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We habitually lie to ourselves and our patients’ families when the word “sleep” leaves our tongues in reference to sedated patients. Why is sleep so vital to survival in the ICU? What prevents our patients from preserving their sanity and cognitive function? What has COVID taught us about the role of sleep in the ICU? Dr. Margaret Pisani, intensivist and sleep researcher, ties it all together for us.

 

Episode Transcription

Kali Dayton 0:00
Let’s talk about sleep again. In Episode 60, we learned from Dr. Williams Roberson, that research clearly demonstrates sedation is not sleep for our patients brains.

So what does that mean for our patients? And episode four, we heard from patients about the tears and hallucinations and horror is experienced while under sedation, and while not sleeping. So how does this all impact our decisions and care at the bedside?

Intensivist and researcher, Dr. Margaret Pisani joins us now to tie it all together. Dr. Pisani, thank you so much for coming on and sharing your expertise with us? Can you introduce yourself?

Dr. Margaret Pisani 1:09
Oh, sure. Thanks for having me, Dr. Margaret Pazhani. And I am a physician at Yale University in New Haven, Connecticut, and I practice pulmonary Critical Care Medicine.

Kali Dayton 1:20
Right. And someone cued me into your expertise, because you had done a lot of research on sleep in the ICU, correct?

Dr. Margaret Pisani 1:28
Yes. And so I actually started out my career with a focus on caring for older patients in the ICU, and that with that focus came delirium research, and subsequently moved on to doing research in sleep, thinking that delirium and sleep are tied in that sleep is really important for recovery of patients.

Kali Dayton 1:47
And what have you found about sleep? Why is it so important to us just even at baseline, and then, especially in the ICU?

Dr. Margaret Pisani 1:54
Well, there’s lots of studies that are done now outside of the ICU that show that sleep is important for immune function. So studies that have looked at patients if you give a patient a vaccine, and you sleep deprived them versus let them sleep, the patients who sleep mount a much more robust antibody response.

There’s also data about sleep and worse cardiovascular outcomes. So lack of sleep contributing to worse cardiovascular outcomes. And also data related to sleep in lung function. So lung function, so forced expiratory volume in one second forced vital capacity, all go down when patients are sleep deprived.

Kali Dayton 2:32
So that baseline is essential for survival.

Dr. Margaret Pisani 2:37
Actually, there’s, I mean, importantly, I didn’t even mention this. But there’s more and more data now that sleep is really important for cognitive function and linking sleep deprivation over time with things like Alzheimer’s development of Alzheimer’s disease,

Kali Dayton 2:52
Which validates a lot of my suspicions, because we see in this post ICU syndrome, and we see these high rates of cognitive dysfunction and patients that have been deeply sedated. Yet we also know that sedation is not sleep that patients that are deeply sedated go however long, what days, weeks without real restorative sleep. So what role do you think sedation plays in the cognitive dysfunction, the sleeplessness in the ICU?

Dr. Margaret Pisani 3:19
Well, so since we’re using sedation as a big mission of mine, now, I think we totally over sedate patients in the ICU. And this has become even more apparent in COVID. And then we maybe don’t choose the correct medicines for sedation. And so there are studies that have looked at what does an EEG look like when you give a medicine like a benzodiazepine, or propofol or dexmedetomidine.

They show they’re really, they really do not mimic normal sleep, you don’t really get those deep stages of sleep that you need for restoration of brain recovery of brain function, and maintaining like good health. And so yes, you’re correct, that sedation is not sleep. And so really reminding people of that, that even though the patient looks like they’re not moving, or they’re asleep, that the sedation isn’t doing the same thing as normal or natural sleep would do for them.

Kali Dayton 4:12
And that’s contributing to this. Or even maybe even causing this post ICU dementia.

Dr. Margaret Pisani 4:17
Right! Well, it definitely could be so some of the sedative meds could be doing it. And there are studies that show that even when you give people like to think, “Oh, well, they’re in the ICU, let’s just sedate them. They won’t remember this. This is awful.” But studies, you know, have shown that patients when they’re more deeply sedated are more likely to have things like post traumatic stress, because they have actually no real memories or no factual memories of what happened to them in the ICU.

