Acta Anaesthesiol Scand 2012; ••: ••–••
Printed in Singapore. All rights reserved
Sleep disturbances in critically ill patients in ICU:
how much do we know?
Y. Boyko1, H. Ørding1,2 and P. Jennum3,4
1
Department of Anaesthesia and Intensive Care, Vejle Hospital, Vejle, Denmark, 2Vejle & Faculty of Health, Southern Danish University,
Odense, Denmark, 3Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Glostrup Hospital and 4Faculty of Health,
University of Copenhagen, Copenhagen, Denmark
Sleep disturbances in the intensive care unit (ICU) seem to lead
to development of delirium, prolonged ICU stay, and increased
mortality. That is why sufficient sleep is important for good
outcome and recovery in critically ill patients. A variety of small
studies reveal pathological sleep patterns in critically ill patients
including abnormal circadian rhythm, high arousal and awak-
ening index, reduced Slow Wave Sleep, and Rapid Eye Move-
ment sleep. The purpose of this study is to summarise different
aspects of sleep-awake disturbances, causes and handling
methods in critically ill patients by reviewing the underlying
literature. There are no studies of level 1 evidence proving the
S leep disturbances are known to impair the func-
tion of immune systems,1 anabolic and regen-
erative processes, neurophysiologic organisation,
consolidation of the memory, and cognitive
function.2–6 In the intensive care unit (ICU), they
may lead to development of delirium,7,8 prolonged
ICU stay, and increased mortality.8 That is why suf-
ficient sleep is important for good outcome and
recovery in critically ill patients.
Critically ill patients in the busy environment of
an ICU are exposed to a range of different distur-
bances such as high level of noise and light, diag-
nostic and therapeutic procedures, mechanical
ventilation, medication, and the critical illness itself.
All these factors may play a role in development of
sleep disturbances in this patient group even though
there is no agreement about which of these factors is
the primary cause of disrupted sleep.
Physiology of sleep
The brain is active during sleep. Sleep is regulated
by several centres including brainstem, hypo-
thalamus, thalamus, and forebrain. Involvement
and down-regulation of the ascending reticular
© 2012 The Authors
Acta Anaesthesiologica Scandinavica
© 2012 The Acta Anaesthesiologica Scandinavica Foundation
ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/j.1399-6576.2012.02672.x
Review Article
positive impact of the tested interventions on the critically ill
patients’ sleep pattern. Thus, disturbed sleep in critically ill
patients with all the severe consequences remains an unresolved
problem and needs further investigation.
Accepted for publication 31 January 2012
© 2012 The Authors
Acta Anaesthesiologica Scandinavica
© 2012 The Acta Anaesthesiologica Scandinavica Foundation
activating system (ARAS) is important for sleep–
wake regulation. This regulation includes some
brain nuclei, especially hypocretinergic, GABAer-
gic, histaminergic, adrenergic, and cholinergic
systems.
Sleep is divided into Rapid Eye Movement
sleep (REM) and non-REM (NREM) sleep. NREM
sleep is further divided into three (previously four)
sleep stages, where N3 and N4 sleep stages are
known as SWS (slow wave sleep). Even though
the exact function of the different sleep stages is
unknown, REM and SWS are thought to be the most
effective in the restorative processes in the body
(the energy restoration). Normal sleep architecture
consists of stages occurring in cycles of 90–120 min
each.9,*
Sleep measurement
Sleep may be assessed in various ways, both by
objective measurement and subjective assays.
*http://www.uptodate.com (Pressman MR. Stages and architecture of
normal sleep 2010) topic last updated: May 17, 2011.
1
Y. Boyko et al.

