REVIEW URRENT C OPINION

Delirium and sleep disturbances in the intensive care unit: can we do better? Gerald L. Weinhouse

Purpose of review Delirium in the ICU affects as many as 60–80% of mechanically ventilated patients and a smaller but substantial percentage of other critically ill patients. Poor sleep quality has been consistently observed in critically ill patients. These problems are associated with worse ICU outcomes and, in many cases, delirium and poor sleep quality may be related. This review will summarize the recent literature relevant to both the problems and provide a potential pathway toward improvement. Recent findings Many cases of delirium and the poor sleep experienced by ICU patients may be iatrogenic. How critical care practitioners prescribe sedatives and analgesics and, perhaps more broadly, how all medications are administered to critically ill patients, may be at the root of some of these problems. Reducing the administration of some commonly used ICU medications, especially some sedatives and anticholinergic medications, and keeping patients more awake and actively engaged in their care during the day may lead to better outcomes. Summary It is our responsibility to apply the best available, evidence-based medicine to our practice. Adherence to new guidelines for the treatment of pain, agitation, and delirium may be the best pathway toward reducing delirium, improving sleep quality, and improving related outcomes. Keywords critical illness, delirium, sedation, sleep deprivation

INTRODUCTION Fifteen years ago, critically ill patients were deeply sedated under the impression that it was the most compassionate approach to management and that it would facilitate patients’ care and recovery. Pioneering work by groups in several hospitals throughout the world has opened our eyes to the risk that such management can lead to worse outcomes than light or even no sedation. One of the most important lessons reinforced in this renaissance in critical care medicine is that the administration of all medications must be considered carefully. Medications given for one indication may have unintended consequences. In critically ill patients already on multiple medications, drug–drug interactions are common [1]. In addition, what may be appropriate for the short duration of an operating room case may not be optimal for a week-long critical illness. The central nervous system is particularly vulnerable to polypharmacy. One recent study found that approximately 25% of ICU patients were

prescribed eight or more medications concurrently and, of those patients, the average number prescribed was more than 13 [1]. It may not be surprising, therefore, that there is a high incidence of delirium in critically ill patients and sleep disturbances are common. Although current practice in the critical care community has evolved and continues to make strides in improving these outcomes, it is certain that we can do even better.

THE DELIRIUM EPIDEMIC Delirium is a clinical syndrome characterized by an acute, fluctuating disturbance in consciousness, inattention, and cognitive dysfunction. It has been Brigham and Women’s Hospital, Boston, Massachusetts, USA Correspondence to Gerald L. Weinhouse, MD, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA. Tel: +1 617 732 5499; e-mail: [email protected] Curr Opin Anesthesiol 2014, 27:403–408 DOI:10.1097/ACO.0000000000000093

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KEY POINTS  The delirium experienced by ICU patients has important implications for patient outcomes; however, many cases are iatrogenic and, therefore, potentially preventable.  Critically ill patients are known to sleep poorly while in the ICU, and this poor sleep may contribute to some cases of delirium.  Medications have not been convincingly shown to improve either sleep or the course of delirium in critically ill patients but their injudicious use may worsen both.  The recently published Clinical Practice Guidelines for the management of pain, agitation, and delirium in adult patients in the ICU represents the current standard of care for the prevention and management of sedation and delirium.  A strategy to improve sleep in the critically ill may be most successful if it involves minimizing medications and keeping patients awake during the day in order to allow for deeper, natural (nonchemically influenced) sleep at night.

a problem since long before the birth of critical care medicine. What is relatively new is the recognition of its prevalence in ICU patients and, more importantly, its relationship to poor ICU outcomes. Only within the past 10–15 years have there been reliable diagnostic tools for delirium in critically ill mechanically ventilated patients [2]. We now know that 60–80% of mechanically ventilated ICU patients will experience delirium, and this figure is even more shocking in light of its consequences [3,4]. Patients who experience delirium during their ICU stay have a three-fold increased mortality at 6 months, longer hospital and ICU stay, increased incidence of post-traumatic stress syndrome, and, for those who survive, worse global cognition and executive function that could last for months-toyears [3,5–8,9 ]. It is now well established that not all delirium is inherent to the critical illness itself but, rather, some cases are iatrogenic. The ICU environment and some of the treatments for critical illness have been associated with the development of delirium [4,10 ,11 ]. Benzodiazepines have become the most high profile example of medications that may lead to delirium [12]. They have been a mainstay of sedation in the ICU and were the sedative drug of choice as recently as 2002 for most critically ill patients; at which time they were endorsed by the multisociety Clinical Practice Guidelines for the management of pain, agitation, and delirium (PAN) in adult patients in the ICU [13]. Not all of &&