And so while we like to think that sedation is good, it’s probably causing increasing of post traumatic stress. We know definitely that it contributes to delirium. And there’s more and more evidence to suggest that maybe delirium in and of itself may include Should you risk for dementia or cognitive impairment later on. And there are studies that show this that patients having increased durations of delirium are more likely to have cognitive impairment 3,12,18 months post intensive care.

Kali Dayton 5:14
Thinking back to moments in my life when I’ve gone, you know, 24 hours or extended periods of time without sleep or weeks with poor sleep. If you talk to any anyone, they remember those periods of times and their their lives because they felt so stressed, they didn’t function they got sick, you know, they remember because it affected them so deeply.

And yet, we’re depriving our patients of sleep for days to weeks. And when you talk to survivors, you can tell that they are deeply, deeply impacted by how much that impacted their cognitive function in their psyche, like you’re saying. And so, in the ICU, of course, you say your mission is to avoid sedation. So that’s going to really improve patient’s opportunity to get real sleep when they’re not sedated. And then why is it important to be awake during the day? How does that impact our sleep cycle?

Dr. Margaret Pisani 6:15
Well, so we’re all governed by something called a circadian rhythm. So all mammals have what’s called a circadian rhythm. And the circadian rhythm is controlled by lots of things that happen in our environment. And so with circadian rhythm, there’s something called a master clock that sits in the Super chi asthmatic nucleus and the hypothalamus of the brain. And so that master clock then controls all of these other peripheral clocks that exist in all these other organs. So in the pancreas, and the liver, in in the lymphocytic cells.

And so what happens is, their circadian clock is the biggest trigger, or the biggest, what we call in training for that is light. And so having bright light during the day and then having it dark at night. And so when you don’t have an and then the other one, or the other things that’s related to circadian rhythm and sleep are very closely tied. And so, you know, you know how, if you get awake in the morning, and as you go through the course of the day, you get this drive to sleep as the evening comes on.

And then what happens is about, depending on patients sleep time, nine to 10 o’clock at night, they get an increase in a hormone called melatonin, that then kind of pushes that then to sleep. And that’s controlled by circadian rhythm and light. And so what happens is, is that if your your circadian rhythm gets messed up, and that’s what happens when people are awake at night sleeping during the day, that impacts then not only your ability to sleep and recover, but lots of other things that we see in the ICU, so pretenders potential for problems with glucose control problems. So again, you know, with immune function and those kinds of things related to misalignment of circadian rhythm and lack of sleep.

Kali Dayton 8:05
Do you think about these COVID patients at baseline, there have this, they’re in this inflammatory process? There, they need their immune systems to fight this virus. They are it’s neurotoxic. So they’re at higher risk of having neurological impacts from the virus. So when we deprive them of sleep, aren’t we impairing their immune system, contributing to the inflammation, compromising their brains even further?

Dr. Margaret Pisani 8:33
Yeah, and so I mean, trying to be able to provide as much sleep and as much normal sleep as possible, for critically ill patients is very important. And so we know from studies outside the hospital that I mean, outside of the hospital, and normal healthy patients, or even in some hospitalized patients, there’s less hard data about sleep, and critically ill patients except for we know that it’s really disrupted. And so we haven’t done.

We’ve done converse studies to show if we really provide good sleep, patients will do better. And those are I think, where we need to go with research and the studies is really proving that, but we definitely know it from other settings. So obviously make sense that it transposes into the ICU, that these are the sickest patients and probably the most ones most in need of getting sleep and being able to sleep overnight and doing other things to really promote their well being to get them out of the ICU.

Kali Dayton 9:30
And we know that sleeplessness causes delirium, and that I’ve personally seen repeatedly that when patients are in delirium, if you can just walk them out, wear him out, finally, get them to sleep at night. They’re so often a different person, at least for a few hours the next day, why does sleep improve delirium so much?

Dr. Margaret Pisani 9:50
Well, so again, probably it’s probably multifactorial, right? So the things that cause if you think about the things that cause delirium, so sleep deprivation causes delirium, right and so obviously When people sleep, you know, improves it. And we know that we’ve they’ve done studies actually on trainees and you sleep deprived them. And after about 48 plus hours of no sleep, they start to act like they are delirious, right?

