title: The Feasibility and Utility of Continuous Sleep Monitoring in Critically Ill Patients Using a Portable Electroencephalography Monitor.
abstract: Sleep disruption in critically ill adults can result in acute decrements in cognitive function, including delirium, but it is underdiagnosed in the setting of the intensive care unit (ICU). Although sleep stages can be assessed by polysomnography (PSG), acquisition and interpretation of PSG is costly, is labor intensive, is difficult to do over an extended period of time with critically ill patients (multiple days of continuous recording), and may interfere with patient care. In this pilot study, we investigated the feasibility and utility of monitoring sleep in the ICU setting using a portable electroencephalography (EEG) monitor, the SedLine brain monitor.
  
  
  
  We first performed a baseline comparison study of the SedLine brain monitor by comparing its recordings to PSG recorded in a sleep laboratory (n = 3). In a separate patient cohort, we enrolled patients in the ICU who were monitored continuously with the SedLine monitor for sleep disruption (n = 23). In all enrolled patients, we continuously monitored their EEG. The raw EEG was retrieved and sleep stages and arousals were analyzed by a board-certified technologist. Delirium was measured by a trained research nurse using the Confusion Assessment Method developed for the ICU.
  
  
  
  For all enrolled patients, we continuously monitored their EEGs and were able to retrieve the raw EEGs for analysis of sleep stages. Overall, the SedLine brain monitor was able to differentiate sleep stages, as well as capture arousals and transitions between sleep stages compared with the PSG performed in the sleep laboratory. The percentage agreement was 67% for the wake stage, 77% for the non-rapid eye movement (REM) stage (N1 = 29%, N2 = 88%, and N3 = 6%), and 89% for the REM stage. The overall agreement was measured with the use of weighted kappa, which was 0.61, 95% confidence interval, 0.58 to 0.64. In the ICU study, the mean recording time for the 23 enrolled patients was 19.10 hours. There were several signs indicative of poor-quality sleep, where sleep was distributed throughout the day, with reduced time spent in REM (1.38% ± 2.74% of total sleep time), and stage N3 (2.17% ± 5.53% of total sleep time) coupled with a high arousal index (34.63 ± 19.04 arousals per hour). The occurrence of ICU delirium was not significantly different between patients with and without sleep disruption.
  
  
  
  Our results suggest the utility of a portable EEG monitor to measure different sleep stages, transitions, and arousals; however, the accuracy in measuring different sleep stages by the SedLine monitor varies compared with PSG. Our results also support previous findings that sleep is fragmented in critically ill patients. Further research is necessary to develop portable EEG monitors that have higher agreement with PSG.
authors.affiliation: From the Departments of *Anesthesia and Perioperative Care and †Medicine, University of California San Francisco, San Francisco, California; and ‡Office of Biostatistics & Quantitative Health Sciences, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii.
authors.forename: Susana
authors.initials: S
authors.lastname: Vacas
authors.forename: Erin
authors.initials: E
authors.lastname: McInrue
authors.forename: Michael A
authors.initials: MA
authors.lastname: Gropper
authors.forename: Mervyn
authors.initials: M
authors.lastname: Maze
authors.forename: Rochelle
authors.initials: R
authors.lastname: Zak
authors.forename: Eunjung
authors.initials: E
authors.lastname: Lim
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Leung
mesh_terms: D000368:Aged; D001143:Arousal; D001921:Brain / Q000503:physiopathology*; D058256:Brain Waves; D003422:Critical Care; D016638:Critical Illness; D003693:Delirium / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology; D004569:Electroencephalography / Q000295:instrumentation*; D004867:Equipment Design; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation*; D010865:Pilot Projects; D019095:Point-of-Care Systems; D000067716:Point-of-Care Testing; D017286:Polysomnography; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012815:Signal Processing, Computer-Assisted; D012892:Sleep Deprivation / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D012894:Sleep Stages; D013997:Time Factors