Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: In a previous episode of the podcast, we discussed the ABCDEF bundle.
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.
Speaker: Much of our discussion on these topics was based on the Society of Critical Care Medicine 2013 Pain, Agitation, and Delirium Guidelines,
Speaker: also known as the PAD guidelines.
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.
Speaker: Our guest is Dr. John Devlin.
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.
Speaker: Dr. Devlin is a recognized authority in the field of critical care medicine with a prolific production as a teacher, author, and researcher.
Speaker: He has received numerous honors and awards for his contributions to the field.
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.
Speaker: Dr. Devlin is the lead author of the 2018 SECM guidelines we're discussing today.
Speaker: John, welcome to Critical Matters.
Speaker: Thanks very much, Sergio.
Speaker: It's great to speak with you today.
Speaker: I think that a good place to begin would be talking about what's new in the 2018 guidelines.
Speaker: I noticed that the name for one thing has changed, which means that you've included other aspects of caring for these patients.
Speaker: Would you start there?
Speaker: Absolutely.
Speaker: So I think one similarity that's really important between the two sets of guidelines is we're really focused on patient symptoms.
Speaker: So these guidelines focus on, just like PAD 2013, pain, agitation, delirium,
Speaker: We're also focusing on immobility as well as disrupted sleep.
Speaker: So those are the two big things.
Speaker: I think the other thing that's important to realize is these guidelines don't necessarily replace the PAD 2013 guidelines.
Speaker: There's some questions that we did approach a little bit differently that are similar but different.
Speaker: But even in questions that are somewhat similar, say, for example, sedative choice in a mechanically ventilated patient,
Speaker: our outcomes that we evaluated for patients are actually quite different.
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,
Speaker: get back to their life after a bout of critical illness.
Speaker: Some of the other differences, you know, we really felt the rehabilitation mobilization field is actively growing.
Speaker: In Pat, 2013, we only had one question devoted to this.
Speaker: So we have a whole section here.
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.
Speaker: And, you know, a lot of these patients,
Speaker: coming into the ICU actually have pre-existing sleep-related issues.
Speaker: So we really wanted to focus on the recognition, prevention, and treatment surrounding sleep.
Speaker: The other big thing we did is we made these guidelines more international.
Speaker: So we had members from European countries as well as Australia.
Speaker: Just because practice and care is different in some of these other westernized countries,
Speaker: importantly, recognizing that these guidelines still do not really tackle what could be done in maybe lower-resourced countries.
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.
Speaker: Is that correct?
Speaker: Absolutely.
Speaker: This has become a really important aspect of guideline development.
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.
Speaker: And there's actually a whole sort of methodology of how to do this.
Speaker: And the most important steps that we use with our patients were
Speaker: actually helping define the topics that turned into questions, helping define some of the outcomes that we evaluated in our questions.
Speaker: And again, they had some influence on some of the post-ICU outcomes.
Speaker: We also had, when we sit around sort of the virtual phone using the grade process, which is sort of the standardized method,
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.
Speaker: It's really useful to have the patient perspective as these recommendations are being formulated.
Speaker: So these patients were on the calls with the expert team as recommendations were being formulated.
Speaker: We then had a live meeting,
Speaker: critical to getting consensus and moving through the process where patients were at that.
Speaker: And, you know, it's really funny.
Speaker: I'll give you a really good example.
Speaker: You know, people were really, really focused on, you know, everybody should get light sedation.
Speaker: And that's definitely what other patients, but most patients want.
Speaker: And our patient, you know, as an older lady,
Speaker: And she jumped in and she's like, there's times I wanted to be deeply sedated.
Speaker: I didn't want to remember everything.
Speaker: I was scared to hell of being in the ICU.
Speaker: And so it's kind of funny, you know, thinking about that.
Speaker: It doesn't mean we're going to change our recommendation that everybody should get deep sedation.
Speaker: But it is important.
Speaker: There's a variability here.
Speaker: 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
Speaker: How deeply sedated do they really want to be?
Speaker: Are they afraid?
Speaker: What are they remembering?
Speaker: Some of those kinds of issues.
Speaker: Yeah, and I think that, like you said, it's just a different perspective.
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.
Speaker: And I think it's always a good reminder for us as clinicians.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: 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.