They’re confused, they’re hallucinating, they’re, they’re inattention, you know, they have inattention all the symptoms of delirium. But and so then the other things that become important and some of the things you mentioned about walking them tiring, or at tiring them out, we know actually, mobility is important, right? So the initial studies of mobility, this wasn’t designed to look at this, but they reported out that there was a decreased incidence and delirium and the patients who got mobilized.

And so why was that? And so it wasn’t because they were so tired out and they got more sleep, and they were less delirious probably played a role. Also, you know, we talked a little bit about circadian rhythm being upright is also a circadian cue. So it tells your body that it’s daytime. And so your body knows, okay, this is daytime. And then when you’re supine, it’s night. And so you get different hormones being released when you’re upright versus supine. And so I think that, you know, having being mobility may actually help maintain circadian rhythm in these patients. Oh, interesting.

Kali Dayton 11:09
And also, I think, if you’re studying all ICU patients, the patients that are awake and walking, are not on sedation, right? So they’re less likely to have delirium just because that one barrier of sedation is removed, in addition to all the baseline things.

Dr. Margaret Pisani 11:25
And so yeah, like I said, Yeah, it’s multifactorial, no sedation being mobilized, which has happened with their circadian rhythm. And, you know, you know, just physically then being more tired right. After that we didn’t, and there’s some data on it’s kind of interesting. But and it’s starting to come out more.

Now there were some studies that came out in the fall, that have looked at a lot of the meds we give in the ICU is can impact melatonin, which again, impacts circadian rhythm, which impacts sleep, right? And so certain meds can decrease or increase your melatonin levels. And so that may be playing a role and benzodiazepines and opioids are in that category. And so that those they also may be through that mechanism affecting circadian rhythm causing sleep disruption, contributing to delirium.

Kali Dayton 12:14
Oh, interesting. I’ve never thought about those. But I consider toxic medications to be impacting melatonin. That makes absolute sense. And why are we giving these medications? We were discussing kind of what’s been going on in your unit, what is what about COVID has suddenly made us run back to the medications that deprive patients asleep.

Dr. Margaret Pisani 12:36
So I mean, what we’ve seen in our ICU, and we did looked at our data in our own ICU where we looked at, you know, the two months, April and March and April, which is when we had our big COVID surges, initially, from the year before and the num, the doses per patient of benzodiazepines and propofol and dexmedetomidine. And opioids was so much higher.

And I think COVID a couple of things, I think, a, we were afraid we didn’t know how to care for these patients. We didn’t know how contagious it was, we didn’t know, you know, they came in really sick to the ICU, how they were going to behave. And so I think one thing in an effort to keep patients safe, we, you know, you would remove them and they will become hypoxemic. And it will take a long time for the nurses if they weren’t in the room to get their PPE on or for us to go in there.

We couldn’t just like run into the room like normal. And so I think people felt safer. If the patient was more sedated, they didn’t have to worry that the 82 was going to come out or something catastrophic could potentially happen to the patient. So I think fear initially was one reason. And I think just, you know, for us, some of it was drug shortages, we had to turn to meds we hadn’t used because we knew they’re harmful, like benzodiazepines like medazepam, in contributing to delirium and adverse outcomes.

But there were drug shortages of other drugs that we would normally use. And other things happen, like because of fear, and again, PPE shortages, we put our mobility program on hold, we didn’t want to expose caregivers before we knew exactly what was going to happen. I mean, a lot of that is resolved now. But I think there are lots of things playing a role in causing increased sedation in these patients. And then some of it was physiology, right? They they would slightly different but similar ARDS patients that we used to see where, you know, you move them any little bit and their oxygen levels plummet. And so I think that contributed to it as well, the physiology,

Kali Dayton 14:36
That is a hard threshold, even though we can walk in ICU once patients cannot oxygenate with movement, then that’s when the paralytics become part of the discussion, and that is a hard threshold. And yet, if there’s a date up until that point, I think it obviously impacts outcomes in that moment and for the long term.

