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PADIS Guidelines Update
1 Plays11 months ago
In this episode, Dr. Zanotti discussed the Society of Critical Care Medicine “Focused Update on the Clinical Guidelines for the Prevention and Management of Pain, Anxiety. Agitation/Sedation. Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU." This is also known as the PADIS Guidelines. He is joined by Joanna L. Stollings, PharmD, a Board-Certified Pharmacotherapy Specialist and a Board-Certified Critical Care Pharmacotherapy Specialist. Joanna is the Medical Intensive Care Unit (MICU) Clinical Pharmacy Specialist at the Vanderbilt University Medical Center. She also served as vice chair for the PADIS Guideline Focused Update and co-authored the guidelines.
Additional resources:
Society of Critical Care Medicine Focused Update on the Clinical Guidelines for the Prevention and Management of Pain, Anxiety. Agitation/Sedation. Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. PADIS 2025 Update: https://pubmed.ncbi.nlm.nih.gov/39982143/
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. PADIS 2018 Guidelines: https://pubmed.ncbi.nlm.nih.gov/30113379/
Link to a previous episode of Critical Matters discussing the PADIS 2018 Guidelines: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=635606964
Landing page for the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center: https://www.icudelirium.org/
Books mentioned in this episode:
The Prophet. By Kahlil Gibran: https://bit.ly/4lA2Jhx
Recommended
Transcript
Podcast Introduction
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
ICU Patient Challenges and PATIS Guidelines
00:00:33
Speaker
Most critically ill patients experience pain, anxiety, agitation, delirium, immobility, and sleep disruption during their stays in the intensive care unit.
00:00:43
Speaker
Today's podcast episode will discuss the Society of Critical Care Medicines' recently published focused update on the clinical guidelines for the prevention and management of pain, anxiety, agitation, sedation, delirium, immobility, and sleep disruption in adult patients in the ICU, also known as the PATIS guidelines.
00:01:02
Speaker
Our guest is Dr. Joanna Stolins, a PharmD doctor in pharmacy with board-certified pharmacotherapy specialist and a board-certified critical care pharmacotherapy specialist.
00:01:13
Speaker
She is the medical intensive care unit, MICU, clinical pharmacy specialist at the Vanderbilt University Medical Center.
00:01:20
Speaker
Her research interests include pharmacotherapy, analgesia, sedation, and delirium agents, non-pharmacologic methods used to prevent delirium, and strategies to facilitate ventilator weaning.
00:01:32
Speaker
A true champion from ICU liberation, Joanna was the vice chair for the PADIS Guideline-focused update and co-authored the guidelines.
00:01:40
Speaker
Joanna, welcome to Critical Matters.
00:01:43
Speaker
Thank you, Sergio.
00:01:43
Speaker
I'm so excited to be here.
00:01:45
Speaker
So why, maybe we can start with just a simple question of why do you think intensivists should care about this topic?
The ABCDF Bundle & ICU Patient Care
00:01:53
Speaker
I mean, I think this topic is one of the most important things with regards to critical care, to be honest.
00:02:00
Speaker
I mean, I just feel like that if we don't treat patients pain, then they can become very agitated.
00:02:06
Speaker
They can develop delirium.
00:02:08
Speaker
We know all the bad outcomes that happened secondary to delirium.
00:02:12
Speaker
We know that patients have increased risk of mortality.
00:02:15
Speaker
We know that they have increased risk of cognitive impairment.
00:02:18
Speaker
It prolongs their stay in the ICU and the hospital.
00:02:20
Speaker
It increased health care costs.
00:02:23
Speaker
I just think that for overall patient care, this is a very important topic.
00:02:29
Speaker
And I think that one of the things that I always share with people from my perspective is that ICU liberation, which includes all the things that you mentioned, and the ABCDF bundle, which obviously includes some of the interventions that we'll talk about today in our evidence base, not only is
00:02:47
Speaker
impact, I mean, patients in a very positive and I think meaningful way for them, but the sheer volume of patients that are affected by this, right, almost every single patient that comes into our ICU is going to benefit from these interventions.
00:03:01
Speaker
And I think that that should make it a constant in terms of what we do every day at the ICU.
00:03:08
Speaker
I 100% agree.
00:03:12
Speaker
And we'll talk a little bit more at the end, but I also think that the other aspect of this is that a lot of people might think, oh, we already do all this.
00:03:21
Speaker
But my challenge to them is that there's always more to do.
00:03:25
Speaker
And no matter how good you think you're doing ICU liberation, you can do it better.
00:03:29
Speaker
So we'll talk about that
Evolution and Updates of PADIS Guidelines
00:03:31
Speaker
at the end.
00:03:31
Speaker
But maybe we could start at the beginning with the PADIS guidelines from 2018 and maybe just at a high level.
00:03:39
Speaker
Tell us a little bit about those guidelines and then we can talk about the focused update and how it's different.
00:03:45
Speaker
Perfect.
00:03:45
Speaker
So the PIDIS guidelines that were published in 2018, so they differed from the PIDIS, so pain, agitation, delirium guidelines that were published in 2013 because they added in the IS.
00:03:55
Speaker
So they added in the early mobility and the sleep aspects.
00:03:58
Speaker
So these were extensive guidelines.
00:04:00
Speaker
I think they made like 30 different recommendations for
00:04:04
Speaker
But John Devlin led them and very, very specific, like with regards to pain, going into very specifics with regards to what to do with each different type of like analgesic, whether that be acetaminophen, ketamine, NSAIDs, et cetera.
00:04:20
Speaker
Specifics with regards to recommending either propofol or dexamethatomidine over benzodiazepines,
00:04:27
Speaker
was another big thing that was stated, is specifically stated that antipsychotics were not recommended for their treatment of delirium.
00:04:36
Speaker
Early mobility was recommended.
00:04:38
Speaker
And then with regards to sleep, like with regards to pharmacotherapy of sleep, there wasn't a lot that was specifically recommended just because there wasn't enough evidence at that time to really suggest that.
00:04:51
Speaker
And I guess that leads to the next question, which is how did the focus update come to be?
00:04:56
Speaker
So the focus update came to be because, like I said, the 2018 PADIS guidelines were so extensive that they took a long time, honestly, to put together.
00:05:05
Speaker
And it was, I think it was frustrating for a lot of people.
