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2018 PADIS Guidelines
13 Plays6 years ago
In today’s episode, we will discuss the recently released 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patient s in the ICU. Our guest is John Devlin, PharmD, BCCCP, FCCM, FCCP. Dr. Devlin is the lead author of these guidelines and a recognized leader in the field.
Additional Resources:
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU: https://bit.ly/2wzFNHv
Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU: https://bit.ly/2vOyVGP
Interpreting and Implementing the 2018 of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Guidelines: https://bit.ly/2waInU7
Nocturnal low-dose Dexmedetomidine to prevent delirium in ICU patients: https://bit.ly/2MJ2TSi
Books Mentioned in This Episode:
Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer: https://amzn.to/2OAfZmD
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:09
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
Speaker
And now your host, Dr. Sergio Zanotti.
00:00:23
Speaker
In a previous episode of the podcast, we discussed the ABCDEF bundle.
00:00:28
Speaker
The management of pain, agitation, that sedation, and delirium are critical components of this bundle and of the daily care of our patients in the ICU.
2013 PAD Guidelines Overview
00:00:37
Speaker
Much of our discussion on these topics was based on the Society of Critical Care Medicine 2013 Pain, Agitation, and Delirium Guidelines,
00:00:45
Speaker
also known as the PAD guidelines.
00:00:47
Speaker
In today's episode, we will discuss the recently released update of these guidelines, the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation-Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the ICU.
00:01:04
Speaker
Our guest is Dr. John Devlin.
2018 Guidelines Updates
00:01:06
Speaker
Dr. Devlin is a professor at the School of Pharmacy of Northeastern University in Boston and also a member of the scientific staff of the Division of Pulmonary Critical Care and Sleep Medicine at Tufts Medical Center in Boston, Massachusetts.
00:01:18
Speaker
Dr. Devlin is a recognized authority in the field of critical care medicine with a prolific production as a teacher, author, and researcher.
00:01:25
Speaker
He has received numerous honors and awards for his contributions to the field.
00:01:28
Speaker
Dr. Devlin's research interests center on critical care pharmacotherapy, and within this field, he has dedicated significant portions of his research efforts to delirium sedation in ICU patients.
00:01:39
Speaker
Dr. Devlin is the lead author of the 2018 SECM guidelines we're discussing today.
00:01:45
Speaker
John, welcome to Critical Matters.
00:01:47
Speaker
Thanks very much, Sergio.
00:01:49
Speaker
It's great to speak with you today.
Focus on Patient Symptoms and Long-term Outcomes
00:01:51
Speaker
I think that a good place to begin would be talking about what's new in the 2018 guidelines.
00:01:56
Speaker
I noticed that the name for one thing has changed, which means that you've included other aspects of caring for these patients.
00:02:02
Speaker
Would you start there?
00:02:05
Speaker
Absolutely.
00:02:06
Speaker
So I think one similarity that's really important between the two sets of guidelines is we're really focused on patient symptoms.
00:02:12
Speaker
So these guidelines focus on, just like PAD 2013, pain, agitation, delirium,
00:02:19
Speaker
We're also focusing on immobility as well as disrupted sleep.
00:02:24
Speaker
So those are the two big things.
00:02:25
Speaker
I think the other thing that's important to realize is these guidelines don't necessarily replace the PAD 2013 guidelines.
00:02:31
Speaker
There's some questions that we did approach a little bit differently that are similar but different.
00:02:37
Speaker
But even in questions that are somewhat similar, say, for example, sedative choice in a mechanically ventilated patient,
00:02:44
Speaker
our outcomes that we evaluated for patients are actually quite different.
00:02:49
Speaker
And sort of an overall trend in these guidelines is we're really looking at longer term, and in many cases, post ICU outcomes, like post ICU cognitive function, longer term mortality, you know, physical functioning, and some of the really important patient centric related outcomes that could really help patients, you know,
00:03:13
Speaker
get back to their life after a bout of critical illness.
Rehabilitation and Sleep Issues in the ICU
00:03:18
Speaker
Some of the other differences, you know, we really felt the rehabilitation mobilization field is actively growing.
00:03:25
Speaker
In Pat, 2013, we only had one question devoted to this.
00:03:29
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So we have a whole section here.
00:03:30
Speaker
And then, of course, I think everybody realizes how, you know, as patients are more awake in the ICU, we're realizing that, you know, there's many, many sleep issues.
00:03:40
Speaker
And, you know, a lot of these patients,
00:03:42
Speaker
coming into the ICU actually have pre-existing sleep-related issues.
00:03:45
Speaker
So we really wanted to focus on the recognition, prevention, and treatment surrounding sleep.
00:03:53
Speaker
The other big thing we did is we made these guidelines more international.
00:03:59
Speaker
So we had members from European countries as well as Australia.
00:04:03
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Just because practice and care is different in some of these other westernized countries,
00:04:12
Speaker
importantly, recognizing that these guidelines still do not really tackle what could be done in maybe lower-resourced countries.
00:04:23
Speaker
And maybe I misunderstood this, but on my reading of the guidelines, I found that a unique aspect that surprised me was the inclusion of patients and non-experts as collaborators in the development of these guidelines.
00:04:36
Speaker
Is that correct?
00:04:38
Speaker
Absolutely.
00:04:39
Speaker
This has become a really important aspect of guideline development.
00:04:43
Speaker
It's not something that has been done much in the way before with critical care guidelines, but in guidelines for other disease states, you know, cardiovascular or other conditions, patients actually are involved.
00:04:58
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And there's actually a whole sort of methodology of how to do this.
00:05:05
Speaker
And the most important steps that we use with our patients were
00:05:08
Speaker
actually helping define the topics that turned into questions, helping define some of the outcomes that we evaluated in our questions.
00:05:18
Speaker
And again, they had some influence on some of the post-ICU outcomes.
00:05:24
Speaker
We also had, when we sit around sort of the virtual phone using the grade process, which is sort of the standardized method,
00:05:33
Speaker
There's important questions in the evidence to decision process where important aspects about what utility that patients feel in these interactions, whether it's risk-benefit decision-making.
00:05:46
Speaker
It's really useful to have the patient perspective as these recommendations are being formulated.
00:05:52
Speaker
So these patients were on the calls with the expert team as recommendations were being formulated.
00:05:59
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We then had a live meeting,
00:06:02
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critical to getting consensus and moving through the process where patients were at that.
00:06:07
Speaker
And, you know, it's really funny.
00:06:09
Speaker
I'll give you a really good example.
00:06:10
Speaker
You know, people were really, really focused on, you know, everybody should get light sedation.
00:06:15
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And that's definitely what other patients, but most patients want.
00:06:20
Speaker
And our patient, you know, as an older lady,
00:06:24
Speaker
And she jumped in and she's like, there's times I wanted to be deeply sedated.
00:06:28
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I didn't want to remember everything.
00:06:29
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I was scared to hell of being in the ICU.
00:06:32
Speaker
And so it's kind of funny, you know, thinking about that.
00:06:35
Speaker
It doesn't mean we're going to change our recommendation that everybody should get deep sedation.
00:06:40
Speaker
But it is important.
00:06:41
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There's a variability here.
00:06:42
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And it's important to think about what patients might want and maybe even asking a patient if it's possible and realizing critical illness might not be what
00:06:50
Speaker
How deeply sedated do they really want to be?
00:06:53
Speaker
Are they afraid?
00:06:54
Speaker
What are they remembering?
00:06:55
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Some of those kinds of issues.
Pain Assessment and Management in the ICU
00:06:57
Speaker
Yeah, and I think that, like you said, it's just a different perspective.
00:07:00
Speaker
But also, I think it's always humbling to be reminded that we talk about patient-centered care, but sometimes our thoughts or what we think is best is not what the patients think is best for them.
00:07:12
Speaker
And I think it's always a good reminder for us as clinicians.
00:07:16
Speaker
Absolutely.
00:07:16
Speaker
Absolutely.
00:07:17
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So I think we can move on and start to go by the different sections or the symptoms, like you said, which constitute the sections and start with pain.
00:07:27
Speaker
And pain is first for a reason.
00:07:29
Speaker
So why don't we start there, John?
00:07:30
Speaker
What comments and highlights can you talk to us about pain management in the ICU with these new guidelines?
00:07:35
Speaker
No, absolutely.
00:07:36
Speaker
You know, it's first for a reason in these guidelines, and it's A is for analgesia and pain in the A to F bundle, which is obviously probably the best way to implement these up on, you know, this bundle in everyday practice.
00:07:48
Speaker
I think the guidelines, you know, reiterate in some ways some of the important statements that pain should always be assessed in critically ill patients.
