The association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU

Critical Care, Aug 2016

Background Poor sleep is common in the ICU setting and may represent a modifiable risk factor for patient participation in ICU-based physical therapy (PT) interventions. This study evaluates the association of perceived sleep quality, delirium, sedation, and other clinically important patient and ICU factors with participation in physical therapy (PT) interventions. Method This was a secondary analysis of a prospective observational study of sleep in a single academic medical ICU (MICU). Perceived sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates included demographics, pre-hospitalization ambulation status, ICU admission diagnosis, daily mechanical ventilation status, and daily administration of benzodiazepines and opioids via bolus and continuous infusion. Associations with participation in PT interventions were assessed among patients eligible for PT using a multinomial Markov model with robust variance estimates. Results Overall, 327 consecutive MICU patients completed ≥1 assessment of perceived sleep quality. After adjusting for all covariates, daily assessment of perceived sleep quality was not associated with transitioning to participate in PT the following day (relative risk ratio [RRR] 1.02, 95 % CI 0.96–1.07, p = 0.55). However, the following factors had significant negative associations with participating in subsequent PT interventions: delirium (RRR 0.58, 95 % CI 0.41–0.76, p <0.001), opioid boluses (RRR 0.68, 95 % CI 0.47–0.99, p = 0.04), and continuous sedation infusions (RRR 0.58, 95 % CI 0.40–0.85, p = 0.01). Additionally, in patients with delirium, benzodiazepine boluses further reduced participation in subsequent PT interventions (RRR 0.25, 95 % CI 0.13–0.50, p <0.001). Conclusions Perceived sleep quality was not associated with participation in PT interventions the following day. However, continuous sedation infusions, opioid boluses, and delirium, particularly when occurring with administration of benzodiazepine boluses, were negatively associated with subsequent PT interventions and represent important modifiable factors for increasing participation in ICU-based PT interventions.

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The association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU

Kamdar et al. Critical Care The association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU Biren B. Kamdar 0 1 Michael P. Combs 1 3 Elizabeth Colantuoni 1 2 8 Lauren M. King 1 7 Timothy Niessen 1 6 Karin J. Neufeld 1 2 5 Nancy A. Collop 1 10 Dale M. Needham 1 2 4 9 0 Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at the University of California , 10833 Le Conte Ave., Room 37-131 CHS, Los Angeles, CA 90095 , USA 1 Biren B. Kamdar and Michael P. Combs are co-first authors 2 Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University , Baltimore, MD 21205 , USA 3 Department of Medicine, David Geffen School of Medicine at the University of California , Los Angeles, CA 90095 , USA 4 Department of Physical Medicine and Rehabilitation, Johns Hopkins University , Baltimore, MD 21205 , USA 5 Department of Psychiatry and Behavioral Sciences, Johns Hopkins University , Baltimore, MD 21205 , USA 6 Department of Medicine, Johns Hopkins University , Baltimore, MD 21205 , USA 7 Department of Palliative Medicine , Wellspan Health , York Hospital , York, PA 17403 , USA 8 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD 21205 , USA 9 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University , Baltimore, MD 21205 , USA 10 Emory Sleep Disorders Center, Wesley Woods Health Center, Emory University , Atlanta, GA 30322 , USA Background: Poor sleep is common in the ICU setting and may represent a modifiable risk factor for patient participation in ICU-based physical therapy (PT) interventions. This study evaluates the association of perceived sleep quality, delirium, sedation, and other clinically important patient and ICU factors with participation in physical therapy (PT) interventions. Method: This was a secondary analysis of a prospective observational study of sleep in a single academic medical ICU (MICU). Perceived sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates included demographics, pre-hospitalization ambulation status, ICU admission diagnosis, daily mechanical ventilation status, and daily administration of benzodiazepines and opioids via bolus and continuous infusion. Associations with participation in PT interventions were assessed among patients eligible for PT using a multinomial Markov model with robust variance estimates. Results: Overall, 327 consecutive MICU patients completed ≥1 assessment of perceived sleep quality. After adjusting for all covariates, daily assessment of perceived sleep quality was not associated with transitioning to participate in PT the following day (relative risk ratio [RRR] 1.02, 95 % CI 0.96-1.07, p = 0.55). However, the following factors had significant negative associations with participating in subsequent PT interventions: delirium (RRR 0.58, 95 % CI 0.41-0.76, p <0.001), opioid boluses (RRR 0.68, 95 % CI 0.47-0.99, p = 0.04), and continuous sedation infusions (RRR 0.58, 95 % CI 0.40-0.85, p = 0.01). Additionally, in patients with delirium, benzodiazepine boluses further reduced participation in subsequent PT interventions (RRR 0.25, 95 % CI 0.13-0.50, p <0.001). Conclusions: Perceived sleep quality was not associated with participation in PT interventions the following day. However, continuous sedation infusions, opioid boluses, and delirium, particularly when occurring with administration of benzodiazepine boluses, were negatively associated with subsequent PT interventions and represent important modifiable factors for increasing participation in ICU-based PT interventions. Sleep; Intensive care unit; Early ambulation; Rehabilitation; Delirium; Sedation Background Prolonged immobility is common in critical illness [ 1–3 ] and associated with intensive care unit (ICU)acquired weakness [ 4, 5 ] which, in turn, is associated with functional impairments and poor health-related quality of life after hospital discharge [ 5–7 ]. Recent evidence has demonstrated that early mobilization in the ICU is feasible and safe [ 8–12 ], and may lead to reductions in delirium [ 9, 10 ], duration of mechanical ventilation [ 9, 13 ], and ICU length of stay [ 10, 13–16 ], along with improved outcomes following hospital discharge [17]. Despite the potential benefits of early mobilization, various patient-related factors have been identified as potential barriers to physical therapy (PT) interventions in the ICU, including higher oxygen requirements, continuous renal replacement therapy, multi-organ dysfunction, and sedating medications [ 18, 19 ]. Poor sleep quality, which is common in ICU patients [20], negatively affects physical functioning among those who are not critically ill [ 21, 22 ]. This observation has led to speculation that sleep may be an important and mod (...truncated)


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Biren Kamdar, Michael Combs, Elizabeth Colantuoni, Lauren King, Timothy Niessen, Karin Neufeld, Nancy Collop, Dale Needham. The association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU, Critical Care, 2016, pp. 261, 20, DOI: 10.1186/s13054-016-1433-z