00:05:08
Speaker
They're always hungry for new information that like, hey, we can't have new guidelines only coming out every seven years.
00:05:14
Speaker
So the Society of Critical Care Medicine really took that feedback into account and said, we're going to have more rapid updates where we only have like five questions, but these are expected to be done within two years.
00:05:26
Speaker
And so that's why that we have a more focused update with only five questions essentially addressed this time.
00:05:32
Speaker
Excellent.
00:05:33
Speaker
So before we go into those questions, could you just give us a little bit of an overview of some of the methodology that was applied?
00:05:40
Speaker
I mean, that I think is the customary methodology applied to these guidelines.
00:05:44
Speaker
And obviously it includes the grade recommendations versus suggestions and the PICO questions that, as you mentioned, for this particular update were five particular questions.
00:05:55
Speaker
Okay, so a grade, if you're not familiar with that, is essentially like a systematic approach used to assess the quality and the quality evidence, I should say, and the strength of the recommendations in a systematic fashion.
00:06:07
Speaker
And so when we were thinking about...
00:06:10
Speaker
early on in these guidelines, like we all like myself, the other vice co-chair and the co-chairs, like we were putting together questions and we asked all our different panel members to essentially put together questions that we thought like enough evidence had came out with with regards to what had changed really since the 2018 PIDIS guidelines.
00:06:30
Speaker
And so people put together questions and we essentially voted to see which we thought would be the first or the best five questions to
00:06:37
Speaker
So essentially, when you do this, like you essentially are looking for what questions you want to answer, and then you're like assessing the evidence that's out there for each of these different questions, grading the actual evidence and then coming up with your recommendation for the guidelines.
Understanding Guideline Recommendations: 'Recommend' vs 'Suggest'
00:06:56
Speaker
And when you come with recommendations based on the amount of evidence, could you explain kind of in simple terms, what's the difference between we recommend versus we suggest?
00:07:09
Speaker
It really just comes down to, excuse me, sorry, quality of evidence, right?
00:07:13
Speaker
There's like lower...
00:07:15
Speaker
suggest something versus if you have higher quality evidence, then you're going to be able to more say that you actually like recommend to do something.
00:07:22
Speaker
So recommending something is a higher quality evidence statement than just suggesting something.
00:07:29
Speaker
And I guess from a patient perspective, a recommendation that we recommend would be something that the majority of patients would probably want considering the available evidence and the pros and cons.
00:07:40
Speaker
And I suggest would be that, okay, that an important number, but there might be some room for discussion based on some preferences, correct?
00:07:49
Speaker
Exactly, 100%.
00:07:51
Speaker
And in terms of policy makers, usually if they're going to make any quality markers or kind of best care, standards of care, it would be based on recommendations that we recommend in a high level of evidence.
00:08:06
Speaker
Would that be fair?
00:08:07
Speaker
Exactly.
00:08:08
Speaker
Excellent.
00:08:09
Speaker
So as we move into the specific questions and the five areas that you explored in the update, could you just maybe just link the PADIS guidelines to the ABCDF bundles?
Mnemonic Connection: PADIS Guidelines & ABCDF Bundle
00:08:21
Speaker
Because they're not the same thing, yet they're intimately related.
00:08:26
Speaker
So interestingly enough, this is kind of a cool story.
00:08:28
Speaker
So when the PAD guidelines, the pain, agitation, and delirium came out in 2013, Wesley was on a flight and he came up with the ABCDF bundle because he wanted to come up with some kind of mnemonic to help essentially the guidelines to be sticky.
00:08:43
Speaker
to help people remember them.
00:08:45
Speaker
So that's why the ABCDF or IC Liberation Bundle was developed, was to essentially initially help people remember the PAD guidelines.
00:08:54
Speaker
And the same has came through with the PADS guidelines in 2018 or this more recent update from this past or from this year.
00:09:02
Speaker
And that's why or how that came to be.
00:09:06
Speaker
And I just want to make sure I think most people know this, but just to
00:09:08
Speaker
Go over it like the A stands for assess, prevent, and manage pain.
00:09:12
Speaker
The B is both spontaneous awakening trials and breathing trials.
00:09:14
Speaker
C is your choice of analgesia and sedation.
00:09:17
Speaker
D is delirium, so assess, prevent, manage delirium.
00:09:20
Speaker
E is early mobility.
00:09:21
Speaker
And F is just incorporating the family into all of that.
00:09:25
Speaker
Excellent.
00:09:26
Speaker
So maybe we can go with each one of the questions.
00:09:30
Speaker
And what I thought, Joanna, is that we can talk about the topic and you can tell us what was the question we're trying to answer.
00:09:36
Speaker
Then maybe just share with us the flat out recommendation and then give us a little bit of insight into the rationale behind that.
00:09:44
Speaker
What's out there in the literature and any comments you have.
00:09:47
Speaker
So I guess just to...
00:09:51
Speaker
to share with the audience, we're going to talk about anxiety, agitation and sedation, delirium, immobility, and sleep.
00:09:58
Speaker
Those are the five areas where questions were developed, where new evidence was available, and where a recommendation came out.
00:10:05
Speaker
So why don't we start with anxiety?
Managing Anxiety in ICU Patients
00:10:07
Speaker
Maybe we can start with what was the question the guideline was trying to answer?
00:10:11
Speaker
So we all, and honestly, I want to make sure that I give 100% credit to Michelle Biles on this because this was her creative idea.
00:10:19
Speaker
But if you think about it, like people, we have tons of people that are anxious in the ICU every day, but we knew that there isn't a validated tool to assess for anxiety in the ICU, right?
00:10:33
Speaker
And there are also, we also knew or were very suspicious before we even did the literature search that there's not good data, right, with regards to what we should be doing to manage anxiety in patients.
00:10:44
Speaker
So specifically, we wanted to look at the question about whether or not we should be using benzodiazepines to manage anxiety in patients ICU.
00:10:52
Speaker
And no, I mean, there's no evidence to support this.
00:10:56
Speaker
So this
00:10:56
Speaker
This question was really put in as really a call to action.
00:10:59
Speaker
Like, anxiety is very prevalent in the ICU.
00:11:02
Speaker
Like, why do we not have better resources to assess for this?
00:11:05
Speaker
Why do we not have better studies to assess how to prevent this, how to treat this, et cetera, with really any kind of drug?
