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What do ICU clinicians really know about patient perspective of sedation and immobility? What are their personal wishes if they were intubated in the ICU? What do ICU providers really understand about the ABCDEF bundle and how is it going in the ICU community at large? I hit the halls at SCCM Congress to find out.

Episode Transcription

Kali Dayton: [00:00:00] This is the walking home from the ICU Podcast. I’m Kelly Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we’ll explore how to give ICU patients the best chance.

To walk out of the ICU and go home to survive and thrive. Welcome to the ICU Revolution.

Last month I was at SCCM, with IC clinicians from all disciplines and from across the United States and to even the world. It was an inspiring atmosphere to be with bright. Driven and compassionate experts that have dedicated so much of their [00:01:00] lives to the saving of the lives of others. My experience presenting there was a huge contrast compared to another large conference I participated in last fall.

I had the incredible honor of joining a panel presentation with. Dr. Wes Ely, Dr. Dale Needham and Heidi Engle, who are all world renowned leading experts and founders of ICU Early Mobility and the A-B-C-D-E-F bundle. I struggled to wrap my mind around Dr. Wes Ely and Dr. Dale Needham. Being in the same room together as they’re both involved in so many things throughout the world and are in very high demand.

They both flew to Boston, basically just present and then to turn around and fly out. I was pitching myself at the opportunity to listen to them. And present beside them. Then we went to present, and it was on the last hour of the last day. The room was almost empty except Dr. Marie Pini and her group from HD Medical that make refrain devices and VR goggles [00:02:00] about delirium and who are already powerful revolutionists.

And then there were a few other wonderful people. It was a little deflating. No one really knows me, but to have so much wisdom and knowledge about how to save and preserve lives in the ICU through the other three experts there, and there were only about 10 to 15 people in the room. Uh, I didn’t know whether till laugh or cry.

So going to SCCM, I was bracing for the same experience when I got to present with Joanna Stallings from episode 149. Patrick and Dari Pandy, who has been huge in delirium research and Heidi Engle, the legend. It was really moving to see the hall, full people standing along the sides, lines out of the door, and unfortunately, people turned away due to maxed capacity.

It wasn’t just the volume of bodies in the room with a sense of eagerness, humility, excitement, and even desperation. To revolutionize critical care medicine. If you had told me five years ago while I was hiding in my [00:03:00] closet with the cheapest mic I could find, and feeling like I was talking to a wall, that someday I would be surrounded by such greatness in that room at that moment and that they would actually want to know about awakened walking ICUs, I would’ve really struggled to believe it.

Yet, part of me isn’t surprised. I always had this unfounded glimmer of hope that felt like a knowledge that there were so many good people out there that were willing to work hard to change and learn how to do the right things for patients. Feeling their energy in that room helped me realize that the revolution is about to make some big leaps in the next few years.

You’re actually out there. You’re doing the work and making a huge difference out there. After Joanna Stallings and Dr. Patric, Pari Pani debated the versus light or no sedation. Heidi Engle asked the audience to raise their hands if they used light sedation in their units. Almost everyone raised their hands.

She then asked, do your patients actually open their eyes [00:04:00] to voice and make eye contact with you? Your hands raised? Dropped by about a fourth to half. I later showed a slide reflecting the spectrum of compliance with the bundle. Heidi asked the audience which level of compliance their team practiced.

When she asked who practice at level A, the lowest level that captured deep sedation. Despite light sedation orders, the SATs and SVTs only happening toward extubation. Only two people raised their hands. Turns out they were from the rehab team from a large renowned hospital that has published on mobility protocols and is a quote model ISU liberation facility.

They later explained that though their team think patients are Aras of negative one when they as PTs and OTs. Prior to work with the patients, they are closer to a RAs of negative four. It is a huge challenge as they were the only people from rehab disciplines in the room. They suspected the other providers may not really be [00:05:00] looking at RAAs objectively, then had asked who practiced at a B level, meaning that the team automatically s sedates patients somewhere between deep and moderate, but does daily awakening and breathing trials.

About 10 to 20 people raised their hands. She then asked, who practiced at A level C, meaning patients are lightly sedated with daily SAT and SBT, and the majority of the room raised their hands. She asked, who practiced at a level D in which patients are awake with no sedation after intubation and. Two people raised their hands in regards to the Level E in which all patients are awake and doing their highest level of mobility promptly unless contraindicated.

No one raised their hands. People came to the presentation because they have a passion for the A, B-C-D-E-F bundle. I am sure many to most of them had been working diligently on it and their teams for many years. Yet it was astounding to realize. How new and surprising the information we shared was it was [00:06:00] received very well, and yet I wondered why in 2025 these pictures, videos, and case studies of critically ill patients being awake and mobile was so surprising when Polly Bailey.