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the most rigorous trials have confirmed that benzodiazepines cause delirium; however, many experts and practitioners remain convinced of the relationship and there is greater agreement that they lead to additional adverse outcomes including longer ICU stay and increased duration of mechanical ventilation compared with other sedatives [14 ]. For more than 10 years, the standard of care has been to practice a daily interruption of sedation when giving continuous sedatives by infusions [15]. Similar to the longer standing practice of administering benzodiazepines using a symptomtriggered approach rather than a regular, fixed schedule for patients withdrawing from alcohol, it is a system designed to give the least cumulative amount of medication necessary in order to facilitate the quickest recovery overall. Now there is a new standard that goes even further to specifically guide away from the use of benzodiazepines when possible. The current version of the PAN Clinical Practice Guidelines published in early 2013 recommends: target the lightest sedation possible, use sedation protocols to facilitate sedation management, use analgesia-first sedation for intubated and mechanically ventilated patients, and use nonbenzodiazepines for sedation (either propofol or dexmedetomidine) rather than benzodiazepines in mechanically ventilated patients [16 ]. Recent studies of sedation practices in Australia and New Zealand found that midazolam and propofol were used as the primary sedative equally, deep sedation occurred in a high prevalence of patients especially within the first 48 h after intubation, and routine assessment of delirium occurred at a low rate [17,18 ]. In a survey of Malaysian hospitals, deep sedation occurred in 71% at first assessment and midazolam was given to 93% of patients [19 ]. A great deal of variability in sedation practice has been found with a greater tendency toward over-sedation rather than under-sedation [20]. Routine objective assessment of delirium is recommended but not routinely performed and may be made more difficult in those patients deeply sedated [21,22 ,23 ]. Hager et al. [24 ] recently demonstrated one way to decrease sedative use as part of a quality improvement project in which they created a new sedation protocol and successfully implemented it using a ‘4Es’ (engage, educate, execute, and evaluate) model. Their process led to a reduction of sedative infusions and more patient days awake and without delirium. It seems likely that adherence to current best practice is a fertile area for improvement. Although benzodiazepines may be the most high profile target for improvement, there are numerous other medications that have been associated with &

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Delirium and sleep disturbances in the ICU Weinhouse

delirium. Other gamma-aminobutyric acid (GABA)agonists, opioids, dopaminergic medications, and anticholinergic drugs may contribute to delirium; there are over 600 medications with anticholinergic side-effects alone and many of them are used in the ICU [25,26]. In addition, little is known of the effects of the numerous combinations of these drugs when administered to vulnerable, critically ill patients. Altered metabolism and volume of distribution, organ dysfunction, compromise of the blood–brain barrier, and uncertain pharmacokinetics combined with systemic inflammation in some patients make it virtually impossible to predict their effects. As compassionate caregivers, our instinct is to try to fix all that is wrong with our patients; however, we can be led astray. Beta-blockers for sinus tachycardia, acetaminophen for fever, sedatives and antipsychotics for restlessness, vasopressors for low blood pressure absent signs of organ hypoperfusion, hypnotics or antidepressants for insomnia, and bronchodilators for mechanical ventilation without bronchospasm are examples of medications sometimes given without clear rationale or clinical indication. It seems reasonable to conclude that if we reduce patients’ exposure to medications they will be more likely to maintain clarity than to expect their brains, already marinating in chemicals, to improve with the addition of more. Restraint may be more difficult than intervention but, in the end, it may lead to quicker recovery for our patients.