00:11:12
Speaker
And I think an important distinction is that we give tons of information
00:11:20
Speaker
sedation and medication for people who are on mechanical ventilation, probably much more than we should, and we'll talk about that.
00:11:25
Speaker
But this is really for patients who might not be intubated, who are about to go for cabbage, who are post-surgery, who are having other issues, right?
00:11:34
Speaker
And like you mentioned, very commonly will be anxious or have a history of anxiety.
00:11:40
Speaker
And that's the question that you were trying to answer, which...
00:11:42
Speaker
This really derived in no recommendation because like you said, there is no data available for this, but maybe this will be a call for action for somebody to start studying this.
00:11:52
Speaker
Exactly.
00:11:54
Speaker
Excellent.
00:11:55
Speaker
The second area was agitation and sedation.
00:11:59
Speaker
And here there's a change or an update from the previous recommendations in the PADIS-CADINS of 2018.
00:12:06
Speaker
Could you tell us what the question was for this area?
Sedation Choices: Dexmedetomidine vs Propofol
00:12:10
Speaker
So we knew that there had been a lot more data that had came out with regards to specifically comparing dexmedetomidine and propofol, because remember the PADIS guidelines from 2018 had said that you could use either dexmedetomidine or propofol, just don't use benzos essentially.
00:12:25
Speaker
And so we wanted to specifically compare the two different agents, dexmedetomidine and propofol, and see if the newer evidence like SPICE-3 and MENSE-2 would change this recommendation.
00:12:37
Speaker
And it did.
00:12:38
Speaker
Essentially, it gave us the ability to make a recommendation essentially to say that Presidex or dexmedetomidine to consider use of that over propofol just because it's been shown to decrease prevalence of delirium and it may decrease the duration of delirium in ICU length of stay.
00:12:57
Speaker
And it may decrease the time to reach the patient's target level of sedation.
00:13:02
Speaker
And it may even improve precox.
00:13:05
Speaker
patients' quality of life and their functional outcomes at six months out with the caveat that obviously dexamethatomidine can cause a lot of bradycardia.
00:13:14
Speaker
But if we value delirium, which I think most of us do, management prevention of delirium over the potential for bradycardia, then to try to use dexamethatomidine over propofol.
00:13:26
Speaker
Now, obviously, there's some caveats to this.
00:13:28
Speaker
You can't deeply sedate someone, unfortunately, with dexamethatomidine.
00:13:31
Speaker
Like if that's the case, if you have a severe ARDS patient,
00:13:34
Speaker
You're going to have to use purple fall over dexamethatomidine.
00:13:37
Speaker
And you have to consider resource limited situations too.
00:13:41
Speaker
Dexamethatomidine is generic now and it's much more cost effective than it used to be, but still might not be available to all institutions and all over the world.
00:13:50
Speaker
And so because of that, there may be instances where other sedatives need to be considered.
00:13:57
Speaker
But it's interesting, obviously, like, what would you say, the span of a decade or a little bit more, the dexmetomidin story, how it's played out, right?
00:14:05
Speaker
Yeah, it's been amazing.
00:14:07
Speaker
Yeah.
00:14:08
Speaker
It's really fascinating.
00:14:09
Speaker
And I know that when it wasn't generic, I mean, and we didn't have any outcome data, there was a big push from our clinical pharmacy colleagues to be more judicious with its use, right?
00:14:21
Speaker
Now, like you said, cost is not an issue for most people, right?
00:14:25
Speaker
I mean, it's generic, and I think it's cost-effective in most places that have access to it.
00:14:29
Speaker
But like you mentioned, I mean, it seems that especially with delirium, there seems to be an advantage, right?
00:14:36
Speaker
So as a first-go drug in the ICU, maybe, I mean, Presidex or dexmedetomidine is now recommended by the guidelines.
00:14:44
Speaker
And that is a departure or a change based on newer studies.
00:14:48
Speaker
In the previous guidelines, it was one or the other over benzos.
00:14:51
Speaker
Now, it clearly seems like the pekinora would be dexmedetomidine, propofol, and benzos for very specific situations.
00:14:59
Speaker
Would that be correct?
00:15:01
Speaker
Yes, that is correct.
00:15:03
Speaker
And I think you already mentioned, but I think it's worth obviously emphasizing that we do also recognize that some patients may need heavy sedation, and that is usually not something that is easily achievable with dexmedetaminin.
00:15:15
Speaker
In those cases, you might have to use something like propofol.
00:15:19
Speaker
Now, not mentioned in the guidelines, but obviously within your expertise, what would you say, or in your practice, what would be examples of situations where you actually do use benzodiazepines?
00:15:32
Speaker
I mean, it is a rare situation where we're going to use benzodiazepine.
00:15:37
Speaker
An example would be a patient that had severe ARDS and needed deep sedation that we had optimized their ventilator settings and we had came to the point where we were having to deeply control.
00:15:49
Speaker
sedate and give high levels of analgesia to the patient and that the patient was at high risk for developing propofol infusion syndrome.
00:15:57
Speaker
So perhaps maybe the patient had triglycerides that were more than 800 or 1,000 or they had a CK that was more and then 5,000, maybe an upturning lactate, like things that were indicative that this patient was at high risk for developing PRIS and that's somebody that we would have to put on a benzodiazepine.
00:16:16
Speaker
And I guess I'm in the only situation, but also Presidex works pretty well there is also for severe alcohol withdrawal or during those tremens, but you probably wouldn't necessarily need a drip, hopefully, if you take care of it early.
00:16:29
Speaker
Exactly.
00:16:30
Speaker
Like I think the other thing to consider too, like with severe alcohol withdrawal, I think if you interviewed practitioners from most institutions, phenobarbital is becoming like a bigger trend.
00:16:41
Speaker
And so our institution specifically, we use a lot more phenobarbital and we don't really use as many benzodiazepines for alcohol withdrawal.
00:16:52
Speaker
Like sometimes in the emergency department, they'll try a couple of doses of benzodiazepines, but if the patient's refractory that, then we're going to put them on a phenobarbital.
00:16:59
Speaker
um
00:17:04
Speaker
The other area that I just wanted to touch briefly before we move on to the next topic, Joanna, is you mentioned bradycardia.
00:17:11
Speaker
And I just wanted your opinion.
