Enhancing Sleep in Critically Ill Perianesthesia Patients Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN SLEEP IS ESSENTIAL to maintain homeostasis and promote healing. Sleep facilitates effective cognitive function and memory,1 enhances metabolism, and supports immune function.2 Unfortunately, sleep abnormalities are common in critically ill patients,3,4 and disruptions in sleep architecture occur after surgery.5,6 Several nursing-driven interventions can be implemented in the postanesthesia care unit (PACU) to promote sleep optimizing the critically ill patient’s recovery.

Sleep Architecture Normal sleep architecture cycles between two states at approximately 90-minute intervals: non– rapid eye movement (NREM) and rapid eye movement (REM) sleep.7 NREM sleep has three stages: Stage N1 (light sleep), Stage N2 (moderate sleep), and Stage N3 (deep sleep or slow wave sleep [SWS]). REM sleep is the last stage and is the most restorative phase.8 Sleep, or the state of decreased arousal, is initiated in the suprachiasmatic nucleus (SCN) located in the hypothalamus. The circadian process that organizes sleep and wake cycles is created by patterns in light and dark that are transmitted through the retina communicating with the SCN.9 A complex series of neurotransmitters, melatonin, and neural pathways regulate circadian rhythms and our sleep-wake cycle.2 Anesthesia, both general and regional, has been found to interfere with normal sleep architecture especially in the first day postoperatively reducing SWS

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, is from the Professional Resources, University of Colorado Hospital, Aurora, CO. Conflict of interest: None to report. Address correspondence to Mary Beth Flynn Makic, Professional Resources, University of Colorado Hospital, 12401 E 17th Avenue, Campus Box 901 Leprino Building, Aurora, CO 80045; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00


and REM stages of sleep, resulting in fragmented sleep.5,6,8

Modifying the Environment Nursing interventions focused on modifying the environment to enhance sleep during nighttime hours and encourage activity during daytime hours have been found to promote healthy sleep-wake cycles in the care of critically ill patients.10,11 The first environmental factor to consider in promoting sleep is noise. The Environment Protection Agency recommends maximum hospital noise levels to be 45 dB during the day and 35 dB at night.12 One study found the average noise in a PACU to be 75 dB.13 The most commonly reported noise disruption is that of staff conversations.13,14 Other causes of noise include alarms, phones, and nursing care. Simple interventions such as establishing quiet zones or implementing noise-tracking devices such as a ‘‘Yacker Tracker’’15 increases people’s awareness of conversational and environmental noise. Visual reminders have been found to be helpful in reducing environmental noise, especially at night, promoting a quieter environment supporting sleep.16 Adjusting alarm volumes near the patient and critically assessing alarm parameters are another intervention that can easily be implemented to reduce nuance alarms and associated noise. Offering the patients earplugs may also be considered to address excessive environmental noise.16,17 Secondly, lowering environmental lighting during normal nighttime hours enhances reestablishing sleep circadian rhythm.5 Finally, bundling care and redesigning work flow to reduce unnecessary activities (eg, routine stocking of room supplies) or interventions (eg, timing of baths or routine labs) during nighttime will help reduce sleep interruptions and associated noise.

Nonenvironmental Nursing Interventions Besides modifying environmental noise, postanesthesia nurses can implement several other

Journal of PeriAnesthesia Nursing, Vol 29, No 2 (April), 2014: pp 140-142



interventions to promote sleep in the care of critically ill patients. Assessing for and treating delirium is an important intervention in the promotion of quality sleep. Although the connection between sleep deprivation and delirium continues to be explored, the fact that sleep deprivation negatively impacts thought processes and memory has been established.1 Critically ill patients are at risk of experiencing both sleep deprivation and delirium especially among those who are elderly and/or mechanically ventilated.18,19 Circadian rhythm disturbances, effects of sedating agents, and inattention occur with both delirium and sleep deprivation.1,18,19 Postanesthesia nurses should routinely assess patients for the presence of delirium using a standardized tool18 and encourage normal sleep-wake cycles to reduce the incidence of delirium and promote quality sleep. Sedation also negatively impacts sleep. GABA agonists (ie, benzodiazepines and propofol) may increase the patient’s total sleep time but adversely affects SWS and REM sleep.7,18 Administration of sedating agents results in disorganization of circadian rhythm sleep-wake cycle, further exacerbating the sleep deprivation associated with post-

