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If we treated patients differently, would their outcomes be different? What if patients never stopped walking during critical illness? In this episode, one ICU dared to ask.

 

Episode Transcription

Kali Dayton
For the past 13 episodes, we have learned about the mental psychological and physical suffering of survivors of prolonged sedation, delirium and immobility. This should mean something to us. It should haunt us, we should be moved to ask:

Why do we put patients in medically induced coma? Is there another way? What can we do to prevent this damage?

I expose this aspect of critical care not just to create awareness and sympathy. Throughout the rest of this podcast, I’m going to dare to suggest and attempt to prove that there is another way.

Of course, this is all of our desires and intentions. But there is still such a huge knowledge gap about patient experience, and long term effects of sedation and immobility within our critical care world. I recently started getting on Twitter, and I’m enjoying it. I get exposed to ideas and concepts that are new and exciting to me. It is a great place to catch a glimpse of the mentality and culture of our field.

I recently saw a post from a well intended intensivist that said, “So help me if any of you put me on a ventilator without sedation, you better run and hide when my endotracheal tube was removed. Because I’m scrappy, and I hold a grudge.”-. This was liked nearly 2000 times and shared all over the place. The comments were just as haunting to me.

After spending years caring for patients awake and walking on the ventilator. And then recently, spending hours interviewing survivors and poring over research. I couldn’t help but wince at the sentiment shared comments from fellow providers such as : “My patients that can be awake and chill on the vent freaked me out. Not right man, Not right.” And, “I want as much sedation as you can legally and morally give me.”

All of it really revealed a lack of understanding we have and what patients really experience. As I’ve said before: how we treat patients really comes down to our own experience, exposure and training. What is not helpful is that our research is also very conflicting and confusing. Despite studies that have shown that the less sedation used, the shorter the time on the ventilator and length of stay is, we are still unconvinced.

I recently saw an article that was published in the New England Journal of Medicine be shared with excitement all over the internet. It endorsed the conclusion that, “There was no difference between non sedation and lighter sedation”. I had to look closer. Our community loved the title and conclusion of the study. But perhaps we didn’t look at the methods or the outcomes measured. The primary outcome measured was 90 days mortality.

Can I just say that, we need to see our outcome goals as more than just life or death. Quality of life should be just as high of a priority to us as healers. I would hope that we would expand our outcome measurements when evaluated in sedation to more long term rates of cognitive deficits, PTSD and overall function. I digress though, there were other aspects measured in this study, such as days free of coma, ICU state and ventilator free days.

When I looked at the methods, I realized that perhaps there was no difference between the outcomes of the groups because there was little difference in the treatment and RASS of the two study groups. The non sedation group still received sedation the first day, then continued to receive it PRN, therefore, the depth of sedation did not really differ. Also, there was no mention of mobility.

One of the most important reasons to avoid making people comatose, is so that they can participate in cognitive and physical therapies. These patients were still RASS negative two to negative one. Same thing in a SPICE III trial, in which over 40% of those patients were in RASS negative three to negative five in the propofol and dexmedetomidine group. So, we can use lighter sedation agents such as dexmedatomodine and still impede our patients from being awake, calm and interactive- which should be our goal.

So my point in mentioning our persistent coma culture is to explain that patients that will tell their stories now, were in an environment in which the RASS goal was zero. They were cared for by a team that truly wanted to see their eyes for more than pupil checks. And important clause to add is that just as deep sedation should not be a blanket standard for every patient, there are circumstances in which sedation is necessary for patient survival. Patients with tenuous intracranial pressures that should not move benefit from temporary sedation. Severe ARDS patients with problems with oxygen consumption should not be moving and awake during their pronation. Alcohol withdrawal is also a difficult circumstance and a cloudy delirium picture. Yet even with that, there should be a goal to keep a patient as awake as a safe and as mobile as possible to avoid ICU acquired weakness.

So there are exceptions. But they should be just that exceptions. If there’s anything to glean from this series, it is that we can and must see beyond a sick organs or acute illness, and see patients as humans, with lives, families, careers and futures to be preserved for. We must personalize our care and cater treatments to optimize preservation of function.

There is so much wonderful research showing incredible improvements to outcome from just turning sedation down and off. Last year huge study of 15,000 patients that received the ABCDEF bundle had improvement in mortality, coma, time the ventilator, it showed that these patients were 46% less likely to be readmitted to the ICU, and 36% more likely to go home. These were great outcomes, yet, only 12% of them were actually on their feet. Only 12% of 15,000 patients were on their feet, meaning 5% for taking steps in the hall and 7% were taking steps at the bedside.