00:17:13
Speaker
In my experience, I think bradycardia more often is something we see as opposed to something that causes problems like hemodynamic problems.
00:17:22
Speaker
However, obviously, you have to think about that in particular in individual patient situations.
00:17:27
Speaker
Has that been your experience as well? 100%.
00:17:31
Speaker
100%.
00:17:32
Speaker
And if you look at like when we performed the men's two trial, like if you look at the specific like exclusion criteria, it's not just bradycardia, it's symptomatic bradycardia.
00:17:41
Speaker
So in other words, is your patient hypotensive with the bradycardia?
00:17:45
Speaker
Like I'm a marathoner.
00:17:47
Speaker
Like if you look at my heart rate, my heart rate's probably 40 right now, you know, and I'm definitely not alone in that, you know, but my blood pressure I'm sure is just fine.
00:17:55
Speaker
So I think you have to consider the whole clinical picture.
00:17:57
Speaker
And this is something we talk about on rounds.
00:17:59
Speaker
And maybe the nurse will be like, yeah, the patient's not tolerating the dexamidotomy because they're so bradycardic.
00:18:04
Speaker
But the very next question needs to be asked is what is their blood pressure?
00:18:08
Speaker
Like, is this symptomatic bradycardia?
00:18:09
Speaker
Because absolutely, if it's not, then you can keep the prestax going for sure.
00:18:14
Speaker
Perfect.
00:18:16
Speaker
So the next question, which I think is one of your favorites, is delirium.
00:18:20
Speaker
It is.
00:18:22
Speaker
So what was the question?
00:18:25
Speaker
And then we can talk about the recommendation and you can tell us a little more about the literature.
Antipsychotics in Delirium Treatment
00:18:28
Speaker
Okay, so the question was, we knew, so actually when the 2018 PIDIS guidelines were published, MindUSA, which was a study we led at our institution comparing Zeprizone, Halidol, and placebo, was not published yet.
00:18:42
Speaker
But this recommendation was still made to not give antipsychotics to treat delirium.
00:18:47
Speaker
But since those guidelines came out, another study had came out, AidICU, which looked specifically at Halidol versus placebo,
00:18:57
Speaker
And actually had shown a mortality reduction as a secondary outcome with the haloperidol.
00:19:03
Speaker
And so with that new evidence, both those big studies, we thought it was very important to reevaluate and to determine whether or not it's appropriate to use antipsychotics for treatment of delirium.
00:19:15
Speaker
Excellent.
00:19:16
Speaker
And what was, I mean, the final, I think this is an area where people still have... This is a tricky one.
00:19:22
Speaker
It's a tricky one.
00:19:23
Speaker
And I think that it's hard to teach an old dog new tricks, right?
00:19:29
Speaker
People keep going for some of these medications over and over again.
00:19:33
Speaker
So where do we stand today?
00:19:35
Speaker
I mean, we honestly didn't feel comfortable making a recommendation just because we found that antipsychotics may decrease 28-day mortality and they mildly might increase delirium-free days.
00:19:50
Speaker
But it just doesn't make...
00:19:51
Speaker
makes sense because they don't affect your time on the vent, time in the ICU, time in the hospital.
00:19:58
Speaker
Like how do they affect mortality if they don't affect any of the things that lead up to mortality?
00:20:03
Speaker
So we really hemmed and hawed on this one and honestly just did not feel comfortable making a recommendation.
00:20:10
Speaker
Looked at various subgroups like hypoactive, hyperactive, lume, et cetera, and just did not feel comfortable
00:20:17
Speaker
I personally don't think it is that we should be using antipsychotics to treat delirium.
00:20:22
Speaker
I do think that if you have a patient that is going to like punch the nurse, harm you, harm themselves, et cetera, then I think it's very appropriate to have antipsychotics.
00:20:31
Speaker
But just to hand them out to people because they're delirious, I don't think is appropriate.
00:20:35
Speaker
I do think that at this point we probably do need larger trials, specifically in patients that have hypoactive or hyperactive delirium.
00:20:45
Speaker
And I think, like you said, I mean, you really should be treating like the almost symptoms of psychotic behavior almost, right?
00:20:53
Speaker
Like, I mean, really aggressive and agitated that might endanger themselves or part of the health care team, which obviously we see in the ICU sometimes.
00:21:02
Speaker
And those patients might be very hard to deal with.
00:21:05
Speaker
sometimes, right?
00:21:07
Speaker
But in terms of just in the general sense of using it for delirium, which I think is very common, right?
00:21:14
Speaker
We just don't have the data.
00:21:16
Speaker
And the studies that have been done so far have not really shown that there's any clear signal there, correct?
00:21:23
Speaker
Exactly.
00:21:23
Speaker
Like I said, the only one was the 8ICU study, but that wasn't a primary outcome.
00:21:26
Speaker
That's a secondary outcome, and it just doesn't make sense.
00:21:29
Speaker
Like, why would those affect mortality when they don't affect any of the things that would lead to mortality?
00:21:35
Speaker
So I think for delirium right now, Joanna, what do you think is the most important?
00:21:40
Speaker
Just to recognize it, prevent it, and talk about it?
00:21:44
Speaker
I mean, obviously, it's kind of frustrating that we know it's associated with bad outcomes for our patients, yet we don't really have any solution for it, right?
00:21:53
Speaker
I mean, but we kind of do though, right?
00:21:55
Speaker
It's just not medications.
00:21:57
Speaker
We know that like, obviously if they need sedation, like dexamethatomidine, like we've already talked about there, but there's tons of non-pharmacologic things that we can do.
00:22:04
Speaker
Like Wesley Lee, and I agree with this completely, likes to treat the new onyx Dr. Dre, like the rapper from Atlanta.
00:22:11
Speaker
So like the first DR is like drug removal, which you know, or I'm sorry, the first DR is disease remediation.
00:22:16
Speaker
So just thinking about treating the sepsis, the heart failure, the COPD, right?
00:22:20
Speaker
And the next ER is drug removal, which obviously I'm always excited to do.
00:22:23
Speaker
Like, don't give benzos.
00:22:24
Speaker
Turn off their sedation every day.
00:22:26
Speaker
Turn off their analgesia.
00:22:27
Speaker
Don't give them their home allergy med or their home med for their overactive bladder.
00:22:31
Speaker
Decrease steroids.