Published her study showing it was safe and feasible to walk intubated patients with a median EF ratio of 89 back in 2007. The A-B-C-D-E bundle came out in 2013, and we’ve had dozens of early mobility studies since then. This information shouldn’t be surprising, right? So I thought this SCM conference would be a good opportunity to get a sense of where the mentalities beliefs, perceptions, and practices were in this group of.

Conference participants from so many different facilities. I had a suspicion that I could learn a lot by reframing my inquiries to make it about what treatments they would want if they were personally in the ICU. So I approached people in the hall and asked if I could ask a few questions for a podcast.

I didn’t tell them who I was. [00:07:00] Or what the podcast was, I told them it was anonymous, candid, and that there were no wrong answers. Everyone I approached was wonderful and willing to participate and were very interested to learn more after they had answered the questions. So this is how it went. What’s your position in the ICU?

Uh, well actually, I, I work as a pharma industry, so Okay. If you were. Intubated on a ventilate in the ICU. Would you want to be Yeah. Awake and moving, or would you want to be in a medically induced coma? Right. I, I, I think I would like to be, um, a medical induced coma. How come? So I, I’ve been working with a medical doctor myself, and I’ve seen patients and my feeling at least one particular case I have in mind that.

She didn’t really feel well while being awake because she felt very, people would do things with her. But I mean, it’s, it’s a case really that I have in [00:08:00] mind. So I don’t have any scientific taste for this. So. And since you don’t work in IC and this is kind of an unfamiliar intervention in environment for you, if the doctor explained to you before having that breathing tube place, that if you were in a medically induced coma.

You’d have high risks of a brain injury, acute brain failure that could the long-term cognitive impairments. Yeah, yeah, yeah. And you might have hallucinations, which would increase your trauma and your fear, and you might lose a significant amount of muscle function in math that would change your ability to sit, stand, and walk after that coma.

How might that change your decision making? So, I don’t know this data, but is it data was as clear like this? Of course, it would change my decision next. Do you feel like patients have a right to be informed of those risks involved? Absolutely. Absolutely. A hundred percent. Thank you. What, what is this for?

You guys are all IIC clinicians. If you were intubated, would you want to be sedated and comatose? [00:09:00] Yes. Why? Um, I’ve been under our anesthesia before and have woken up during an or the surgery, and so I have a firsthand experience of what that. Might feel like, and I can imagine that for days upon days and so, yeah.

So you experienced severe pain, unprepared, I mean, it wasn’t supposed to happen. Correct. Okay. That was really traumatizing physical impact of being on a ventilator, being in that environment, the loss of control, just all of that to me, I would want to not have to be consciously aware of it. And kind of skip that to when I’m ready to wake up, get up, get going, get better when I can actually do something about it.

And what have you heard from patients that you’ve treated about what they experience sedated? I think that depends on the patient. There are some patients that have either had that experience before or are more [00:10:00] cognitively intact prior to the intubation that they have more of a. Experience of let me get better where there are other patients that don’t recall any of it.

So it just, it really varies from patient to patient. How would do patients usually come outta sedation when you go to juju? An awakened trial. You guys Okay. You’re the ones turn out with sedation. Are you so excited about turn off sedation? How do patients usually come out? No, it depends on the patient. I mean, um, we pound with the younger population, it’s uh, a little bit trickier when they’re coming off.

Um, why? I think it’s the way they metabolize the medications. So I think that they are ones we always look out for, um, for more cautious, I should say, because of what kind of reaction do they have. They can just bounce right out of sedation. They, one minute they’re comatose and you shut it off where the average person will probably take a minute and then boom, they’re wide awake.

So could their strength have something to do with it as well? Absolutely. [00:11:00] Absolutely. For sure. Absolutely. We actually have a, uh, being new to the ICU when I was. I was warned, like we’re doing a spontaneous breathing trial, you just stay with those patients. If those are the ones that are gonna throw you for a loop and try to self extubate or because they are strong and if you metabolize those medications.

And what does it do to your stress level when you have to do awakening trials? And you’ve heard maybe from the previous nurse, they were rodeo, they went wild. Right. What is, as you’re approaching that, how do you feel as a nurse? How does this impact you? Initially I used to get nervous and I used to get like worried.

And I’ve learned as my experience grew to get excited for the patient. And once I came into the room with that excited energy, you could see the patient kind of flip in their response to being extubated. I love that. What if they don’t pass their breathing trial on your unit? What’s the normal next step in terms of sedation if you don’t pass the breathing trial?[00:12:00]

Sedation Or does the patient stay awake? It just depends on the patient. Depends on how they do during their awakening trial. So if they do well with the awakening trial, we try to limit the amount of sedation that we’re giving them. You know, we try to give them a little bit more, like we try to give them some freedom.

I guess you could some autonomy over how they. What defines doing well, being able to follow command, being able to stay calm. Sometimes they freak out and they’re like thrashing and they’re usually restrained, so they’re like pulling on the restraint. So as long as they can stay like calm and cool, we just try to limit the of sedation that’s given.