00:07:56
Speaker
We focus a lot on not only self-reported pain, which is still the gold standard for patients, but we also, um,
00:08:05
Speaker
you know, present a lot of additional data on behavioral pain assessment, realizing that many patients, for example, patients with delirium, patients that require deeper sedation, can't self-report pain.
00:08:16
Speaker
So this is, we really go through that literature, and there's a lot of confusion, and I'm obviously not a total expert in this field, but in many ICUs, I'm not quite sure that we're using behavioral pain scales like the BPS or CPOT exactly correctly.
00:08:34
Speaker
And then we also go into some interesting discussions.
00:08:39
Speaker
There's evolving literature on proxy reporters, for example, family members.
00:08:43
Speaker
Do they have a role in helping evaluate pain?
00:08:47
Speaker
And then, of course, some of the physiologic measures.
00:08:51
Speaker
I think we're not changing in these guidelines the importance, and this is a really important thing,
00:09:00
Speaker
ICUs have a protocolized approach to assess and treat pain.
00:09:05
Speaker
In many cases, you know, it should be an opioid.
00:09:08
Speaker
So that's not really changing from the 2013 guidelines.
00:09:12
Speaker
You know, we do make a conditional recommendation on the use of an analgesia-first or anadolcedation approach based primarily on European data.
00:09:22
Speaker
And again, it's not based…it's not a strong recommendation even though there's randomized studies-supported use.
00:09:29
Speaker
simply because the evidence is still not as strong as people would like to see, especially from an American perspective.
00:09:38
Speaker
One big group of questions we tackled with the, you know, quote, opioid epidemic is, you know, the concern, are we using too many opioids in ICUs?
00:09:48
Speaker
And I think most people would agree, it's not necessarily the ICU that people are concerned about usage, but a lot of this opioid use flows to the floor to rehab and to patients at home.
00:09:59
Speaker
And so there's been an evolving literature, particularly in surgical critical care patients, with the use of a multimodal approach for analgesia.
00:10:09
Speaker
So that's another important component where we rigorously look at these agents.
00:10:14
Speaker
And, you know, we do make conditional recommendations, which again are sort of weak recommendations, using, you know, a protocol that might include acetaminophen, ketamine, and
00:10:29
Speaker
and neuropathic pain medications and potentially a COX-2 specific NSAID.
00:10:41
Speaker
We also, people will see, you know, the drug Nefepan, which actually is quite usually, quite commonly used in European ICUs.
00:10:50
Speaker
It's a multimodal strategy in critically ill surgical patients.
00:10:54
Speaker
not available in North America, but there is a question about this, and this just sort of speaks to the global approach of these agents.
00:11:02
Speaker
Again, I think it's really important that people realize that we actually, other than neuropathic pain and then one other recommendation, all of our recommendations that we're making are conditional or weak.
00:11:13
Speaker
And so that really suggests that
00:11:16
Speaker
You know, it applies to subgroups, important subgroups of patients.
00:11:21
Speaker
And again, in multimodal analgesia, most of the data is in surgical critical care patients, particularly patients undergoing major abdominal surgery or cardiac surgery.
00:11:32
Speaker
The supporting evidence, there could be some gaps.
00:11:36
Speaker
Obviously, the benefits away the risk.
00:11:40
Speaker
But there's not this overwhelming evidence profile that this is absolutely what you should do.
00:11:45
Speaker
And if another study came out, it could change the recommendation.
00:11:48
Speaker
Benefits generally outweigh burdens.
00:11:52
Speaker
But again, you know, this is sort of a stopgap where we think it's the way to go.
00:11:56
Speaker
But, for example, medical patients, we're still not really sure, you know, exactly how to best deliver, say, a multimodal approach.
00:12:07
Speaker
And I think that's really, those are kind of the big things.
00:12:11
Speaker
We do focus a lot on procedural pain, and obviously there's some important non-pharmacological interventions that I was interested to learn over the process that, such as, you know, cold therapy, massage therapy.
00:12:29
Speaker
These are, you know, music therapy that actually can have a substantial decrease on
00:12:36
Speaker
OPO requirements and help control pain.
00:12:39
Speaker
Not saying they're going to replace these things, but again, there are important adjuvants in patients that might be, you know, under planned painful procedure, for example, like a chest tube removal.
00:12:49
Speaker
So non-pharmacologic strategies absolutely play a role here as well and should be considered sort of in the pain realm.
00:12:56
Speaker
So I think that in summarizing some actionable take-home messages for the pain portion, similar to the 2013 guidelines, really the emphasis on making sure that we assess pain first.
00:13:08
Speaker
The first thing you should treat in an ICU patient, the ventilator, otherwise, is make sure you're addressing pain.
00:13:14
Speaker
And to that effect, since a lot of our patients, like you said, can't report their pain, to use objective measures such as the behavioral pain score and others to quantify and then
00:13:25
Speaker
guide how we would treat those patients.
00:13:28
Speaker
And number two, I think you mentioned, John, was that the idea of this analgesic sedation, which is really start with a light analgesic.
00:13:38
Speaker
And many times that might be enough for our patients.
00:13:41
Speaker
And an example in practice would be starting with fentanyl, some of our patients, and see if that by itself takes care of the pain and sometimes might provide some comfort and sedation as well.
00:13:52
Speaker
And then the third thing that you mentioned is at least thinking of multimodal approaches,
00:13:57
Speaker
in terms of decreasing the amount of opioid use, but also improving pain control with other therapies where pharmacologic or non-pharmacologic.
00:14:06
Speaker
And you did mention that the neuropathic pain treatment, that is usually something that's been studied, I guess, more in surgical patients, both post-abdominal and cardiac surgery, correct?
00:14:17
Speaker
That's correct.
00:14:18
Speaker
Okay.
Sedation Strategies in Critical Care
00:14:19
Speaker
Excellent.
00:14:19
Speaker
So I think that, and I think a lot of times the instinct of providers is when a patient is quote unquote agitated, that might mean a lot of things, but we should always remind ourselves that the first question really is, are they in pain?
00:14:33
Speaker
And that's why they're exhibiting whatever they're exhibiting and address that first.
00:14:37
Speaker
And I think that is something that we can never do too many times in terms of making sure that we're addressing pain and taking care of that symptom first and foremost.
00:14:47
Speaker
Yeah.
00:14:50
Speaker
And I think that the last comment on pain, John, is I think that a lot of us, and I don't know if you reviewed this literature in the guidelines, sometimes forget that being an ICU patient by the nature of what it entails with devices and tubes and different orifices and laying in bed, it will cause pain in different ways, regardless of whether we have a clear source of pain like an ischemic bowel.
00:15:13
Speaker
And I think sometimes we overlook that.
00:15:16
Speaker
Yeah, I think that's a really good point.
00:15:18
Speaker
And when you talk to some of our pain specialists that were involved in the guidelines like Kathleen Pontillo and Celine Gellinette, they always remind us that even daily care procedures like moving a patient in bed or simple sort of routine things, we're not talking chest tube removal, but the routine thing, these are often have a lot of discomfort in patients.
00:15:43
Speaker
We need to be thinking about those things
00:15:46
Speaker
as we're doing them, and again, making sure we have an analgesia strategy for those patients.
00:15:51
Speaker
Excellent.
00:15:52
Speaker
So let's move on to the next category, which is agitation-sedation.
00:15:55
Speaker
And I guess the first question I would ask here is, what should be our first-line agents, or are there agents that you would prefer over some others in terms of the outcomes that have been studied, and how has that changed or not changed since 2013?
00:16:10
Speaker
Yeah, so great question and people always want to know, well, what should I use as my first-line sedative in patients?
00:16:18
Speaker
So I'd like to kind of build on the really nice summary that you provided with pain is, first of all, think about what's causing the agitation.
00:16:26
Speaker
Does the patient need to be calmed?
00:16:28
Speaker
Are they in pain?
00:16:29
Speaker
Should they get some fentanyl?
00:16:31
Speaker
And thinking of those things first, I think it's really important also to think about withdrawal states in patients with drinking opioids or benzos.
00:16:40
Speaker
That's a lot of patients that we see in US ICUs.
00:16:43
Speaker
So thinking about some of those reasons.
00:16:46
Speaker
And then, of course, does the patient have valerium?
00:16:49
Speaker
But assuming that we've gone through that list very quickly and we do want to use the sedative,
00:16:55
Speaker
You know, our guidelines, similar to PAD 2013, do recommend propofol or dex and etomidine.
00:17:01
Speaker
I think there's differences between these agents, and we think we need to think about, well, what's our sedative goal?