Dr. Margaret Pisani 14:56
And then, if I can Sorry to interrupt the one thing I read thinking was that what then we struggled with was taking them off the sedation, because everybody was worried about withdrawal. And, and, and so I think patients ended up on meds longer. Because we didn’t taper them as quickly as we could ever maybe we weren’t addressing the other things that were maybe causing their agitation.

I mean, we did see lots of agitation in these patients. And so some of the agitation related to side effects of the meds, but what I think people always have to remember is you really, really need to think carefully about all the things causing the ad potentially causing the agitation and addressing them instead of sedating patients.

Kali Dayton 15:37
Which must be really difficult. From your perspective, I think a lot of times, I think culturally, when we see that agitation, the assumption is it’s the ventilator. So it’s more humane to just restart the sedation that can’t tolerate it. It’s the synchronous, you know, those are all the the assumed things. And so restarting. sedation is the natural and easier option.

But it’s not so conflicting when you don’t know anything else. Whereas you have an advocate for delirium prevention, you’re, you’ve studied sleep, you’ve been promoting good sleep hygiene. And then you’re in the situation where patients are deeply sedated with the worst kind of medications. And when you’re trying to get them to wean off you are seeing delirium, but maybe not everyone sees it that way. How has this personally impacted you? And how conflicting is that to watch,

Dr. Margaret Pisani 16:24
I’m sure they’re tired of me in the ICU, because I literally go around all day long. Let’s put the sedation down, I want to see what happens myself. And so actually, ventilator, oftentimes, you’re right, a lot of it is ventilator dyssynchrony. But oftentimes, you can adjust the ventilator, you need to be patient, you need to work with your respiratory therapist, to make the patient comfortable.

So, you know, I just gave a talk. And I actually gave it told the story of a patient I just had last week, who you know, had a really sick patient with COVID and had been on ECMO and had, every time they tried to lighten a sedation, he got agitated and desaturate. And I say I want to see what happens. And what was happening was that the way the ventilator was set, when the patient tried to breathe at all on his own, he did something called invert his I:E ratio.

So now he was inhaling for much longer than he was exhaling, so he never had enough time to really exhale. And as soon as we adjusted the settings on the ventilator to a little bit unconventional numbers, we that standard numbers, he was totally fine. But you know, we needed to see that for ourselves.

Kali Dayton 17:31
Doctor precisely how many patients have been deeply sedated so that they work for the ventilator and not the ventilator for them?

Dr. Margaret Pisani 17:39
Well, I mean, probably a lot. I mean, there’s probably no way to quantify that. But I think what happens is, is that you need people need to a understand how ventilators work and how to adjust them to make the patient comfortable. And so that’s something we need to focus on teaching trainees and making sure respiratory therapists are really well trained and nurses even right, because, you know, typically, nurses don’t get trained in details of ventilators.

They know how they work, but not the little intricacies of Wait, maybe it’s the ventilator that’s causing not causing the problem, but it’s not working well with the patient. The other thing I discovered recently with this whole pandemic is people don’t do the sedation scale correctly. And so you know, in using we use in the cloud, the RAS, the Richmond education station scale. And so people I would go in, and everyone’s minus four minus five, and they’re all charted as like, you know, minus two or minus one.

And I’m like, How could this be that my classes are always so different? And it turns out, people don’t understand that with the minus one, the lighter levels of sedation, it’s your responses to voice. And so they go in, and they stimulate and shake the patient and whatever, and then they charge them as a minus two, but it’s really a minus four, because now you know, they physically stimulated the patient. And so I think at least an RSC we’re working on making sure we have a lot of nurses and a lot of travelers making sure everyone understands really how to score sedation scales. So patients because we target our sedation to scales, right. And so trying to make sure that we do it correctly.

Kali Dayton 19:08
I think you’re gonna have physical therapists and occupational therapists trying to kiss you through their devices, because this has been their plight for so long. They’re saying I’m seeing this rash charted, but I go in and try to work with this patient and there’s no one there. And it’s very, I think, some of it yes, it’s misunderstanding Some of it’s certainly it’s easier, it makes people feel better. nurses say I don’t want patients to move on muscle. And yeah, then they have this parameter saying titrate to a RASS of negative one, negative two, well, they can, you know, people can chart whatever and then do something different.