The golden standard for sleep measurement is Aim

polysomnography (PSG). The method is challeng-
ing in critically ill patients because of various dis- The aim of this study is
turbed electroencephalogic (EEG) patterns such as, • First – to review the existing literature describing sleep
occurrence of low frequencies, focal changes, par- disturbances in critically ill patients in ICU; and
oxysmal (epileptogenic) activity, altered conscious- • Second – to summarise different aspects of sleep–awake
ness, and reduced reactivity. These are caused by disturbances, causes, and handling methods in critically
possible cerebral metabolic changes seen in sepsis, ill patients.
electrolytic disorders, intoxications; neurological
pathology, and medication influencing sleep
pattern. Stage of sleep is normally scored in accord- Methods
ance with the American Association of Sleep Medi-
The PubMed database was searched using the fol-
cine (AASM) 2007 criteria. Due to EEG changes, the
lowing key words and settings:
classification criteria cannot always be met. That is
Sleep disturbances AND ICU, Sleep disturbances
why alternative or supplementary criteria for PSG
AND critically ill patients, Sleep AND critically ill
scoring in critically ill patients have been sug-
patients, Sleep AND intensive environment, Sleep dis-
gested.10,11 Currently, there is no validation of these
turbances AND intensive and mechanical ventilation,
criteria.
Sleep quality AND intensive AND mechanical ventila-
It has been discussed whether computer-based
tion, Sleep AND critically ill patients AND melatonin.
analysis of EEG in polysomnography is useful for
The search limits were: 1) humans and 2) adults
sleep measurement. Amborgio et al. demonstrated
ⱖ 19 years old.
the advantage of a computer-based method of
The age limit was chosen because The PubMed
sleep-assessment compared to three manual
database sets the age of adults to be ⱖ 19 years.
methods in their study from 2008.12 The manual
Papers identified by the search were considered
method may be superior in people with diseases
relevant and included if the title or the abstract indi-
which disturb the sleep pattern.13,14 Bispectral index
cated the subject to be intensive care plus one of the
(BIS) and actigraphy are two alternative methods of
following items: sleep pattern, sleep disturbances,
sleep measurement.
causes of sleep disruption, methods of sleep meas-
BIS is calculated from EEG measurements and is
urement, and interventions directed at promoting
normally used for the evaluation of depth of
sleep in critically ill patients in the ICU.
anesthesia. It does not give any information about
Papers dealing with sleep apnoea only were
sleep architecture.15
excluded.
Actigraphy is a method based on measurement of
Papers considered relevant were retrieved and
the patient’s motor activity by use of a wristwatch-
read. If it was obvious that results of a study were
like device, placed around a wrist or an ankle. The
published in several papers, the most important
presence of movements indicates wakefulness, and
paper only was included.
the absence indicates sleep.16 It does not give any
The selected papers were ranked in five classes
information about sleep stages either.
due to the absence of studies fulfilling normal crite-
Patient questionnaires are widely used, such
ria for evidence. Therefore, the following classifica-
as The Richards-Campbell Sleep Questionnaire
tion was used:
(RCSQ), a five-item visual analogue scale. The RCSQ
has been tested and found reliable and valid in the • Class 1: Studies with sleep records obtained in
study of Richards K. C. et al.,17 in which 70 awake, critically ill patients in a real intensive
oriented critically ill males were enrolled. Over- care environment, with the use of 24-h
night, PSG was used as control. PSG.
Nurse observation forms are another subjective • Class 2: Studies with sleep records obtained in
method for sleep measurement. critically ill patients in a real intensive
The advantages of subjective sleep measurement care environment with the use of over-
are: they are simple and easy to use for both staff night PSG.
and patients, and they are non-expensive. However, • Class 3: Studies with sleep records obtained in
they give no information about sleep architecture, critically ill patients in a real intensive
and comatose patients cannot respond to the care environment with the use of other
questionnaires. than PSG objective methods of sleep.