00:17:06
Speaker
So why would we choose propofol or benzodiazepine?
00:17:10
Speaker
But again, the point I really want to make is, you know, it's an important decision when we start a continuous sedative in a patient, and I think
00:17:19
Speaker
You know, still in practice, there's people like, oh, they're intubated, mechanically ventilated, let's start them on Propofol.
00:17:27
Speaker
And not everybody who's intubated, mechanically ventilated necessarily absolutely needs a continuous fusion of a sedative.
00:17:35
Speaker
So, you know, there's other ways of working around that.
00:17:38
Speaker
You know, in terms of benzodiazepines, you know, there still is a role for this group of drugs, despite, you know, lots of propofol versus benzo and dex versus benzo studies showing, you know, longer generations of mechanical ventilation, a lot of post-ICU, you know, worsening outcome.
00:17:57
Speaker
And then, of course, delirium is a big thing, but the use of a benzo versus propofol or dex,
00:18:03
Speaker
However, you know, there is potential roles for these agents, maybe in some patients, for really deep sedative sedations needed.
00:18:11
Speaker
Obviously, patients may be having seizures, patients on neuromuscular blockers.
00:18:15
Speaker
So there could be a role for benzos in some of these patients, but they're a little bit few and far between, I think, in most ICUs.
00:18:22
Speaker
I think the, you know, we really can't make a good recommendation, at least in our guidelines, between Propofol and DEC.
00:18:30
Speaker
There's still only
00:18:32
Speaker
really a couple randomized control studies and they showed minimal difference between outcomes in these studies, particularly the PRODEX study.
00:18:41
Speaker
You know, there's a large, the MEN-SOO study is nearing completion and that's a PRO-VOLDEX patient study in sepsis patients.
00:18:48
Speaker
So, you know, hopefully in the next year we'll get some results from that.
00:18:52
Speaker
So we're still not really sure which one to use, but I think, you know,
00:18:56
Speaker
An educated clinician knowing the differences in pharmacology and pharmacokinetics between these patients probably could choose one or the other despite us not making a recommendation.
00:19:09
Speaker
And I think, John, in terms of going back, so it seems that a Propofol and DEX would be more first-line agents for the majority of patients and reserving benzos for more specific cases because of all the associated effects that we've seen over the years with benzos.
00:19:26
Speaker
Now, would you think that those specific cases, like you said, include maybe severe alcohol withdrawals, patients with seizures, or patients requiring deep sedation, or
00:19:35
Speaker
for a conjunction with neuromuscular blockers, right?
00:19:39
Speaker
But in general... Yeah, I think those are a lot of the patients.
00:19:42
Speaker
And, you know, even with alcohol withdrawal, you know, many people are using, you know, things like... And we didn't discuss alcohol withdrawal in our guidelines.
00:19:51
Speaker
I think that requires a whole different guideline, even though obviously these patients have sort of an agitated delirium-type state.
00:19:59
Speaker
And I think, you know, there's quite a bit of evolving literature about using anticovalescence, particularly, you know, phenobarb and potentially dexamidotomidine, not replacing the use of benzos, but benzos not necessarily the first-line aggressive agent that people are using.
00:20:17
Speaker
So I think practices in this area are changing a little bit too.
00:20:21
Speaker
And what about between Propofol and DEX?
00:20:26
Speaker
So like you said, there's not enough literature to say this is superior.
00:20:29
Speaker
But in terms of clinical framework or recommendations, it would seem that in general, if we need deeper sedation, probably DEX would not be our first choice and we would go to Propofol.
00:20:40
Speaker
And on the other hand, if we're trying to get somebody extubated, I know that there's some literature on patients who are agitated and that's particularly an extubation that DEX might be the agent of choice.
00:20:49
Speaker
Can you comment on that a little bit more?
00:20:51
Speaker
I know it's a great point and that's what I was kind of getting with the pharmacology response.
00:20:55
Speaker
So absolutely, propofol is a GABA agent.
00:20:58
Speaker
It's an anesthetic.
00:21:00
Speaker
It will provide deeper sedation in patients.
00:21:03
Speaker
It is obviously advantages it has, for example, over a benzo is it's titratable organ.
00:21:11
Speaker
It's cleared independently of renal and hepatic failure.
00:21:15
Speaker
So, you know, it's a terrific agent for deeper sedation in patients.
00:21:19
Speaker
And, you know, it's obviously probably the most prevalent sedative used in the United States.
00:21:24
Speaker
Dexanatomidine, generally lighter sedation.
00:21:27
Speaker
Sometimes you can get a little bit deeper sedation, but then you end up having to use doses that are so high, you know, doses well over one microgram per minute and you're just, or prior story, and you're, you know, spending a lot of money
00:21:40
Speaker
and maybe not always gain the benefits of DEX.
00:21:42
Speaker
And then there's some patients, you know, at our Institute, at Tusk Medical Center where I work, you know, we really, we sort of have a hard stop at 0.7.
00:21:49
Speaker
So in terms of if patients aren't responding to our goals of sedation at a dose of 0.7, then, you know, it requires another order to go higher, like up to 1.5.
00:22:03
Speaker
So we're not titrating the drug up to two or three.
00:22:07
Speaker
mics when in fact the patient's heart rate hasn't budged and for whatever reason we're not getting our sedative goals.
00:22:12
Speaker
So it's important to use Presidex, particularly I kind of say for our clinicians use Presidex with a plan and sometimes you'll get the effect you want, sometimes you won't.
00:22:24
Speaker
Certainly in our delirium recommendation we do make them in patients that are agitated that, you know,
00:22:32
Speaker
it's a barrier to extubation.
00:22:34
Speaker
Certainly, I think there's a role in those patients that have agitated delirium.
00:22:39
Speaker
I think the most important thing with sedation and also a little bit with analgesia is this should be sort of a daily discussion point during the interdisciplinary rounds when you're going through the ABCDEF.
00:22:54
Speaker
And what's happening, I think, a lot more now is
00:22:57
Speaker
Plans are changing on a daily basis based on where the patient's at, where we're trying to go, and what we're trying to achieve with the patient in terms of extubation or mobilization.
00:23:08
Speaker
So there's a lot more of an individualized approach.
00:23:11
Speaker
So I think gone are the days where we just use one sedative in all our patients and just keep it going until the time of extubation.
00:23:18
Speaker
And from a pharmacological standpoint or a clinical and pharmacological standpoint, is there any really benefit or role to having both propofol and dex on board?
00:23:28
Speaker
Absolutely.
00:23:29
Speaker
Absolutely.
00:23:30
Speaker
I mean, there's definitely patients where, you know, you're struggling to extubate them.
00:23:35
Speaker
You need them a little bit chilled out, but, you know, you still maybe want them to be able to mobilize, move around.
00:23:44
Speaker
And I think dex is a great drug for that.
00:23:48
Speaker
Generally, some people get caught up in the cardiovascular effects, particularly hypotension and sometimes the bradycardia.
00:23:57
Speaker
I would say the cardiovascular profiles of these agents are fairly similar.
00:24:01
Speaker
So it really comes down to depth of station and what your goals are that day with the patient.
00:24:08
Speaker
And the bradycardia with DEX, I mean, in some studies that at least I reviewed, it's something we see, but it's something that has rarely led to the need for interventions.
00:24:22
Speaker
Can you comment on that a little bit?
00:24:23
Speaker
No, absolutely.
00:24:25
Speaker
You know, many of these patients, I think the patients that we have to really be careful with DEX with,
00:24:31
Speaker
from my experience is people that have really poor cardiac function in terms of ejection fraction.
00:24:37
Speaker
People with bad CHF with ejection fractions, in the teens for example, those are sometimes patients that really don't do, don't tolerate DECS particularly well.
00:24:49
Speaker
But generally with the bradycardia, we often see heart rates in the 50s.
00:24:52
Speaker
Actually, I like to see that it usually means that the drug's decreasing the sympathetic drive, which is its main mechanism.
00:24:59
Speaker
And most patients tolerate it quite well.
00:25:01
Speaker
But occasionally, you start seeing heart rates sliding into the 40s, and people either have to down titrate the rate or, you know, very occasionally, as you mentioned, actually switch to another sedative.
00:25:14
Speaker
Excellent.
00:25:15
Speaker
So we talked a little bit about the interdisciplinary rounds and how our plans change on a daily basis.
Maintaining Optimal Sedation Levels
00:25:21
Speaker
And one of the things that I think is also emphasized in previous guidelines, but also in these guidelines, is that light sedation,
00:25:29
Speaker
is better than deep sedation in terms of outcomes.