Speaker: And pain is first for a reason.
Speaker: So why don't we start there, John?
Speaker: What comments and highlights can you talk to us about pain management in the ICU with these new guidelines?
Speaker: No, absolutely.
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.
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.
Speaker: We focus a lot on not only self-reported pain, which is still the gold standard for patients, but we also, um,
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.
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.
Speaker: And then we also go into some interesting discussions.
Speaker: There's evolving literature on proxy reporters, for example, family members.
Speaker: Do they have a role in helping evaluate pain?
Speaker: And then, of course, some of the physiologic measures.
Speaker: I think we're not changing in these guidelines the importance, and this is a really important thing,
Speaker: ICUs have a protocolized approach to assess and treat pain.
Speaker: In many cases, you know, it should be an opioid.
Speaker: So that's not really changing from the 2013 guidelines.
Speaker: You know, we do make a conditional recommendation on the use of an analgesia-first or anadolcedation approach based primarily on European data.
Speaker: And again, it's not based…it's not a strong recommendation even though there's randomized studies-supported use.
Speaker: simply because the evidence is still not as strong as people would like to see, especially from an American perspective.
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?
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.
Speaker: And so there's been an evolving literature, particularly in surgical critical care patients, with the use of a multimodal approach for analgesia.
Speaker: So that's another important component where we rigorously look at these agents.
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
Speaker: and neuropathic pain medications and potentially a COX-2 specific NSAID.
Speaker: We also, people will see, you know, the drug Nefepan, which actually is quite usually, quite commonly used in European ICUs.
Speaker: It's a multimodal strategy in critically ill surgical patients.
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.
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.
Speaker: And so that really suggests that
Speaker: You know, it applies to subgroups, important subgroups of patients.
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.
Speaker: The supporting evidence, there could be some gaps.
Speaker: Obviously, the benefits away the risk.
Speaker: But there's not this overwhelming evidence profile that this is absolutely what you should do.
Speaker: And if another study came out, it could change the recommendation.
Speaker: Benefits generally outweigh burdens.
Speaker: But again, you know, this is sort of a stopgap where we think it's the way to go.
Speaker: But, for example, medical patients, we're still not really sure, you know, exactly how to best deliver, say, a multimodal approach.
Speaker: And I think that's really, those are kind of the big things.
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.
Speaker: These are, you know, music therapy that actually can have a substantial decrease on
Speaker: OPO requirements and help control pain.
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.
Speaker: So non-pharmacologic strategies absolutely play a role here as well and should be considered sort of in the pain realm.
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.
Speaker: The first thing you should treat in an ICU patient, the ventilator, otherwise, is make sure you're addressing pain.
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
Speaker: guide how we would treat those patients.
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.
Speaker: And many times that might be enough for our patients.
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.
Speaker: And then the third thing that you mentioned is at least thinking of multimodal approaches,
Speaker: in terms of decreasing the amount of opioid use, but also improving pain control with other therapies where pharmacologic or non-pharmacologic.
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?
Speaker: That's correct.
Speaker: Okay.
Speaker: Excellent.
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?
Speaker: And that's why they're exhibiting whatever they're exhibiting and address that first.
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.
Speaker: Yeah.
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.
Speaker: And I think sometimes we overlook that.
Speaker: Yeah, I think that's a really good point.
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.
Speaker: We need to be thinking about those things
Speaker: as we're doing them, and again, making sure we have an analgesia strategy for those patients.
Speaker: Excellent.
Speaker: So let's move on to the next category, which is agitation-sedation.
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?
Speaker: Yeah, so great question and people always want to know, well, what should I use as my first-line sedative in patients?
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.
Speaker: Does the patient need to be calmed?
Speaker: Are they in pain?
Speaker: Should they get some fentanyl?
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.
Speaker: That's a lot of patients that we see in US ICUs.
Speaker: So thinking about some of those reasons.
Speaker: And then, of course, does the patient have valerium?
Speaker: But assuming that we've gone through that list very quickly and we do want to use the sedative,
Speaker: You know, our guidelines, similar to PAD 2013, do recommend propofol or dex and etomidine.
Speaker: I think there's differences between these agents, and we think we need to think about, well, what's our sedative goal?