2

• Class 4: Studies with sleep records obtained in
critically ill patients in a real intensive
care environment with the use of subjec-
tive methods of sleep.
• Class 5: Studies with the sleep records obtained in
healthy persons in a real or simulated
intensive care environment with the use
of PSG or other methods.
Due to the absence of large studies with polysom-
nography used for sleep measurement, a small
sample size was not considered to be a criterion for
assigning a lower evidence class.
Inclusion criteria
Class 1 studies were prioritised because of disturbed
circadian rhythm and high percentage of daytime
sleep in critically ill patients. In some subsections, if
class 1 studies were absent, then class 2 and 3
studies were used instead. Those of class 4 and 5
were only mentioned if there was a shortage of
studies with a higher evidence level.
The papers selected for this review were then
sorted according to the following subjects:
• Sleep pattern in critically ill patients
• The influence of ICU environment on sleep in critically ill
patients
• The influence of mechanical ventilation on sleep in criti-
cally ill patients
• The role of melatonin
• The influence of medications
Results
The initial search resulted in 580 papers in total, 100
of which were regarded as relevant. Of these, 31
papers were repeated one or more times resulting in
55 repeats in total, thus leaving 45 papers for
primary consideration.
Sleep pattern and consequences of sleep
disturbances in critically ill patients
Sufficient sleep and good sleep quality is extremely
important for critically ill patients.5 The lack of sleep
in these patients is related to impaired immune
response,1 development of delirium,7,8 prolonged
stay in ICU, and increased mortality.2,8 Detailed
results of sleep monitoring in ICU patients are given
in Table 1.
There are five class one studies, showing sleep
pattern in critically ill patients in ICU, presented
in this review.10,18–21 The following features are
described: abnormal circadian rhythm and frag-
Sleep disturbances in ICU
mentation of sleep with high arousal index short-
ened or absent restorative sleep (REM and/or SWS).
The general conclusion is that sleep architecture is
altered in ICU patients (Table 1).
The role of ICU environment in sleep
impairment and interventions
Noise and other environmental factors, characteris-
tic for an ICU, have been thought to play a signifi-
cant role.22 A retrospective review study by
Tamburri et al., analysing the medical records of 50
patients from four different ICUs, made between 7
pm and 7 am (147 nights reviewed), showed the
mean number of care interactions per night to be
42.6 per patient.23
Some studies describe a positive effect of
earplugs/eye masks on sleep quality. They are only
class 4 or class 5 because of the following limitations:
1) only a subjective method of sleep evaluation is
used;24,25 2) healthy subjects, exposed to simulated
ICU environment, are used in the study.26,27
There are a few small studies, showing some
effect of ‘white noise’,28,29 class 4 and 5 respectively,
or alternative methods, such as back massage and
relaxation intervention,30 class 2, for promoting
sleep in critically ill patients.
The following two studies, actually the only two
of class 1 and thus optimally matching the inclusion
criteria, call the importance of environmental factors
into question.
Freedman et al. described only 11.5% and 17.0%
of the overall arousals and awakenings, respectively,
being caused by environmental noise. Twenty-two
patients were included in the project, and 17 of these
had scorable PSG data. Twenty-four to forty-eight
hours polysomnography was used for sleep assess-
ment together with time synchronised recording of
environmental noise.21
Gabor et al. showed noise and patient-care activi-
ties together to be responsible for less than 30.0% of
arousals and awakenings. Seven critically ill patients
and six healthy subjects were investigated with 24-h
PSG.31
These findings make one believe that other factors
may play at least as big and possibly a bigger role
than environmental factors in sleep disturbances in
critically ill patients.
The role of other possible factors (critical illness)
in sleep disturbances in ICU
A few studies indicate that severe disease by itself
and ventilation mode are significant factors in sleep
3
4
Table 1
Sleep pattern in critically ill patients.
Studies Type of ICU/patients n PSG-duration PSG-findings
Hilton BA Respiratory ICU. 10 mechanically ventilated ptt. 24-h (PSG-recordings for Varying TST (from 6 min to 13 h)
1976. Ptt. with respiratory 48 continuous hours) ↑stage 1 NREM
Y. Boyko et al.

