j o u r n a l o f s u r g i c a l r e s e a r c h 1 7 7 ( 2 0 1 2 ) 3 1 0 e3 1 4

Available online at www.sciencedirect.com

journal homepage: www.JournalofSurgicalResearch.com

Association for Academic Surgery

Sleep disruptions and nocturnal nursing interactions

in the intensive care unit5

Angela Le, MS,a Randall S. Friese, MD,a,1 Chiu-Hsieh Hsu, PhD,b Julie L. Wynne, MD,a
Peter Rhee, MD,a and Terence O’Keeffe, MB, ChB, MSPHa,*
a
Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ, USA
b
Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ, USA

article info abstract

Article history: Background: Sleep deprivation, common in intensive care unit (ICU) patients, may be
Received 7 January 2012 associated with increased morbidity and/or mortality. We previously demonstrated
Received in revised form that significant numbers of nocturnal nursing interactions (NNIs) occur during
24 April 2012 the routine care of surgical ICU patients. For this study, we assessed the quantity and
Accepted 10 May 2012 type of NNIs in different ICU types: medical, surgical, cardiothoracic, pediatric, and
Available online 1 June 2012 neonatal. We hypothesized that the number and type of NNIs vary among different ICU
types.
Keywords: Material and methods: We performed a prospective observational cohort study at our
Sleep academic medical center examining potential sleep disruption in ICU patients secondary to
Intensive care unit NNIs from the hours 2200e0600 nightly. From May through November 2011, bedside
Nursing nursing staff in five different ICUs collected data on NNIs, including the frequency and
nature of each event (patient care activity, nursing intervention, nursing assessment, or
patient-initiated contact) as well as the length of time of each event and whether the
bedside care provider thought that the event could have been safely omitted without
negatively affecting patient care. Additional data collected included patient demographics,
the need for mechanical ventilation, and sedative/narcotic use.
Results: Two hundred ICU patients were enrolled over 51 separate nocturnal time periods
(3.9 patients/nocturnal time period). Of those 200 patients, 53 (26.5%) were mechanically
ventilated; 12.5% underwent sedative infusion; and 23.0% underwent narcotic infusion.
There were a total of 1831 NNIs; most (67%) were due to nursing assessment or patient care
activity. The surgical ICU had the most frequent NNIs (11.8
9.0), although they were the
shortest (6.66
6.06 min), as well as the highest proportion of NNIs that could have been
safely omitted (20.9%). Nursing staff estimated that, of all NNIs in all ICU types, 13.9% could
have been safely omitted.
Conclusions: NNIs occur frequently and vary across different ICU types. Many NNIs are due
to nursing assessment and patient care activities, much of which could be safely omitted or

5
This manuscript was presented as an oral presentation at the 7th Annual Academic Surgical Congress, Las Vegas, Nevada, February
14e16, 2012.
* Corresponding author. Division of Trauma, Department of Surgery, University of Arizona, 1501 N. Campbell Avenue, Rm. 5411D,
Tucson, AZ 85724-5063, USA. Tel.: þ1 520 626 0478; fax: þ1 520 626 5016.
E-mail address: tokeeffe@surgery.arizona.edu (T. O’Keeffe).
1
Dr. Frieses work is supported in part by a grant from the Arizona Biomedical Research Commission, Grant number 9-022
0022-4804/$ e see front matter ª 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jss.2012.05.038
 j o u r n a l o f s u r g i c a l r e s e a r c h 1 7 7 ( 2 0 1 2 ) 3 1 0 e3 1 4 311

clustered. A protocol for nocturnal sleep promotion is warranted in order to standardize

ICU NNIs and minimize nighttime sleep disruptions.
ª 2012 Elsevier Inc. All rights reserved.

