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2025 PACUPrep BCCCP Preparatory Course

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  1. Pulmonary

    ARDS
    4 Topics
    |
    1 Quiz
  2. Asthma Exacerbation
    4 Topics
    |
    1 Quiz
  3. COPD Exacerbation
    4 Topics
    |
    1 Quiz
  4. Cystic Fibrosis
    6 Topics
    |
    1 Quiz
  5. Drug-Induced Pulmonary Diseases
    3 Topics
    |
    1 Quiz
  6. Mechanical Ventilation Pharmacotherapy
    5 Topics
    |
    1 Quiz
  7. Pleural Disorders
    5 Topics
    |
    1 Quiz
  8. Pulmonary Hypertension (Acute and Chronic severe pulmonary hypertension)
    5 Topics
    |
    1 Quiz
  9. Cardiology
    Acute Coronary Syndromes
    6 Topics
    |
    1 Quiz
  10. Atrial Fibrillation and Flutter
    6 Topics
    |
    1 Quiz
  11. Cardiogenic Shock
    4 Topics
    |
    1 Quiz
  12. Heart Failure
    7 Topics
    |
    1 Quiz
  13. Hypertensive Crises
    5 Topics
    |
    1 Quiz
  14. Ventricular Arrhythmias and Sudden Cardiac Death Prevention
    5 Topics
    |
    1 Quiz
  15. NEPHROLOGY
    Acute Kidney Injury (AKI)
    5 Topics
    |
    1 Quiz
  16. Contrast‐Induced Nephropathy
    5 Topics
    |
    1 Quiz
  17. Drug‐Induced Kidney Diseases
    5 Topics
    |
    1 Quiz
  18. Rhabdomyolysis
    5 Topics
    |
    1 Quiz
  19. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
    5 Topics
    |
    1 Quiz
  20. Renal Replacement Therapies (RRT)
    5 Topics
    |
    1 Quiz
  21. Neurology
    Status Epilepticus
    5 Topics
    |
    1 Quiz
  22. Acute Ischemic Stroke
    5 Topics
    |
    1 Quiz
  23. Subarachnoid Hemorrhage
    5 Topics
    |
    1 Quiz
  24. Spontaneous Intracerebral Hemorrhage
    5 Topics
    |
    1 Quiz
  25. Neuromonitoring Techniques
    5 Topics
    |
    1 Quiz
  26. Gastroenterology
    Acute Upper Gastrointestinal Bleeding
    5 Topics
    |
    1 Quiz
  27. Acute Lower Gastrointestinal Bleeding
    5 Topics
    |
    1 Quiz
  28. Acute Pancreatitis
    5 Topics
    |
    1 Quiz
  29. Enterocutaneous and Enteroatmospheric Fistulas
    5 Topics
    |
    1 Quiz
  30. Ileus and Acute Intestinal Pseudo-obstruction
    5 Topics
    |
    1 Quiz
  31. Abdominal Compartment Syndrome
    5 Topics
    |
    1 Quiz
  32. Hepatology
    Acute Liver Failure
    5 Topics
    |
    1 Quiz
  33. Portal Hypertension & Variceal Hemorrhage
    5 Topics
    |
    1 Quiz
  34. Hepatic Encephalopathy
    5 Topics
    |
    1 Quiz
  35. Ascites & Spontaneous Bacterial Peritonitis
    5 Topics
    |
    1 Quiz
  36. Hepatorenal Syndrome
    5 Topics
    |
    1 Quiz
  37. Drug-Induced Liver Injury
    5 Topics
    |
    1 Quiz
  38. Dermatology
    Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
    5 Topics
    |
    1 Quiz
  39. Erythema multiforme
    5 Topics
    |
    1 Quiz
  40. Drug Reaction (or Rash) with Eosinophilia and Systemic Symptoms (DRESS)
    5 Topics
    |
    1 Quiz
  41. Immunology
    Transplant Immunology & Acute Rejection
    5 Topics
    |
    1 Quiz
  42. Solid Organ & Hematopoietic Transplant Pharmacotherapy
    5 Topics
    |
    1 Quiz
  43. Graft-Versus-Host Disease (GVHD)
    5 Topics
    |
    1 Quiz
  44. Hypersensitivity Reactions & Desensitization
    5 Topics
    |
    1 Quiz
  45. Biologic Immunotherapies & Cytokine Release Syndrome
    5 Topics
    |
    1 Quiz
  46. Endocrinology
    Relative Adrenal Insufficiency and Stress-Dose Steroid Therapy
    5 Topics
    |
    1 Quiz
  47. Hyperglycemic Crisis (DKA & HHS)
    5 Topics
    |
    1 Quiz
  48. Glycemic Control in the ICU
    5 Topics
    |
    1 Quiz
  49. Thyroid Emergencies: Thyroid Storm & Myxedema Coma
    5 Topics
    |
    1 Quiz
  50. Hematology
    Acute Venous Thromboembolism
    5 Topics
    |
    1 Quiz