SLEEPLESS IN THE ICU Studies dating back at least 40 years have been consistent in describing the poor sleep of the critically ill. The obstacles to sleep – noise, stress, pain, light, critical illness itself, and numerous medications – are ubiquitous in ICUs [27]. The method of mechanical ventilatory support, too, may adversely affect sleep quality for some patients [28–31]. The sleep typical for critically ill, especially mechanically ventilated, patients is characterized by severe fragmentation with numerous awakenings. Commonly, patients experience short periods of sleep distributed throughout the 24 h day rather than in one long (consolidated) period at night [32–34]. These patients are likely to have little to no rapid eye movement (REM) sleep nor slow wave sleep (SWS) that is the deepest phase of healthy sleep. Further, they are known to have disorganization of circadian timing [35]. This poor sleep quality is memorable for survivors of critical illness who consistently report it as having been an important stressor during their ICU stay [36,37].

Polysomnography in healthy volunteers has demonstrated that many of the medications administered to these critically ill patients have adverse effects on sleep. Opioids and benzodiazepines potently suppress slow wave sleep. Propofol suppresses REM and worsens overall sleep quality in critically ill patients [38]. Dexmedetomidine, once thought to more physiologically reproduce natural sleep, has proven no better and was recently found to be associated with severely disturbed sleep absent of both REM and SWS stages [39]. Vasopressors, corticosteroids, antidepressants, and the lipidsoluble beta-blockers suppress REM sleep and numerous medications such as beta-agonists that are associated with insomnia. On the other hand, these medications may be specifically addressing an underlying cause of the poor sleep, such as bronchospasm, so there are times when administering select medications can improve sleep, despite their well-described adverse affects on the sleep EEG [40]. Attempts to improve sleep in the ICU are laudable but often misguided. Hypnotics have not been well studied in critically ill patients, and some are associated with the development of delirium that secondarily worsens sleep. It is easy to assume that the unconscious state induced by sedatives and opioids is equivalent to sleep or an adequate substitute for naturally occurring sleep, but this is not likely to be true [41]. It seems unreasonable to conclude that a chemically induced unconscious state is as beneficial as a natural physiologic state that has evolved over millions of years. Chemically induced unconsciousness lacks the cyclic progression of welldefined sleep stages, circadian regulation, and easy reversibility of naturally occurring sleep. Interestingly, there is an increase in removal of potentially neurotoxic degradation products of neural activity that accumulate from the awake central nervous system under both natural sleep and the state of unconsciousness induced by anesthesia [42 ]. It may be the case, therefore, that some of the functions of sleep necessary for survival may also proceed under other unconscious states, but it seems less likely that higher functions attributed to sleep including memory processing occurs to the same degree if at all. There is no protocol yet designed that has consistently been shown to enhance sleep in critically ill patients. It has been assumed that sleep would only come when accommodations were made to allow uninterrupted time for sleep and when patients were guaranteed a safe, quiet, comfortable, hospitable environment. Small trials of the use of sleep aids, including eye masks and earplugs, relaxation techniques, and melatonin, have demonstrated some success [43–45]. However, the most potent force for inducing natural sleep is sleepiness itself. What

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is sometimes referred to as sleep homeostasis is governed by the principle that as one’s sleep deficit builds, there is a similar increase in his/her tendency to sleep longer and deeper. A sleep-deprived individual falling asleep at the wheel of a car, thus overwhelming the most basic survival instinct, is an example of the intensity of this pressure to sleep. Short, intermittent naps as experienced currently by critically ill patients likely serve to temporarily decrease this sleep pressure. It might make sense, then, to leverage this most potent, natural gift by helping patients stay awake during the day in order to create the best conditions for natural, deep, nocturnal sleep.