Speaker: So why would we choose propofol or benzodiazepine?
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
Speaker: You know, still in practice, there's people like, oh, they're intubated, mechanically ventilated, let's start them on Propofol.
Speaker: And not everybody who's intubated, mechanically ventilated necessarily absolutely needs a continuous fusion of a sedative.
Speaker: So, you know, there's other ways of working around that.
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.
Speaker: And then, of course, delirium is a big thing, but the use of a benzo versus propofol or dex,
Speaker: However, you know, there is potential roles for these agents, maybe in some patients, for really deep sedative sedations needed.
Speaker: Obviously, patients may be having seizures, patients on neuromuscular blockers.
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.
Speaker: I think the, you know, we really can't make a good recommendation, at least in our guidelines, between Propofol and DEC.
Speaker: There's still only
Speaker: really a couple randomized control studies and they showed minimal difference between outcomes in these studies, particularly the PRODEX study.
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.
Speaker: So, you know, hopefully in the next year we'll get some results from that.
Speaker: So we're still not really sure which one to use, but I think, you know,
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.
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.
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
Speaker: for a conjunction with neuromuscular blockers, right?
Speaker: But in general... Yeah, I think those are a lot of the patients.
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.
Speaker: I think that requires a whole different guideline, even though obviously these patients have sort of an agitated delirium-type state.
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.
Speaker: So I think practices in this area are changing a little bit too.
Speaker: And what about between Propofol and DEX?
Speaker: So like you said, there's not enough literature to say this is superior.
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.
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.
Speaker: Can you comment on that a little bit more?
Speaker: I know it's a great point and that's what I was kind of getting with the pharmacology response.
Speaker: So absolutely, propofol is a GABA agent.
Speaker: It's an anesthetic.
Speaker: It will provide deeper sedation in patients.
Speaker: It is obviously advantages it has, for example, over a benzo is it's titratable organ.
Speaker: It's cleared independently of renal and hepatic failure.
Speaker: So, you know, it's a terrific agent for deeper sedation in patients.
Speaker: And, you know, it's obviously probably the most prevalent sedative used in the United States.
Speaker: Dexanatomidine, generally lighter sedation.
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
Speaker: and maybe not always gain the benefits of DEX.
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.
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.
Speaker: So we're not titrating the drug up to two or three.
Speaker: mics when in fact the patient's heart rate hasn't budged and for whatever reason we're not getting our sedative goals.
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.
Speaker: Certainly in our delirium recommendation we do make them in patients that are agitated that, you know,
Speaker: it's a barrier to extubation.
Speaker: Certainly, I think there's a role in those patients that have agitated delirium.
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.
Speaker: And what's happening, I think, a lot more now is
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.
Speaker: So there's a lot more of an individualized approach.
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.
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?
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: I mean, there's definitely patients where, you know, you're struggling to extubate them.
Speaker: You need them a little bit chilled out, but, you know, you still maybe want them to be able to mobilize, move around.
Speaker: And I think dex is a great drug for that.
Speaker: Generally, some people get caught up in the cardiovascular effects, particularly hypotension and sometimes the bradycardia.
Speaker: I would say the cardiovascular profiles of these agents are fairly similar.
Speaker: So it really comes down to depth of station and what your goals are that day with the patient.
Speaker: And the bradycardia with DEX, I mean, in some studies th at at least I reviewed, it's something we see, but it's something that has rarely led to the need for interventions.
Speaker: Can you comment on that a little bit?
Speaker: No, absolutely.
Speaker: You know, many of these patients, I think the patients that we have to really be careful with DEX with,
Speaker: from my experience is people that have really poor cardiac function in terms of ejection fraction.
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.
Speaker: But generally with the bradycardia, we often see heart rates in the 50s.
Speaker: Actually, I like to see that it usually means that the drug's decreasing the sympathetic drive, which is its main mechanism.
Speaker: And most patients tolerate it quite well.
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.
Speaker: Excellent.
Speaker: So we talked a little bit about the interdisciplinary rounds and how our plans change on a daily basis.
Speaker: And one of the things that I think is also emphasized in previous guidelines, but also in these guidelines, is that light sedation,
Speaker: is better than deep sedation in terms of outcomes.