What does the sense, some of the main causes of that kind of restlessness, impulsiveness, confusion, especially for these patients that you’ve seen. I mean, it’s just the change in, um, environment. Probably went under one circumstance and they’re waking up under a different one. And so, and time has gone [00:13:00] by, they don’t know how much, or it might seem like a slip in time.

And so, I mean, just confusion. I think that is the biggest one, especially with the, like we were talking about, the younger patients who have the more strength, but even the older who have met, have dementia stuff on top of that and are just truly confused about where they’re at every year. Absolutely a role.

Does delirium playing this a whole problem? It depends on how long the patients spend there. ’cause even our young ones can have that, you know, we call it the ICU delirium where it makes all this, as far as the spontaneous A and extubation, very challenging. And as nurses, when you’ve got a patient that has, is delirium and they’re scared and they’re anxious and they’re confused, so they’re trying to self extubate.

They failed their breathing trial. Maybe it was from delirium, right? Maybe they were because they were delirious or whatnot, right? Maybe they just are too weak to breathe yet, right? So we’re not gonna extubate them and now they have [00:14:00] delirium. What tools do you have in your toolbox to manage that delirium and help them better from it?

Here’s like on the medications we’re using, maybe rural as the Fentanyl sx, where it’s where we can still activate. Help them transition through. I’ve seen that happen. Raquel is always an option as far as medications go to kind of help with that as well. We try to like do the day and night thing where like during the day, make sure like we have all the lights on, make sure we have the lines open at night, like, you know, down, and try to have them put into regular, normal, I don’t sound like day nurses.

Okay. Okay. Well, okay. It’s a good mix though, honestly. Tell me honestly, both. From both ends. Just they should go up at night. Yes, yes, yes. They need to sleep. They need to rest during normal circadian rhythm hours. I think that is more beneficial. Would you be surprised to learn that [00:15:00] propofol, especially a verset as well, inhibit REM cycle three and four?

I’ve read that. Is that commonly talked about in your unit? Are you as nurses equipped with that kind of knowledge there? Mm-hmm. Talked about? Yeah. So then turn out at night and then day shift gets to try to keep the patient calm. Right? And a patient that’s plus one or plus two, they have delirium, they’re confused.

They can’t be extubated yet. Now, let’s say you’re in rounds. The physician says, let’s mobilize them. How do you feel about that? Just tell me just. Totally. Honestly, I’m sorry. I’m always excited. You’re my style. I love it. How about the rest of your team? Like what’s a normal kind of response? I would assume that most of them would go, oh my God, how am I gonna do that?

And when am I gonna do that? And how is the patient gonna respond? How’s the PA family gonna respond? Um, so I think it would be a challenge. Just like challenge. Yeah. Any other [00:16:00] thoughts on that? I think it would definitely be very beneficial for the patient. To start the mobility process, even though they’re intubated, like Ruth said, it would be a challenge ’cause we would have to get like therapy on board.

We would have to get RT like prepared for us to start the process. And of course like just make sure everyone on the unit kind of is aware of what’s going on. It’s like an daunting thing to orchestrate. And it sounds like it’s not something that’s been done or is commonly done, uh, in our unit. That’s not something that you do and its own position was like, go do it.

But our patient population is different. Um, and that’s one thing I’ve noticed coming from a trauma center to our little community hospital, our patients are different. We did mobilize our trauma patients where these are generally, the patients that are intubated are pretty sick and wouldn’t have mobilized even if they weren’t on the vent.

And so I feel like our patient population worked. We might have a few patient patients that we might be missing the mark on, [00:17:00] but it’s not a big population of patients that we have that they’d be a good candidate to mobilize even though they’re vented. Most of your patients have been bedbound, all leading up to IC admission.

A lot of them. And how do you feel like the A-B-C-D-F bundle is going in your unit? Um, I think it works well. Um, I see trends and I see things improving and when the patient is improving. So I think it’s working well. Awesome. Have you guys ever heard a verticalization bed beds that can stand for your bedbound patients?

Yes, we access saw those downstairs. Yes. Yes. That sounds like it’d be a good fit for your team and make it easy for everyone involved. Thank you so much. Yes, it was. So as an intensivist, if you were intubated, would you want to be sedated in comatose? Uh, yes. I would like to be s How come? Um. It’s like a drowning if something is in your throat Yeah.

You, you may feel like you’re drowning. [00:18:00] Absolutely. So I’m completely fear of situation, so I wanted to be sated. I want, I don’t wanna remember anything. Okay. And what have your survivors told you about what it was like to be sedated in comatose uh, patients? Honestly, I interviewed some patients about being sedated or being reintubated.

And they said they don’t want to be intubated again about ion. They did not remember anything. So I don’t know how they felt about ion. They don’t remember anything. Did they about the ICU, did they have any other experiences? Experiences? They do not felt hungry, but some of the patients told me that they wanted drink again once ated.