Class 118 insufficiency but ↓stagees 2–4 NREM

various primary ↓REM
diagnoses. Disturbed circadian rhythm: 50–60% of sleep
during the night period
Aurell J Surgical ICU. 9 ptt.; two of them received postoperative ventilation. 24-h (PSG-recordings ↓TST
et al. Ptt. after major started within 2 h of ↑stage 1 NREM
1985. non-cardiac surgery. the operation and ↓stage 3,4 NREM
Class 120 continued until ↓REM
discharge from the
ICU, for a maximum of
83 h)
Cooper AB Medical – surgical ICU. 20 mechanically Disturbed sleep group: 24-h (PSG-recordings for ↑stage 1 NREM
et al. Critically ill ptt. with mild ventilated ptt. 8 ptt. 24 h) ↓REM
2000. to moderate acute Disturbed circadian rhythm
Class 110 lung injury. APACHE II ↑increased frequency of arousals and
10 ⫾ 5. awakenings
Atypical sleep group: Absence of stage 2 NREM (in 4 of 5 ptt.)
5 ptt. Absence of REM (in 3 of 5 ptt.)
Pathological wakefulness
Coma group: 7 ptt. EEG features of coma
Freedman Medical ICU. 22 ptt.; 20 of them 17 24 -hour Large variation of TST: mean 8,8 ⫾ 5.0 h
NS et al. Ptt. with various primary received mechanical (PSG-recordings for ↑stage 1 NREM
2001. diagnoses. ventilatilation. 24–48 h) ↓stage 2–4 NREM
Class 121 ↓REM
Disturbed circadian rhythm
5 Not scorable PSG data because of septic
encephalopathy
Hardin KA Medical ICU. 18 mechanically Intermittent sedation: 6 24-h (PSG-recordings for ↑TST
et al. Ptt. with respiratory ventilated ptt. 24 h) ↑SWS
2006. failure. ↓REM
Class 119 disturbed circadian rhythm
Continuous sedation: 6 ↑TST
↑stage 1 NREM
↓stage 2 NREM
↑SWS
REM not analyzed: 50% ptt. had detectable
REM
disturbed circadian rhythm
Continuous sedation and ↑TST
neuromuscular ↑SWS
blocking agent: 6 REM not analyzed: no ptt. had detactable
REM
disturbed circadian rhythm

TST, total sleep time; SWS, slow wave sleep; REM, rapid eye movement sleep; NREM, non-rapid eye movement sleep; EEG, electroencephalography; APACHE II, acute
physiology and chronic health evaluation II score; PSG, polysomnography; ICU, intensive care unit.