1. Introduction 2. Materials and methods

Sleep is critical in the recovery process for intensive care unit
(ICU) patients. Sleep disruptions can result not only from the
patient’s illness or injury but also from the ICU environment
itself. The intense ICU routine entails a multitude of round-
the-clock nursing tasks, including administering medica-
tions and making clinical assessments as well as monitoring
ventilators and other equipment. In addition to adversely
affecting patients during their ICU admission, the effects of
sleep disruptions may linger even after discharge. Studies
have shown that patients recall frequent interruptions, with
over 60% of surviving ICU patients reporting poor sleep or
experiencing sleep deprivation [1].
Regardless of their diagnosis, ICU patients have disrupted
and abnormal sleep. The goal of promoting healthy sleep in
such patients in order to improve outcomes is garnering
increasing interest [2,3]. Research thus far has produced
conflicting findings, which may be because the studies
included different types of patient populations, different
nursing activities, and different unit designs and workloads,
as well as different practices in patient care and sedative use.
We previously demonstrated that sleep interruptions are very
common in an adult surgical ICU and that up to 25% of the
nursing interactions could have been safely avoided [4].
In our current study, our primary objective was to analyze
the frequency and the nature of nocturnal nursing interactions
(NNIs) among five ICUs of differing types. We hypothesized that
the number and the type of NNIs vary among the different ICU
types. Our secondary objective was to identify differences in the
proportions of these interactions that could be safely omitted.
We hoped that we would be able to use our data to identify best
practices that could then be harmonized across different ICUs.
2.1. Hospital and ICU characteristics
The University of Arizona Medical Center is an urban,
academic teaching hospital that has five ICUs: medical (MICU,
with 20 beds), surgical (SICU, with 20 beds), cardiothoracic
(CTICU, with 16 beds), pediatric (PCIU, with 20 beds), and
neonatal (NICU, with 24 beds).
2.2. Patient characteristics
From May through November 2011, patients from each of our
institution’s five ICUs were prospectively enrolled. We
included patients admitted to one of the five ICUs for
a minimum of 48 h. Patients receiving sedative drips of more
than 10 mg/h for lorazepam (Ativan) or 25 mcg/h of propofol
and/or narcotic drips of more than 10 mg/h for morphine or
100 mcg/h for fentanyl were excluded.
2.3. Nursing interactions
During the 7-mo study period, questionnaires were distrib-
uted to nursing staff for each of these 200 patients from
the five ICUs. The questionnaires recorded the number,
approximate length, and type of NNIs from 2200 to 0600
nightly (10 PM to 6 AM) for each enrolled patient. The NNIs
were then classified into four groups: patient care activity,
nursing intervention, nursing assessment, or patient-initiated
contact. The nursing staff also indicated the proportion of
these activities that they thought could have been safely
omitted without negatively affecting patient care and thereby

Table 1 e Demographic and clinical characteristics of patients in the different ICUs.

ICU type CTICU SICU MICU PICU NICU
n ¼ 40 n ¼ 40 n ¼ 40 n ¼ 40 n ¼ 40

Mean age (y) 60.5
13.6 56.2
17.6 58.3
15.4 4.4
5.3 0.2
0.5
Male % 23 (57.5%) 21 (53.8%) (n ¼ 39) 14 (35.0%) 22 (55.0%) 23 (57.5%)
Mean length of stay (d) 5.6
2.9 6.1
3.5 (n ¼ 39) 6.8
3.5 5.4
3.4 (n ¼ 39) 6.4
3.4 (n ¼ 39)
Mean pain level 1.8
2.7 (n ¼ 36) 2.4
2.7 (n ¼ 25) 1.5
2.6 (n ¼ 26) 0.7
1.2 (n ¼ 36) 0.4
1.0 (n ¼ 36)
Mean RASS score 0.4
0.7 (n ¼ 38) 0.3
1.9 (n ¼ 39) 0.8
1.5 (n ¼ 39) 0.3
0.8 (n ¼ 11) N/A
% ventilated 5 (12.5%) 16 (41.0%) (n ¼ 39) 19 (47.5%) 8 (20.5%) (n ¼ 39) 5 (12.8%) (n ¼ 39)
% sedated 1 (2.5%) 6 (15.4%) (n ¼ 39) 10 (25.0%) 5 (12.8%) (n ¼ 39) 3 (7.7%) (n ¼ 39)
% on narcotics 8 (20.0%) 9 (23.1%) (n ¼ 39) 18 (45.0%) 7 (18.0%) (n ¼ 39) 4 (10.3%) (n ¼ 39)
Type of admission diagnosis
Cardiac, n (%) 21 (52.5%) 0 1 (2.5%) 22 (55.0%) 1 (2.5%)
Pulmonary, n (%) 10 (25.0%) 3 (7.5%) 14 (35%) 5 (12.5%) 7 (17.5%)
Neurological, n (%) 0 20 (50.0%) 11 (27.5%) 6 (15.0%) 2 (5.0%)
Gastrointestinal, n (%) 6 (15.0%) 7 (17.5%) 4 (10.0%) 1 (2.5%) 9 (22.5%)
Postsurgical, n (%) 0 5 (12.5%) 2 (5.0%) 2 (5.0%) 0
Miscellaneous/other, n (%) 3 (7.5%) 5 (12.5%) 8 (20.0%) 4 (10.0%) 21 (52.5%)

RASS ¼ Richmond Agitation Sedation Scale.