Speaker: Could you give us a working definition of light sedation?
Speaker: And then I have a follow-up question for that.
Speaker: Yeah, absolutely.
Speaker: So in the guidelines we define, there's not really a perfect definition for light sedation.
Speaker: But the consensus of our group in many studies in the literature is a RASP of minus 2 to plus 1.
Speaker: So that would be a Riker SAS of around 3 or kind of a light 2.
Speaker: And so that's the goal theory.
Speaker: Definitely someone that is at minus three or in a coma, obviously that is not like sedation.
Speaker: Some people might consider like sedation to be minus one RAS, right?
Speaker: Minus two might even be sedated.
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.
Speaker: Some people would say it's a minus three and some people would say it's a minus two.
Speaker: So there's a little bit of variability in how it's best.
Speaker: reliability.
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.
Speaker: It's funny how there is some variability.
Speaker: It's important to try to standardize that.
Speaker: That's all through education and maybe some checks by someone else.
Speaker: But in terms of light sedation, it's definitely a goal.
Speaker: And I think the most important thing to emphasize with light sedation is
Speaker: We're trying to keep light sedation 24-7, okay?
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,
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.
Speaker: That's not the intent, right?
Speaker: We're trying to keep these patients at a lighter level of sedation 24-7.
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
Speaker: of helping on a 24-7 basis to keep patients at these lighter levels of sedation.
Speaker: And that's allowed us actually to focus a little bit more on sleep improvement.
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.
Speaker: But I have found, John, that the more challenging step is actually –
Speaker: making sure that a given RAS score
Speaker: is associated with a therapeutic conduct.
Speaker: Maybe similar, the analogy I can make is to insulin drips.
Speaker: If you have a blood sugar of X, that usually informs what you're going to do with your drip.
Speaker: And I think that having that step become automatic is sometimes difficult.
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.
Speaker: Any tips or comments on that?
Speaker: Yeah, I think it's really important.
Speaker: It's a really important point because, again, this is all about how you work with your nurses and clinicians to define this.
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.
Speaker: And that was a study where everybody got benzos if they needed continuous sedation.
Speaker: And they were managed with an hourly nurse-driven sedation protocol.
Speaker: And in the intervention group, they added on daily sedation interruption at least once a day on top of this hourly protocol.
Speaker: We enrolled about 60 patients at Tufts Medical Center and I was the PI on it.
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
Speaker: preferred doing an hourly protocol 24-7 than they actually did doing the daily sedation interruption.
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.
Speaker: But it is important that nurses really prefer this.
Speaker: And we actually had really, really good compliance with our night nurses.
Speaker: Again, I'm not trying to blame our night nurses.
Speaker: That's classically been the population, I think, at night where over-separation can happen sort of cumulatively for various reasons.
Speaker: And we would often find when this protocol was used, our patients would be, you know, just lightly sedated in the morning.
Speaker: And then they obviously were able to get on SVTs.
Speaker: And
Speaker: When you talk to the individual nurses, they don't mind making small changes.
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.
Speaker: And again, this study was completed eight years ago, so probably it would be a propofol drift now.
Speaker: They would make small changes.
Speaker: You know, they were supposed to be dropping it down by a milligram per hour.
Speaker: So they would make these changes every hour until the patient was at their citation goal,
Speaker: And if they were to the sedation goal when they're on like one milligram an hour of midazoline, they stopped the sedative.
Speaker: And that actually stoppage might happen for hours, you know, if the patient was persistently deeply sedated.
Speaker: But the nurses actually felt very comfortable with this.
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
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.
Speaker: It requires a concentrated effort to down-totrate until you're at your light sedation goal.
Speaker: And also, like you mentioned, the needs, not only the plan, but the needs of the patients changes constantly in the ICU.
Speaker: So that's why what kept them lightly sedated now might not be enough next time or vice versa.
Speaker: So I think it's important.
Speaker: Well, absolutely.
Speaker: And there could be something the patient's undergoing a procedure.
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
Speaker: fentanyl, which could cause them to have deeper sedation.
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?
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.
Speaker: And that's the most important thing with daily sedation interruption or a spontaneous awakening trial.
Speaker: When you're
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.
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.
Speaker: Absolutely.