THE SLEEP–DELIRIUM CONNECTION It seems likely that sleep disturbances and delirium in some critically ill patients may be related [46]. The diagnostic clinical features of delirium have all been observed in individuals deprived of sleep. Fluctuating mental status, inattention, and poor cognitive function have been found in both sleep-deprived individuals and in those with delirium. Neuroimaging studies have further demonstrated changes in regional perfusion and metabolism in similar parts of the central nervous system, specifically the prefrontal cortex and the nondominant parietal cortex, in these patients. One recent study also found that delirium is independently associated with the most severe reduction in REM sleep in a cohort of surgical ICU patients [47]. Several recent studies have further characterized abnormal features of the ‘sleep’ EEG in critically ill patients. Investigators have confirmed that some critically ill patients will have concurrent electrophysiologic signs of sleep but behavioral signs of wakefulness and, conversely, electrophysiologic signs of wakefulness with behavioral signs of sleep [48 ,49 ]. The ‘atypical sleep’ and ‘pathologic wakefulness’ have been described in mechanically ventilated patients both sedated and unsedated. Drouot et al. [48 ] specifically excluded patients who were known to be delirious; however, when atypical sleep was identified the majority of those patients were subsequently diagnosed with delirium. So it may be that there is a relationship between the dissociative states observed when studying these patients with the clinical syndrome of delirium. It is fortuitous that early mobilization and lighter sedation targets are now becoming standard practice. Keeping patients more awake and engaged in their care during the day should lead to longer, deeper natural sleep if we can also provide them with uninterrupted sleep time at night. Kamdar et al. [50 ] recently undertook a quality improvement &

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project designed to improve patients’ sleep while in the ICU. Interestingly, controlling the environment, using nonpharmacologic aids such as earplugs and eye masks, using pharmacologic aids only with specific guidelines, and keeping patients active during the day along with uninterrupted time for sleep at night led to a significant reduction in delirium. Improvements in patients’ perceived sleep quality by an assessment tool, the Richards– Campbell Sleep Questionnaire, did not reach statistical significance in this study; however, polysomnography or other objective measures of sleep were not done. More studies are needed. A more complete understanding of the relationship between delirium and sleep deprivation in critically ill patients may only come with a more integrated understanding of neurophysiology combining clinical information with neuroimaging techniques, measures of microvascular metabolism and perfusion, and electrophysiology. It is possible that the more enlightened clinical practice of minimizing sedatives and other offending or unnecessary medications and mobilizing patients and keeping them awake during the day will lead to a significant lessening of this problem even before such an understanding is achieved.

CONCLUSION We now have a new standard of care for the management of pain, agitation and delirium, which is based on best available data. It is almost certain that more formal recommendations for sleep in these patients will be part of subsequent revisions of the Clinical Practice Guidelines for the management of pain, agitation, and delirium in adult patients in the ICU. The principles put forth in the current guidelines are sound and broadly applicable to a variety of types and acuity of illnesses. Adherence to these guidelines can serve as a pathway for us to ‘do better’. Acknowledgements None. Conflicts of interest There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Bertsche T, Pfaff J, Schiller P, et al. Prevention of adverse drug reactions in intensive care patients by personal intervention based on an electronic clinical decision support system. Intensive Care Med 2010; 36:665–672.