Data was not available for all fields in every patient. Where N < 40, this indicates that data was not available for that variable.
312 j o u r n a l o f s u r g i c a l r e s e a r c h 1 7 7 ( 2 0 1 2 ) 3 1 0 e3 1 4

Table 2 e Classification of patient interaction/disturbance by ICU.

ICU type Frequency of Frequency of Frequency of Frequency of Total # of
assessment n (%) intervention n (%) activity n (%) patient-initiated n (%) interaction n (%)

CTICU 133 (34.2) 114 (29.3) 85 (21.9) 115 (29.6) 389 (21.3)
SICU 116 (24.6) 131 (27.8) 224 (47.6) 63 (13.4) 471 (25.7)
MICU 100 (23.3) 172 (40.0) 156 (36.3) 45 (10.5) 430 (23.5)
PICU 158 (44.5) 117 (33.0) 100 (28.2) 48 (13.5) 355 (19.4)
NICU 109 (58.6) 34 (18.3) 53 (28.5) 32 (17.2) 186 (10.2)

allow the patient uninterrupted time for sleep. The same
questionnaires were distributed to the nursing staff of all
units studied. Appendix A (supplemental material, available
online at doi:10:1016/j.jss.2012.05.038) demonstrates the
actual questionnaire instrument. In addition, we collected
baseline demographic data, including the patient’s gender
and age, the admission diagnosis, any sedative or narcotic
drips administered, use of mechanical ventilation, the length
of ICU stay, the current visual analog pain score (where
possible), and the Richmond Agitation Sedation Scale score.
We entered data into a computerized spreadsheet (Excel;
Microsoft, Redmond, WA). For our analysis, we used SAS
version 9.2 (SAS, Cary, NC). To analyze differences between
groups, after adjusting for the patient’s gender and age, we used
a mixed-effects logistic regression model and a linear mixed-
effects model, with a random intercept to analyze percentages
of NNIs and lengths of NNIs that could have been safely omitted,
respectively. Proportions are presented herein as percentages,
continuous variables as means
standard deviation.
3. Results
We prospectively enrolled 40 patients from each of our institu-
tion’s five ICUs for a total of 200 patients during the study period.
The baseline characteristics by ICU type are described in Table 1.
The proportion of male patients ranged from 35.0% in the MICU to
57.5% in the NICU and CTICU. The mean age of all study patients
was 35 y. A total of 1831 NNIs were recorded across all ICUs.
The SICU recorded the most NNIs (471; 25.7%); the NICU
recorded the fewest NNIs (186; 10.2%). The most frequent
reasons for admission were related to surgery for the SICU,
pulmonary illnesses for the MICU, cardiac illnesses for the
PICU and the CTICU, and prematurity for the NICU.
The most common type of NNI was nursing assessment in
the PICU and CTICU (158 and 133 respectively), nursing inter-
vention in the MICU (172), and patient care activity in the SICU
(224). Overall, among all five ICUs, the most common type of NNI
was nursing assessment, with an average of 123 such interac-
tions (Table 2). There were significant differences between the
various ICUs in the mean frequency of NNIs (Table 3).
The SICU reported the highest percentage of NNIs that
could have been safely omitted (20.9%), compared to the NICU,
which had 9.4% (Table 4). However, we found no statistically
significant difference in the percentage of NNIs that
could have been safely omitted among the different ICUs
(P ¼ 0.4115). In contrast, we found statistically significant
differences in the average length of the NNIs between the
different ICUs (P < 0.0001). Specifically, the SICU had the
lowest average length of the NNI (6.66
6.06 min) and the
NICU had the highest average length (16.34
9.40 min, P <
0.0001) (Table 5).
On average, NNIs that could have been safely omitted were
longer in the NICU (11.00
10.39 min) than in the SICU (6.34

5.83 min), especially for nursing assessment, nursing inter-
vention, and patient care activity. The average length of NNIs
that could have been safely omitted varied significantly
among the different ICUs (P ¼ 0.0116) (Table 6).

Table 3 e Mean frequency of interaction/disturbance (per patient) by ICU.