  51. Drug-Induced Thrombocytopenia
    5 Topics
    |
    1 Quiz
  52. Anemia of Critical Illness
    5 Topics
    |
    1 Quiz
  53. Drug-Induced Hematologic Disorders
    5 Topics
    |
    1 Quiz
  54. Sickle Cell Crisis in the ICU
    5 Topics
    |
    1 Quiz
  55. Methemoglobinemia & Dyshemoglobinemias
    5 Topics
    |
    1 Quiz
  56. Toxicology
    Toxidrome Recognition and Initial Management
    5 Topics
    |
    1 Quiz
  57. Management of Acute Overdoses – Non-Cardiovascular Agents
    5 Topics
    |
    1 Quiz
  58. Management of Acute Overdoses – Cardiovascular Agents
    5 Topics
    |
    1 Quiz
  59. Toxic Alcohols and Small-Molecule Poisons
    5 Topics
    |
    1 Quiz
  60. Antidotes and Gastrointestinal Decontamination
    5 Topics
    |
    1 Quiz
  61. Extracorporeal Removal Techniques
    5 Topics
    |
    1 Quiz
  62. Withdrawal Syndromes in the ICU
    5 Topics
    |
    1 Quiz
  63. Infectious Diseases
    Sepsis and Septic Shock
    5 Topics
    |
    1 Quiz
  64. Pneumonia (CAP, HAP, VAP)
    5 Topics
    |
    1 Quiz
  65. Endocarditis
    5 Topics
    |
    1 Quiz
  66. CNS Infections
    5 Topics
    |
    1 Quiz
  67. Complicated Intra-abdominal Infections
    5 Topics
    |
    1 Quiz
  68. Antibiotic Stewardship & PK/PD
    5 Topics
    |
    1 Quiz
  69. Clostridioides difficile Infection
    5 Topics
    |
    1 Quiz
  70. Febrile Neutropenia & Immunocompromised Hosts
    5 Topics
    |
    1 Quiz
  71. Skin & Soft-Tissue Infections / Acute Osteomyelitis
    5 Topics
    |
    1 Quiz
  72. Urinary Tract and Catheter-related Infections
    5 Topics
    |
    1 Quiz
  73. Pandemic & Emerging Viral Infections
    5 Topics
    |
    1 Quiz
  74. Supportive Care (Pain, Agitation, Delirium, Immobility, Sleep)
    Pain Assessment and Analgesic Management
    5 Topics
    |
    1 Quiz
  75. Sedation and Agitation Management
    5 Topics
    |
    1 Quiz
  76. Delirium Prevention and Treatment
    5 Topics
    |
    1 Quiz
  77. Sleep Disturbance Management
    5 Topics
    |
    1 Quiz
  78. Immobility and Early Mobilization
    5 Topics
    |
    1 Quiz
  79. Oncologic Emergencies
    5 Topics
    |
    1 Quiz
  80. End-of-Life Care & Palliative Care
    Goals of Care & Advance Care Planning
    5 Topics
    |
    1 Quiz
  81. Pain Management & Opioid Therapy
    5 Topics
    |
    1 Quiz
  82. Dyspnea & Respiratory Symptom Management
    5 Topics
    |
    1 Quiz
  83. Sedation & Palliative Sedation
    5 Topics
    |
    1 Quiz
  84. Delirium Agitation & Anxiety
    5 Topics
    |
    1 Quiz
  85. Nausea, Vomiting & Gastrointestinal Symptoms
    5 Topics
    |
    1 Quiz
  86. Management of Secretions (Death Rattle)
    5 Topics
    |
    1 Quiz
  87. Fluids, Electrolytes, and Nutrition Management
    Intravenous Fluid Therapy and Resuscitation
    5 Topics
    |
    1 Quiz
  88. Acid–Base Disorders
    5 Topics
    |
    1 Quiz
  89. Sodium Homeostasis and Dysnatremias
    5 Topics
    |
    1 Quiz
  90. Potassium Disorders
    5 Topics
    |
    1 Quiz
  91. Calcium and Magnesium Abnormalities
    5 Topics
    |
    1 Quiz
  92. Phosphate and Trace Electrolyte Management
    5 Topics
    |
    1 Quiz
  93. Enteral Nutrition Support
    5 Topics
    |
    1 Quiz
  94. Parenteral Nutrition Support
    5 Topics
    |
    1 Quiz
  95. Refeeding Syndrome and Specialized Nutrition
    5 Topics
    |
    1 Quiz
  96. Trauma and Burns
    Initial Resuscitation and Fluid Management in Trauma
    5 Topics
    |
    1 Quiz
  97. Hemorrhagic Shock, Massive Transfusion, and Trauma‐Induced Coagulopathy
    5 Topics
    |
    1 Quiz
  98. Burns Pharmacotherapy
    5 Topics
    |
    1 Quiz
  99. Burn Wound Care
    5 Topics
    |
    1 Quiz
  100. Open Fracture Antibiotics
    5 Topics
    |
    1 Quiz