Yeah, absolutely. And where do you practice? In Japan? In Japan? Yes. Um, this is kind of not off topic, but the Japanese culture. If patients had had hallucinations and they were very traumatized, would they feel comfortable telling other people or a [00:19:00] physician they saw demons in the bedroom or that they were in another alternative reality?

Would that be culturally acceptable to talk about those things? Yes. And have you ever heard that from patients don’t care about patients that had ation? Hall tip. Yes. Uh, we have some patients. They’re able to talk about it. Yes. Would you ever be willing to mobilize your own patients? Do your intubated patients get up and stand up at the bedside while intubated?

I try to, uh, with the help of our, we have medication while they have the breathing tube? Yes. Okay. So they’re not comatose, they’re not in a medically induced coma. No, we do not move our patients. Who, but you have a lot of patients that are awake Yes. While intubated? Yes. On the ventilator? Yes. Stand at the bedside.

Walking sometimes, but only a few me meters walk. Okay. But you personally would like to be comatose rather [00:20:00] than demobilized like that? Uh, so you mean that you, you wanna sit it to the level of Yeah. Uh, you personally? Now I like to hear something, but I do not re uh, remember something bad. So you feel like some sedation?

Yes. But you still like to be awake and mobile. Mm-hmm. Be able to get off the ventilator. Yes. A tricky right. Thank you so much as an EM doctor. If you were intubated, would you want to be sedated in the ICUI would 100% wanna be sedated. We intubate people in the ER frequently and send them off to the ICU, and one of the things that I find personally is cruel is to not start them on sedation when we intubate them.

So that’s something I am personally very cognizant of and very, very passionate about, is if we’re intubating somebody, I want them to be sedated for their [00:21:00] comfort and. Everybody else’s comfort as well. Safety, everything. And what kind of SIVs do you usually use? It depends. So we see so many different kinds of patients.

So if they’re septic, that’s obviously going to make things a little bit different. ’cause they usually have the soft blood pressure. That’s when I usually, I see U doctors will cringe at this, but em, docs love ketamine. So that one works great, fentanyl works great. And then if they have an okay blood pressure, the old propofol always works.

And have you ever talked to. Survivors that have been sedated for prolonged periods of time. I have, yes. I work, the project I’m presenting is with survivors of the ICU and I’ve also talked to people once they’ve been extubated in the ICU and their memories of getting intubated and waking up afterwards and stuff, and it’s a very traumatizing event.

We have those few patients who are very calm and chill and they actually. Just fine letting them out of [00:22:00] sedation. They are able to look around the room and interact with their family without having issues. But if we start to wing that sedation and they’re not doing well with it, we turn it back on and we don’t want them traumatized from that event.

What role do you think delirium plays in them not doing well when sedation’s coming off? Delirium definitely plays a role. It’s kind of a chicken or the egg. Is the delirium causing them to not do well or is the trauma of. Waking up and having a tube down your throat, contributing to them developing delirium.

So I think they’re kind of tied and I don’t know which one comes first. So would you want to be mobilized on mechanical ventilation if you were in the ICU? Um, I personally. I don’t think I would. No, I think I’d like to be asleep through it. Perfect. Thank you. As an intense fist, if you were intubated, would you want to be sedated for prolonged periods of time with an altered level of consciousness for the procedural intubation or any other procedure which might involve pain and suffering, then?

Yes. An intubation is one of those [00:23:00] procedures, so that’s why rapid sequence intubation would require that sedation and if, for example, those patients who cannot tolerate that level of sedation, then conscious sedation, mild level of sedation to finish the procedure successful. Would you want to be able to write on a clipboard text, be informed, and make decisions while you are intubated?

Yes. If my clinical condition is getting better and keeping me awake does not impair my clinical, uh, condition and doesn’t worsen the situation, then waking up on a daily basis will definitely be appropriate. And the same reason mobilizing on a daily basis if my clinical condition doesn’t worsen with that.

Uh, and we ask about walking around the ICU if my clinical condition doesn’t get worse because of the walk in, then yes. Would you want to be sedated overnight with a daily awakening, like an interruption of sedation for these things? Or would you want to be awake continually? Well, even when I’m best of my health, I don’t stay awake at night.

So to maintain that [00:24:00] diurnal variation in the ICU is very important. So sleeping at night. With the help of medications definitely will be helpful. And then waking up in the morning if my clinical condition doesn’t impair me. Waking up and waking up in the morning on a daily basis to see my readiness for extubation.

What would you want to have given overnight on yourself? Light pain medication will be effective if I’m able to sleep with light pain medications. Downsides. Okay, that fabulous. And are your own patients awake and walking while intubated as a normal occurrence? If clinical condition allows and their overall trajectory is getting better, then yes, we do spontaneous awakening and breathing trial.

And with that, if those patients who are not able to get extubated because of two area number of reasons, then they are mobilized out of the bed and walk. So once they’re stable, like what’s the highest ventilator setting that you would allow a patient to mobilize on? In fact, that question will tie up with the highest ventilator setting at which the patient can wake up and do the spontaneous breathing trial, [00:25:00] and that will be the minimum ventilation, and that can be anything between 30% to 50% of IO two and be between six to eight, depending upon the body habitus.