ICU type Assessment Intervention Activity Patient-initiated Overall

CTICU (n ¼ 40) 3.3
2.3 2.9
2.5 2.1
2.2 2.9
4.7 9.7
5.5
SICU (n ¼ 40) 2.9
2.6 3.3
3.8 5.6
5.2 1.6
2.2 11.8
9.0
MICU (n ¼ 40) 2.5
1.6 4.3
5.1 3.9
4.9 1.1
2.2 10.8
7.6
PICU (n ¼ 40) 4.0
1.9 2.9
3.6 2.5
4.2 1.2
1.2 8.9
5.5
NICU (n ¼ 40) 2.7
1.4 0.9
1.4 1.3
1.5 0.8
1.5 4.7
1.8
P value* 0.0188y 0.0073z <0.0001x 0.0226k 0.0002{

Results given as means
SD.

* Overall P value derived from multiple linear regression with adjusting for age and gender, using Tukey HSD test.
y PICU had significantly more assessment NNIs than MICU. There were no significant differences in assessment NNIs between the other ICUs.
z SICU and MICU had significantly more intervention NNIs than NICU. There were no significant differences in intervention NNIs between the
other ICUs.
x SICU had significantly more activity NNIs than PICU, CTICU, and NICU. MICU had significantly more activity NNIs than NICU. There were no
significant differences in activity NNIs between the other ICUs.
k CTICU had significantly more patient-initiated NNIs than PICU, MICU, and NICU. There were no significant differences in patient-initiated
NNIs between the other ICUs.
{ NICU had significantly fewer NNIs than the other ICUs. There were no significant differences in NNIs between the other ICUs.
 j o u r n a l o f s u r g i c a l r e s e a r c h 1 7 7 ( 2 0 1 2 ) 3 1 0 e3 1 4 313

Table 4 e Percentage of interactions that can be safely skipped by ICU and classification of patient interaction/disturbance.
ICU type Assessment % (n) Intervention % (n) Activity % (n) Patient-initiated % (n) Total % (n)

CTICU 15.8 (20/127) 10.0 (11/110) 14.5 (11/76) 13.0 (3/23) 14.6 (42/288)
SICU 27.2 (31/114) 15.8 (20/127) 17.9 (40/224) 14.3 (2/14) 20.9 (88/421)
MICU 18.4 (18/98) 15.2 (26/171) 23.9 (37/155) 42.9 (6/14) 19.6 (78/399)
PICU 11.8 (18/153) 7.6 (8/105) 6.9 (6/87) 5.6 (1/18) 9.9 (31/312)
NICU 4.8 (5/105) 9.4 (3/32) 9.4 (5/53) 33.3 (6/18) 9.4 (16/170)
P value* 0.1389 0.6886 0.9264 0.2757 0.4115

Note: Some of the interactions were not evaluated as to whether they could be safely skipped.
* P values derived from mixed-effects logistic regression models adjusting for age and gender with a random intercept.

For the number of nocturnal interactions, there was no
significant difference between genders (female: 8.85
6.22;
male: 9.48
7.29; P ¼ 0.5174). However, the Pearson correla-
tion coefficient between number of nocturnal interactions and
patient’s age was 0.22 (P ¼ 0.0017).
4. Discussion
This study found that care in the surgical ICU resulted in more
frequent nocturnal nursing interactions than other ICUs, and
these were the shortest in length, but were also the most likely
to be identified as safe to omit by bedside nurses. In contrast,
the NICU had the least number that could have been safely
omitted (which went along with less frequent but longer NNIs).
In ICU patients, reasons for sleep deprivation are multi-
factorial, and sleep disruptions are frequent. Environmental
factors that contribute to sleep disruptions include patient
care activity (e.g., bathing, breathing treatments, medica-
tions), nursing intervention (e.g., intravenous [IV] line place-
ment, IV flushing, wound care), nursing assessment (e.g., vital
signs, neurologic checks, IV pump monitoring), and patient-
initiated contact. Reduced sleep quality has detrimental
effects on critically ill patients, including respiratory irregu-
larities and immune system compromise [6].
Another contribution to sleep deprivation in ICUs is
mechanical ventilation. Mechanically ventilated patients
frequently have fragmented sleep [5,6]. They may also experi-
ence dyssynchrony with the ventilator, especially during
periods of nonerapid eye movement sleep, when the range of
respiratory frequencies that they can adjust to is narrowed [7].
Although mechanical ventilation is important and frequently
used for pulmonary support, ventilated patients experience 20
to 60 disruptions per hour of sleep. Several studies have shown
that the mode of mechanical ventilation influences sleep
quality [8]. In our study, the MICU had the highest proportion of
mechanically ventilated patients (47.5%); that fact could have
contributed to its having the second-highest frequency of NNIs.
Some sedatives have also been discovered to have a nega-
tive effect on sleep. Propofol, a common sedative used in ICUs,
increases the length of sleep time without enhancing REM
sleep [9]. In our study, the MICU had the highest proportion of
sedated patients (25.0%).
Unfortunately, our study was not able to provide clear
indications of why the SICU had such short and frequent
NNIs. The approach to patients by nursing staff in the SICU,
particularly as compared with the NICU, may differ, or the
disease states of those sets of patients may differ. Interest-
ingly, we found no statistically significant differences
between those two units in the number of NNIs due to patient-
initiated contact; one might imagine that the number in the
SICU would be far higher than in the NICU, given the age of the
patients. But, in fact, the opposite was seen, with longer
patient-initiated NNIs in the NICU (Table 5). In fact, our study
showed that older patients tended to have more nocturnal
interactions, although there were no gender differences.
The ICU environment can be made more conducive to
sleep by rescheduling, to the extent feasible, patient care
activity to daylight hours and by clustering NNIs to minimize
their number [10]. In addition, routine nighttime care (such as
bedding changes, bathing, medication delivery, routine radi-
ology testing, and laboratory blood draws) can be relegated
instead to daylight hours [6]. Of course, not all patient care
activities can be eliminated or rescheduled; however, night-
time assessments can be omitted or minimized in patients
with continuous monitors in place. Furthermore, careful