And I think, ultimately, it comes down to ignorance, right? They don’t know what that really means for patients, Otherwise, they wouldn’t they wouldn’t do they wouldn’t even want to start sedation and I think a lot of the dyssynchrony me, like you said, comes from the settings not being appropriate for patients. I think delirium causes this presentation or dyssynchrony. The erratic breathing, the biting, the thrashing, the coughing, the gagging, a lot of that is delirium. It’s from the brain and not necessarily from even the tube or the ventilator or the lungs themselves. Would you? Would you concur?

Dr. Margaret Pisani 20:14
Well, yeah, so I mean, I think, yeah, when they’re when they’re agitated enemy and and we see this. And if you look at the studies, hyperactive delirium is were in the ICU, because as soon as they’re hyperactive, we sedate them. And now they’ve converted to hypoactive delirium, right?

So if you look at like studies, like the big mind, USA study, only 11% of that patients had hyperactive delirium, because the minute they move or do anything, we sedate them, right. And part of it is culture of trying to keep patients safe. And from a nursing standpoint, you know, they’re responsible, right? They, if patients have X debates, or the patient falls out of bed or something, and so I think the fear of that kind of dictates some of what gets done.

And I think, you know, I often think about this, because this is kind of a little tangent, but in like, Shaco, and one of the measures for hospitals is false, right. And so the best way to prevent false is to never move anybody, right? If no one ever gets out of bed, they can’t ever fall. And so, you know, I think the pendulum needs to swing a little bit back towards the middle. So we can, you know, actually move and mobilize patients, because it’s important, not only for maintaining functional status, but you know, again, like I said, I think it’s a circadian cue to be upright, and then we’ll help with sleep.

Kali Dayton 21:34
The ironic thing is, when we don’t move people, when we keep them, quote, unquote, safe and bed, we create fall risks, we let them get so weak and atrophy that they will eventually fall because they can’t hold their own weight. Whereas if we’d started right away, we would have prevented that fall risk and the safety of delirium. I mean, delirium is a huge risk.

That’s when you get the self extubations, and the falls, and thrashing. The line removals, and yet patients are safer when they’re not sedated and not so weak and delirious. So what does that mean for your unit? Now? Have you seen patients be on ventilators longer have they been? has this impacted their discharge dispositions? I mean, have you witnessed the statistics that we see with sedation?

Dr. Margaret Pisani 22:17
Yeah, so I mean, actually, we were doing good for COVID. So I, now we have to get back there, because I think, you know, people are starting to translate even some of that practice from COVID into patients who don’t have COVID. And I’m like, you know, and, and so I think we’re working on, you know, re-education, and making sure people understand sedation and delirium and the importance of sleep.

And so we actually have a sleep protocol in our ICU that allows for like, what we thought, obviously, patients need more than this, but we thought four hours of dedicated sleep was something we could at least guarantee for everybody, where people aren’t in the room, we have to really amazing young mentees, Melissa Canard and Lauren Franti who are both investigating this kind of stuff.

Looking at sleep and circadian biology as Melissa can our area of interest and then Lauren Franti looks at functional status, cognitive decline and interventions to improve outcomes and older ICU patients that include like, and they’re both looking at bundles, so things that include occupational therapy, physical therapy, sleep promotion, in the ICU, and looking at circadian biology in the ICU as well.

And so I think, really trying to get people I think, if we can check in some of this cultural change in practice change, right, we’ve actually done this part, we’ve done a good job with this, like getting nurses to stop drawing labs at two in the morning, or getting them to stop giving baths in the middle of the night, you know, allowing them time to sleep we’re not doing when we returned to everything we’ve done in our ICUs.

They don’t do the floors, they don’t empty the trash in the middle of the night anymore. Like and, you know, they used to, and so really trying to do that, and then working on reducing medications, and then working on making sure everybody gets PT, OT mobilization, early mobilization when possible, are the things we’re focusing on. We’ve done some stuff that has looked at sleep in the ICU. And like other places, we’ve shown like when we’ve done polysomnography, that patients don’t sleep.

