 2011

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