Table 5 e Average length (in minutes) of patient interaction by ICU and classification of patient interaction/disturbance.
ICU type Assessment n (%) Intervention n (%) Activity n (%) Patient-initiated n (%) Total n (%)

CTICU 8.34
7.05 (n ¼ 132) 7.35
6.06 (n ¼ 112) 8.38
6.28 (n ¼ 85) 7.11
6.16 (n ¼ 95) 7.44
6.18 (n ¼ 366)
SICU 7.81
6.83 (n ¼ 116) 6.53
6.42 (n ¼ 131) 7.23
6.33 (n ¼ 224) 6.33
6.21 (n ¼ 63) 6.66
6.06 (n ¼ 471)
MICU 13.36
8.70 (n [ 99) 7.39
7.07 (n ¼ 170) 9.74
8.18 (n ¼ 156) 8.33
6.62 (n ¼ 45) 8.96
7.61 (n [ 428)
PICU 10.17
6.42 (n ¼ 158) 7.71
5.69 (n ¼ 116) 8.81
6.63 (n ¼ 99) 11.81
8.60 (n ¼ 48) 8.96
6.29 (n ¼ 353)
NICU 19.49
8.43 (n [ 109) 15.24
9.83 (n [ 34) 15.63
10.09 (n [ 52) 12.53
10.18 (n ¼ 32) 16.34
9.40 (n [ 185)
P value* <0.0001 <0.0001 0.0008 0.3123 <0.0001

Values are given as means
standard deviation.

Bolded values represent those interactions that are significantly different from SICU in average length of patient interaction (i.e., P value <0.05)
with adjustment of multiple comparisons using Tukey-Kramer method.
* P value derived from a linear mixed-effects model with a random intercept adjusting for age and gender.
314 j o u r n a l o f s u r g i c a l r e s e a r c h 1 7 7 ( 2 0 1 2 ) 3 1 0 e3 1 4

Table 6 e Average length (in minutes) of patient interaction that can be safely skipped by ICU and classification of patient
interaction/disturbance.
ICU type Assessment Intervention Activity Patient-initiated Total

CTICU 3.70
2.90 (n ¼ 20) 7.00
4.34 (n ¼ 11) 9.09
5.84 (n ¼ 11) 11.67
11.55 (n ¼ 3) 5.86
4.67 (n ¼ 42)
SICU 6.32
6.57 (n ¼ 31) 5.80
4.49 (n ¼ 20) 6.70
6.53 (n ¼ 40) 7.50
3.54 (n ¼ 2) 6.34
5.83 (n ¼ 88)
MICU 7.94
7.14 (n ¼ 18) 7.92
6.14 (n ¼ 26) 9.62
8.63 (n ¼ 37) 11.00
7.07 (n ¼ 6) 8.35
7.19 (n ¼ 78)
PICU 9.00
4.81 (n ¼ 18) 10.00
5.98 (n ¼ 8) 9.17
3.76 (n ¼ 6) 5 (n ¼ 1) 9.42
4.84 (n ¼ 31)
NICU 17.20
9.96 (n [ 5) 15.33
12.66 (n ¼ 3) 14.20
12.68 (n ¼ 5) 8.00
9.94 (n ¼ 6) 11.00
10.39 (n [ 16)
P value* 0.0004 0.2341 0.1089 0.2388 0.0116

Values are given as means
standard deviation.