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Delirium and sleep disturbances in the ICU Weinhouse 2. Ely EWW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit. JAMA 2001; 286:2703–2710. 3. Ely ES, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753–1762. 4. Sharma A, Malhotra S, Grover S, Jindal SK. Incidence, prevalence, risk factor and outcome of delirium in intensive care unit: a study from India. Gen Hosp Psychiatry 2012; 34:639–646. 5. Lin S, Liu C, Wang C, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 2004; 32:2254–2259. 6. Thomason JWW, Shintani A, Peterson JF, et al. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 nonventilated patients. Crit Care 2005; 9:R375–R381. 7. Kress JP, Gehlbach B, Lacy M, et al. The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med 2003; 168:1457–1461. 8. Treggiari MM, Romand J, Yanez D, et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med 2009; 37:2527–2534. 9. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impair&& ment after critical illness. NEJM 2013; 369:1306–1316. One of the most rigorous investigations of the cognitive performance of patients who survive critical illness. 10. McPherson JA, Wagner CE, Boehm LM, et al. Delirium in the cardiovascular & ICU: exploring modifiable risk factors. Crit Care Med 2013; 41:405–413. A prospective, observational study of cardiac surgery patients. Delirium prevalence was 26%, mostly the hypoactive subtype, and associated with the use of both chemical (benzodiazepine) and physical restraints. 11. Zaal IJ, Spruyt CF, Peelen LM, et al. Intensive care unit environment may affect & the course of delirium. Intensive Care Med 2013; 39:481–488. Prospective study of the number of days of delirium in the ICU before and after moving from an ICU with open wards to one with only single rooms. 12. Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006; 104:21–26. 13. Jacobi J, Fraser GL, Coursin DB, et al. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians: Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:119–141. 14. Fraser GL, Devlin JW, Worby CP, et al. 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Formal recommendations for sleep, however, are not part of this document but will likely be part of the next version of it. 17. Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med 2012; 186:724–731. 18. Elliott D, Aitken M, Bucknall TK, et al. Patient comfort in the intensive care unit: & a multicentre, binational point prevalence study of analgesia, sedation and delirium management. Crit Care Resusc 2013; 15:213–219. A review of the assessment and management of analgesia, sedation and delirium in Australia and New Zealand showing a relatively low rate of formal sedation, pain, and delirium assessment. 19. Shehabi Y, Chan L, Kadiman S, et al. Sedation depth and long-term mortality & in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 2013; 39:910–918. Prospective longitudinal cohort study linking the depth of sedation within the first 48 h of mechanical ventilation to clinical outcomes. 20. Jackson DL, Proudfoot CW, Cann KF, Walsh TS. The incidence of suboptimal sedation in the ICU: a systematic review. Crit Care 2009; 13:R204. 21. Guenther U, Weykam J, Andorfer U, et al. Implications of objective vs subjective delirium assessment in surgical intensive care patients. Am J Crit Care 2012; 21:e12–e20. 22. Woien H, Balsliemke S, Stubhaug A. The incidence of delirium in Norwegian & intensive care units; deep sedation makes assessment difficult. Acta Anaesthesiol Scan 2013; 57:294–302. A study of the incidence of delirium at two Norwegian ICUs and the difficulties associated with assessing for it with the confusion assessment method for the ICU (CAM-ICU) when patients are deeply sedated.

