BCCCP: Sleep Disturbance Management

A 65-year-old man, 3 days post–coronary artery bypass graft (CABG), remains on synchronized intermittent mandatory ventilation (SIMV) with a propofol infusion titrated to a Richmond Agitation-Sedation Scale (RASS) score of –1 to 0. A central venous catheter is in place for vasopressor support. Despite attempts to optimize his sleep environment and wean sedation, he reports significant difficulty initiating sleep, and nursing staff note frequent awakenings during nightly rounds. For his sleep-onset insomnia, ramelteon 8 mg orally nightly is initiated. According to the American Academy of Sleep Medicine clinical practice guideline (strong recommendation, moderate quality evidence), which of the following is the MOST appropriate monitoring plan to evaluate the efficacy and safety of this intervention?

A 62-year-old man presents to your sleep clinic with a 6-month history of difficulty initiating sleep. He reports lying awake for more than 45 minutes each night before finally falling asleep. He denies nocturnal awakenings, early morning awakening, daytime fatigue, or napping. He has no significant medical comorbidities or medications. After optimizing sleep hygiene measures without success, which pharmacologic intervention is most appropriate to initiate for his sleep-onset insomnia?

A 65-year-old man in the intensive care unit reports difficulty initiating sleep but no problems maintaining sleep. His Richmond Agitation–Sedation Scale score is consistently –1 to 0, and he has no evidence of delirium. After optimizing nonpharmacologic sleep measures, the team considers a medication to address his sleep onset insomnia while minimizing risks such as delirium, cognitive impairment, and respiratory depression. Which of the following is the most appropriate initial agent?

A 62-year-old man is admitted to the intensive care unit for severe sepsis and is on mechanical ventilation with a continuous propofol infusion. During evening rounds, it is noted that despite sedation weaning attempts during the day, he experiences significant sleep fragmentation. The patient is frequently awake but unable to initiate sleep, often becoming agitated. His current Richmond Agitation-Sedation Scale (RASS) score fluctuates between -1 and 0 when propofol is minimized. Given this patient’s primary sleep disturbance, which of the following pharmacologic interventions is most appropriate?

A 62-year-old man was recently extubated after acute respiratory distress syndrome and is now stable in the ICU awaiting transfer to a general ward within 1–2 days. He reports persistent difficulty falling asleep, often lying awake for hours despite adequate pain control and a quiet environment. Which of the following is the most appropriate initial pharmacologic agent for his sleep-onset insomnia?

A 68-year-old man with a history of chronic insomnia is being discharged from the hospital. He reports difficulty falling asleep for over an hour each night and frequent nocturnal awakenings despite taking zolpidem as needed. As the clinical pharmacist, which of the following is the most appropriate first-line intervention upon his discharge?

A 68-year-old patient is being treated for septic shock in the intensive care unit. The patient is on assist-control ventilation, receiving a norepinephrine infusion via a central line, and undergoes daily sedation interruptions. During evening rounds, the nursing staff reports the patient has significant difficulty initiating sleep despite adequate pain management. The patient is alert and cooperative but states, “I just lie here awake for hours.” Care is being guided by the ABCDEF bundle to mitigate the risk of post–intensive care syndrome (PICS).

Which of the following is the most appropriate pharmacological intervention to address this patient’s difficulty initiating sleep?

A 65-year-old man in the ICU was mechanically ventilated and received propofol sedation for 48 hours but has now been off sedation for 24 hours and is alert (RASS 0 to –1). Despite environmental sleep-promoting measures (noise reduction, clustered care), he takes several hours to fall asleep. He has no prior history of chronic insomnia. Which of the following is the most appropriate pharmacologic intervention to improve sleep onset while minimizing adverse effects in this critically ill patient?

A 62-year-old man with acute respiratory distress syndrome is intubated and mechanically ventilated in the ICU. He is receiving a continuous propofol infusion titrated to a Richmond Agitation-Sedation Scale (RASS) of –2. During daily sedation interruptions, he reports difficulty falling asleep at night, feeling “wide awake” for hours despite adequate daytime sedation and ventilator synchrony. His sleep remains fragmented, and you are asked to recommend an initial intervention to improve his nocturnal sleep quality. Which of the following is most appropriate?

A 62-year-old man is admitted to the ICU following severe sepsis and has been mechanically ventilated. He was weaned from a continuous propofol infusion 48 hours ago. Despite optimized nonpharmacologic sleep measures (noise/light reduction, clustered care) and no evidence of pain, delirium, or metabolic disturbances, he reports persistent difficulty initiating sleep, often lying awake for several hours each night. His vital signs are stable. Which of the following is the most appropriate initial pharmacologic agent to treat his sleep-onset insomnia?