They don’t ever get into the deep levels of sleep. So they want to forget it or in general, both. And so And actually, in some of the patients, we did this study where we looked at the EEG s that were done in our ICU, and the patients with delirium really had no discernible a lot of them couldn’t you couldn’t even grade sleep on being you know, like if you looked at the EEG for sleep, because they didn’t have the normal characteristics of sleep on their EEG. And so, you know, I think that there’s an important link there.

Kali Dayton 24:57
Absolutely. And this has to be real. ironic if someone’s hearing this episode for the first time, I mean, carrying the podcast for the first time for through this episode, they’re gonna be really confused because we say that patients are sleeping all the time. Right for people that culturally follow this myth of sedation asleep, we give sedation so that patients sleep, this must be really confusing to realize that we are causing weeks of sleeplessness and patients.

Dr. Margaret Pisani 25:25
But yeah, so and that I’ve actually have a slide in a talk I gave that says sedation is not sleep, hammer home that point that really it it, the sleep architecture is really disrupted when we give sedation and people don’t get into normal stages of sleep. And they specifically don’t get into those deep stages of sleep that they need for brain recovery, removal of toxic waste from the brain, all those kinds of things.

Kali Dayton 25:51
I think none of that really made sense until I heard it from survivors. So my fourth episode on this podcast is called sedation is not sleep. And I asked survivors, what did you experience under sedation, leave a message on this voicemail. And I didn’t give any cues, didn’t tell them talk about your hallucinations. They didn’t say anything. But all they talked about was their delirium, their hallucinations, their tears, the anxiety, the fear, they experienced under sedation, no one talked about how cozy they were. No one talked about how wonderful sleep they received the whole time.

Dr. Margaret Pisani 26:23
And there are qualitative studies that have looked at this in patients. And the way they describe it is it’s like longing for sleep or, you know, again, being agitated, being unable to sleep being totally disrupted all the time. And things that we don’t even think about that are important. Like, one of the big things that patients will remember, is like voices, loud voices in the hallway.

And, and but not being able to really discern conversations and then being scared that, you know, what were they being spoken about? Or, you know, was there something going on with them that they didn’t understand. And so I think as care providers, we need to be cognizant of all these things about things that we might not be thinking about how they’re impacting the patient in the room. So once you’ve mentioned

Kali Dayton 27:05
Some really good parameters, if you could have the ICU change, I know five things about their practices to facilitate sleep. What would that be?

Dr. Margaret Pisani 27:17
I mean, I really think noise reduction overnight. So really focusing on noise reduction, and everyone thinks of noise reduction as Okay, well, we, I mean, we’ve reduced our alarms, we, you know, people, hopefully I’ve done stuff to do alarm, noise reduction from alarm, those kinds of things. And there’s certain things you can’t control, like the outside noises.

And unfortunately, for us, our Hello pad happens to be right near our ICU. So when that comes in, there’s nothing you can do about that. But really things like that voices of staff are disruptive to patients. So thinking about ways to reduce noise, and it’s like, I had a patient who was his room was outside the right next to the bank have alarms in the hallway. And the wife clearly said to me, every time they’ll start buzzing, he gets more and more agitated.

So and he can’t sleep. So for sleep, I would say trying to work on noise reduction, and limiting in room interventions overnight. So really trying to cluster care outside of a window to give patients time to sleep. And so this requires coordination among nurses. It requires coordination among day and night nurses, right, because there’s these culture thoughts that well, I need to get a, b and c down overnight. So that leave the work for the daytime nurses.

And so I think at a leadership level thinking about how to divide the work, you know, so like tasks that can be done at different, you know, like that can be spread out. So people don’t feel like they are getting more work versus others, those kinds of things. So like, you know, there’s just pushed, you know, let me repeat all the electrolytes before the day shift shift comes in, or those kinds of things and really just thinking about creative ways. So that we’re not, we’re doing these things that need to be done for the patient, but not doing them in a time that disrupts their sleep.

Kali Dayton 28:57
I think pharmacy can really participate in this to change in times of medications, being aware of what has to be given at night and what doesn’t have to be given.

Dr. Margaret Pisani 29:05
And so that was one of the first things we did was work with our pharmacists. And so like, that’s kind of automatic. Now we don’t like you know, like QA meds or time so they’re not given in the middle of the night and those kinds of things. And we’ve given the nurses ability to return meds, so they don’t occur during that overnight period as well.