00:25:32
Speaker
Could you give us a working definition of light sedation?
00:25:36
Speaker
And then I have a follow-up question for that.
00:25:39
Speaker
Yeah, absolutely.
00:25:40
Speaker
So in the guidelines we define, there's not really a perfect definition for light sedation.
00:25:44
Speaker
But the consensus of our group in many studies in the literature is a RASP of minus 2 to plus 1.
00:25:50
Speaker
So that would be a Riker SAS of around 3 or kind of a light 2.
00:26:00
Speaker
And so that's the goal theory.
00:26:02
Speaker
Definitely someone that is at minus three or in a coma, obviously that is not like sedation.
00:26:07
Speaker
Some people might consider like sedation to be minus one RAS, right?
00:26:10
Speaker
Minus two might even be sedated.
00:26:12
Speaker
And there is some, you know, it's funny how, you know, I find with RAS scores of minus two, you know, you could have 10 clinicians and some people would say, oh, that's a minus one.
00:26:22
Speaker
Some people would say it's a minus three and some people would say it's a minus two.
00:26:24
Speaker
So there's a little bit of variability in how it's best.
00:26:27
Speaker
reliability.
00:26:27
Speaker
That's another important thing is making sure all your pain scores, delirium assessments and sedation assessments are, you know, it's important to stay on top of reliability and documentation.
00:26:42
Speaker
It's funny how there is some variability.
00:26:43
Speaker
It's important to try to standardize that.
00:26:46
Speaker
That's all through education and maybe some checks by someone else.
00:26:51
Speaker
But in terms of light sedation, it's definitely a goal.
00:26:53
Speaker
And I think the most important thing to emphasize with light sedation is
00:26:57
Speaker
We're trying to keep light sedation 24-7, okay?
00:27:00
Speaker
So we're not trying to have a period, say, after a daily, you know, after a spontaneous waking trial or a daily sedation interruption where the patient has, you know, been, say, at a RAS of minus 3 or minus 4,
00:27:17
Speaker
we shut off the sedation or aggressively down titrated, we get the RAS up to minus one, and then we put the sedative back on and they're back to being minus three.
00:27:26
Speaker
That's not the intent, right?
00:27:28
Speaker
We're trying to keep these patients at a lighter level of sedation 24-7.
00:27:31
Speaker
And, you know, at Tufts Medical Center where I'm based, we've spent a lot of time working with our night nurses, and I think they do a really good job of
00:27:42
Speaker
of helping on a 24-7 basis to keep patients at these lighter levels of sedation.
00:27:47
Speaker
And that's allowed us actually to focus a little bit more on sleep improvement.
00:27:51
Speaker
And I think for a lot of our teams, the progression of no objective measurement to objective measurement and making sure the RAS scores or whatever they use are reliably done and documented is the first step.
00:28:05
Speaker
But I have found, John, that the more challenging step is actually –
00:28:10
Speaker
making sure that a given RAS score
00:28:13
Speaker
is associated with a therapeutic conduct.
00:28:17
Speaker
Maybe similar, the analogy I can make is to insulin drips.
00:28:20
Speaker
If you have a blood sugar of X, that usually informs what you're going to do with your drip.
00:28:25
Speaker
And I think that having that step become automatic is sometimes difficult.
00:28:29
Speaker
And you have to remind new nurses who are learning this or going through this process that we actually want to adjust in order to keep the sedation light or whatever we define as our target score throughout the day.
00:28:40
Speaker
Any tips or comments on that?
00:28:42
Speaker
Yeah, I think it's really important.
00:28:44
Speaker
It's a really important point because, again, this is all about how you work with your nurses and clinicians to define this.
00:28:51
Speaker
I think one thing I'd like to allude to is I think some people might be familiar with a Canadian critical care trials group study called the SLEEP study.
00:28:58
Speaker
And that was a study where everybody got benzos if they needed continuous sedation.
00:29:03
Speaker
And they were managed with an hourly nurse-driven sedation protocol.
00:29:08
Speaker
And in the intervention group, they added on daily sedation interruption at least once a day on top of this hourly protocol.
00:29:15
Speaker
We enrolled about 60 patients at Tufts Medical Center and I was the PI on it.
00:29:19
Speaker
And what's interesting is, and we actually surveyed all the nurses at all the centers about this, and our nurses at Tufts, just anecdotally and then across the whole study, because we surveyed them so regularly, they vastly
00:29:36
Speaker
preferred doing an hourly protocol 24-7 than they actually did doing the daily sedation interruption.
00:29:44
Speaker
Now in this study we actually found that adding daily sedation interruption to this hourly protocol really didn't make a difference in any of the outcomes including duration of ICU stay or time to extubation.
00:29:58
Speaker
But it is important that nurses really prefer this.
00:30:00
Speaker
And we actually had really, really good compliance with our night nurses.
00:30:04
Speaker
Again, I'm not trying to blame our night nurses.
00:30:06
Speaker
That's classically been the population, I think, at night where over-separation can happen sort of cumulatively for various reasons.
00:30:15
Speaker
And we would often find when this protocol was used, our patients would be, you know, just lightly sedated in the morning.
00:30:21
Speaker
And then they obviously were able to get on SVTs.
00:30:24
Speaker
And
00:30:24
Speaker
When you talk to the individual nurses, they don't mind making small changes.
00:30:28
Speaker
So, you know, if the RAS score was minus three, the protocol, the goal was minus one, minus two, well then, and the patient would stay on a day's land drift.
00:30:36
Speaker
And again, this study was completed eight years ago, so probably it would be a propofol drift now.
00:30:41
Speaker
They would make small changes.
00:30:43
Speaker
You know, they were supposed to be dropping it down by a milligram per hour.
00:30:46
Speaker
So they would make these changes every hour until the patient was at their citation goal,
00:30:51
Speaker
And if they were to the sedation goal when they're on like one milligram an hour of midazoline, they stopped the sedative.
00:30:57
Speaker
And that actually stoppage might happen for hours, you know, if the patient was persistently deeply sedated.
00:31:02
Speaker
But the nurses actually felt very comfortable with this.
00:31:05
Speaker
So I think this is an important thing when people, and we do have a, you know, recommendation in our guidelines that either daily sedation interruption or protocolization should be used, but it's
00:31:17
Speaker
critical that these protocols aren't just like checking a RAS score every six hours and doing either nothing with it or not much change.
00:31:27
Speaker
It requires a concentrated effort to down-totrate until you're at your light sedation goal.
00:31:34
Speaker
And also, like you mentioned, the needs, not only the plan, but the needs of the patients changes constantly in the ICU.
00:31:40
Speaker
So that's why what kept them lightly sedated now might not be enough next time or vice versa.
00:31:46
Speaker
So I think it's important.
00:31:47
Speaker
Well, absolutely.
00:31:48
Speaker
And there could be something the patient's undergoing a procedure.
00:31:50
Speaker
Maybe the patient is a little more awake and, you know, they communicate they want to be more deflucidated or people realize they're in pain and they give a dose of a
00:31:59
Speaker
fentanyl, which could cause them to have deeper sedation.
00:32:02
Speaker
But again, it's so much better when you have a patient that you need to give more sedation to than a patient who's deeply, deeply sedated and you have no idea if the patient even needs this degree of sedation, right?
00:32:15
Speaker
You can always give more sedation, but if you don't peel it off, you're never going to know what the patient needs.
00:32:19
Speaker
And that's the most important thing with daily sedation interruption or a spontaneous awakening trial.
Delirium Prevention and Management
00:32:25
Speaker
When you're
00:32:26
Speaker
stopping it is you're hoping that you can either not restart it at all, manage the patient with a couple of boluses, maybe even just the fentanyl.
00:32:34
Speaker
But if you are going to restart it, start it at half the rate or even a lower rate, and then you can always go back up.
00:32:41
Speaker
Absolutely.
00:32:42
Speaker
So I think that this can lead us into the next topic, which is delirium.
00:32:47
Speaker
And I know that as being somebody who obviously lives in the pharmacological world, talking about non-pharmacological interventions must not be your favorite.
00:32:56
Speaker
But I think we have to start there with delirium.
00:32:59
Speaker
No, absolutely.
00:33:00
Speaker
That's like the most important thing.
00:33:01
Speaker
So delirium is all about risk reduction, right?
00:33:04
Speaker
All these patients come into the hospital.
00:33:06
Speaker
Some of them have, you know, a lot of predisposing factors that we usually can't do much about, right?
00:33:11
Speaker
That they're old.
00:33:12
Speaker
They have maybe some history of cognitive dysfunction, blah, blah, blah.