disruption in critically ill patients. Our literature
search found two articles, both class 1:
Gabor et al. described shortened sleep time,
reduced SWS and increased awakening index in
patients with higher acute physiology and chronic
health evaluation (APACHE) II score compared with
healthy subjects in the same environment. Seven
male patients and six healthy male subjects were
enrolled in the study. Twenty-four-hour PSG was
used for sleep measurement.31
Fanfulla et al.32 stated high severity score (SAPS)
and alkalosis to be the primary cause of sleep dis-
turbances in critically ill patients but not mechanical
ventilation. Twenty-four-hour PSG was recorded in
22 patients admitted to ICU for intensive observa-
tion or weaning from ventilator.
The importance of ventilation mode
A large proportion of critically ill patients require
respiratory support. Mechanical ventilation is con-
sidered as one of the causes of poor sleep quality
in this patient category. This is why different venti-
lator modes and their influence on sleep were
investigated.33–38 No class 1 studies were found. The
results of five of the six trials (small randomised
cross-over studies) suggest patient-ventilator asyn-
chrony and possibly hyperassistance resulting in
central apnoea to be the cause of sleep disturbances
in critically ill patients. The mode pressure support
seems to be associated with more sleep fragmenta-
tion than the mode assist-control. The results are
presented in Table 2.
The role of melatonin
Melatonin, the hormone secreted by the pineal
gland, takes part in the regulation of sleep
and circadian rhythm. Measurement of 6-
sulfatoxymelatonin (6-SMT), which is a melatonin
metabolite and is excreted with urine, reflects
secretion of melatonin in healthy subjects. The con-
centration of plasma melatonin though is more
informative in critically ill patients with multi-organ
failure.39
Melatonin secretion is described suppressed in
critically ill patients. Shilo et al. has studied day
secretion of melatonin in a group of intensive care
patients compared to a group of patients from ordi-
nary medical wards. He found a missing nocturnal
top of melatonin in all intensive care patients but
two, and these did not require ventilator therapy.
Melatonin secretion was estimated from 6-SMT in
urine samples, collected every third hour during
24 h.40
Sleep disturbances in ICU
Mundigler et al. found disturbed circadian secre-
tion of melatonin in intensive care patients with
sepsis (16 out of 17 patients) but preserved circadian
rhythm in intensive care patients who did not have
sepsis (six out of seven patients). 6-SMT in urine was
measured every fourth hour during 24 h.41
Olofsson et al. has measured serum melatonin
every fourth hour during 3 consecutive days in eight
sedated ventilator treated critically ill patients. Urine
was collected twice a day during 1 h, and urine
melatonin was calculated. Disturbed melatonin
secretion was found in seven out of eight patients.42
There are only a few studies investigating the
influence of melatonin treatment on sleep quality in
critically ill patients. The studies are of class 3 evi-
dence level according to the classification used for
this review. Shilo et al. showed improved sleep
quality and sleep length in critically ill chronic
obstructive pulmonary disease (COPD) patients and
patients with pneumonia treated with exogenous
melatonin in his double-blind placebo-controlled
pilot study. Sleep was measured by actigraphy.43
Bourne et al. found a more effective night sleep
when using exogenous melatonin in critically
ill patients in his small randomised double-
blind placebo-controlled trial in which 24 patients
were enrolled.44 Oral melatonin 10 mg/placebo
were administered at 9 pm during four consecutive
nights. BIS and actigraphy together with subjective
sleep assessment by staff and the patients were used
for sleep measurement.
A few works suggest it can take up to 3 days to
achieve sufficient effect of melatonin on sleep length
and sleep quality.44–46 This aspect of melatonin
treatment has not been investigated in critically ill
patients though.
Mistraletti et al. studied pharmacokinetics of
melatonin given orally in intensive care patients
and found a good oral bioavailability of the drug.
Radio-immuno-assay was used for identification of
melatonin in serum after administration of 3 mg
oral melatonin.47 It is still unknown, however,
which dose of melatonin is optimal in critically ill
patients.
The influence of medications
Sedation is widely used in the ICU, especially in
mechanically ventilated patients. Frequently used
sedation agents in ICU are propofol, opioides,
and benzodiazepines. Propofol and benzodiaze-
pines, which are GABA-receptor agonists, increase
total sleep time but decrease N3 and REM-
sleep stages.48–50 Benzodiazepines, lorazepam in
5
6
Table 2
Y. Boyko et al.

Sleep pattern in critically ill patients depending on ventilation mode*.