00:22:33
Speaker
Only use them if you absolutely have to.
00:22:35
Speaker
And then the last being the environment.
00:22:37
Speaker
So putting on patients' eyeglasses, putting their hearing aids on, mobilizing patients'
00:22:42
Speaker
and trying to just do everything you can to normalize their sleep-wake cycle.
00:22:45
Speaker
So stop waking them up in the middle of the night and to give them some random medication or to check labs if we don't have to.
00:22:50
Speaker
Yeah, and I think you make a good point, right?
00:22:53
Speaker
I mean, there actually is a lot that we can do, and I think to prevent or mitigate the effects of delirium.
00:23:02
Speaker
And again, I think even people who think that they're doing it, there's probably opportunity to do it a little bit better every day.
00:23:08
Speaker
And I think that should be kind of the journey with the ICU liberation, with the A to F bundles.
00:23:13
Speaker
But yeah, Dr. Dre was coming to my mind as I was asking that question.
00:23:18
Speaker
And I definitely have seen Wes and your team share that with in multiple presentations.
00:23:24
Speaker
So that's very, very useful.
00:23:27
Speaker
Anything else you want to add for delirium in terms of upcoming studies or things that you are interested in that are coming down the pipe?
00:23:37
Speaker
I mean, I think one other thing I'll say that I think is interesting that is that we published a secondary announcement of Mind USA last year, specifically looking at a QT prolongation, just because that's another big thing with antipsychotics is people go bananas for lack of a better word.
00:23:53
Speaker
When people were on anticegata, it was like, oh, my gosh, we got to check the QT every single day, you know.
00:23:57
Speaker
And we essentially, when we looked at QT prolongation on patients that got haloperidol, saprosin and placebo, there essentially was no difference between the three different groups.
00:24:09
Speaker
And in fact, the only thing that really predicted that they were going to have a long QT is if they had a baseline long QT.
00:24:16
Speaker
So I think that really highlights that we over monitor these drugs when we give them.
00:24:20
Speaker
So A, do you need to give the drug?
00:24:22
Speaker
But B, if you are, then please don't be checking their QTC as often as you maybe have historically.
00:24:29
Speaker
Perfect.
00:24:31
Speaker
The next category relates to early mobility or immobility.
00:24:36
Speaker
And I think that this is an area where, based on some more recent studies, I think some people have taken the wrong conclusion, right?
00:24:47
Speaker
Agreed.
00:24:47
Speaker
And I think it's important to kind of set the standard.
00:24:50
Speaker
So why don't we start with what the question you were trying to answer was, and then you can talk about the recommendation, and we can go into a little bit more detail about that.
Early Mobility in ICU: Myths and Evidence
00:25:00
Speaker
I think that said that the big question was like, should we be doing early mobility and all these patients?
00:25:05
Speaker
And we didn't just want it as like early mobility.
00:25:07
Speaker
We actually classified it as as enhanced mobility and enhanced mobility is essentially just one step up from whatever your ICU normally does.
00:25:17
Speaker
And so kind of bridging back to what you were talking about, there was a study that came out and
00:25:23
Speaker
pretty recently within the last like I think year and a half we'll say called the MOVE trial that essentially showed that too much mobility actually may be harmful to patients but what people failed to realize when they read the results of that study is that we do mobility in patients and so their placebo or like their baseline like group already were getting some mobility it was just their treatment group got a little more so maybe there is a fine line on
00:25:50
Speaker
how much you should do for patients, and you are going to have to individualize that with regards to what the patient can tolerate.
00:25:57
Speaker
But it absolutely does not mean that we should not be doing this.
00:26:00
Speaker
We should.
00:26:01
Speaker
It is very beneficial to patients.
00:26:04
Speaker
We've already talked about that it's specifically...
00:26:07
Speaker
can be positive with regards to decreasing ICU acquired weakness.
00:26:11
Speaker
It may decrease delirium, may decrease time on the vent, it may decrease to patients stay in the ICU or the hospital length of stay.
00:26:18
Speaker
So this is hugely important with regards to patient outcomes and we do need to be doing this.
00:26:24
Speaker
And the actual recommendation from the update was we suggest providing enhanced mobilization.
00:26:29
Speaker
Yes.
00:26:30
Speaker
Slash rehabilitation or usual care mobilization slash rehabilitation to adult patients that made to the ICU.
00:26:36
Speaker
And just to clarify, enhanced means to do a little bit more aggressive of what you were doing at baseline in your ICU.
00:26:44
Speaker
Is that correct?
00:26:45
Speaker
That is 100% correct.
00:26:47
Speaker
And I think also that this is an area where what I have seen being able to look at multiple practices throughout our practice is that people sometimes talk about, oh, yeah, we do it.
00:27:03
Speaker
We walk somebody on the vent.
00:27:04
Speaker
But it's not kind of the things that you remember you did once, twice, or a couple of times.
00:27:09
Speaker
It's what do you do every day for every patient, right?
00:27:11
Speaker
And that is really, I mean, where I think there's opportunity to be more systematic, to make sure that we're moving the needle, and to keep improving what we're doing.
00:27:20
Speaker
Any comments of what your experience is in your institution?
00:27:24
Speaker
Yeah, I mean, I like to, I mean, as a pharmacist specifically, I like to recommend early mobility a lot.
00:27:31
Speaker
And I remember the very first time I recommended it, I was like, hey, can we do PT?
00:27:35
Speaker
And I remember the provider looking at me like, hey, this patient isn't on Warfarin.
00:27:39
Speaker
They were like floored that a pharmacist would ask for physical therapy.
00:27:42
Speaker
But it's so important.
00:27:44
Speaker
So I like to evaluate the patient.
00:27:46
Speaker
I like to remember this like very simple mnemonic, which is MOVE.
00:27:50
Speaker
which essentially means like the patients, the M stands for like myocardial infarction or like an arrhythmia.
00:27:56
Speaker
And the O is their oxygenation, like that they're not on more than like FO2, more than 60 percent or a P more than 10.
00:28:02
Speaker
The V, they're not on vasopressors or E. It's lack of engagement of voice.
00:28:06
Speaker
So their RAS is not less than negative three.
00:28:08
Speaker
But if people meet those criteria, I ask for it on patients every single day because...
00:28:12
Speaker
It is so important.