Speaker: So I think that this can lead us into the next topic, which is delirium.
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.
Speaker: But I think we have to start there with delirium.
Speaker: No, absolutely.
Speaker: That's like the most important thing.
Speaker: So delirium is all about risk reduction, right?
Speaker: All these patients come into the hospital.
Speaker: Some of them have, you know, a lot of predisposing factors that we usually can't do much about, right?
Speaker: That they're old.
Speaker: They have maybe some history of cognitive dysfunction, blah, blah, blah.
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.
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.
Speaker: And so we do talk a lot about risk factors.
Speaker: about risk reduction and the risk factors.
Speaker: So I'm not going to revisit all those, but there's some really obvious ones.
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?
Speaker: Is there a new infection?
Speaker: So there's things that could lead to a further diagnostic workup on the part of the ICU team.
Speaker: I think the other thing that I just wanted to allude to is the importance of delirium prediction.
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.
Speaker: But these delirium prediction tools have come a long way.
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?
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.
Speaker: But the point I'm trying to get is sometimes we're not.
Speaker: You know, we only can mobilize so many people.
Speaker: We can only do so many things.
Speaker: So why not focus on the people that have the highest predicted risk of delirium, particularly when things are modifiable?
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.
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.
Speaker: But a lot of these things are very low risk.
Speaker: And there's, so we, the one thing we really evaluate is light therapy.
Speaker: And actually that hasn't really been shown to, it's like bright light therapy to help prevent delirium as a non-pharmacolactics.
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.
Speaker: And some of these things are simply involving families
Speaker: reorientating patients, waking them up more, and then of course mobilization.
Speaker: So all these things sort of come into play, which I think are pretty firmly defined in the A to F bundle.
Speaker: Yep, absolutely.
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,
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.
Speaker: And actually there is some data that probably giving them their glasses is helpful, right?
Speaker: Well, and hearing aids and absolutely.
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?
Speaker: What do they like to do?
Speaker: What are the things, you know?
Speaker: What's their baseline status from a sort of a social, functional basis?
Speaker: And you want to kind of try to push that and promote that, realizing the confines of critical analysis and intubation.
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.
Speaker: And that is true because preventing is always better than treating.
Speaker: But I think it also rings especially true in delirium because we don't really have a lot of good treatments.
Speaker: But what can you comment briefly, John, on what the guidelines say about treating symptomatic delirium with pharmacotherapy?
Speaker: Overall, I think what's the most important thing surgery to emphasize here is
Speaker: Does the patient have a delirium associated with symptoms that needs treatment?
Speaker: That's probably the most important place to start.
Speaker: But is the patient having hallucinations or delusions?
Speaker: Is the patient fearful?
Speaker: Is the patient having agitation related to their confusion and delirium that's not related to withdrawal or pain?
Speaker: If a patient's having that, then regardless of what
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.
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.
Speaker: What happens when we do these guidelines, what happened in 2013 happens here is
Speaker: the symptomatology hasn't been as well differentiated in these randomized studies.
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.
Speaker: So overall, the signal of using antipsychotics, giving a statin, you know, giving drugs like ketamine even,
Speaker: really have not been shown to have much of a role as a sort of a standard treatment for delirium.
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.
Speaker: And that's probably not the best approach, and that's not what our guidelines are advocating.
Speaker: But if people do have a specific symptom,
Speaker: that's biliary related, we need to think about how we can treat that.
Speaker: So that's probably the most important thing.
Speaker: There is some important studies coming down the pipeline.
Speaker: MindUSA study is going to be presented in October.
Speaker: That's a large, the Prazidone-Haldol versus placebo study in a large cohort of medical and surgical critically ill patients.
Speaker: So I think we're going to get some more data in the next few months for what to do.
Speaker: But in terms of our guidelines and what was available,
Speaker: Remember, the evidence for our guidelines, actually, we only had evidence up to, you know, the up to 2015, the fall of 2015.
Speaker: So our guidelines, I mean, 2016, sorry.
Speaker: So our guidelines are a little bit old, like they always are.
Speaker: So there's things that we're missing.
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.
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.
Speaker: No, you're absolutely right.
Speaker: And our evidence did stop in October 2015.
Speaker: I didn't mean to say 2016.