Study n/Type of ICU/patients PSG-duration Ventilation mode PSG- findings
Parthasarathy 11 ptt. with respiratory 10:00 pm–06:00 am Assist-control (2 h) ↓sleep fragmentation 6 ptt. had features of
et al. 2002. failure; medical ICU. TST: 90 ⫾ 6 min. stage 1 NREM sleep.
Class 234 PS (2 h) ↑↑sleep fragmentation 5 ptt. had features of
stage 2 NREM sleep.
TST: 75 ⫾ 6 min. No ptt. had SWS.
PS – ↑dead space (2 h) ↑sleep fragmentation 4 ptt. had REM sleep; 1
of these 4 achieved
TST: 82 ⫾ 7 min.
REM with all 3 modes.
Toublank 20 ptt. with chronic lung 10:00 pm–06:00 am Assist-control (4 h) During the first part of the night:
et al. 2007. disease and need for ↑stage 1 NREM (34.8 ⫾ 18.6%)
Class 235 mechanical ventilation ↑stage 2 NREM (33.0 ⫾ 24.6%)
because of an episode No difference in stage 3–4 NREM or REM
of acute respiratory ↓wakefulness (30.8 ⫾ 28.2%)
failure During the second part of the night:
No difference in stages 1–2 NREM, REM, wakefulness
↑stage 3 NREM (6.3 ⫾ 7.7%)
↑stage 4 NREM (5.4 ⫾ 13.2%)
PS (4 h) During the first part of the night:
↓stage 1 NREM (17.1 ⫾ 15.0%)
↓stage 2 NREM (11.4 ⫾ 15.9%)
No difference in stage 3–4 NREM or REM
↑wakefulness (69.0 ⫾ 26.2%)
During the second part of the night:
No difference in stages 1–2 NREM, REM, wakefulness
↓stage 3 NREM (0.3 ⫾ 1.0%)
Absent stage 4 NREM
Bosma et al. 13 ptt. weaning from 10:00 pm–08:00 am Proportional assist ventilation TST: 334 ⫾ 124 min
2007. mechanical ventilation; (over the night) ↓sleep fragmentation (arousals/h – 9)
Class 236 medical – surgical ↑SWS (3%) and REM (9%)
ICU. PS (over the night) TST: 314 ⫾ 140 min
↑sleep fragmentation (arousals/h – 16)
↓SWS (1%) and REM (4%)
Cabello et al. 15 ptt., mechanically 02:00 pm–08:00 am Assist-control (6 h) Median TST: 514 min
2008. ventilated; medical SWS (median) was normal: 19%
Class 233 ICU. Reduced REM: 10% of TST
Clinically adjusted PS (6 h) High fragmentation: 29 arousals and awakenings/h
Automatically adjusted PS (6 h) No difference of sleep quality depending on ventilation mode found
 Sleep disturbances in ICU

particular, are described to have a deliriogenic

↑fragmentation (40 ⫾ 20 arousals and awakenings/h)

↓fragmentation (16 ⫾ 9 arousals and awakenings/h)
effect.50 The central nervous system opioid receptor
agonists, decrease both total sleep time and the deep
sleep stages – N3 and REM.48,49 The antipsychotic
↓REM; absent REM in 2 ptt. (8.9 ⫾ 7.4) agent haloperidol, which is a dopamine-receptor

↑REM;detected in all ptt. (17.3 ⫾ 5.4)

antagonist and is often used in treatment of inten-
sive delirium, increases total sleep time and
N3-sleep stage but decreases sleep latency.48
↑arousal index (29.9 ⫾ 17.2/h)

↓arousal index (16 ⫾ 12.6/h) Other drugs, used in ICU, such as vasoactive

SWS, slow wave sleep; REM, rapid eye movement sleep; NREM, non-rapid eye movement sleep; PS, pressure support; PSG, polysomnography.
↑stage 3 NREM (20.5%)
drugs (norepinephrine/epinephrine, clonidine)

↓stage 3 NREM(16.5%)
↑stage 1 NREM (7.5%)
↓stage 2 NREM (55%)

↑stage 2 NREM (68%)

TST: 281.1 ⫾ 41.6 min

TST: 346.4 ⫾ 99.9 min

↓SWS (17.7 ⫾ 9.81%)

↓stage 1 NREM (4%)

and inotropic agents (dopamine), amiodarone,
↑SWS (25.1 ⫾ 10.8)

↑REM (16.5%) corticosteroids, are well known for causing sleep

disturbances.48,49 This influence of medication on

↓REM (4.5%)
sleep disturbance in critically ill patients is dis-
cussed in several reviews and randomised control-
led trials.48,49