Imagine how much better their outcomes could be yet if they had not been automatically sedated in the first place. And especially if they were mobilized. Dr. Ely mentioned for early mobility studies, only two of them showed improved outcomes. So I think an important clarification is that the definition of early is highly subjective early for physical therapy to meet his upon admission. He made an important point that only two out of the four studies were not early that only two of those four studies showed physical therapy by day two.

And all the studies, the patients were sedated, but only two of them had sedation vacations, the definition of mobility is also very subjective. Only one of the studies had the patient engaging their own muscles to be able to sit by themselves by transfer from the ICU. The other three studies had mobility defined as passive range of motion. And none of the early mobility studies had patients walking on the ventilator.

So the survivor stories from this “Awake and Walking ICU” did not receive the “standard treatment” of “early mobility”. They received the standard of prompt walking. We will dive into culture later. But this is one of our main barriers to mobilizing patients. Most of our ICU world doesn’t believe it’s possible.

The failure to standardize standardize this is not feasibility or safety. It is belief and the priority. So let’s go to those that can prove it to us. We have been convinced for decades that patients must be comatose, and a mobile to tolerate the ventilator. For decades, no one was allowed to prove otherwise. Now we have survivors that have walked their way through critical illness, and can give us the truth on whether or not they were traumatized and tortured by being allowed to be awakened walking on the ventilator. The next five episodes will be dedicated to those that have lived it.

I must first explain a little about the culture, environment and process that these patients were brought into the moment they rolled into this specific ICU. Yet this isn’t about a hospital or an ICU. This is all about a process a culture and perspective that I believe can be implemented anywhere. Also, I know that we are not the only ones to be doing things like this. I want this to be a conversation and a collaboration. We want to learn from you too.

A physical therapist told me that when they walk their patients on ventilators, they play music chosen by the patient for their walks. We loved that and have since adopted it. So please share your ideas, practices and success stories. When I share our process, people usually think that I’m either delusional, lying or both. You may think with all the rest that I am crazy, or that this is not a real ICU with dying patients. The prior is more likely than the latter. But no, I’m not crazy. I will let my colleagues further explain their practices. But I need to generally explain explain our process of care so that there is context for our survivors stories and outcomes.

Of course, we are not perfect. But I can say with confidence that this team and process is exceptional. Patients come into the ICU for a myriad of reasons. And they are immediately walking at least three times a day. Hopefully this prevents them intubations in the long run, get if they end up intubated, we keep them walking.

These patients are doing everything that were physically able to do before and in some cases, they end up going beyond their baseline capacity. You will hear about a patient that hadn’t walked in weeks two months prior to admission for severe pneumonia. If we hadn’t pushed him to move, he would have had a tracheostomy. Instead, he literally walked out of the ICU.

So for these patients, right after the intubation sedatives are off. The patients are allowed to wake up and be reoriented and have the opportunity to know what is going on. We avoid opioids, benzodiazepines and narcotics and first, try non pharmacological approaches and other pharmacological options to treat pain and anxiety. We do not have visiting hours for family and they are immediately educated on delirium, and empowered to participate in delirium prevention and cognitive therapies.

On the very same day that they’re intubated, nearly all of these patients are walking. Just as we titrate our drugs, we titrate mobility according to the patient needs and capacities to optimize outcomes. This is always case by case and a personalized approach. But the goal is optimal early and prompt walking. All patients maximize their activity, which is usually walking at least three times a day.

The last walk is later in the evening. So they are bathed often in a real shower room with clean sheets so that they are tired and able to have real restorative sleep. Patients are working with cognitive therapy through occupational and speech therapy. They are communicating on paper, texting or letter boards. They’re able to interact with staff and express their needs, fears and wishes. They know what is going on and actively participate in their care.

This way, they maintain their identity, dignity and autonomy. They’re able to connect with and be supported by their loved ones at the bedside. They’re able to have their pain and anxiety treated because they can express it unmasked by sedation. Most patients truly are alert, oriented, appropriate, cooperative and even so pleasant.

Yet ICU delirium is not entirely avoidable. We often receive patients from outside hospitals after days to weeks of sedation that are severely delirious. Alcohol withdrawal, and sepsis can bring on the storm of delirium. Yet this team is determined to do everything possible to improve the severity and shorten the duration of delirium. In these cases, we do as much physical activity as the patient’s brain can participate in. Sometimes that means that the team does most of the work of keeping a patient erect in a dangle at the bedside, just to have the patient hold their own head up.

Yet, it is amazing to see the patient start to open their eyes more squeeze hands even kick on command from the clarity and stimulation of physical activity. The next session or the next day, the team finds gratification in seeing that same floppy delirious patient cruising around the unit. They knew that sedation was not the answer for delirium and agitation, and they presevered to try to spare them worsening consequences of it.