Speaker: You're absolutely right.
Speaker: And it's important.
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.
Speaker: And if it's working, you know, maybe down titrate the dose and see if the symptoms reoccur.
Speaker: But if it's not working, stop it.
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.
Speaker: There's so many patients that are left on
Speaker: you know, quetiapine, for example, for weeks on end.
Speaker: And that's where you really get into safety issues.
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.
Speaker: Absolutely.
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.
Speaker: We were talking before the podcast,
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.
Speaker: Any quick comments?
Speaker: And I will link the reference in the show notes.
Speaker: Yeah, so this is a study that I collaborated with Ioannis Grobik on from Montreal.
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.
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.
Speaker: And so our hypothesis, well, if it could do this with sleep architecture, we know critically ill patients have really poor disorganized sleep.
Speaker: If you can reorganize and improve their sleep in patients without delirium, our hypothesis was that maybe we can help prevent delirium.
Speaker: Now, the interaction and relationship between disorganized sleep and delirium and whether delirium worsens sleep
Speaker: That's a little bit of a quagmire, I'll be very honest.
Speaker: We know there's some kind of association, but it remains quite controversial in the literature and among experts.
Speaker: But with all that said, and again, we did pick primarily mechanically ventilating patients.
Speaker: All our patients were getting some sedation.
Speaker: So we had some pretty sick patients.
Speaker: Our Apache 2 scores, I'm just going by memory, but I believe they were around 20s, low 20s.
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.
Speaker: to 6.30 in the morning, we gave them dexamintitomity.
Speaker: We started at 0.2, and we can go all the way up to 0.6.
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.
Speaker: We down-tried to shut it off, and if the patient became agitated,
Speaker: we turned up their existing sedation.
Speaker: We kept analgesia the same, and a lot of these people were on fentanyl.
Speaker: And then what we did in the morning is we did a intensive care delirium screening test.
Speaker: So we did a delirium assessment at 7 a.m.
Speaker: So the night nurse, before she went home, scored the patient over that shift of having delirium or not.
Speaker: Then we also did what's known as the lead sleep evaluation questionnaire, which is
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.
Speaker: So what we found is we found a pretty large treatment effect.
Speaker: You know, the absolute difference, you'll have to remind me, in fact, what the treatment effect was.
Speaker: I'm kind of embarrassed to say.
Speaker: I think it was around 30%, 25%, from around 45% to the low 20s.
Speaker: So that's the incident delirium.
Speaker: So these are the patients that, you know, either did get delirium or never had delirium between the two groups.
Speaker: And then we actually, interestingly enough, we found no signal with the sleep scores in the patients that we could adjust this.
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.
Speaker: Now, of course, some of the questions that come up from this is we're still not really sure
Speaker: you know, is it avoiding some of the sedatives we're giving patients and using more dex at night?
Speaker: Is that the protective effect that maybe we, would that account for some of the reduced incident delirium we saw?
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
Speaker: non-DEX sedatives or is it the DEX that's actually having an effect?
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?
Speaker: So we really consider this a pilot study.
Speaker: You know, we did show a big treatment effect.
Speaker: I think it was a well done study.
Speaker: We didn't measure any other post ICU outcomes at all.
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.
Speaker: You know, maybe it would, it definitely will reduce the layer and improve, and maybe improve sleep.
Speaker: Again, there's some, you know, longer term outcomes and some other things that I think should also be further evaluated.
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.
Speaker: But I think that definitely, I mean, like you said, a food for thought and more to come, I'm sure.
Speaker: So we'll keep tuned into that.
Speaker: So...
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.
Speaker: Any general comments?
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.
Speaker: But any general comments you can give us on this topic before we go into talking a little bit more about sleep?
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.
Speaker: I think what you might see is the evidence for PAD 2013, where we make a recommendation that
Speaker: early mobilization should be used because it reduces delirium.
Speaker: That's basically based on the Schweikert study.
Speaker: Again, very strong study, and it sort of launched this whole area of inquiry.
Speaker: But what's interesting, there's been 15 other large randomized studies published since then.
Speaker: And some of the important things are there's a lot of variability in these studies in terms of
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.
Speaker: And then there's also a lot of variability of the types of safety and efficacy outcomes that were evaluated in these studies.
