Sleep Promotion in ICU Patients

Non-Pharmacological Interventions

A sleep-promoting, multicomponent protocol is recommended as the first-line approach for improving sleep in ICU patients, with pharmacological interventions considered only when non-pharmacological measures are insufficient, as recommended by the Society of Critical Care Medicine 1, 2
Offering earplugs and eyeshades to all ICU patients can improve sleep, according to the Society of Critical Care Medicine 2
Implementing noise and light reduction strategies, including controlling environmental light (bright light during day, darkness at night), can improve sleep in ICU patients, as recommended by the Society of Critical Care Medicine 1, 2, 3
Clustering patient care activities to minimize nighttime disruptions can help improve sleep in ICU patients, as recommended by the Society of Critical Care Medicine 3
Providing relaxing music when appropriate can be a useful non-pharmacological intervention for improving sleep in ICU patients, according to the Society of Critical Care Medicine 2

Melatonin is associated with relatively few adverse effects, is inexpensive, and generally well-tolerated, but its quality and consistency are not regulated by the FDA, as noted by the Society of Critical Care Medicine 2
Dexmedetomidine may be considered for use in specific situations, such as when a sedative infusion is already indicated for a hemodynamically stable patient, as it can increase stage 2 sleep and preserve day-night cycling, according to the Society of Critical Care Medicine 1, 2
Propofol should not be used specifically to improve sleep in ICU patients due to its association with REM suppression, hemodynamic side effects, and respiratory depression, as recommended by the Society of Critical Care Medicine 1, 2
Benzodiazepines are associated with an increased risk of delirium, as noted by the Society of Critical Care Medicine 3

Behavioral interventions, including cognitive behavioral therapy for insomnia (CBT-I), progressive muscle relaxation, mindfulness meditation, and regular morning or afternoon exercise, can help improve sleep quality in patients, as recommended by the American College of Critical Care Medicine 1, 2, 4, 5
Yoga has demonstrated significant improvements in global sleep quality, daytime functioning, sleep efficiency, and reduced need for sleep medications, with a strength of evidence supporting its use 4
Mindfulness meditation significantly decreases sleep disturbance compared to sleep hygiene education alone, with moderate evidence supporting its effectiveness 4
Regular morning or afternoon exercise improves sleep quality, with meta-analyses showing exercise improves sleep at 12-week follow-up, as recommended by the American College of Sports Medicine 4

The American College of Critical Care Medicine recommends sleep hygiene practices, including maintaining a regular sleep-wake schedule, ensuring exposure to bright light during daytime, creating a dark, quiet, and comfortable sleep environment, avoiding heavy meals before bedtime, and avoiding caffeine after 4:00 PM, to improve sleep quality in patients 1, 2
Evaluating the severity and type of sleep disorder, determining if it is insomnia of onset, maintenance, or early awakening, and ruling out sleep apnea and restless legs syndrome is essential in patients, as recommended by the American Academy of Sleep Medicine 6

Lower doses of sleep interventions are typically required in certain populations, such as the elderly 7
Trazodone 25-50mg is recommended for patients with CKD without dialysis, and trazodone 25mg with gradual adjustment for patients with CKD on dialysis, and mirtazapine 7.5-15mg for patients with comorbid depression 6
Non-benzodiazepine hypnotics (zolpidem, zaleplon) should be used with caution and in reduced doses in patients with CKD, as recommended by the Mayo Clinic Proceedings 6
Benzodiazepines, especially those with long-acting effects like diazepam, should be avoided in patients with CKD due to the risk of accumulation, prolonged sedation, and falls, according to the Mayo Clinic Proceedings 6

Relying solely on sleep hygiene without additional interventions, using sedating medications long-term without addressing underlying causes, and ignoring comorbid conditions that may affect sleep are common pitfalls to avoid, as recommended by the American Academy of Sleep Medicine 4, 8, 7
Consuming any acidic beverage, such as citrus juices, close to bedtime may cause gastric discomfort or reflux, potentially worsening sleep quality, and there is no scientific evidence supporting the use of orange juice to improve sleep in patients 1, 2, 9