That’s just because that’s not, they’re usually not awake before then, right? Uh, no. I, I would, I would answer that question in a different way. It is because their lungs are not ready before that. Their whole body is not ready before that. Just, that’s the reason they’re using FI O2 more than 50%. And that’s the reason they’re using p higher than the at minimum standard of the peak.

Is that your hospital policy? Those later settings as parameters, we put that in our spontaneous breathing trial policy, that this much settings should be there and overall clinical conditions should be getting better, and that is evidence supported as the core of the evidence is there, in which spontaneous breathing trial readiness should be done with clinical, uh, condition Improving and specific indicators of clinical conditions have been very clearly marked in a good quality evidence.

So the breathing trial parameters applied to the [00:26:00] mobility parameters as well? For sure. Yeah. Alright. Thank you so much. Perfect. Well thanks a lot As an intensivist and respiratory therapist in Panama, if you were in into ICU, would you want to be, um, sedated or awake while intubated? I prefer to sedated.

And why? For best control to the situation, sta stability for the patient for the best to the enter to the patient. Have you ever spoken to your patients that have been sedated for days or weeks? And have they told you what it was like? I talk with the patient before to sedated and the the family for the requirements to the sedation to the ventilation.

And I say, how many days? I don’t know, depend to the patient response and the clinical proof to the situation. And then when they’re. Clinical picture has improved and they’re extubated or have a tracheostomy. You [00:27:00] get to talk with the patient and hear about what it was like while they were sedated. Yes.

What have they said? The patient’s person? No. Remember the situation. It makes comfortable with the stay, and in few particular cases, remember voices, any voices, any messages. If you stay, example, today is Thursday. If you stay in the ICU, if you improve better, don’t worry. We, we are care for you. Your family.

Stay here. And some patients remember that the major population, major people not remember anything, not have pain, have discomfort, stay good. And they’re able to tell you that after they’ve been intubated. They said, I don’t experience anything. I never had pain. I was good. No, yes. No, no pain. And, uh, if you were intubated, would you want to be mobilized?

Would you want to stand and get out of bed? Walk? Yes. Yeah. No walk. [00:28:00] But mobilized is Yes. Physio, active physio, yes. Acting, yes. But if you’re sedated, that would pose a challenge, right? Eh? Sit in the bed. Sit in the bed, and move the arms. Move the leg. Like have the nurses and physios. Do the moving forth the patient?

Yes. While they’re sedated with their eyes closed. No movement. Only practice. Movement. And does your team practice the A, B, CDEF bundle? It’s bundle, yes. Every day. Great. And do you ever have patients out of bed standing while intubated? Not standing in or ICU? It’s not walking with a, okay. No. So everyone is usually laying in bed with their eyes closed?

Yes. They have a tube, yes. And how is your team worried about delirium? Delirium? Delirium is must not have delivery in the ICU in all patients. Okay. We put early ED for prevent and [00:29:00] management delirium. That’s great. And so your nurses are screened for delirium? Everyone’s checking it throughout each shift.

The nurses is not, it’s only the medic medical team. Okay. The doctors, the fellowships, and the attending. So it’s, oh, it’s, so it’s the doctors that are doing the cam ICU and everybody. Yes. Only doctors. How about nurses? Okay. Thank you so much. Or measures. I know you, if you were intubated in the ICU, would you want to be awake or sedated?

Sedated, definitely. Why? Because it’s easy to, in. Dated for the procedure of intubation and then after intubation, would you want to wake up, write on the clipboard while you have the breathing tube, or would you want to be with laying there with your eyes closed the whole time? Depends of the parameters of the ventilator.

Okay. Because if the parameter is down, I [00:30:00] try to awake the patients. I try to use the TEDx exome or awake the patients soon. So if the parameters are high, if ventilator settings are high, patient needs more support from the ventilator, it’s, IM, I feel like it’s important to have sedation going. Yeah. I try to use, uh, totally vocational and I use midol and Fentanyl.

Um, on, on drips, like for, for days I tried to don a lot of alone days because that increased the mortality. And it’s not good for the patient, but depend of the condition because if the patient have RDS is not easy to awake, it’s not recommended to awake because you have to to achieve goals. You know, perfusion, oxygenation [00:31:00] goals and that, and you feel like sedation helps enable that.

I try to use, uh, the common sedation and, you know, midline fentanyl and when, as soon as possible, I try to use the breach with precedex in order to awake the patient. And when you awake the patients, it’s because you’re looking towards extubation? Yeah, yeah, yeah. Okay. I prefer to use support pressure to extubate the patient.

Once they can be on pressure support. Now you’re looking at support. Yeah. Exhibition. Have you talked to your survivors that have been sedated? Yeah. What have you heard about what they experience while they’re sedated? This is bad if for long time it’s bad because they don’t have a good awake. They are very agitated, you know, have a big problem and very bad experience for them.

