Sleep in the Hospitalized Patient

1. Sleep in the Hospitalized Patient Robyn Woidtke MSN,RN, RPSGT,CCP,CCSH OCTOBER 24 KASP 2014

2. Objectives At the completion of the session, the attendees will: • Summarize contributors to sleep loss • Describe the impact of sleep loss in the hospitalized patient • Explain the rationale for screening for sleep apnea in patients admitted to the hospital • Emphasis • The perioperative environment • The ICU

3. Why is sleep important? • Animal models, sleep loss leads to • Failure of body temperature regulation • Increased metabolism • Deterioration of hypothalamic neurons • Progressive breakdown of host defenses • Death Redeker &McEnany, 2011

4. Functions • Conserve energy and metabolism • Physiologic systems within homeostatic mechanisms • Maintain host defenses • Reverse/restore physiologic processes that degrade during wakefulness • Memory Consolidation • Learning Redeker &McEnany, 2011

5. Factors Contributing to Sleep Loss • Voluntary curtailment (social) • Environment (i.e. work, technology, etc) • Role (new mom, school) • Sleep Disorders • Medical and psychiatric disorders Redeker &McEnany, 2011

6. Sleep Deprivation • Poor job performance • Cognition Impaired • Lose the ability to make sound judgment; interpretation of events is affected • Reduced ability to handle stress • Greater alcohol use • Higher incidence of drowsy driving Redeker &McEnany, 2011

8. Acute Sleep Deprivation • Excess diuresis and natriuresis during acute sleep deprivation in healthy adults (Kamperis, 2010). • Acute sleep deprivation reduces energy expenditure in healthy men (Benedict, 2011) • Increase levels of ghrelin in the morning • Declines in neurocognition, increased sympathetic and decreased parasympathetic modulation (Zhonget al., 2004)

9. Outcomes of Disturbed Sleep • Alterations in immune function • Increased stress hormones (catacholamines) • Insulin and glucose regulation • Ability to perform activities of daily living • Lack of mental processing of self care activities upon discharge • Decrease in SWS • HGH • Alterations in processing and consolidating newly acquired information

10. Correlates and Consequences Hospital Environment Acute Illness Treatment • Sleep • Quantity • Continuity • Diurnal Timing • Quality • Perceptions Symptoms Functional Status Age, Gender, Comorbidity Physiologic Status Sleep Disorders Adapted from Redeker and Hedges, 2002

11. General Sleep Assessment (1) • Challenges • Sleep problems typically occur gradually; patients may not be aware or concerned • May attribute daytime symptoms to other causes • Assessment • BEARS (all ages) • B-bedtime problems • E-Excessive Sleepiness • A-Awakenings • R- Regularity of sleep • S-Sleep disordered breathing Redeker &McEnany, 2011

12. General Sleep Assessment (2) • General health • Specific Conditions • Co-morbid/bi-directionality (heart disease, asthma, diabetes, Parkinsons, pain, depression and anxiety) • Anthropometric data • HT/Wt(BMI >30), neck circumference (17 m, 16 f) correlate with OSA in adults • Waist circumference and BMI>95th percentile in children • Inspection of the profile, oral and nasal cavities • Mallampati • Cardiovascular (BP, EKG, heart sounds) • Pulmonary system (scoliosis, muscle tone) • Neuromuscular (restless legs syndrome) • Glycemic control Redeker &McEnany, 2011

13. Nursing Staff: Do Not assume “ While knowledge of findings like these (referring to sleep apnea) have raised my awareness of the dangers of untreated sleep apnea, I can tell you that a majority of the nurses at my hospital, and even those within my own critical care unit still do not aggressively address the issue of having the MD order studies to diagnose and/or treat OSA which has been diagnosed” (2012, Personal Communication, Anonymous Critical Care RN, MSN student)