anesthesia recovery. Sedation agents should be limited and when possible GABA agonist agents should be avoided.18 Effective pain management is essential in promoting sleep. Pain and the associated inflammatory response trigger REM sleep disturbances.9 Frequent assessment and effective treatment of a patient’s reported pain, especially in the first postoperative night, have been found to significantly improve sleep quality.6 Offering complementary therapies, such as massage, music, aromatherapy, and acupressure, have been shown to enhance relaxation and potentially reduce sympathetic nervous system activation, thereby enhancing sleep.20

Implications for Practice Sleep is an essential function for healing. Promoting high-quality sleep postoperatively is an important intervention for a patient’s successful recovery. Developing and implementing nurse-driven protocols within the PACU that effectively address both environmental and nonenvironmental causes of sleep disruption are important first steps in improving the quality of sleep critically ill postoperative patients experience.

References 1. Diekelmann S, Born J. The memory function of sleep. Nat Rev Neurosci. 2010;11:114-126. 2. Kamdar BB, Needham DM, Collop NA. Sleep deprivation in critical illness: Its role in physical and psychological recovery. J Intensive Care Med. 2012;27:97-111. 3. Parthasarathy S, Tobin MJ. Sleep in the intensive care unit. Intensive Care Med. 2004;30:197-206. 4. 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. 5. G€ ogenur I, Wildschiøtz G, Rosenberg J. Circadian distribution of sleep phases after major abdominal surgery. Br J Anaesth. 2008;100:45-49. 6. Dette F, Cassel W, Urban F, et al. Occurrence of rapid eye movement sleep deprivation after surgery under regional anesthesia. Anesth Analg. 2013;116:939-943. 7. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. N Engl J Med. 2010;363:2638-2650. 8. Dodds C. The physiology of sleep. Curr Anaesth Crit Care. 2002;13:2-5. 9. Roehrs T. Sleep physiology and pathophysiology. Clin Cornerstone. 2000;2:1-12. 10. Bosma K, Ranieri VM. Filtering out the noise: Evaluating the impact of noise and sound reduction strategies on sleep quality for ICU patients. Crit Care. 2009;13:151-157.

11. Freedman NS, Gazendam J, Levan L, Pack AI, Schwab RJ. Abnormal sleep/wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit. Am J Respir Crit Care Med. 2001;163:451-457. 12. US Environmental Protection Agency. Information on Levels of Environmental Noise Requisite to Protect Public Health and Welfare With an Adequate Margin of Safety. Washington, DC. Available at: Accessed January 2, 2014. 13. Allaouchiche B, Duflo F, Debon R, et al. Noise in the postaneaesthsia care unit. Br J Anaesth. 2002;88:369-373. 14. Smykowski L. A novel PACU design for noise reduction. J Perianesth Nurs. 2008;23:226-229. 15. Mayer-Johnson. Yacker-TrackerÔ. Available at: http:// &gclid5CLShmIna57sCFclcMgodfHUATw. Accessed January 2, 2014. 16. Murphy G, Bernardo A, Dalton J. Quiet at night: Implementing a nightingale principle. Am J Nurs. 2013;113:43-53. 17. Van Rompaey B, Elseviers MM, Van Drom W, et al. The effect of earplugs during the night on the onset of delirium and sleep perception: A randomized controlled trial in intensive care patients. Crit Care. 2012: R73. Available at: Accessed December 4, 2013.


18. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41:263-306. 19. Weinhouse GL, Schwab RJ, Watson PL, et al. Bench to bedside review: Delirium in ICU patients—Importance of sleep

MARY BETH FLYNN MAKIC deprivation. Crit Care. 2009;13:234. 20. Tamrat R, Huynh-Le MP, Goyal M. Non-pharmacologic interventions to improve the sleep of hospitalized patients: A systematic review. J Gen Intern Med. 2013 Oct 10. [Epub ahead of print]

Enhancing sleep in critically ill perianesthesia patients.

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