00:33:16
Speaker
There's not much we can do about that, but there's a lot of things that we can do about with the precipitating causes that happen to come up on a daily basis in the ICU.
00:33:25
Speaker
So it's really important to have an approach, like a quality improvement approach, which is kind of built into the A to F bundle under D, is thinking about what are the modifiable risk factors for delirium if we get a positive CAMICU test that patients can address and remove.
00:33:42
Speaker
And so we do talk a lot about risk factors.
00:33:44
Speaker
about risk reduction and the risk factors.
00:33:47
Speaker
So I'm not going to revisit all those, but there's some really obvious ones.
00:33:51
Speaker
And then there's things, if a patient doesn't have delirium and then the next day their blood pressure is down and they have a fever and their white counts up, well, are they sliding into sepsis?
00:34:00
Speaker
Is there a new infection?
00:34:01
Speaker
So there's things that could lead to a further diagnostic workup on the part of the ICU team.
00:34:07
Speaker
I think the other thing that I just wanted to allude to is the importance of delirium prediction.
00:34:14
Speaker
You know, there's many, many things that we can give our patients, particularly things like mobilization and all sorts of things to try to prevent delirium.
00:34:24
Speaker
But these delirium prediction tools have come a long way.
00:34:27
Speaker
And so I'd encourage people to read that section and think about, probably it could be put into their electronic records and you can get a report spit out each day of, well, what's the patient's risk of developing delirium?
00:34:42
Speaker
And, you know, if it's very, very low, probably if we're limited with resources, and in the ideal world, obviously, we can give everything to everybody and prevent all the delirium in the ICU if possible.
00:34:54
Speaker
But the point I'm trying to get is sometimes we're not.
00:34:56
Speaker
You know, we only can mobilize so many people.
00:34:58
Speaker
We can only do so many things.
00:35:00
Speaker
So why not focus on the people that have the highest predicted risk of delirium, particularly when things are modifiable?
00:35:06
Speaker
In terms of non-pharmacologic interventions, you know, a lot of the things to prevent delirium are actually somewhat sleep-related, Sergio, and maybe we can talk on that when we get to sleep.
00:35:19
Speaker
You know, we did look at single entities to prevent delirium, and we actually don't have anything that has rigorous evidence that it really works.
00:35:31
Speaker
But a lot of these things are very low risk.
00:35:33
Speaker
And there's, so we, the one thing we really evaluate is light therapy.
00:35:37
Speaker
And actually that hasn't really been shown to, it's like bright light therapy to help prevent delirium as a non-pharmacolactics.
00:35:46
Speaker
But there's a tremendous number of things that can be done on a routine basis with patients to try to reduce or, you know, cause a reduction of delirium.
00:35:57
Speaker
And some of these things are simply involving families
00:36:01
Speaker
reorientating patients, waking them up more, and then of course mobilization.
00:36:07
Speaker
So all these things sort of come into play, which I think are pretty firmly defined in the A to F bundle.
00:36:13
Speaker
Yep, absolutely.
00:36:14
Speaker
And one of the things that when I was reading the guidelines kind of brought me back to my residency and gave me a little bit of a chuckle was when I was a resident and fellow, I'm not going to date myself, but many years ago,
00:36:27
Speaker
We used to say kind of in jest but joking, but it was also real that if you really want to make an ICU patient better, look better, just put glasses on them.
00:36:36
Speaker
And actually there is some data that probably giving them their glasses is helpful, right?
00:36:40
Speaker
Well, and hearing aids and absolutely.
00:36:43
Speaker
Yeah, and really figuring out these patients, you know, it's really important to know, like, and this is where family can be useful, like what's this patient's normal status?
00:36:53
Speaker
What do they like to do?
00:36:55
Speaker
What are the things, you know?
00:36:57
Speaker
What's their baseline status from a sort of a social, functional basis?
00:37:02
Speaker
And you want to kind of try to push that and promote that, realizing the confines of critical analysis and intubation.
00:37:10
Speaker
And I think you mentioned when you started the discussion of delirium, I mean, obviously the priority and kind of the most important thing is working on prevention of delirium.
00:37:18
Speaker
And that is true because preventing is always better than treating.
00:37:21
Speaker
But I think it also rings especially true in delirium because we don't really have a lot of good treatments.
00:37:26
Speaker
But what can you comment briefly, John, on what the guidelines say about treating symptomatic delirium with pharmacotherapy?
00:37:35
Speaker
Overall, I think what's the most important thing surgery to emphasize here is
00:37:40
Speaker
Does the patient have a delirium associated with symptoms that needs treatment?
00:37:46
Speaker
That's probably the most important place to start.
00:37:49
Speaker
But is the patient having hallucinations or delusions?
00:37:52
Speaker
Is the patient fearful?
00:37:54
Speaker
Is the patient having agitation related to their confusion and delirium that's not related to withdrawal or pain?
00:38:03
Speaker
If a patient's having that, then regardless of what
00:38:07
Speaker
Our guidelines say and what randomized control studies say, these, you know, probably smaller group of patients, they probably need some kind of intervention.
00:38:16
Speaker
It could be pharmacologic, but generally these patients might need a short trial of an antipsychotic, right, if they're having hallucinations or they're really fearful.
00:38:27
Speaker
What happens when we do these guidelines, what happened in 2013 happens here is
00:38:32
Speaker
the symptomatology hasn't been as well differentiated in these randomized studies.
00:38:37
Speaker
And so generally, we basically find that there's not really much of a treatment effect overall in terms of delirium resolution or improvement in other secondary outcomes like time-tipification off the ventilator or to the ICU and those kinds of things.
00:38:53
Speaker
So overall, the signal of using antipsychotics, giving a statin, you know, giving drugs like ketamine even,
00:39:02
Speaker
really have not been shown to have much of a role as a sort of a standard treatment for delirium.
00:39:12
Speaker
So, you know, I always kind of cringe if a hospital has a delirium protocol that everybody gets started on an apsychotic, say, crotiapine or something, you know, when they have delirium.
00:39:23
Speaker
And that's probably not the best approach, and that's not what our guidelines are advocating.
00:39:27
Speaker
But if people do have a specific symptom,
00:39:30
Speaker
that's biliary related, we need to think about how we can treat that.
00:39:33
Speaker
So that's probably the most important thing.
00:39:36
Speaker
There is some important studies coming down the pipeline.
00:39:39
Speaker
MindUSA study is going to be presented in October.
00:39:44
Speaker
That's a large, the Prazidone-Haldol versus placebo study in a large cohort of medical and surgical critically ill patients.
00:39:53
Speaker
So I think we're going to get some more data in the next few months for what to do.
00:39:57
Speaker
But in terms of our guidelines and what was available,
00:40:00
Speaker
Remember, the evidence for our guidelines, actually, we only had evidence up to, you know, the up to 2015, the fall of 2015.
00:40:10
Speaker
So our guidelines, I mean, 2016, sorry.
00:40:13
Speaker
So our guidelines are a little bit old, like they always are.
00:40:16
Speaker
So there's things that we're missing.
00:40:18
Speaker
But I think that the distinction of you don't treat delirium per se with these antipsychotics, you treat symptoms when they occur is very important because I do agree with you.
00:40:27
Speaker
There are plenty of protocols out there that if somebody has a positive cam boom, they get put on antipsychotic and that might not be the way to go based on the available evidence today.
00:40:38
Speaker
No, you're absolutely right.
00:40:40
Speaker
And our evidence did stop in October 2015.
00:40:42
Speaker
I didn't mean to say 2016.
00:40:43
Speaker
You're absolutely right.
00:40:45
Speaker
And it's important.
00:40:46
Speaker
If you are, even if you're treating symptoms with, say, an antipsychotic and delirium, is you measure the response of the patient to that intervention.
00:40:56
Speaker
And if it's working, you know, maybe down titrate the dose and see if the symptoms reoccur.
00:41:02
Speaker
But if it's not working, stop it.
00:41:04
Speaker
And make sure you have really good plans to, you know, get these agents off as patients transition from the ICU to the floor into home.
00:41:13
Speaker
There's so many patients that are left on
00:41:16
Speaker
you know, quetiapine, for example, for weeks on end.
00:41:18
Speaker
And that's where you really get into safety issues.
00:41:21
Speaker
And it's much harder, you know, for a primary care physician, for example, seeing the patients two months after they left the ICU to decide that they'd be stopped on their antipsychotic versus the actual team in the hospital stopping them.
00:41:32
Speaker
Absolutely.
00:41:33
Speaker
So if you don't mind, John, I would like to step out of the guidelines for one second and just ask you if you could comment.