And so that’s something that we worked on initially was with the retirement of meds, other things are, you know, for sleep is mobility, right? So you keep getting the patient’s awake and mobilizing them during the day will help with sleep at night. And really trying to make sure this is one of the things we’re studying to is providing bright light during the day. So every day when I walk in, I have to go and open the curtains like It’s like already, like nine o’clock in the morning and like everyone’s it’s middle of the day, and it’s totally dark because everyone’s curtains are gone.

And some of that is maybe sickness behavior, like patients might want to dark when they don’t feel well. But most of the patients are like oh yeah, open my curtains or even if they can’t, if they’re are on the ventilator. And they can’t tell you that trying to provide bright light for them during the day will help maintain their circadian rhythm will help with their sleep. And again, like really trying to avoid sedation as much as possible.

Kali Dayton 30:14
And it makes such a difference to the whole tone of the unit. I toured a unit about a year ago, and I was coming home from the awakened walk and I see you stepped into this unit. And it was three o’clock in the afternoon and everyone was in bed, everyone’s eyes were closed, every all the rooms were dark. It just felt like a zombie zone. And I had spent years being out of those kind of ICUs. So I forgot what that was like, and how different that is. But even though it was a scary, hard, difficult environment, it really can be a much happier place when we allow sunshine in literally allow the sunshine in.

Dr. Margaret Pisani 30:50
I mean, there’s studies that show that people do better, right, there’s studies that have looked at old ICUs that didn’t have windows and compare them to you know, more ICU said, do a Windows people sleep better, there’s less delirium in the patients who have windows in their rooms.

Now, it doesn’t help if we have windows in our rooms, and let’s change our clothes. The whole point is for them to get bright light. And people I’ve even looked at where they are like what kind of sunlight they get, like, do they get morning sun, afternoon sun and you know, try to discern, you know, what works actually best, but like, so we’re fortunate all of our ICUs have windows.

Kali Dayton 31:24
That’s great. And I love that we can focus on these higher principles like noise control sunlight, because hopefully, we have more understanding of what sedation does. So as we lighten and avoid sedation, then we can even improve quality sleep beyond that. And that’s probably sounds like one of our main barriers, is the automatic sedation of our cultural practices.

Dr. Margaret Pisani 31:48
Right. And so I think, really trying to educate and convince people that you know, people are okay, on a ventilator without sedation, or with like, minimal sedation, obviously, we need to focus on and treat pain if they’re in pain. But patients don’t need to be totally paralyzed, comatose.

And it’s not really what ICUs are designed for. It’s kind of we’ve taken the culture from anesthesia where people are in the O R, and translated it to an ICU, which is not what the intent was, right? It’s not, we shouldn’t be sedating people like they’re in the operating room, they you know, that wasn’t the intent.

Kali Dayton 32:24
Yes, absolutely. But we relate our understanding of sedation, to our own experiences and or for few hours. And we assume that patients have that same experience for a few days or weeks.

Dr. Margaret Pisani 32:34
Right. And remember that all these drugs that we give, were not designed for what we’re using them for, right? So none, they were all designed for short term use in the operating room. They none of them were designed to be used long term for days on end, in critically ill patients, right.

And so all of their characteristics, all their pharmacokinetics pharmacodynamics changed when you use them long term. And also they were designed for pretty mostly healthy people who are getting surgery, right? I mean, people are sick, but they’re not designed for they weren’t designed for people with multi organ failure, who aren’t going to be able to metabolize them the same way.

And so I think that’s where we need to really focus is that, okay, these drugs weren’t designed for this, they’re not metabolized the same way, we really need to think about all these things about who our patient is, and really think about minimizing what we’re giving them.

Kali Dayton 33:25
Oh, absolutely speak so much truth. And I think a lot of it comes down to as well, this assumption that it will be more work to get people off of sedation, but from what you’re seeing with delirium, compared to where you are with pre COVID. And now here, enter COVID. How much more is the work now that your delirium rates are up?