Speaker: And one big message that I know the guideline, this section of the guideline group really wants to communicate is
Speaker: It's not just mobilization, and so there's really large emerging data on rehabilitation.
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.
Speaker: I mean, there's all sorts of different types of interventions that fit under this, you know,
Speaker: thing and basically all mobilization is rehabilitation.
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.
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
Speaker: walking out into the ICU.
Speaker: Absolutely.
Speaker: So that's how we only make a conditional recommendation, but that's a lot.
Speaker: It doesn't mean that there's a lot of safety risks.
Speaker: There's almost no safety risk.
Speaker: It's just the variability of all these interventions and outcomes.
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.
Speaker: And what are the starting and stopping criterias for rehabilitation mobility?
Speaker: I think there's a tremendous variability that happens in discussions at ICU bedsides.
Speaker: But we can't do this with this patient because they're on CBHT.
Speaker: Or we can't do this patient because they're on two of our AP.
Speaker: I think it goes on and on.
Speaker: And, you know, they reviewed over 20,000 patient cases in huge cohort studies as well as all of the RCTs.
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.
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.
Speaker: But I think, you know, when clinicians are making these decisions for their individual patients, it is these types of
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.
Speaker: Yeah, and I think that for somebody who's been in the field for several decades, more than one for sure,
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.
Speaker: But it all goes around getting people back to productive life outside of the ICU as soon as possible.
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.
Speaker: Right.
Speaker: Absolutely.
Speaker: So let's talk about sleep and sleep.
Speaker: I think is very fascinating to me as a topic in terms that,
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.
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.
Speaker: So why don't you tell us a little bit about the sleep incorporation into these guidelines?
Speaker: Yeah, so I think, you know, with sleep, we, you know, we know people, patients are exhausted when they leave the ICU.
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.
Speaker: So we know all that exists.
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
Speaker: with many patients, with nurses and the whole ICU team, where patients are agitated.
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.
Speaker: And then there's much more data on the risk factors for sleep as well as the outcomes associated with poor sleep.
Speaker: you know, there's this, you know, really important relationship between sleep and delirium.
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.
Speaker: And in terms of pharmacological options, I know that there are some recommendations or maybe no recommendation that,
Speaker: We actually didn't make any recommendations at all.
Speaker: In fact, with Propol we said no.
Speaker: Some of this is the agents that we chose.
Speaker: Some of this is the data that's come out.
Speaker: So, for example, we didn't have a question on remelteon.
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.
Speaker: And then of course there's our dexamontamin study, will this reduce delirium if you're using it to try to improve sleep?
Speaker: So there's some of this is evolving, but based on the data, October 2015, there wasn't too much.
Speaker: You know, as guideline groups, we hate not making a recommendation.
Speaker: And so we tried, and our methodologist from McMaster really, really pushed us.
Speaker: They were like either make a recommendation conditionally against or for, obviously ideally strong, but if you're on the fence,
Speaker: try to make a conditional recommendation for gains.
Speaker: But for drugs like melatonin, we really were on the fence.
Speaker: And we just, it's a fairly low risk cheap drug.
Speaker: And there is some evolving data that maybe has some benefits, but it's really, the evidence remains quite weak.
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.
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.
Speaker: So we're very concerned, even for a cheap and fairly safe drug like melatonin, that if we made a recommendation
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.
Speaker: And we didn't want that to happen because we strongly felt that we weren't there quite yet with the data.
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.
Speaker: and it's not particularly strong, and because where the real data with sleep is with non-pharmacologic intervention.
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.
Speaker: Those are the big things.
Speaker: Offering patients earplugs if they want them, but obviously remembering to take them out.
Speaker: You know, we do make other conditional recommendations where actually the data is fairly strong.
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.
Speaker: But there's pretty good randomized data suggesting that that might be a beneficial effect.
Speaker: I think the most important thing, our recommendation from the sleep section is that
Speaker: ICU should be developing a sleep protocol for their patients.
Speaker: And simply, you know, there's some patient assessment.
Speaker: We're still not sure the best way to evaluate patient assessment.
Speaker: Obviously, we're not doing PSGs in these patients.
Speaker: But, you know, there's Richard Campbell's scales.