00:28:14
Speaker
And our patients are so critically ill, this gets forgotten a lot.
00:28:17
Speaker
And so I just think it's important to not forget to assess for this.
00:28:24
Speaker
And I think it's also important to remember that it is not uncommon, unfortunately, to have a shortage of physical therapists and occupational therapists.
00:28:32
Speaker
We have that at my institution.
00:28:34
Speaker
And I think it's important to remember that nurses can help with a lot of this.
00:28:38
Speaker
They can help set the patient on the side of the bed.
00:28:40
Speaker
They can get them to a chair.
00:28:42
Speaker
And this is a very common practice in our ICU.
00:28:44
Speaker
And even the family that is there can help with this as well.
00:28:47
Speaker
So just trying to utilize all our resources.
00:28:50
Speaker
Excellent.
00:28:51
Speaker
And I think that there's also, obviously, as part of the IC Liberation Bundle, the F, like you said, starts for family involvement.
00:29:00
Speaker
And SECM has also recently released guidelines regarding family involvement and family care in the ICU.
00:29:07
Speaker
So maybe in the future we'll talk about that.
00:29:09
Speaker
But like you said, it's recruiting all available hands, all hands on deck, right?
00:29:13
Speaker
I think that it's something that really makes a difference for the patient.
00:29:16
Speaker
and that we should be really finding a way to make sure that every patient in our ICU is getting a little bit more every day.
00:29:24
Speaker
Excellent.
00:29:26
Speaker
So the last area relates to sleep.
Melatonin's Role in Sleep and Delirium
00:29:30
Speaker
And sleep is, I think, one of those areas that has really kind of emerged as a critical aspect of health over the last decade.
00:29:41
Speaker
Not only, obviously, in patients in the ICU, but I would also argue that the people who take care of those patients are probably not taking care of their sleep, but that's a conversation for another day.
00:29:51
Speaker
But could you tell us what the question was regarding sleep and what was the recommendation?
00:29:56
Speaker
And we can talk a little bit about the literature, because this is also something that I think is new compared to a previous guideline.
00:30:03
Speaker
The question was specifically, like, should we be using melatonin for sleep in our critically ill patients?
00:30:10
Speaker
And we did analyze the data and found that utilization of melatonin does decrease the prevalence of delirium.
00:30:17
Speaker
It may increase sleep quality.
00:30:18
Speaker
It may decrease icing length of stay.
00:30:21
Speaker
So I think it's very important.
00:30:23
Speaker
We specifically wanted to get to look at this question just because I think we all go to our individual institutions.
00:30:29
Speaker
Utilization of sleep aids is common.
00:30:32
Speaker
And there has been a lot of data that has came out specifically with melatonin since the Pataskalans.
00:30:37
Speaker
And so that's why we wanted to.
00:30:39
Speaker
Look at this.
00:30:40
Speaker
But I and it would be performed on my part if I did not say that this is not to say that you should hand out melatonin to every person in their ICU because you shouldn't.
00:30:49
Speaker
We should really be doing non pharmacologic things to enhance sleep before we're doing this.
00:30:54
Speaker
So some of the stuff we already talked about with regards to delirium.
00:30:57
Speaker
Like making sure we're not waking patients up in the middle of the night inappropriately for lab draws or medications if not needed and opening their blinds, um, during the day, just to help normalize their sleep wake cycle, mobilizing the patients.
00:31:10
Speaker
Like when people ask me about sleep aids, it's going to be the very first thing I look like, Hey, are we doing PTOT on this patient?
00:31:15
Speaker
Let's just wear them out.
00:31:16
Speaker
Um, so that they can go to sleep, you know?
00:31:18
Speaker
So I think we have to remember that too.
00:31:21
Speaker
And I think that's an important distinction because, uh,
00:31:25
Speaker
There's really no medication that can replace a natural good night of sleep, right?
00:31:32
Speaker
Right.
00:31:33
Speaker
And I think historically people have used all sorts of medications that maybe help them fall asleep, quote unquote, but they don't provide the restful sleep that people really need to be healthy.
00:31:46
Speaker
Right.
00:31:47
Speaker
And I know that a lot of older people use all sorts of even some benzos and other drugs, which really, unfortunately, in the ICU, would just cause more problems.
00:31:56
Speaker
Exactly.
00:31:56
Speaker
I think recognizing that is very important.
00:31:58
Speaker
But like you said, I think it goes back to the Dr. Gray mnemonic.
00:32:02
Speaker
Sometimes if we don't have like one magic bullet, if we optimize several little things, we can actually have a very good impact, right, in improving their sleep.
00:32:12
Speaker
And you mentioned some of those things for sleep.
00:32:15
Speaker
But now in this new update, the data does suggest that there might be some benefits in some patients of using melatonin as a sleep aid.
00:32:25
Speaker
Is that correct?
00:32:26
Speaker
Yes.
00:32:27
Speaker
And what did the studies mostly talk about?
00:32:30
Speaker
Did they look at the quality of sleep or just looking at outcomes like delirium?
00:32:34
Speaker
Actually, both.
00:32:35
Speaker
I mean, a lot of them looked at delirium, but some of them did look at sweet quality as well.
00:32:40
Speaker
Excellent.
00:32:41
Speaker
So in terms of putting things together, I know that you've been a big champion and with your whole team of ICU liberation, right, of recognizing that we can do better for our patients, that we can help their patients.
Starting ICU Liberation: Tips and Education
00:32:57
Speaker
What we do in the ICU has tremendous impact on what happens to them once they leave the ICU.
00:33:02
Speaker
And ultimately, the goal is for them to be able to go back home and live their lives as best and as active as possible.
00:33:12
Speaker
Can you talk about maybe some pearls and pitfalls about ICU liberation, about A to F bundles that you have learned over the years?
00:33:22
Speaker
And maybe start with some advice for ICU teams that are starting this journey who may not be as experienced.
00:33:29
Speaker
I think that, Joanna, with COVID, we've seen a lot of turnaround in a lot of programs and even programs that may have been doing
00:33:35
Speaker
the ADF bundle, have a whole bunch of new people to teach, and they're kind of like in many places starting all over again.
00:33:43
Speaker
So any advice, either pearls or pitfalls to avoid in people who are starting this journey?
00:33:50
Speaker
Sure.
00:33:51
Speaker
I mean, I think the biggest thing is, like, I'll say two things.