14. Sleep in the ICU Friese, R. (2008) Crit Care Med

15. Environmental and Pathophysiological Factors Friese, R. (2008) Crit Care Med

16. ICU Delirium • Delirium affects up to 80% of ICU patients, and it is estimated that ICU costs associated with delirium equal between $4 billion and $16 billion annually in the US.(1) • This form of acute brain dysfunction is associated with increased length of ICU and hospital stays, time on the ventilator, mortality, and long-term neuropsychological deficits (1) • Characteristic features of the syndrome include impaired short-term memory, impaired attention, disorientation, development over a short period of time, and a fluctuating course(2) • Caused by a general medical illness, intoxication, or substance withdrawal (2) • OSA has been demonstrated as a risk factor (3) American Association of Critical Care Nurses, 2014 Cavallazzi, et al., 2012 Annals of Intensive Care Flink, et al.2012 Anesthesology

17. Medications • Opioids • Increase arousal • Precipitate osa • Worsen hypoxia • Ventilator asynchrony • Benzodiazapines • Increase theta; reduce SWS • Loss of SWS has been shown to increase delirium • Dexmedetomidine • Reduces ventilator days • Reduces delirium

18. Interventions • Reduce Effects of Environmental Stimuli • Decrease noise • Cluster patient care interventions • Provide eye masks and ear plugs if appropriate • Complementary and Alternative Medicine • Relaxation, music and biofeedback • White noise may improve sleep quality in cardiac post op patients • Massage • Meditation • Review Drug interactions, understand the consequences

19. Interventions • Plan for uninterrupted time for sleep • Minimize night time assessments • Set monitor alarms down to reasonable loudness • Orient patient frequently • If possible, cycle light to day/night frequency • Sleep may change ventilator synchrony, proportional assist has demonstrated improved ventilatory matching requirements and improved sleep "We haven't recognized the importance of prescribing sleep“ Friese, R 2007 Friese, R. (2008) Crit Care Med

20. Measuring Sleep Quality • Richards-Campbell Sleep Questionnaire • Brief validated 5 item questionnaire; visual analog scale (100mm), higher numbers= better • Study to determine nurses vs. patients subjective ratings of sleep; inter-rater reliability • Johns Hopkins (June-July 2010; 16 bed private room MICU; nurse to patient ratio 1:2; 12 hour shifts); questionnaires completed 30 minutes prior to the end of shift; 33 patients/92 paired assessments • Results: Patient/Nurse agreement was slight to moderate; nurses tended to over estimate sleep quality Kamdar et al. (2012) AJCC

21. OSA in the Hospital • 25% of candidates for elective surgery • OSA undiagnosed in 80% at the time of surgery • Estimates of OSA in hospitalized patients • >50% • National Hospital Discharge Survey • 5.8% received CPAP with a diagnosis of OSA (Spurr, 2008) • <20% with a diagnosis of OSA received therapy during hospitalization (Premier Inc, Database, Memtsoudis, 2013, NEJM)

22. Screening for OSA • Variety of questionnaires • Epworth, Berlin, STOP/STOP BANG, Sleep Apnea Clinical Score • Pulse Oximetry • Home sleep testing for all elective surgical procedures • Full polysomnography

23. STOP-BANG

24. High STOP-BANG score = higher probability of OSA • Evaluation of the association between STOP-Bang scores and the probability of OSA. • METHODS: • Patients answered STOP questionnaire and underwent either laboratory or portable polysomnography (PSG). PSG recordings were scored manually. The BMI, age, neck circumference, and gender (Bang) were documented. • Over 4 yr, 6369 patients were approached and 1312 (20.6%) consented. Of them, 930 completed PSG, and 746 patients with complete data on PSG and STOP-Bang questionnaire were included for data analysis. Chung, F. Br. J of Anesthesia doi: 10.1093/bja/aes022

25. High STOP-Bang score indicates a high probability of obstructive sleep apnoea • RESULTS: • The median age of 746 patients was 60 yr, 49% males, BMI 30 kg m(-2), and neck circumference 39 cm. • OSA was present in 68.4% with 29.9% mild, 20.5% moderate, and 18.0% severe OSA. • STOP-Bang score of 5, the odds ratio (OR) for moderate/severe and severe OSA was 4.8 and 10.4, respectively. • STOP-Bang 6, the OR for moderate/severe and severe OSA was 6.3 and 11.6, respectively. • STOP-Bang 7 and 8, the OR for moderate/severe and severe OSA was 6.9 and 14.9, respectively. • The predicted probabilities for moderate/severe OSA increased from 0.36 to 0.60 as the STOP-Bang score increased from 3 to 7 and 8. • CONCLUSIONS: In the surgical population, a STOP-Bang score of 5-8 identified patients with high probability of moderate/severe OSA. The STOP-Bang score can help the healthcare team to stratify patients for unrecognized OSA, practice perioperative precautions, or triage patients for diagnosis and treatment.