00:41:40
Speaker
We were talking before the podcast,
00:41:43
Speaker
about a recent randomized study, a recent study that you had published with a group of co-investigators where they had the use of low-dose nocturnal decks to prevent ICU delirium.
00:41:53
Speaker
Any quick comments?
00:41:55
Speaker
And I will link the reference in the show notes.
00:41:59
Speaker
Yeah, so this is a study that I collaborated with Ioannis Grobik on from Montreal.
00:42:06
Speaker
And our hypothesis was that we felt that, you know, dexmedetraubinine, there's evolving data, there's even more data now suggesting that it does improve, you know, PSG, so basically sleep architecture when administered at night in critically ill patients.
00:42:23
Speaker
There's a really good study by Wu Nong in anesthesiology from last year that sort of is a sub-analysis from a large cardiac surgery randomized study that was published in Lancet.
00:42:33
Speaker
And so our hypothesis, well, if it could do this with sleep architecture, we know critically ill patients have really poor disorganized sleep.
00:42:44
Speaker
If you can reorganize and improve their sleep in patients without delirium, our hypothesis was that maybe we can help prevent delirium.
00:42:52
Speaker
Now, the interaction and relationship between disorganized sleep and delirium and whether delirium worsens sleep
00:42:59
Speaker
That's a little bit of a quagmire, I'll be very honest.
00:43:01
Speaker
We know there's some kind of association, but it remains quite controversial in the literature and among experts.
00:43:09
Speaker
But with all that said, and again, we did pick primarily mechanically ventilating patients.
00:43:14
Speaker
All our patients were getting some sedation.
00:43:16
Speaker
So we had some pretty sick patients.
00:43:18
Speaker
Our Apache 2 scores, I'm just going by memory, but I believe they were around 20s, low 20s.
00:43:25
Speaker
We gave nocturnal dexamintine or placebo, we shut the sedation down by half if the patient tolerated it, and then from 9.30 p.m.
00:43:34
Speaker
to 6.30 in the morning, we gave them dexamintitomity.
00:43:37
Speaker
We started at 0.2, and we can go all the way up to 0.6.
00:43:40
Speaker
You know, again, trying to induce sleep, which we defined as like a RAS of minus one, maybe minus two, and then we just shut it off.
00:43:51
Speaker
We down-tried to shut it off, and if the patient became agitated,
00:43:55
Speaker
we turned up their existing sedation.
00:43:57
Speaker
We kept analgesia the same, and a lot of these people were on fentanyl.
00:44:01
Speaker
And then what we did in the morning is we did a intensive care delirium screening test.
00:44:05
Speaker
So we did a delirium assessment at 7 a.m.
00:44:08
Speaker
So the night nurse, before she went home, scored the patient over that shift of having delirium or not.
00:44:14
Speaker
Then we also did what's known as the lead sleep evaluation questionnaire, which is
00:44:19
Speaker
sort of like the Richard Campbell, and we basically, if patients had a RAS score of minus one or greater, and they didn't always have this, we would then ask them what their perceived quality of sleep would be.
00:44:30
Speaker
So what we found is we found a pretty large treatment effect.
00:44:33
Speaker
You know, the absolute difference, you'll have to remind me, in fact, what the treatment effect was.
00:44:37
Speaker
I'm kind of embarrassed to say.
00:44:38
Speaker
I think it was around 30%, 25%, from around 45% to the low 20s.
00:44:46
Speaker
So that's the incident delirium.
00:44:48
Speaker
So these are the patients that, you know, either did get delirium or never had delirium between the two groups.
00:44:53
Speaker
And then we actually, interestingly enough, we found no signal with the sleep scores in the patients that we could adjust this.
00:45:01
Speaker
So we weren't able to link a treatment effect in terms of the patient's perceived quality of sleep, but there definitely was a pretty strong signal with reducing delirium.
00:45:09
Speaker
Now, of course, some of the questions that come up from this is we're still not really sure
00:45:14
Speaker
you know, is it avoiding some of the sedatives we're giving patients and using more dex at night?
00:45:20
Speaker
Is that the protective effect that maybe we, would that account for some of the reduced incident delirium we saw?
00:45:25
Speaker
You know, that's obviously kind of a situation that you see in some of the, like the men's study, the Ben-Pioma-Daisland versus dexamintomidine study, is it avoidance of
00:45:36
Speaker
non-DEX sedatives or is it the DEX that's actually having an effect?
00:45:40
Speaker
And of course, we weren't able to do PSCs in these patients, so we're still not really quite sure, did they in fact have improved sleep architecture or is it just something else about DEX or was it just layer protected by a different mechanism?
00:45:54
Speaker
So we really consider this a pilot study.
00:45:57
Speaker
You know, we did show a big treatment effect.
00:45:59
Speaker
I think it was a well done study.
00:46:01
Speaker
We didn't measure any other post ICU outcomes at all.
00:46:05
Speaker
So I think it suggests that there may be a role in these patients that are, you know, that it could, you know, by chilling them out with some DEX, and we use, most of the, the average dose is around 0.4 in patients, so we weren't using very much.
00:46:20
Speaker
You know, maybe it would, it definitely will reduce the layer and improve, and maybe improve sleep.
00:46:25
Speaker
Again, there's some, you know, longer term outcomes and some other things that I think should also be further evaluated.
00:46:31
Speaker
So it's an important study, but it's not the be-all and end-all, you know, studies that should suggest that everybody in the ICU should be put on a journal death.
00:46:40
Speaker
But I think that definitely, I mean, like you said, a food for thought and more to come, I'm sure.
00:46:44
Speaker
So we'll keep tuned into that.
00:46:46
Speaker
So...
00:46:48
Speaker
In terms of moving on with the guidelines, I really wanted to dive into the sleep portion, but we're going to respect the order of the guidelines and go into immobility first.
00:46:59
Speaker
Any general comments?
00:47:00
Speaker
You did mention at the beginning of the podcast, John, that this edition or version of the guidelines did address a lot more questions about immobility and how to address that symptom.
Early Mobilization and Rehabilitation Strategies
00:47:10
Speaker
But any general comments you can give us on this topic before we go into talking a little bit more about sleep?
00:47:18
Speaker
Yeah, so this is a section that Dale Needham from Hopkins led, and we had a number of just amazing intensivist nurses, physiotherapists, rehab specialists, and occupational therapists helped with the guidance and development of this section.
00:47:36
Speaker
I think what you might see is the evidence for PAD 2013, where we make a recommendation that
00:47:45
Speaker
early mobilization should be used because it reduces delirium.
00:47:49
Speaker
That's basically based on the Schweikert study.
00:47:53
Speaker
Again, very strong study, and it sort of launched this whole area of inquiry.
00:47:58
Speaker
But what's interesting, there's been 15 other large randomized studies published since then.
00:48:06
Speaker
And some of the important things are there's a lot of variability in these studies in terms of
00:48:13
Speaker
the type of intervention, the intensity of intervention in terms of mobilization or other rehab strategies, and how early it was initiated in patients.
00:48:23
Speaker
And then there's also a lot of variability of the types of safety and efficacy outcomes that were evaluated in these studies.
00:48:30
Speaker
And one big message that I know the guideline, this section of the guideline group really wants to communicate is
00:48:41
Speaker
It's not just mobilization, and so there's really large emerging data on rehabilitation.
00:48:48
Speaker
And so rehabilitation could include, you know, it depends on the patient, everything from passive leg raises to, you know, ergometric things like bicycling and bed.
00:49:00
Speaker
I mean, there's all sorts of different types of interventions that fit under this, you know,
00:49:07
Speaker
thing and basically all mobilization is rehabilitation.
00:49:11
Speaker
Rehabilitation is anything that's applied to the patient over and above sort of routine patient care that's really focusing on optimizing functioning and reducing disability of patients with critical illness.
00:49:27
Speaker
Where mobilization is just a set one where we're actually trying to get patients standing on the edge of the bed and getting them moving and walking and eventually maybe even
00:49:37
Speaker
walking out into the ICU.
00:49:39
Speaker
Absolutely.
00:49:40
Speaker
So that's how we only make a conditional recommendation, but that's a lot.
00:49:44
Speaker
It doesn't mean that there's a lot of safety risks.
00:49:46
Speaker
There's almost no safety risk.
00:49:47
Speaker
It's just the variability of all these interventions and outcomes.
00:49:51
Speaker
I think the other really important things, and I know we just move on, is Dale and his group did a really, really good job about carefully summarizing and obviously instilling a lot of expert, experiential opinion.
00:50:04
Speaker
And what are the starting and stopping criterias for rehabilitation mobility?