Participants 432

  • Allison Clemens
  • April
  • ababaabhay
  • achoi2392
  • adhoward1
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Lesson 77, Topic 4
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Supportive Care, Environmental Strategies, and Monitoring

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Supportive Care and Sleep Hygiene in the ICU

Supportive Care, Environmental Strategies, and Monitoring

Objective Icon A checkmark inside a circle, symbolizing an achieved goal.

Objective

Recommend evidence-based supportive care and monitoring strategies to optimize sleep hygiene and circadian alignment in ICU patients, reducing sleep fragmentation, delirium, and associated complications.

1. Environmental Modifications

ICU noise, light, and room design profoundly disrupt sleep and circadian rhythms. Targeted environmental interventions can improve sleep continuity, boost REM/N3 sleep, and lower delirium rates.

Noise Reduction

  • Aim for ambient sound < 50 dB (WHO recommendation) with earplugs (–15–20 dB) and eye masks.
  • Centralize alarm routing, adjust volumes, and apply delay algorithms to cut nuisance alarms by 40–60%.

Light Modulation

  • Deliver 2,000–5,000 lux of blue-enriched light in the morning (06:00–10:00) and dim warm light < 50 lux after 20:00.
  • Align lighting schedules with local sunrise/sunset and seasonal changes.

Architectural Considerations

  • Single-patient rooms with acoustic paneling reduce ambient noise by 10–15 dB.
  • Blackout blinds, door-position sensors, and biophilic window views support dark nights and daytime alertness.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Key Pearls
  • Integrate earplugs and eye masks into ICU admission order sets to achieve > 90% adherence within two weeks.
  • Program LED fixtures to follow day–night cycles for sustained use and patient tolerance.
  • Retrofitting modular acoustic panels and motorized blinds can be completed in < 6 months with minimal workflow disruption.