Bolded values represent those interactions that are significantly different from SICU in average length of patient interaction (i.e., P value <0.05)
with adjustment of multiple comparisons using Tukey-Kramer method.
* P value derived from a linear mixed-effects model with a random intercept adjusting for age and gender.

attention should be paid to monitoring alarms, ventilators and
other equipment, telephones, and staff-related noise.
Reducing noise levels could help promote sleep in ICU
patients [10]. Noncritical alarms should be placed in a central
area and their thresholds set to sound at a reasonable level.
Critical alarms should remain at the bedside to allow for rapid
staff response [6]. The patient needs to be allowed as much
time as possible for uninterrupted sleep. Nurses need to
reduce disruptions by clustering their care at night [10].
Three limitations to our study should be acknowledged.
First, this was a convenience sample as we were dependent on
the number of admissions to each unit, the acuity of the
patient, and also the willingness of the nursing staff to assist
in our research. This may have introduced bias into the
results. Enrollment in the five different ICUs clearly proceeded
at different speeds; the nurses in one of the ICUs were less
open to participation, often citing responsibility for patients
who were more demanding or a lack of time. However, we feel
that the nurses were unlikely to have deliberately over-
estimated or underestimated the number of NNIs in enrolled
patients. Secondly, information in the literature is limited on
the reliability and validity of sleep questionnaires in the crit-
ical care setting. The most reliable measure would be direct
observation of the patient and the number of NNIs, but in an
unfunded study like ours, this was not possible. Further
prospective studies are needed to obtain more reliable data
and to identify exactly which practices could be exported from
one ICU to another (e.g., clustering NNIs, taking x-rays later in
the morning, changing phlebotomy timing, etc.). Thirdly, we
believe that the contribution of the ancillary staff may have
contributed to the differences seen across the ICUs; however,
our study was not designed to take into account interactions
by other ancillary staff besides nurses, such as nursing
auxiliaries or patient care technicians, which may have led us
to underestimate the true frequency of NNIs in each ICU.
5. Conclusion
Sleep in ICUs is often perceived by patients to be poor. In our
study, we found that patient care activity was a prime contributor
to sleep disruptions, with a large number of NNIs during regular
sleep hours (2200 to 0600). There were significant differences
noted between different ICU types. Clustering of nursing care
should be included in a formal protocol for nocturnal sleep
promotion that is standardized across different ICU types.
Supplementary data
Supplementary data related to this article can be found online
at doi:10.1016/j.jss.2012.05.038.
references
[1] Hardin KA. Sleep in the ICU: Potential mechanisms and
clinical implications. Chest 2009;136:284.
[2] Gabor JY, Cooper AB, Hanly PJ. Sleep disruption in the
intensive care unit. Curr Opin Crit Care 2001;7:21.
[3] Friese RS, Diaz-Arrastia R, McBride D. Quantity and quality of
sleep in the surgical intensive care unit: Are our patients
sleeping? J Trauma 2007;63:1210.
[4] Friese RS, Wallace L, McBride D, et al. Nocturnal care
interactions and sleep disruption in the intensive care
unit. In: Fourth Annual Academic Surgical Congress.
Sanibel Island, Florida. J Surg Res 2009;151(2):292.
[5] Cooper AB, Thornley KS, Young GB, et al. Sleep in
critically ill patients requiring mechanical ventilation.
Chest 2000;117:809.
[6] Friese RS. Sleep and recovery from critical illness and injury:
A review of theory, current practice, and future directions.
Crit Care Med 2008;36:697.
[7] Simon PM, Zurob AS, Wies WM, et al. Entrainment of
respiration in humans by periodic lung inflations. Effect
of state and CO(2). Am J Respir Crit Care Med 1999;
160:950.
[8] Parthasarathy S, Tobin MJ. Sleep in the intensive care unit.
Intensive Care Med 2004;30:197.
[9] Weinhouse GL, Schwab RJ. Sleep in the critically ill patient.
Sleep 2006;29:707.
[10] Tembo AC, Parker V. Factors that impact on sleep in
intensive care patients. Intensive Crit Care Nurs 2009;25:314.