00:50:09
Speaker
I think there's a tremendous variability that happens in discussions at ICU bedsides.
00:50:14
Speaker
But we can't do this with this patient because they're on CBHT.
00:50:17
Speaker
Or we can't do this patient because they're on two of our AP.
00:50:20
Speaker
I think it goes on and on.
00:50:21
Speaker
And, you know, they reviewed over 20,000 patient cases in huge cohort studies as well as all of the RCTs.
00:50:29
Speaker
And I think the table one that's actually right in the guidelines is a really, really important one because I think it gives a good roadmap to help guide some of these discussions with clinicians.
00:50:39
Speaker
Again, and I think, you know, we need to say this at some point in this conversation, guidelines are meant to guide and it doesn't replace expert clinician opinion.
00:50:50
Speaker
But I think, you know, when clinicians are making these decisions for their individual patients, it is these types of
00:50:56
Speaker
of expert summary documents like this table, one in the guidelines for starting and stopping rehab mobility, I think could really help guide decisions there.
00:51:06
Speaker
Yeah, and I think that for somebody who's been in the field for several decades, more than one for sure,
00:51:15
Speaker
we've seen an evolution, and that's what guidelines help us move, from people who were heavily sedated all the time with no rehabilitation to people being sedated less and less, paying more attention to pain, getting people up and moving with a ventilator.
00:51:31
Speaker
But it all goes around getting people back to productive life outside of the ICU as soon as possible.
00:51:36
Speaker
And I think that that's been a big movement over the last 20 years in our field that I think is obviously a very positive one.
00:51:45
Speaker
Right.
Sleep Improvement Interventions in the ICU
00:51:46
Speaker
Absolutely.
00:51:46
Speaker
So let's talk about sleep and sleep.
00:51:48
Speaker
I think is very fascinating to me as a topic in terms that,
00:51:52
Speaker
I think you can read more and more about the benefits of sleep in healthy people, highly functional people, high performance such as athletes and busy professionals.
00:52:04
Speaker
There's a resurgence of really taking care of sleep hygiene in healthy people and it only makes sense that we should be worried about it in people who are trying to recover and are critically ill as well.
00:52:16
Speaker
So why don't you tell us a little bit about the sleep incorporation into these guidelines?
00:52:21
Speaker
Yeah, so I think, you know, with sleep, we, you know, we know people, patients are exhausted when they leave the ICU.
00:52:29
Speaker
We know definitely there's lots of self-reports from patients that they had horrible sleep, you know, in terms of they couldn't fall asleep or they were interrupted and woke up.
00:52:40
Speaker
So we know all that exists.
00:52:42
Speaker
As we've, as you kind of mentioned, as we've down titrated sedatives, I think this has been really plain in this day in many
00:52:50
Speaker
with many patients, with nurses and the whole ICU team, where patients are agitated.
00:52:57
Speaker
If you ask them questions about their sleep, they're going to report that they can't fall asleep or they're waking up.
00:53:02
Speaker
And then there's much more data on the risk factors for sleep as well as the outcomes associated with poor sleep.
00:53:11
Speaker
you know, there's this, you know, really important relationship between sleep and delirium.
00:53:16
Speaker
So we all know this is, you know, an evolving area and it's really important, and I think there's a lot of things that we can do, you know, to help try to improve, to recognize sleep and try to improve it.
00:53:30
Speaker
And in terms of pharmacological options, I know that there are some recommendations or maybe no recommendation that,
00:53:38
Speaker
We actually didn't make any recommendations at all.
00:53:40
Speaker
In fact, with Propol we said no.
00:53:42
Speaker
Some of this is the agents that we chose.
00:53:46
Speaker
Some of this is the data that's come out.
00:53:49
Speaker
So, for example, we didn't have a question on remelteon.
00:53:51
Speaker
You know, there is a, you know, Japanese randomized control study that was recently published in Crocker Medicine suggested if you give remelteon maybe it'll reduce days with delirium.
00:54:03
Speaker
And then of course there's our dexamontamin study, will this reduce delirium if you're using it to try to improve sleep?
00:54:09
Speaker
So there's some of this is evolving, but based on the data, October 2015, there wasn't too much.
00:54:15
Speaker
You know, as guideline groups, we hate not making a recommendation.
00:54:19
Speaker
And so we tried, and our methodologist from McMaster really, really pushed us.
00:54:24
Speaker
They were like either make a recommendation conditionally against or for, obviously ideally strong, but if you're on the fence,
00:54:32
Speaker
try to make a conditional recommendation for gains.
00:54:34
Speaker
But for drugs like melatonin, we really were on the fence.
00:54:38
Speaker
And we just, it's a fairly low risk cheap drug.
00:54:43
Speaker
And there is some evolving data that maybe has some benefits, but it's really, the evidence remains quite weak.
00:54:50
Speaker
And we're talking randomized control evidence with the outcomes and the rigor by which you'd really be able to evaluate efficacy and safety.
00:54:59
Speaker
The other big concern for any of these prevention things is we're concerned as a guideline group that if we say, sure, this is a recommendation that melatonin, for example, could be administered to patients for sleep in the ICU, that's basically suddenly clinicians are feeling that, hey, we could be using melatonin in all our ICU patients and it's going to improve sleep.
00:55:22
Speaker
So we're very concerned, even for a cheap and fairly safe drug like melatonin, that if we made a recommendation
00:55:29
Speaker
when there really wasn't great evidence, suddenly everybody would start using, I'm being facetious, but you know, everybody would be like, oh, let's at least start using melatonin.
00:55:38
Speaker
And we didn't want that to happen because we strongly felt that we weren't there quite yet with the data.
00:55:42
Speaker
So that's kind of where some of the thing, the other important thing is, you know, this comes to a delirium is you just have to really be careful with pharmacologic approaches when you're not sure of the evidence.
00:55:53
Speaker
and it's not particularly strong, and because where the real data with sleep is with non-pharmacologic intervention.
00:55:59
Speaker
So, as you alluded to, some of the approaches that you've used clinically, Sergio, but it's asking the patients how they're sleeping, you know, noise reduction, light reduction, or light changes.
00:56:13
Speaker
Those are the big things.
00:56:14
Speaker
Offering patients earplugs if they want them, but obviously remembering to take them out.
00:56:20
Speaker
You know, we do make other conditional recommendations where actually the data is fairly strong.
00:56:23
Speaker
Like, for example, patients that are on a, you know, putting patients on, you know, SIV or IMB mode, putting them back on an AC mode at night, realizing that might actually increase their sedative needs.
00:56:37
Speaker
But there's pretty good randomized data suggesting that that might be a beneficial effect.
00:56:42
Speaker
I think the most important thing, our recommendation from the sleep section is that
00:56:48
Speaker
ICU should be developing a sleep protocol for their patients.
00:56:54
Speaker
And simply, you know, there's some patient assessment.
00:56:57
Speaker
We're still not sure the best way to evaluate patient assessment.
00:57:00
Speaker
Obviously, we're not doing PSGs in these patients.
00:57:03
Speaker
But, you know, there's Richard Campbell's scales.
00:57:04
Speaker
Some people are using it.
00:57:06
Speaker
But, you know, trying to find out some qualitative measure of how the patient's sleeping
00:57:11
Speaker
But most importantly, you know, just asking the patients, are they having a hard time falling asleep and or keeping asleep and, you know, offering non-pharmacologic interventions.
00:57:23
Speaker
There may be a role in some patients, just like with delirium, if they're symptomatic and they're, you know, like, I absolutely cannot fall asleep just by having earplugs and being quiet.
00:57:32
Speaker
Well, then probably just a role for a pharmacologic sleep aid to help initiate sleep.
00:57:37
Speaker
But we're not quite sure the patient and even which agent to use, other than it probably shouldn't be a benzodiazepine.
00:57:45
Speaker
Absolutely.
00:57:46
Speaker
And I think that, like you said, the take-home message is that we should be looking at sleep.
00:57:51
Speaker
We should be developing protocols for non-pharmacologic interventions.
00:57:54
Speaker
And I think it also translates to our providers.
00:57:58
Speaker
I mean, just think about it, having a good sleep hygiene, especially for those of our providers who go from night shift to day shift back and forth, having shades, having masks, earplugs, white noise, all these things actually help sleep when you're healthy.
00:58:13
Speaker
And similar things can actually help
00:58:14
Speaker
help our patients sleep a little bit better and recover.
00:58:18
Speaker
Right.
00:58:18
Speaker
And this is another question to ask family members, you know, or the patients themselves, like what's your normal sleep habits before you came to the ICU?
