Most critically ill adults with COVID-19 are going to have disruptive sleep. Over the next few slides, I'm going to talk about opportunities as well as barriers to improving sleep in this challenging population. Poor sleep is a common complaint and source of distress for many ICU patients. Sleep disruption in the critically ill can be severe and is characterized by sleep fragmentation, abnormal circadian rhythms, increased light sleep, and decreased time spent with deep sleep or red sleep. Sleep is considered a potentially modifiable risk factor influencing recovery in critically ill adults, including those with COVID-19. The 2018 PAD-IS guidelines that I served as chair answered nine actionable questions and seven descriptive questions. This slide highlights four key strategies that can be used to improve sleep in critically ill adults. Generally, patients with COVID-19 will be impossible to obtain a pre-ICU sleep history given family are not around and the patients are generally quickly intubated and deeply sedated. Ideally, it is good to ask patients about how they slept the prior night. Of course, this is impossible with a sedated patient, but as patients become more wakeful and move towards excavation, this might be possible. Non-pharmacologic strategies are the foundation for sleep improvement in the ICU, and there are many simple ones that can be considered for patients with COVID-19. Generally, the PAD-IS guidelines suggest the judicious use of sleep aid medications, although it is important to note that there is a very high prevalence of delirium in the COVID-19 patients. Daytime strategies can be altered to help promote good sleep at night. In COVID-19 patients, probably the easiest strategy is to turn on the overhead lights and allow as much natural sunlight into the room as possible. With clinicians spending far less time in the patient room, it's going to be challenging to discourage napping or prevent daytime sleeping. With physiotherapists, occupational therapists and nurses spending far less time in the patient room, rehab and mobility efforts will certainly be decreased, although certainly as patients wake up and, of course, depending on staffing situations, mobility and some patient stability activities still may be able to be accomplished. Generally reserved to stable patients, ideally sleep can be improved and if a protected period at night, generally four to six hours, is used for tailored sleep promotion. This, in fact, although COVID-19 patients are generally not always stable, some of this I think is already happening with bedside clinicians reducing their time spent at the bedside in terms of clustering nursing interventions, avoiding routine assessments, and clustering medication administrations. Another key strategy is reducing light at night. These strategies may include turning down the lights down and to ensure light pollution is minimized in the patient room, reducing the general room lighting, using red lights or flashlights if possible when clinicians enter the room. Offering an eye mask is another strategy, but this is probably not appropriate for the COVID-19 patient because of issues with PPE and contamination. Increased noise leads to disruptive sleep. It's important to consider as we focus on reducing noise in COVID-19 patients to think about noise in the room and then hallway noise. Certainly in the room with the doors shut with the doors shut and if some alarms can be decreased, noise in the room might be reduced. It's going to be harder to reduce hallway noise because certainly that's where a lot of the care team is gathering and pump and the infusion pumps are operating, etc. Generally earplugs, white noise, and other strategies to reduce noise should be avoided in patients with COVID-19. The temperature of the room can also have an impact on sleep. Generally, it's fairly easy to adjust the room temperature for patient comfort, although of course the sedated patient will not be able to communicate what the desired room temperature is. Generally, I guess a fan could be brought in to patients, although concerns could certainly exist with contamination of the fans, so probably this might not be a good idea. And then if the patient's cold, warm blankets could be offered. Although most patients have a preferred position to sleep in, in COVID-19 patients, strategies to adjust positioning could be quite challenging. First of all, many patients could be prone during periods of the ICU stay and certainly in a deeply sedated patient, it can be impossible to know what their preferred sleep positions are. Patient comfort has an important influence on sleep quality. Certainly, clinicians should try to ensure the pain is adequately assessed and treated, fully realizing that the number of bedside pain assessments might be reduced. Generally, things like family presence, music, or other home sleep aids like special blankets or pillows, of course, are all precluded from use in the COVID-19 patients because of contact precaution issues. The PADIS guidelines demonstrated there's no medications that have been shown to improve sleep or reduce delirium in the critically ill. Generally, non-pharmacologic strategies should be considered before medication-based strategies to improve sleep. However, some ICU patients, for example, patients that can't initiate sleep or the patient with delirium who has nocturnal agitation, may benefit from a sleep aid at night such as an antipsychotic like quetiapine. I hope over the last few minutes I've been able to give you some strategies about how to improve sleep in the critically ill COVID-19 patients that you're caring for. Thank you.

improving sleep

COVID-19

sleep disturbances

non-pharmacologic approaches

patient comfort