00:33:54
Speaker
Like, first of all, like, you can't expect to just go from doing this on nobody in your unit to doing it on everyone else.
00:34:02
Speaker
the next day.
00:34:03
Speaker
Like that's, you're just setting yourself up for failure.
00:34:06
Speaker
Like you've got to choose like a small number of patients and honestly, like a couple letters to really focus on first.
00:34:14
Speaker
And it's amazing what will happen when you do that.
00:34:16
Speaker
Like the nurses and providers will see the positive outcomes that seem to happen from doing that.
00:34:21
Speaker
And then they'll want to do this on everybody.
00:34:24
Speaker
I think the other big thing to remember is exactly what you said there.
00:34:28
Speaker
A lot of institutions really took steps back during COVID just because, unfortunately, we did have to use a lot of benzodiazepines at that point just because people were on high doses of sedation for a long period of time.
00:34:42
Speaker
People were scared.
00:34:44
Speaker
It was harder to mobilize patients if they weren't allowed to leave their room.
00:34:48
Speaker
A lot of institutions did not allow the family to come and
00:34:51
Speaker
visit.
00:34:52
Speaker
There were a lot of limitations there.
00:34:54
Speaker
And there's been a huge turnover in healthcare, specifically nurses since then.
00:35:00
Speaker
And even without that, a lot of nurses advance their degrees, right?
00:35:05
Speaker
They go on to get a nurse practitioner degree or go on to become a nurse anesthetist and they leave.
00:35:10
Speaker
So we're constantly have this inflow of new nurses.
00:35:13
Speaker
I think it's very important and something that I do at our university
00:35:17
Speaker
in our MICU here at Vandy is I go over this at Talk to Nurses probably three or four times a year.
00:35:24
Speaker
I also, every single day, like we talk about this on rounds, but I'm specifically talking to the nurse as well and making sure that they know that they should be turning off the sedation and analgesia, that they know how to document this as well.
00:35:39
Speaker
So just like it's a never ending educational process, even without COVID.
00:35:44
Speaker
So the big things are start small and
00:35:46
Speaker
You can't ever quit educating.
00:35:48
Speaker
Yeah, I think those are very timely advice.
00:35:53
Speaker
What about teams that are already doing, and I think that the danger sometimes is people get a little bit cocky, right?
00:36:01
Speaker
And I think that we should be humble and have always a beginner's mind and what can we be doing better?
00:36:06
Speaker
But I talked to a lot of teams and they already said, oh, we're doing the ICU liberation, we're doing the bundle.
00:36:11
Speaker
But then when you really start digging deep, you see that there's plenty of opportunity for improvement.
00:36:15
Speaker
Any thoughts there?
00:36:17
Speaker
I mean, I think there's always room for improvement just because something we've done at Vanderbilt that I really think has been successful with the bundle is, so I have 20 different tendings that roll through the MICU every year.
00:36:30
Speaker
And then we get new medicine residents like every two weeks, right?
00:36:34
Speaker
And then like we said, we've already talked about the turnover of like nursing.
00:36:38
Speaker
So like me as the pharmacist, I've really became the champion of this because I'm always there.
00:36:45
Speaker
So you really just want to have this process so embedded in your ICU that like the nurse, our nurses present on rounds and they go over every letter of the A through F bundle.
00:36:56
Speaker
And so and they tell us what they're doing with regards to that.
00:36:59
Speaker
You don't want to leave this to the medicine residents.
00:37:03
Speaker
Not that they couldn't do that, but they're there for such a short period of time.
00:37:08
Speaker
that you don't want to leave this process for them to figure out.
00:37:12
Speaker
Like it's important they're educated about this and know what our unit processes are for how this happens.
00:37:18
Speaker
But the actual performance of that should not be left to them to conduct.
00:37:23
Speaker
Yeah, I think that's a real issue to consider in a lot of teaching programs because, like you said, the residents and the fellows come and go all the time, but the clinical pharmacists attached to that unit and the nurses have that kind of, let's call it a programmatic or institutional memory, and they know this is important, we're going to keep doing it every day.
00:37:44
Speaker
That does not change.
00:37:45
Speaker
So that is an important point.
00:37:47
Speaker
The other area that I always...
00:37:51
Speaker
think about and people who are doing it already is to just always have that curiosity of what we could be doing better, right?
00:37:57
Speaker
And not think that you're dumb because the reality is new data is coming out, right?
00:38:02
Speaker
But also there's always opportunity to do things a little bit better.
00:38:04
Speaker
And like you mentioned, there's so many things that we can do for these patients that help
00:38:09
Speaker
mitigate, minimize delirium to get them to mobilize.
00:38:13
Speaker
And I think that it's really the emphasis that you mentioned on a daily basis and consistency, right, that moves the needle.
00:38:22
Speaker
Yes, I 100% agree with that.
00:38:24
Speaker
Could you talk a little bit about SIBS and what it is?
00:38:27
Speaker
And we're going to link the website in the show notes.
Post-ICU Patient Care and Follow-Up
00:38:32
Speaker
But I think it's important because this has also opened a whole new area in critical care, which is obviously what happens to people who survive critical illness.
00:38:42
Speaker
And just talk a little bit about all the things that you're doing and how SIBS came to be.
00:38:48
Speaker
Sure.
00:38:49
Speaker
So SIB stands for Critical Illness Brain Dysfunction Survivorship Center.
00:38:54
Speaker
So Wesley and Prateek Pondaharapandi are kind of the co-leads of this, but essentially they developed this group to put together like a variety of different clinicians, so pharmacists, nurses, doctors.
00:39:08
Speaker
physicians, et cetera, from all different disciplines, whether that be anesthesia, neurology, palm critical care, et cetera.
00:39:15
Speaker
But to come together and essentially like to do research is a large part of it to improve outcomes of these patients.
00:39:23
Speaker
But like you said, I think what's important to remember about it, it's not just patients that are in
00:39:29
Speaker
the ICU.
00:39:29
Speaker
We're also concerned about like what happens after they leave the ICU.
00:39:34
Speaker
So like Carla Steven, who I know you said you had had on the podcast before, leads our post ICU center here at Vanderbilt and was really one of the, at the first, I think it's fair to say in the US and we've really helped expand that to numerous post ICU clinics like everywhere, really just not focusing on getting patients out of the ICU, but kind of what happens to them long term.