23. Bigatello LM, Amirfarzan H, Haghighi AK, et al. Effects of routine monitoring of delirium in a surgical/trauma intensive care unit. J Trauma Acute Care Surg 2013; 74:876–883. A study to see if routine monitoring of delirium leads to earlier treatment and improved outcomes. Neither earlier treatment nor improved outcomes resulted although more patients were pharmacologically treated for delirium when daily assessments were performed. 24. Hager DN, Dinglas VD, Subhas S, et al. Reducing deep sedation and delirium & in acute lung injury patients: a quality improvement project. Crit Care Med 2013; 41:1435–1442. A quality improvement project to reduce sedation and delirium. Applies a ‘4Es’ method (engage, educate, execute, and evaluate). Use of sedative infusions was successfully decreased and days awake without delirium were increased. 25. Pisani MA, Murphy TE, Araujo KLB, et al. Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 2009; 37:177–183. 26. Zaal IJ, Slooter AJC. Delirium in critically ill patients. Epidemiology, pathophysiology, diagnosis and management. Drugs 2012; 72:1457–1471. 27. Bihari S, Doug McEvoy R, Matheson E, et al. Factors affecting sleep quality of patients in intensive care unit. J Clin Sleep Med 2012; 8:301–307. 28. Parthasarathy S, Tobin M. Effect of ventilator mode on sleep quality in critically ill patients. Am J Respir Crit Care Med 2002; 166:1423–1429. 29. Delisle S, Ouellet P, Bellemare P, et al. Sleep quality in mechanically ventilated patients: comparison between NAVA and PSV modes. Ann Int Care 2011; 1:42. 30. Alexopoulou C, Kondili E, Plataki M, Georgopoulos D. Patient-ventilator synchrony and sleep quality with proportional assist and pressure support ventilation. Intensive Care Med 2013; 39:1040–1047. 31. Andrejak C, Monconduit J, Rose D, et al. Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients? Respir Med 2013; 107:534–541. 32. Cooper AB, Thornley KS, Young GB, et al. Sleep in critically ill patients requiring mechanical ventilation. Chest 2000; 117:809–818. 33. Gabor J, Cooper A, Crombach S, et al. Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care Med 2003; 167:708–715. 34. Freedman N, Kotzer N, Schwab R. Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Respir Crit Care Med 1999; 159:1155–1162. 35. Gehlbach BK, Chapotot F, Leproult R, et al. Temporal disorganization of circadian rhythmicity and sleep-wake regulation in mechanically ventilated patients receiving continuous intravenous sedation. Sleep 2012; 35:1105–1114. 36. Rotondi AJ, Lakshmipathi C, Sirio C, et al. Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med 2002; 30:746–752. 37. Simini B. Patients’ perceptions of intensive care. Lancet 1999; 354:571– 572. 38. Kondili E, Alexopoulou C, Xirouchaki N, Georgopoulos D. Effects of propofol on sleep quality in mechanically ventilated critically ill patients: a physiological study. Intensive Care Med 2012; 38:1640–1646. 39. Oto J, Yamamoto K, Koike S, et al. Sleep quality of mechanically ventilated patients sedated with dexmedetomidine. Intensive Care Med 2012; 38:1982– 1989. 40. Wiegand L, Mende CN, Zaidel G, et al. Salmeterol vs theophylline: sleep and efficacy outcomes in patients with nocturnal asthma. Chest 1999; 115:1525–1532. 41. Peitz GJ, Balas MC, Olsen KM, et al. Top 10 myths regarding sedation and delirium in the ICU. Crit Care Med 2013; 41:S46–S56. 42. Xie L, Kang H, Xu Q, et al. Sleep drives metabolite clearance from the adult & brain. Science 2013; 342:373–377. A fascinating study in mice showing that during both natural sleep and under anesthesia there is an increase in clearance of potentially neurotoxic waste products such as b-amyloid. 43. Chen JH, Chao YH, Lu SF, et al. The effectiveness of valerian acupressure on the sleep of ICU patients: a randomized clinical trial. Int J Nurs Stud 2012; 49:913–920. 44. Alway A, Halm MA, Shilhanek M, St. Pierre J. Do earplugs and eye masks affect sleep and delirium outcomes in the critically ill? Am J Crit Care 2013; 22:357–360. 45. Bourne RS, Mills GH, Minelli C. Melatonin therapy to improve nocturnal sleep in critically ill patients: encouraging results from a small randomised controlled trial. Crit Care 2008; 12:R52. 46. Weinhouse GL, Schwab RJ, Watson PL, et al. Bench-to-bedside review: delirium in ICU patients – importance of sleep deprivation. Critical Care 2009; 13:234. 47. Trompeo AC, Vidi Y, Locane MD, et al. Sleep disturbances in the critically ill patients: role of delirium and sedative agents. Minerva Anestesiol 2011; 77:604–612. 48. Drouot X, Roche-Campo F, Thille AW, et al. A new classification for sleep & analysis in critically ill patients. Sleep Med 2012; 13:7–14. A study of the sleep of nonsedated patients with respiratory failure requiring noninvasive or invasive mechanical ventilation. More than one of four were not able to be scored by standard criteria; the states of ‘atypical sleep’ and ‘pathologic wakefulness’ are discussed. &

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Drugs in anesthesia 49. Watson PL, Pandharipande P, Gehlbach BK, et al. Atypical sleep in ventilated patients: empirical electroencephalography findings and the path toward revised ICU sleep scoring criteria. Crit Care Med 2013; 41:1958–1967. A further analysis of the sleep EEG of sedated, mechanically ventilated patients with a proposal for revising the current sleep scoring system for these patients.

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50. Kamdar BB, King LM, Collop NA, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med 2013; 41:800–809. This is a three-stage quality improvement project that demonstrates that a process aimed at improving sleep and cognition can lead to improved ICU outcomes.

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Delirium and sleep disturbances in the intensive care unit: can we do better?

Delirium in the ICU affects as many as 60-80% of mechanically ventilated patients and a smaller but substantial percentage of other critically ill pat...
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