2. Nursing Care Clustering and Timing

Consolidating overnight vital sign checks and procedures preserves sleep continuity without compromising safety.

Vital Sign Clustering

  • Replace routine every-4-hour checks with individualized schedules (e.g., every 6 hours overnight for low-risk patients).
  • Use a red–amber–green risk-stratification tool to guide monitoring intervals.

Bundling Tasks

  • Coordinate blood draws, medication administration, and nursing tasks into single room entries (e.g., ~02:00–04:00).
  • Embed prompts in electronic flow sheets or CPOE to flag ideal windows.
Pearl IconA shield with an exclamation mark, indicating a clinical pearl. Key Pearls
  • Clustering can cut sleep interruptions by 40–50% and has been shown to improve Richards–Campbell Sleep Questionnaire (RCSQ) scores by ~20 points.
  • Sustained adherence (> 85%) is achieved by integrating bundled-care checklists into nursing documentation.

3. Daytime Mobilization and Physical Therapy

Early and regular mobilization reinforces circadian cues, reduces daytime sleep propensity, and consolidates nocturnal sleep.

Circadian Entrainment Mechanisms

  • Physical activity elevates core body temperature and stimulates peripheral clock genes.
  • Passive range-of-motion exercises in sedated patients still convey time-of-day signals.

Early Mobility Protocols

  • Initiate within 48 hours if hemodynamically stable (minimal vasoactive support; FiO₂ ≤ 0.6; PEEP ≤ 10 cmH₂O).
  • Use standardized safety checklists to minimize orthostatic hypotension and unplanned extubations.
Pearl IconA shield with an exclamation mark, indicating a clinical pearl. Key Pearls
  • Early mobilization reduces sleep fragmentation by ~25%, shortens mechanical ventilation by 1–2 days, and lowers delirium incidence by ~40%.
  • Incorporate physical and occupational therapists into daily rounds to ensure protocol consistency.

4. Staff Education and Culture Change

A well-trained multidisciplinary team committed to sleep hygiene principles ensures sustainable practice change.

Sleep Hygiene Training

  • Conduct interactive workshops on sleep architecture, circadian biology, and environmental factors.
  • Use simulation scenarios to foster empathy for sleep disruption.

Culture Change Strategies

  • Launch noise-level leaderboards and gamified feedback to improve compliance by > 50%.
  • Integrate sleep quality metrics into daily multidisciplinary rounds to maintain accountability.

Protocol Development

  • Form interdisciplinary committees (physicians, nurses, therapists, engineers).
  • Pilot test via Plan–Do–Study–Act (PDSA) cycles, refining based on stakeholder feedback.
Pearl IconA shield with an exclamation mark, indicating a clinical pearl. Key Pearls
  • Appoint a dedicated ‘sleep steward’ to champion interventions and report weekly metrics.
  • Reconcile discipline-specific priorities (e.g., infection control vs. low-light environment) through facilitated evidence reviews.

5. Integration of Pharmacologic and Non-Pharmacologic Pathways

A stepped-care algorithm prioritizes environmental and behavioral measures, with pharmacotherapy reserved for refractory sleep disturbance or delirium.