Discussion
Usual setting (over the

Neurally adjusted ventilation assist (NAVA)

Physiological setting

Sleep disturbance in critically ill ICU patients is a

(over a night)

significant problem. Even though the existing

PSG- findings

studies were performed in different ICU settings

night)

– medical or surgical, and including various

patient categories, the current data has shown
*PSG-findings when using different ventilation modes are described in comparison to each other.

similarities.10,18–21 The range of sleep disturbance

PS (two 4-h periods)
(two 4-h periods)

includes altered circadian rhythm, poor sleep

Ventilation mode
Noninvasive PS

quality with fragmentation, frequent arousals and

awakenings, lack of the deeper sleep stages (3,4 or
N3 and REM-sleep). Total sleep time (TST) can be
normal or reduced.
Most studies are case series, and there is generally
a lack of good, controlled trials. A possible reason
nights while ventilated
during to consecutive
measurements: PSG

for this is the great difficulty in performing clinical

with to different PS

12.00 pm–04.00 pm
10.00 pm–02.00 am
03.00 am–07.00 am
07.00 am–11.00 am

research in critically ill patients who are often unable

Four 4-h periods:

to give informed consent to participation in clinical

PSG-duration

trials due to either the severity of the disease or

necessary sedation. Another reason may be the tech-
Nighttime

modes

nical challenges associated with PSG recording and

interpretation of the results in this patient category,
which is heterogeneous. Finding the underlying
mechanical ventilation;

cause of abnormal sleep patterns is only possible

long-term noninvasive
n/Type of ICU/patients

with larger, more homogenous patient groups and

14 ptt. weaning from
disease, requiring

requires many resources.

neuromuscular

The existing literature suggests disrupted sleep

medical ICU
ventilation

and poor sleep quality in intensive care patents to be

9 ptt. with

the result of a combination of different factors,

where ICU environment with noise, light, and clini-
Table 2 Continued

cal interventions, the critical illness itself, abnormal

melatonin secretion, mechanical ventilation, and
Fanfulla et al.

Delisle et al.

various medications all play a role. It is not yet

Class 237

Class 238

known, which of these factors plays the primary or

2004.

2011.
Study

major role. However, there is no doubt – the exog-

enous factors are significant, although the results of

7
Y. Boyko et al.
some studies31,32 suggest the endogenous mecha-
nisms associated with the severity of disease to be
essential.
Intensive care medicine is expensive, and in the
treatment of these critically ill patients – the most ill in
all the hospital – no effort in diagnostics or treatment
is omitted. Why is it then that we do not have a good
understanding of the severe sleep disturbances our
patients do suffer from in the ICU? It is of major
clinical relevance to find those sleep disturbing
factors we are able to influence in order to improve
sleep quality in the ICU. There is enough evidence for
the serious consequences of sleep disturbances in
critically ill patients – increased mortality.
Conclusion
Because of the importance of good sleep in critically
ill patients, further research is absolutely necessary.
It will not be easy, but the following types of studies
are recommended:
1. Large multi-centre studies with investigation of
sleep disturbances in larger and more homoge-
neous patient groups.
2. Investigation of possible practical interventions
for promoting sleep in the ICU
• Possible changes in ICU culture, and thus improve-
ment of ICU environment;
• More physiological variants of mechanical ventilation
improving patient-ventilator synchrony;
• Exogenous melatonin;
• More restrictive attitude towards many ‘ICU drugs’
known to cause sleep disturbances;
• Rational for limited sedation.
The suggested interventions may improve sleep
quality and stabilise circadian rhythm in critically ill
patients.
Acknowledgement
Departmental funding only.
Conflicts of interest: The authors have no conflicts of interest.
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Address:
Yuliya Boyko
Department of Anaesthesia and Intensive Care
Vejle Hospital
DK-7100 Vejle
Denmark
e-mail: yuliyabk@yahoo.dk