26. Identification of Patients at Risk for Postoperative Respiratory Complications Using a Preoperative Obstructive Sleep Apnea Screening Tool and PostanesthesiaCare Assessment Gali, et al., Anesthesiology 2009; 110:869–77

27. OSA in the Hospitalized Patient • Why OSA is an important assessment • Association with MI, arrhythmias, CHF, stroke, sudden cardiac death • Sudden death ~ 50% those with OSA compared to 21% without OSA • Die during the sleep hours (12-6 AM) • Sudden death related to the AHI, the more severe the higher the risk • Depressed arousal mechanisms due to sleep fragmentation and deprivation; acquired arousal failure in obese patients • Narcotics further delay arousal Kaw& Mokhlesi (2012) Sleep and Breathing

28. Types of patients at high risk for OSA • CHF • Obese • Patients undergoing bariatric surgery • Atrial Fibrillation • Refractory Hypertension • Type 2 diabetes • Stroke • Nocturnal cardiac arrhythmia • Pulmonary Hypertension AASM Task Force, 2009 JCSM

29. Patterns of Unexpected Hospital Death

30. ALARM FATIGUE

32. Perioperative Environment -OSA • Difficulty with intubation (8 times as often) • Unanticipated transfers to ICU • Overall LOS longer; longer ICU • 5 fold increase in intubation and mechanical ventilation after surgery Kaw& Mokhlesi (2012) Sleep and Breathing

33. Impact of Anesthesia • Exacerbates the anatomical alterations which result in pharyngeal collapse • Blunt the arousal mechanisms • Reduce tone of the upper airway • Depress ventilation • Diminish ventilatory response to carbon dioxide • In children, apneic episodes were increased 50% after modest doses of fentenyl (0.5µg/Kg)

34. Perioperative Outcomes-Other • Higher rates of • Hypercapnia • Oxygen desaturations • Cardiac arrhythmias • Myocardial injury • Delirium OSA Adesanya, et al. 2012 CHEST

35. Key Take Away OSA patients live in a state of perpetual “arousal dependent survival” (Lynn & Curry,2011) Acquired arousal failure Nursing staff may not be educated Protocols may/may not be in place or followed

36. Mitigating Risk Studies demonstrate that patients who are treated for OSA have reduced complications and improved outcomes

37. 2 Relevant Joint Commission Directives

38. Clinical Practice Guidelines “The consultants agree that, in the absence of a sleep study, a presumptive diagnosis of OSA may be made based on consideration of the following criteria: increased body mass index, a weight or body mass index greater than 95th percentile for age (pediatric patients), increased neck circumference, snoring, congenital airway abnormalities, daytime hypersomnolence, inability to visualize the soft palate, and tonsillarhypertrophy. They strongly agree that observed apnea during sleep is an additional criterion.”

39. New Guidelines

40. Post Operative • Postoperative concerns in the management of patients with OSA include (1) analgesia, (2) oxygenation, (3) patient positioning, and (4) monitoring. • Risk factors for respiratory depression include the systemic and neuraxialadministration of opioids, administration of sedatives, site and invasiveness of surgical procedure, and the underlying severity of the sleep apnea. • In addition, exacerbation of respiratory depression may occur on the third or fourth postoperative day as sleep patterns are reestablished and “REM rebound” occurs.

43. Pre-operative Evaluation

44. Extended Stay PACU Protocol

48. Risk ManagementThe Perils of Litigation

49. ADVOCATE, ADMIT and MONITOR…….

50. Value of a program • Analysis of the WestLaw Data base on osa cases • 54 cases included in analysis • 61% in favor of defendant • 12% resolved out of court • 9% jury award • most frequent factors in litigation • Failure to diagnose OSA; failure to use CPAP postoperatively • Failure to use CPAP, all cases resolved with payment > 1 million Svider, et al., AAO 2013