Speaker: Some people are using it.
Speaker: But, you know, trying to find out some qualitative measure of how the patient's sleeping
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.
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.
Speaker: Well, then probably just a role for a pharmacologic sleep aid to help initiate sleep.
Speaker: But we're not quite sure the patient and even which agent to use, other than it probably shouldn't be a benzodiazepine.
Speaker: Absolutely.
Speaker: And I think that, like you said, the take-home message is that we should be looking at sleep.
Speaker: We should be developing protocols for non-pharmacologic interventions.
Speaker: And I think it also translates to our providers.
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.
Speaker: And similar things can actually help
Speaker: help our patients sleep a little bit better and recover.
Speaker: Right.
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?
Speaker: Because there's a lot of people that have kind of abnormal sleep habits and routine.
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.
Speaker: Right.
Speaker: And then also asking them about which sleep aid medications that they use at home.
Speaker: And it's,
Speaker: I think the prevalence of this is far higher than we think.
Speaker: I'm sure it's probably at least 15 to 20% of our ICU patients, particularly the elderly.
Speaker: Yeah, absolutely.
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.
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.
Speaker: Any comments on this aspect before we go to some closing questions?
Speaker: Yeah, so obviously there's a lot of potential barriers with these things.
Speaker: There's a lot of sort of implementation parts to this.
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.
Speaker: But again, it requires communication, documentation, ICU team dynamics about who's doing what and all those sorts of things.
Speaker: And I think that's just a really important part of it.
Speaker: But I would suggest institutions as they take their current ADF practices and figure out is there things from the pad
Speaker: IS guidelines that maybe could help inform or reprioritize or practices that they're doing or not doing.
Speaker: And that's probably the best step.
Speaker: If people have never implemented any part of the ADAF bundle, I mean, I'm sure people are doing some of these things.
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.
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.
Speaker: I think you need the process first before you start trying to make different changes.
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.
Speaker: And what's really important, and we have a publication coming out, is
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.
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.
Speaker: Pick something, incrementally increase it and make change.
Speaker: you're actually going to have profound effects on the outcome of your patients by doing these things.
Speaker: Some people will start with mobilization, some people might focus a little bit more on wakefulness and less sedation.
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.
Speaker: Excellent.
Speaker: Well, I think this was a wonderful conversation on a very, very relevant topic to our practice.
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.
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.
Speaker: Would that be okay?
Speaker: Absolutely.
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?
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.
Speaker: You know, I actually grew up in Canada, did some of my training there and so
Speaker: I think this is something that we do struggle with as clinicians and as institutions, with patients and families.
Speaker: And it's a hard area to deal with.
Speaker: So I think it's just a really good late read.
Speaker: It's very well written.
Speaker: So this is what I've given to some colleagues and trainees.
Speaker: And I think that's probably one of the most,
Speaker: an important book for people to be thinking about.
Speaker: Absolutely.
Speaker: And we will include links to all these articles we discussed and also to the books that John has mentioned.
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?
Speaker: Yeah, that's kind of a hard one.
Speaker: I would say, you know, just don't make assumptions.
Speaker: And
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.
Speaker: And I think, unfortunately, that takes time, right?
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.
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.
Speaker: So I think that's probably, I think, one of the things that I see the most in critical care.
Speaker: And I think that that's a great point that you made.
Speaker: And time, obviously, is always a commodity that we don't seem to have enough.
Speaker: But I do think that we can improve our use of time by priorities.
Speaker: And one of the things that we have tried to push within our group and I encourage listeners to think about is,
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.
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.
Speaker: Excellent.
Speaker: And the final question is, what would you want every intensivist and provider who listens to us today to know?
Speaker: Yeah, I think of me personally,
Speaker: ICU care is a means to the end to get a patient through critical illness, right?
Speaker: And it's, you know, the patient is most interested in what their life is going to be beyond critical care.
Speaker: They're going to try to block out a lot of their memories from the ICU for good or bad.
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
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.
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.
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,
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.
Speaker: It's a team-based approach, absolutely.
Speaker: Absolutely, and I think that that's a perfect point to stop.
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.
Speaker: Okay, thanks very much, Sergio.
Speaker: Have a great day.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