00:39:58
Speaker
So thinking about cognitive impairment, anxiety, post-traumatic stress disorder, their quality of life, like what can we do to really enhance that?
00:40:05
Speaker
So once again, like doing research specifically to figure out like what we can do to help with PICS.
00:40:10
Speaker
And even like we're doing some research now looking at things that we can do in patients that have had COVID as well.
00:40:18
Speaker
And I think that with COVID, obviously, I mean, they call it long COVID and a lot of things, but with a number of patients being in the ICU, a lot of it, it's another form of picks, right?
00:40:28
Speaker
I mean, and recognizing that getting them out of the ICU does not mean that we're done with our job, right?
00:40:34
Speaker
There's still...
00:40:35
Speaker
I think a big uphill battle for many of our patients.
00:40:38
Speaker
And that's why doing all the things we can upstream with the ADF bundle can mitigate that and make it a little bit easier for our patients.
00:40:48
Speaker
I think it's very, very important.
00:40:52
Speaker
So, Joanna, I agree with you in terms that the importance of this topic can't be, I think, highlighted enough just because it really impacts all our patients and it impacts the outcomes of every single patient that we see in the ICU.
00:41:05
Speaker
So I hope that our listeners look at the guidelines, will link the update, but also link the original PADIS guidelines and also some link to the SIBS website.
00:41:20
Speaker
As we close the podcast, Joanna, we like to ask our guests a couple of questions unrelated to the clinical topic.
00:41:27
Speaker
Would that be okay?
00:41:28
Speaker
Yeah, sure.
00:41:29
Speaker
So the first question relates to books.
00:41:32
Speaker
Is there a book that has really influenced you or a book that you have often gifted to other people?
00:41:39
Speaker
I think a book that really influenced me that I read in high school, honestly, was just To Kill a Mockingbird.
00:41:44
Speaker
And just really shows that I think the take home from that is that you can learn something from everyone and that everybody brings something that's important to the table.
00:41:53
Speaker
And I think that you can apply that to the ICU because every person, whether it be a nursing aide or the attending physician...
00:42:03
Speaker
like bring something that's very important to the patient's care.
00:42:07
Speaker
And I just think that's important that we all remember to help each other.
00:42:11
Speaker
And I think it's a great point.
00:42:15
Speaker
I often say that every single person in the ICU or every person you meet actually in life knows something that you don't know.
00:42:26
Speaker
Right.
00:42:26
Speaker
And if you're curious and you give them their respect, you might be able to learn.
00:42:31
Speaker
And in this case, it's really, I mean, like you said, bringing this knowledge forward.
00:42:36
Speaker
together towards the patient's benefit, which is most important.
00:42:40
Speaker
Now, I never thought about To Kill a Mockingbird in that context, but I think you're absolutely right.
00:42:45
Speaker
And I think it's a great way to think.
00:42:48
Speaker
And again, I think it illustrates the value of having a multidisciplinary team.
00:42:54
Speaker
Everybody has a different angle, has a different set of knowledge, has different expertise on the patient.
00:43:00
Speaker
And all together, we can really make a difference for that patient.
00:43:04
Speaker
The second question relates to something that you have changed your mind about over the last couple of years.
00:43:10
Speaker
So could you share with us something you changed your mind, the way you think about?
00:43:15
Speaker
Sure.
00:43:16
Speaker
So I really like evidence-based medicine and like when new studies come out, especially when they're like practice changing.
00:43:22
Speaker
And I think that something that's really changed over the last few years is the duration of antibiotics that we should be using for gram-negative bacteremias.
00:43:30
Speaker
And so I think that we have historically had some retrospective data to essentially show that you could treat for less than two weeks for seven days in some patients.
00:43:39
Speaker
And now we do have a prospective study that most recently came out from the New England Journal of Medicine to show this as well.
00:43:49
Speaker
And so I think that it's made me more interested.
00:43:54
Speaker
conscious and thoughtful about like maybe we can treat this patient for a shorter duration, assuming that they aren't immunocompromised or they don't have a grand positive bacteremia.
00:44:03
Speaker
And so I think that it's always nice to see that we can do something for a shorter period of time, especially when you consider side effects and things that people can get from being on a longer duration of therapy.
00:44:12
Speaker
Yeah, and I think it also speaks to how sometimes things that are very dogmatic, right, in our practice, when we do the right study, all of a sudden it makes us wonder, okay, well, maybe we were wrong here and there's opportunity to do less, which I think is also a common theme in the ICU.
00:44:28
Speaker
Sometimes less is better, right?
00:44:31
Speaker
Yes, 100%.
00:44:32
Speaker
And trying to get there.
00:44:33
Speaker
Excellent.
00:44:34
Speaker
The final question is what would you want every listener to know?
00:44:38
Speaker
It could be a quote, a fact, or just a parting thought.
00:44:41
Speaker
I mean, I think the biggest thing, and we kind of like already hit on this already, but I just think it's so important that we have to say it again.
00:44:47
Speaker
It's just like, I think it's all too common for us to pat ourselves on the back when we help patients get better and leave the ICU and we kind of forget about them.
00:44:55
Speaker
And I think it's just important that we don't do that.
00:44:58
Speaker
I think it's important that we remember that patients, all the different things that can happen to patients when they leave the ICU, whether that be the cognitive impairment, the depression, the anxiety, the PTSD, and that we're very conscious about cleaning up their medication, et cetera, when they leave, and that we do refer patients that have risk factors, whether that be sepsis or ARDS, just to name two, to resources that we have, like post-intensive care clinics, just because they
00:45:27
Speaker
We do want to not only get them out the door, but we want them to have the best outcomes as possible.
00:45:32
Speaker
Excellent.
00:45:33
Speaker
And I think this is a perfect place for us to stop.
00:45:35
Speaker
Joanna, thank you so much for sharing your expertise and your time with us.
00:45:41
Speaker
I definitely hope to have you back on the podcast to talk about this and other topics.
00:45:47
Speaker
Okay.
00:45:47
Speaker
Thank you so much, Sergio.
00:45:48
Speaker
This was really fun.
00:45:55
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:45:58
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:46:04
Speaker
Sounds transforming the way critical care is provided in hospitals across the country.
00:46:09
Speaker
To learn more, visit www.soundphysicians.com.