Is Midazolam been a common sedative in your ICU? Yeah, because I work in a public hospital and that’s [00:32:00] very common. Um, yeah, that’s challenging. Do you ever have patients, or would you, if you were intubated, would you want to be standing at the bedside, moving around, even walking while intubated? I think that is not possible, but I want to see that.

Yeah. Yeah. You’d be willing to try. Yeah. Yeah. I try because I know that it’s important that to awake as soon as possible, the patient. Yeah. It’s very important for decreasing mortality. Absolutely. How is the A-B-C-D-E-F bundle going in your Yeah, we try to use, we try to use for, for pain only fentanyl, what is possible acetaminophen.

Mm-hmm. And Tylenol. Tylenol, yes, and we try to pass to the PEX because we have a good experience with Pex and we follow the [00:33:00] deadlines with PEX in order to improve the experience of the patient. Avoid the painful experience. Um, that’s it. Do many of your patients have tracheostomies? Yeah. Yeah. A lot. We have a lot of patients with tracheostomy, you know it.

We have a narrow ICU. Okay. Yeah. Narrow. ICU. A lot of patients, we implement the early tracheostomy. Okay. For the injuries? Yeah. Mm-hmm. What about your patients that have other medical problems, respiratory problems that require mechanical ventilation? Do they have tracheostomies at the end? I try to avoid, but if the patient pass 10 days, 14 days, I definitely, I avoid the tracheostomy.

Do you feel like respiratory muscle weakness is a common cause of not being able to get off the ventilator? Yeah, definitely. And the weakness of the muscles is have a close relationship with the upper [00:34:00] doses to the sedate. Absolutely. Do you feel like your team is worried about. Sedation or delirium or the muscles, is that a concern for your team?

Yeah, yeah, yeah, definitely. Now we can try to change quickly is possible to a ketapine and din as soon as possible and use lower doses to fentanyl and melan that, and that all depends on the ventilator settings. Yeah, yeah, yeah. Okay. I try to control by pressure or control by the volume, but we try to change quickly.

Operation support as soon as possible. And this is all in Panama, right? Yeah, yeah, yeah. Okay. Yeah, yeah. In Panama. Thank you so much. Thank you so much. As fellows in the ICU, if EU were intubated, would you want to be sedated? Yes. Yes, absolutely. Why? Early traumatic experience, and then maybe the sensation of a breathing tube?

I [00:35:00] think in the abnormal pattern of breathing, that would be. Uncomfortable if there’s no adequate sedation or some sort of an anxiolytic. Yeah, I, I mean, I think I’m a little less worried as a young person of my delirium than I am of my remembering being paralyzed with a tube in my throat. Yeah, I just don’t wanna remember the intubation.

And RSI really, well, certainly RFI, that’s a procedure paralyzed during that time requires sedation, and after that, once the paralytics are worn off. Yeah, something, something. So I’m not too freaking out when I wake up, but doesn’t have to be deep. Would you want to be mobilized while intubated? Yeah. I think my, my butt started itching or something.

Right. Would I leave my, I dunno. At some point, yeah. What would you want your rest goal to be? Depends on how sick on, early on, really deep. At least a three-ish, negative ish after that. [00:36:00] Oh, physician RAs with the nursing RAs. Why do you say that? Oh, it’s just the joke that we say zero negative one, knowing that it’ll be negative two, negative three.

I’ve done some manual audits that confirm that. Absolutely. Do patients feel endotracheal tube when they’re RA with negative three or negative four or negative five? Not that I’ve ever been in that situation, but I don’t think so. I think it’s very hard to, I mean, they don’t even barely respond to noxious stimuli or they’re delocated so.

Have you been able to talk to survivors that have been sedated for prolonged periods of time about what they experienced? I can’t think of one, anyone in particular right now, but I do remember people telling me that they remember, it’s more around their RSI, but post extubation, you ever ask, how was your experience or can you communicate?

Can you sit down and chat with these people? Or what are they like post extubation? Unfortunately, I feel like I, I get to see them with their, at their post extubation confusion state where they don’t really remember much, but maybe once they’re in the [00:37:00] outpatient world, they might talk a little bit more about how traumatic it was and how do you feel like your team is doing at the A-B-C-D-E-F bundle.

It’s almost annoying how adherent we are with our checklist and bundle board care, like at least we check it twice a day, at least. And how many of your intubated patients are out of the bed being mobilized once? It’s very difficult now because if they’re deeply stated, we’re not gonna do that Basically means they have some kind of a lung condition, but in our Mic U usually if he’s alert and oriented, we’ll try to liberate them and then if we can, there’s always some sort of a issue in deconditioning and then.