Ultimately, we probably have a “backward approach” to the mainstream mentality. When patients are critically ill, we don’t think, “oh, they are so sick, we’d better not get them up.” Rather, our mentality is, “Wow, this patient is so sick, we had better get them up.” Hemodynamics often improves mental status and lungs improve, morale is lifted, anxiety is extinguished. And it truly is a life saving and preserving intervention.

If they end up proned, or an ECMO, at least they have been kept mentally and physically strong, and have been walking up until that point. If they go on ECMO, there will be something to work with. Hopefully, they will continue to walk on ECMO. We will approach this in a later episode, but starting from weeks of immobility and delirium does not help outcomes of ECMO.

So, you’re going to hear practices and concepts that will be new and surprising to you. It is difficult to believe what we have not seen and even harder to teach what we do not practice. You will hear patients talk about walking on the ventilator right away in their ICU admission. And on settings that are not validated in literature yet.

I have had an article way to my face that was published in the Journal of critical care in 2014, recommending that patients can only do active mobility. If their ventilator FI02 two settings were less than 60%. And they were oxygen oxygenating more than 90%. I don’t mean to dispute peer reviewed publications. But I think the methodology in this case is worth considering this recommendation of FI02 to less than 60% and oxygenating 90% was formulated through discussions between five intensivists 17 physical therapists and one nurse. They bounced around ideas and didn’t make a final decision on where to draw the line for active mobility until there was 100% consensus. Therefore, these were opinions from experiences and theories. Rather than any actual events that demonstrated adverse events are dangerous with mobilizing patients that require more support from the ventilator.

Again, it is hard to believe what we have not seen. It is even harder to research and speak to what we do not practice. I have been told on Twitter to stop advocating for mobility in the cases like the ones the survivors will share. I started to understand their perspective when I realized that a “normal protocol” prohibits even dangling at the bedside until the fi02 is less than 50. And PEEP is less than eight.

So when these patients talk about walking with a peep of 20 and 100%. Some of you are going to flip. We will get into the finer details of this later. But I have not been able to find research that demonstrates that this “harms patients”. We are seeing incredible benefits to patients in the short and long term. I am going to apply the golden rule and say that if I am admitted for ARDS or even just severe pneumonia, ICU community: please do not leave me to rotten bed and tell my Fi02 and PEEP are that low. ARDS is a hard and long journey. It can take a long time until I reach that Fi02 to low settings. By then, if I haven’t moved, all I will be able to do is dangle limply at the bedside while the team holds my head up for me. After seeing patients literally walk out of our ICU after ARDS and being proned, if I end up with a trach for deconditioning, I’m going to be a bit bitter.

So if I’m oxygenating well on 90% Peep of 16 or 20. Let’s roll get me up. I need to walk I get I have the assurance of experience. So I can say this with confidence. It can be done. It is frequently done here and it blesses lives. You will hear things that I cannot provide published research on a lot has not been researched because it is not done.

Again some of this is off the books. We have not been able to conduct studies for every aspect of our process. But our experiences and patients witness that these things are possible and effective. To truly appreciate what is to be shared, you may need to open and cleanse your mind of the limited research and your own ingrained culture.

Any advancement in our field has come because someone saw a problem or a need and asked “why?” or “why not?”, and even, “what if?”. Later on, we will explore how these questions impacted the culture in this ICU, and therefore 1000s of lives. For now, just know that the patients sharing their stories in the next few episodes did not have “standard treatment”.

They were cared for by a team that doesn’t blink about walking patients with sick lungs. They do thorough evaluations of their oxygenation, lung compliance hemodynamics instability, they have never had an adverse event caused by early walking, they continually witness patients get better, faster and go home to their lives. Again, 98% of these patients go straight home from the hospital.

The general research validates these patient outcomes but do not necessarily reflect the full benefit of this process, since it was not the same process done in the studies. So we must be aware as we try to compare some of these stories side by side. It is a little like comparing apples to oranges.

For example, if we compared days on the ventilator between those that were comatose and a mobile, to those that were awake and walking, it will not be an accurate reflection of acuity. These patients could have been equally sick or even sicker. Yet they got better, faster and recovered better. We know that the stronger patients stay, the quicker they improve and are extubated. We will see demonstrated in their stories that it is as the ABCDEF bundle 2019 study showed the impact to outcomes with sedation cessation and mobility truly is dose dependent.

The more we improve our humane treatment of patients, the less sedation we use, the more we mobilize them: the better their short and long term outcomes are. Very soon we will have an episode dedicated to all the important questions and concerns about tidal volumes then of ventilation risk of baurotrauma, VALI, etc. For this portion of the podcast, we are still focusing on our why and we’ll explain more of the how later. For now, just know that we may be the only team practicing this way. So when you hear survivors talking about walking to during the worst of the respiratory failure, and then returning to work two months later, they are not exaggerating. Their outcomes are different because their treatment was different.

Transcribed by https://otter.ai

 

References:

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