00:58:25
Speaker
Because there's a lot of people that have kind of abnormal sleep habits and routine.
00:58:31
Speaker
And we've got to be careful that we're not trying to normalize them to falling asleep at nine and waking up at six when they've never, ever done that their whole life.
00:58:38
Speaker
Right.
00:58:39
Speaker
And then also asking them about which sleep aid medications that they use at home.
00:58:43
Speaker
And it's,
00:58:44
Speaker
I think the prevalence of this is far higher than we think.
00:58:47
Speaker
I'm sure it's probably at least 15 to 20% of our ICU patients, particularly the elderly.
00:58:52
Speaker
Yeah, absolutely.
00:58:55
Speaker
So I think that as we close, one of the things that I found also very refreshing on these guidelines was the associated publications that came out at Critical Care Medicine with it, specifically the one on interpretation and implementation.
00:59:11
Speaker
Like we talked about earlier before we started the podcast, John, the guidelines are guidelines that recommend and suggest based on the available evidence, but they only matter if they become a reality at the bedside.
00:59:25
Speaker
Any comments on this aspect before we go to some closing questions?
00:59:29
Speaker
Yeah, so obviously there's a lot of potential barriers with these things.
00:59:34
Speaker
There's a lot of sort of implementation parts to this.
00:59:40
Speaker
I think you already had a podcast on the ADF bundle, and I don't think there's a better way to make with the ADF bundle.
00:59:49
Speaker
But again, it requires communication, documentation, ICU team dynamics about who's doing what and all those sorts of things.
00:59:57
Speaker
And I think that's just a really important part of it.
01:00:01
Speaker
But I would suggest institutions as they take their current ADF practices and figure out is there things from the pad
01:00:10
Speaker
IS guidelines that maybe could help inform or reprioritize or practices that they're doing or not doing.
01:00:18
Speaker
And that's probably the best step.
01:00:22
Speaker
If people have never implemented any part of the ADAF bundle, I mean, I'm sure people are doing some of these things.
01:00:28
Speaker
I would suggest institutions before they even spend a ton of time worrying about everything in the PAT-IS guidelines, they need to get a system in there.
01:00:37
Speaker
bundled care that's multi-disciplinary team based that's being used in a consistent fashion before they start making small incremental change based on the new guidelines.
01:00:48
Speaker
I think you need the process first before you start trying to make different changes.
01:00:52
Speaker
And I think what's really important, and there's a really important paper, SCSIM had this ICU liberation effort that I was involved with, and there's certainly been other publications on implementing the ADF bundle.
01:01:03
Speaker
And what's really important, and we have a publication coming out, is
01:01:07
Speaker
You know, for every time you can increase compliance with one of these bundle components on a daily basis, patient outcome can really improve, including ICU mortality and post-ICU mortality.
01:01:21
Speaker
So, you know, people don't have to be too hard on themselves that, oh, I can't, I'm not doing everything all at once with all these patients.
01:01:28
Speaker
Pick something, incrementally increase it and make change.
01:01:31
Speaker
you're actually going to have profound effects on the outcome of your patients by doing these things.
01:01:35
Speaker
Some people will start with mobilization, some people might focus a little bit more on wakefulness and less sedation.
01:01:44
Speaker
Lastly, certainly a lot of the powers that be with the ADAP bundle, I think most of the sleep things probably fit within delirium, but I think there's going to be some small changes made to the bundle to really account for this rapidly growing sleep area.
01:02:01
Speaker
Excellent.
01:02:01
Speaker
Well, I think this was a wonderful conversation on a very, very relevant topic to our practice.
01:02:07
Speaker
Like you said, I mean, something that have done well in a dose response way, an incremental way can really make a difference for our patients that's meaningful.
01:02:17
Speaker
So in critical matters, John, we usually like to finish the podcast with some general questions that maybe not related to the topic directly, but I think relevant to what we do as critical care providers and practitioners.
01:02:29
Speaker
Would that be okay?
01:02:31
Speaker
Absolutely.
01:02:32
Speaker
So the first question is, what book or books have influenced you the most or what book have you gifted most often to others?
01:02:41
Speaker
Well, I would say from a healthcare perspective, I really enjoyed a few years ago reading Shannon Brownlee's book and it was sort of over-treated, why too much medicine is making us sicker and poor.
01:02:53
Speaker
You know, I actually grew up in Canada, did some of my training there and so
01:02:59
Speaker
I think this is something that we do struggle with as clinicians and as institutions, with patients and families.
01:03:10
Speaker
And it's a hard area to deal with.
01:03:12
Speaker
So I think it's just a really good late read.
01:03:15
Speaker
It's very well written.
01:03:16
Speaker
So this is what I've given to some colleagues and trainees.
01:03:21
Speaker
And I think that's probably one of the most,
01:03:28
Speaker
an important book for people to be thinking about.
01:03:31
Speaker
Absolutely.
01:03:31
Speaker
And we will include links to all these articles we discussed and also to the books that John has mentioned.
01:03:39
Speaker
So the second question relates to what do you believe to be true in medicine or in life that most other people don't believe?
01:03:49
Speaker
Yeah, that's kind of a hard one.
01:03:51
Speaker
I would say, you know, just don't make assumptions.
01:03:57
Speaker
And
01:03:58
Speaker
You know, you have a patient and their family, they're in the ICU, and really learn from that patient and family about what's going on.
01:04:06
Speaker
And I think, unfortunately, that takes time, right?
01:04:09
Speaker
And as clinicians, I don't think we learn enough about where the patients come from, what the family knows about them, what their wishes and concerns are.
01:04:20
Speaker
And I think this can really drive a lot of decision-making and the things we do in the ICU and the quality of care we provide or not provide.
01:04:28
Speaker
So I think that's probably, I think, one of the things that I see the most in critical care.
01:04:35
Speaker
And I think that that's a great point that you made.
01:04:38
Speaker
And time, obviously, is always a commodity that we don't seem to have enough.
01:04:44
Speaker
But I do think that we can improve our use of time by priorities.
01:04:48
Speaker
And one of the things that we have tried to push within our group and I encourage listeners to think about is,
01:04:54
Speaker
When you implement the A to F bundles and you include families in terms of presence and you include them in multidisciplinary rounds, think of them as the experts on the person who you're treating and utilize those interactions to maybe get some of that information about the person itself and maybe sleep habits, what do they enjoy doing, what do they fear, which I think will inform your overall treatment as John was mentioning.
01:05:21
Speaker
Absolutely, and I think having that engagement makes some of the tougher discussions, maybe if patients aren't doing particularly well or there's big decisions that have to be made, I think that just builds a relationship in real time and makes those discussions easier.
01:05:36
Speaker
Excellent.
01:05:37
Speaker
And the final question is, what would you want every intensivist and provider who listens to us today to know?
01:05:45
Speaker
Yeah, I think of me personally,
01:05:49
Speaker
ICU care is a means to the end to get a patient through critical illness, right?
01:05:55
Speaker
And it's, you know, the patient is most interested in what their life is going to be beyond critical care.
01:06:02
Speaker
They're going to try to block out a lot of their memories from the ICU for good or bad.
01:06:06
Speaker
And I just think we need to think about what's the trajectory of the patient and focus on that and not just sort of the
01:06:15
Speaker
you know, that's kind of where the ICU liberation comes from, you know, so we're not just trying to get the patient out of the ICU and hopefully not readmitted, but we're really thinking about what's the trajectory, what we can do in the ICU to really do that.
01:06:27
Speaker
There's a tremendous amount in the whole PAD-IS or ADAP-Fund, or whatever you want to call it, realm to do this.
01:06:33
Speaker
And I think when you're talking to intensivists, I think it's really important that, you know, make sure you're surrounded yourself with a strong,
01:06:43
Speaker
well-trained interdisciplinary team, because this is the only way that you – and make sure that you use your team and delegate responsibility for care, because that's the only way, as I know you already know, that you're really going to optimize a lot of these interventions in the whole PA, PIS arena.
01:07:05
Speaker
It's a team-based approach, absolutely.
01:07:08
Speaker
Absolutely, and I think that that's a perfect point to stop.
01:07:11
Speaker
Again, John, I really appreciate your time, your willingness to share your expertise with our audience, and look forward to having you again on Critical Matters soon to discuss very interesting topics related to our practice.
01:07:24
Speaker
Okay, thanks very much, Sergio.
01:07:25
Speaker
Have a great day.
01:07:28
Speaker
Thanks again for listening to Critical Matters.
01:07:31
Speaker
Make sure to subscribe to this podcast on iTunes or Google Play.