It’s very rare to see them walking, but maybe working with ptl intubated, but not walking and mobilizing that way. Do you feel like your team is worried about delirium? Are nurses concerned about delirium, like acute brain failure that doubles the risk of dying? Yes. I mean, in our institution we talk a lot about delirium [00:38:00] is a risk factor for adverse outcomes, et cetera.

I don’t know if we have, you know, other than generalized care and prevention. We feel like we can outside a bundle, how much we can, can do for it other than addressing it when it’s interfering with care and extreme right from a clinical standpoint. But yes, I mean we, I think people are very aware of it, so it’s a significant barrier to improving, getting out the ICU.

So my summary is on your unit, people are aware of delirium, they’re fairly concerned about it. They’re obsessed with a checklist. They’re going over the bundle every single day, and very few patients are actually mobilizing early enough to be able to walk, but they get deconditioned and to the point in which it’s hard to get off the ventilator.

They’re confused after extubation, and yet everyone’s prioritizing the bundle pretty much. Great. Thank you. Alright. As a pharmacist in the ICU, if you were intubated, would you want to [00:39:00] be sedated? If I was intubated, would I wanna be sedated? Absolutely. Why? Um, because I think it could be very uncomfortable with just having a tube in your throat.

Obviously I would like minimal sedation, just enough to make me comfortable, though, not enough to deeply sedate me and put me in so-called the coma state. What would you want your REST score to be? I would want Myra score to be like a negative one, negative two at most. Would you want to be mum?

Absolutely. I want to be mobilized. I want to prevent delirium in any way I can and mobilization can definitely help. At Ara of negative one, do you think you’d be safe to mobilize if you’re conducting meine and opening your eyes to voice, making eye contact? Do you think you’d be ready to walk? Probably not ready to walk, but there’s different other like rotational exercises that can be done, just range of motion, things like that, which I think are also definitely beneficial.

Aside from just walking, what’s the most common level of mobility done for your intubated patients in your ICU? Um, I’m pretty sure we just stick to mainly range of motion, but I think it is definitely [00:40:00] dependent on the provider and how aggressive they wanna be. How deeply are your patients usually sedated?

Not what’s charted as a pharmacist. If you were to go and assess the rest and most of your patients on any given day, what is it actually at? I would say we mainly be a more like a negative two. And how is the A BCF bundle going in your unit? How do we adhere to it? I think we adhere to it very well. Our physicians are very diligent with doing it and especially with trying to include like families and kind of those later aspects of the bundle as well.

Um, what’s a normal timing for intubated patients As far as at what point do they. Get out of bed, bear weight. And I would like to say that we try to at least like get them to the chair within 24 hours of them, like being extubated. We, we try to be more aggressive, obviously taking into consideration the patient’s state, but again, we try to mobilize as early as possible.

How are they usually placed in the chair? Are they getting themselves to the chair? Are they being lifted to the chair? Yeah, so especially in that acute period right after extubation, typically they’ll be lifted to the chair and just kind [00:41:00] of like re in by the nurse and then progressively each day will help assist them or eventually leave to them getting to the chair on their own.

Excellent. Thank you so much. If you as an anesthesiologist, intensivist in Tanzania were intubated, would you want to be sedated? Yes. Why? I don’t wanna feel it. I don’t wanna feel the pain, the, the sensation of having something in my throat. And I wanna be able to get the best out of the care that is being provided.

I think I need to be sedated. I can’t tolerate without. And have you ever had a patient be awake? And texting to you or riding on a clipboard while intubated? Uh, yes. Not texting or something, but yes. Uh, somebody was awakened with a tube. Yeah. Would you want to be mobilized? Would you want to stand and walk while intubated?

I need two maybe. Yeah, if it’s [00:42:00] possible and I can mobilize and have my, all my other systems. More watching then why not? Yeah. Have you ever talked to any of your survivors after they’ve been sedated for days or weeks? Have you ever talked to them and heard what they experienced under sedation? Mm, not really.

No. I can’t really recall what they have said, but I’ve, I’ve talked to people before and some of them are sedated, but um, maybe not fully sedated and they remember some of the things. So yeah, I can say that. Yes. No, it’s not something they’re focused on. We’re doing some research on patient survivors right now, and to see the experiences, not entirely just on, on sedation and intubation, but just the overall experience.

Maybe we’ll learn a lot from that study, but currently I don’t have really anecdotes on, yeah, a lot of times I see we don’t get to talk to the after. And how are patients usually after they’re extubated or do you see a lot of tracheostomies in your icu? We do quite a number of [00:43:00] tracheostomies ’cause yeah, we sometimes have to stay with patients for longer than a week or so and they’re intubated.

We don’t have very good ICUs, so sometimes we, we end up with tra. Yeah. And do you ever have intubated patients? Mobilizing? No. No, we don’t mobilize them on the intubated. Does your team practice the F bundle? Yes. And how’s it going? Uh, well, I think, uh, I’ve, not in this, I’ve not been with in my ICU for some time, I’m doing a lot of research outside right now.