Stepwise Algorithm

ICU Sleep Management Algorithm A flowchart showing the stepped-care approach to managing sleep in the ICU. It starts with universal non-pharmacologic interventions, followed by assessment. If sleep is poor or delirium is present, melatonin is added. If still refractory, dexmedetomidine is considered. Step 1: Universal Sleep Bundle on Admission Environmental Controls, Clustered Care, Mobilization Step 2: Assess After 24h RCSQ Score & CAM-ICU Status OK Monitor RCSQ > 50 No Delirium RCSQ ≤ 50 OR New Delirium Step 3: Add Pharmacotherapy Melatonin 3–5 mg enteral at 21:00 Still Refractory? (Ventilated & Stable) Re-evaluate daily NO Continue YES Step 4: Consider Advanced Therapy Dexmedetomidine 0.2–0.4 μg/kg/h. Re-evaluate & de-escalate.
Figure 1: ICU Sleep Management Algorithm. This flowchart illustrates a stepped-care approach, starting with universal non-pharmacologic interventions and escalating to pharmacotherapy based on daily assessments of sleep quality and delirium.

Patient Tailoring

  • Adjust for renal/hepatic function and hemodynamic status.
  • Avoid benzodiazepines and antipsychotics due to delirium risk.
Case Vignette IconA clipboard icon representing a patient case.

Case Vignette

A 62-year-old post-operative ventilated patient remained delirious after 48 hours of optimized lighting, earplugs, and mobilization. Melatonin was initiated at 3 mg at 21:00, yielding a 20-point improvement in RCSQ and resolution of delirium over the next 48 hours.

Pearl IconA shield with an exclamation mark, indicating a clinical pearl. Key Pearls
  • Embed the stepped-care algorithm into electronic order sets to reduce time to intervention by ~30%.
  • Combine melatonin with non-pharmacologic measures for synergistic effects; reserve dexmedetomidine for clear indications.

6. Monitoring and Evaluation

Continuous assessment of sleep quality, delirium incidence, and protocol adherence drives quality improvement.

Sleep Metrics

  • RCSQ for subjective assessment: Scores ≤ 50 indicate need for escalation.
  • Actigraphy for objective trends, with caution in immobilized patients.

Delirium Surveillance

  • Daily CAM-ICU screening to track prevalence and duration.
  • Secondary outcomes: mechanical ventilation days, ICU length of stay, falls.

Quality Improvement

  • Key performance indicators: overnight noise levels, average RCSQ score, delirium days, protocol adherence.
  • Use PDSA cycles and real-time dashboards linking sleep and delirium data to target lapses.
Pearl IconA shield with an exclamation mark, indicating a clinical pearl. Key Pearls
  • Integrating sleep and delirium metrics into a unified dashboard enables rapid identification of protocol gaps.
  • Regularly share QI data with frontline staff to sustain engagement and continuous refinement.

References

  1. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for pain, agitation/sedation, delirium, immobility and sleep disruption in adult ICU patients. Crit Care Med. 2018;46(9):e825–e873.
  2. Van Rompaey B, Elseviers MM, Van Drom W, et al. Earplugs at night reduce delirium and improve sleep perception in ICU patients: a randomized trial. Crit Care. 2012;16:R73.
  3. Barr J, Fraser GL, Puntillo K, et al. Pain, agitation and delirium management guidelines in adult ICU patients. Crit Care Med. 2013;41(1):263–306.
  4. Tan X, van Egmond L, Partinen M, et al. Interventions for improving sleep and reducing circadian disruption in inpatients: a narrative review. Sleep Med. 2019;59:42–50.
  5. Mottram V, Middleton B, Williams P, et al. Bright white vs. blue-enriched light effects on sleep and circadian phase in polar winter. J Sleep Res. 2011;20(1 Pt 2):154–161.
  6. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in ventilated ICU patients: a randomized trial. Lancet. 2009;373(9678):1874–1882.
  7. Patel J, Baldwin J, Bunting P, et al. Multicomponent bundle effects on sleep and delirium in ICU patients. Anaesthesia. 2014;69(5):540–549.
  8. Sateia MJ, Buysse DJ, Krystal AD, et al. Pharmacologic treatment of chronic insomnia in adults: clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349.
  9. Su X, Meng ZT, Wu XH, et al. Dexmedetomidine for delirium prevention after non-cardiac surgery: randomized trial. Lancet. 2016;388(10054):1893–1902.