Dr. Margaret Pisani 33:44
Well, I mean, it’s what’s happening is that patients are staying much longer in the ICU. So our ICUs are way more crowded, we have had, you know, we’re, you know, we’ve expanded did our ICU is longer than our, you know, not just for acute patients, but now we have these, what we’re calling chronic patients, and some of it is the fact that they’re still recovering from all the impact of sedation, delirium, their illness itself, right.

And so I think that I think it a crease costs and patients are staying longer, right? Because there’s a date, right? So if you, even once their organ function is improved, they’re still delirious, and so you can’t send so I can get somebody better from the pulmonary standpoint. But if they’re that delirious, I can’t send them out of the ICU to the floor because their nursing staffing isn’t safe to care for them on the floor. So we’re creating a problem of, you know, increasing our ICU numbers for patients who wouldn’t be there if they weren’t so delirious.

Kali Dayton 34:40
Absolutely. And the repercussions of that are so much more obvious now than they were a year ago. And so hopefully, this is going to be our trigger. This is going to really put this right in our faces that we have to address, what’s happened in our system and how to decrease the suffering as well as costs and impacts to our kids. Unity? Well, thank you so much for all your research and good work on sleep in the ICU. Is there anything else you would share the IC community?

Dr. Margaret Pisani 35:09
I mean, I would say really, you know, make sure you’re screening for delirium, always look for reversible causes of it right? And so instead of before you reach to sedate somebody who’s delirious, really look for what are the things that are causing this agitation or this problem, because oftentimes, there are treatable things, look for metabolic problems, look for issues with the ventilator, make sure they’re not infected, and treat the underlying problem because delirium is from an underlying problem, and then really focusing on changing your culture to try to improve sleep in the ICU because sleep and delirium are really well linked.

And then if you can mobilize patients, these are my dreams, right? Mobilize, let them sleep, reduce their sedation, right? Because those are going to all improve long term outcomes, right? People are gonna have less functional impairment, less long term cognitive impairment, they’re gonna get off the ventilator faster, actually, you know, they’ll be up and out and, you know, back to their lives.

Kali Dayton 36:06
Absolutely. And Dr. Swamy, in a previous episode said we don’t give beta blockers for tachycardia. So why are we giving benzodiazepines or sedation for delirium? So I think you provide so much evidence behind that. Thank you so much. And we will link studies that have been referred to as well as Dr. Pisani’s is other studies and the blog that is linked to the podcast. Thank you so not so much, Dr. Pisani.

Dr. Margaret Pisani 36:32
Thank you for having me.

Transcribed by https://otter.ai

 

References

Knauert, M. P., Pisani, M., Redeker, N., Murphy, T., Araujo, K., Jeon, S., & Yaggi, H. (2019). Pilot study: an intensive care unit sleep promotion protocol. BMJ open respiratory research, 6(1), e000411. https://doi.org/10.1136/bmjresp-2019-000411

Knauert, M. P., Redeker, N. S., Yaggi, H. K., Bennick, M., & Pisani, M. A. (2018). Creating Naptime: An Overnight, Nonpharmacologic Intensive Care Unit Sleep Promotion Protocol. Journal of patient experience, 5(3), 180–187. https://doi.org/10.1177/2374373517747242

Altman, M. T., Knauert, M. P., & Pisani, M. A. (2017). Sleep Disturbance after Hospitalization and Critical Illness: A Systematic Review. Annals of the American Thoracic Society, 14(9), 1457–1468. https://doi.org/10.1513/AnnalsATS.201702-148SR

Pisani, M. A., Kong, S. Y., Kasl, S. V., Murphy, T. E., Araujo, K. L., & Van Ness, P. H. (2009). Days of delirium are associated with 1-year mortality in an older intensive care unit population. American journal of respiratory and critical care medicine, 180(11), 1092–1097. https://doi.org/10.1164/rccm.200904-0537OC

Kim, R. Y., Murphy, T. E., Doyle, M., Pulaski, C., Singh, M., Tsang, S., Wicker, D., Pisani, M. A., Connors, G. R., & Ferrante, L. E. (2019). Factors Associated With Discharge Home Among Medical ICU Patients in an Early Mobilization Program. Critical care explorations, 1(11), e0060. https://doi.org/10.1097/CCE.0000000000000060

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