I think, uh, it’s a very good way of guiding them, uh, through the process, know the system thinking and everything. Yeah, I think it’s going well. I’m not sure I can really say as much. Thank you so much. If you’ve been listening to this podcast, you are likely convinced that sedation and mobility practices in the ICU need to change.

The ICU community is facing incredible difficulty with the trauma from the Pandemic staffing crisis and burnout. We cannot afford to continue [00:44:00] practices that result in poor patient outcomes. More time in the ICU. Higher healthcare costs and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task.

How does this transformation start? It can begin with the consultation with me to discuss your team’s current practice. Barriers and to formulate a plan to help your ICU become an AWAKE and walking ICUI help teams master the A-B-C-D-E-F bundle through education consulting, simulation training, and bedside support.

Let’s work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

Now, of course this was not a test. No one was graded or even judged for their answers to these questions. I’m so appreciative that they were willing to talk with me and were candid and honest. [00:45:00] Their answers reflected practices and beliefs that they have inherited, and I am confident I would have the same perspective if I had not spent seven years in an awakened walking ICU and the past five years diving deep into these problems.

Even during my two years in 11 other ICUs, I fell into the same culture and perspective, so I absolutely understand. This little snapshot reminded me of DPE Una’s publication this year with a one day point prevalence setting in which they audited 135 ICUs and 54 countries and found that less than 10% of all patients on mechanical ventilation.

Received early mobility. These wonderful participants that I talked with gave great insights into gaps and mentalities that I have seen throughout the country and world, from ICUs that I have visited. The hundreds of clinicians that I have spoken to, these conversations captured the following common, but erroneous beliefs and the practices.[00:46:00]

One, mobility for intubated patients is path of range of motion, early end quote, aggressive mobility is. Slinging them to the chair after extubation. Two. Sedation is sleep and causes peaceful. Lack of awareness. It is comfortable, humane, and therefore the personal preference of ICU providers themselves.

Three. Since sedation is sleep, it is increased overnight to enhance the circadian rhythm. Four, there are different rashes. Physician prescribed RA and nursing RAs. The nursing RAs is usually about two points lower than what is prescribed, but that’s okay. It’s just how it’s, it’s a running joke that we know about, but except as benign and a laughable reality, five, it is best to be deeply sedated right after intubation, which is actually an independent predictor of mortality.

But that’s the belief. Let’s deep lift the data after intubation while we’re really sick. [00:47:00] That’s the best thing. Six. Awakening trials are just for extubation. It is best to keep patients sedated and comatose until the acute processes resolve. Their lungs are better and it’s time to do an SBT. SATs and SBT are to always be done together.

We wait until patients meet criteria for an sbt. If they fail their s bt, they’ll probably get sedated if they’re not perfectly still and calm seven. The agitation seen during awakening trials is primarily because of the endotracheal tube. Delirium is an afterthought and may even be caused by being aware of the tube.

We sedate them so that they are not aware of the tube. Eight sedation is essential for sick lungs. The sicker the lungs, the higher the ventilator settings, the more sedation patients need. Nine. The bundle is a checklist of things to document. The main point of it is to liberate patients from the ventilator, and [00:48:00] therefore, SATs and SPTs are the most important part.

As long as we’re checking the boxes of charting CP RAAs, S-A-T-S-B-T CAM Early Mobility screening, we’re compliant. Patients don’t have to be awake, communicative, autonomous, or even able to move their own bodies to be compliant with the bundle wasting. Number nine, reaffirmed in the SECM Centers of Excellence program.

The criteria for bronze, silver, and gold awards with the plaques that can be hung in the unit is based on compliance with charting. As long as screening for SAT is charted, that is compliant. Even if the SAT is only a flicker of sedation off the pump and a prompt reception of sedation at full dose, a team can get a gold star for compliance with the bundle.

The entire ICU can be charted as bedrest for the early mobility screening. But as long as the A-B-C-D-E-F bundle dashboard shows high volume of taring, the ICU [00:49:00] will get their award. In the end, we can check off the books of the A BCF bundle as done, but patients can still be deeply sedated and mobilized and with higher risks of death, trauma, injury, and lifelong disability.

But we will still be led to believe we are practicing the bundle. Because our charting looks good. I keep thinking about this cliche phrase, the truth will set you free, but here the reality is that the truth will set our patients free. If this is the first time you’re hearing this podcast, lean into your own beliefs and practices with an open mind.

Go back to the previous episodes and listen to the survivors themselves. Check out my website, dayton i osteo consulting.com, and under the podcast tab for clinicians. You can find a category dedicated to survivors of sedation and immobility, and a category for survivors of awake and walking. Nice use.

Listen to them. Read the research, [00:50:00] question your reality and find the truth. It will change your practices and the lives of your patients. Welcome to the ICU Revolution

To schedule a consultation for your ICU. As well as find supportive resources such as the free ebook, case studies, episode, citations, and transcripts, please check out the rest of my website.

Transcribed by https://otter.ai

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