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Are there any other “Awake and Walking ICUs” outside of Salt Lake City, Utah? Dr. Thomas Strom shares with us his team’s success and research in Denmark. He provides powerful insight into the gaps and future of critical care medicine.

Episode Transcription

Kali Dayton 0:37
Okay, I am so excited about this really powerful episode. As I’ve mentioned before the awakened walking ICU was part of a multi hospital system when the critical care department discusses sedation and mobility practices and then compares to the awakened walk in ICU. The defense has always said, quote, “Well, they’re not that sick. And that’s why they can walk them.”- Unquote. Despite the same Apache scores as there’s high ventilator settings, and now the same COVID diagnosis in the same community.

Something I would hear from one of my colleagues was, “No, they all start out just as sick, if not sicker, the differences we don’t make them sicker. We don’t cause all the other complications and demise.”

The exploration and learning I’ve obtained to doing this podcast has brought a new level of appreciation for the validity of his comments. For so long, it is seems that this awakened walking ICU was the only ICU in the world that had the practice of allowing almost all patients to wake up and even mobilize after intubation. I am relieved to be wrong and thrilled to hear from an awake and walking ICU team in Denmark. Dr. Strom, thank you so much for coming on the podcast. Do you mind introducing yourself?

Dr. Thomas Strom 1:56
No, not at all. And thank you very much for having me. I’ve been looking very much forward to this. This is a great opportunity to connect with the ICU community in general and I think this will be very interesting. Well, my name is Thomas Ryan 49 years old. I live in Denmark, we’re in Denmark. I’m a physician MD and I’ve been doing most of my work has been just like yours, Kali, with doing awake and mobilize patient turning off sedation.

Normally when I gave a talk I always start with you know, a slide with “no conflicts of interest”. And that is easily overcome because no pharmaceutical company whatsoever want to sponsor a guy who turns up the drugs so so this is very idealistic work, but I think it’s it’s it’s a funny area also my my training is in Denmark, I’m, we have a link with anesthesia and intensive care.

So every physician working in the ICU have an anesthesia intensive care background. I think that’s a little perhaps not uncommon in the US where the doctors are normally I don’t know, internal medicine, medicine, pulmonologist and whatsoever surgeon but here we are trained anesthesiologist, so I mostly make a joke about being an anesthesiologist and turning off sedation. But that’s my line of work.

So yeah, so so that was a basic introduction. So I think if I could tell a little bit more about myself and how I come about working with the awake, intubated patient, in the ICU, I think we go back. Denmark is a very, very small country, compared especially to the US. But around 5.5, or more, a little less than six millions Danes in the country we have for University Hospital. And I studied in one of the cities called Odinson, in the middle of Denmark.

It’s the birth town of Hans Christian Andersen, if anyone is the poet, if anyone is historically interested, I started medicine here, the and I worked a little bit as the student and medical student in the ICU, and I think that was when I got my interest in. In the ICU. I liked the atmosphere, the kind of action in the ICU and I think a lot of, you know, anesthesia intensive care personnel had been recruited that way.

And when I was a young medical student, I the patients in odunsi were deeply sedated like you would traditional way to be sedated. A lot of noradrenaline and stuff like that. Then I moved away to some basic training as a doctor, and came back in 2001. And I would say there has been a small revolution, a big revolution, in my opinion, the patient were woken up.

And I have some older colleagues here, who have been asking themselves, the story is that that at the time, before 1999, we use the Midazolam to sedate the patients, and fentanyl, and dialysis was not offered on a routine basis. So we have a lot of accumulation of drugs.

So my older colleagues, Sean Nipson and yen Shibbit they were facing some time to be in having a discussion whether or not to, you know, end therapy in patients. And, and they then the patient woke up and and just, you know, being on the edge of stopping active therapy in patients who are just, you know, pharmaceutically, you know, in a coma, that makes them wonder if this was the right thing.

And they had the discussion with the nurses there were shifted, you know, we have there was at the time more modern ventilators offering pressure support, they had one to one nurse patient ratio and, and they decided to give it a try one day to the other they weren’t, well, the patient, or at least, they didn’t start sedation after the patient were intubated. So that was the start of it.

And I heard of it and I started started here as a young doctor and I went through the same thing saying, okay, that that can be true. This is This is nonsense, because an intubated patient needs sedation, that let it’s like gravity, you know, you don’t need to test it, because it’s a fact.

But you know, here patients were awake, accepting that you will use some the, we still do lose use large ball soft, soft blue line tubes, and we use a large diameter and half nine, also for for women, and in this ICU patient patient at that time, and still do, were awake. And at that time, as we discussed, it was not common for all ICUs to offer renal replacement therapy. So we had a lot of septic patient with renal failure transfer for to this University Hospital.

And often just by turning off sedation, you know, renal function in a way came back, and you will get out of norepinephrine. And it was amazing. It was you know, I was struck by it, it was amazing. So we were discussing it, what to do, how how do we get the community on board that that this is the way to go.

And when we take when I was younger doctor and took you know, courses in order to became an intensivist, we were talking about the method and people didn’t believe it, they said okay, this, this, this is the crazy ones from ordinances. And we were discussing it and how to go from here. And there my senior colleague at that time said, Okay, people can just come and see it, but you know, that, that that is not how you you, you write history.

So and then we had a new new professor down here pellet soft, and he was struck by the same okay, this is this is amazing. And we knew we need to do you know, basic science, we need to do a randomized control trial. And so we need to set up a trial saying we randomized to either sedation with daily juega trial like JP Chris in Chicago had described at the time.

And, and I are our standard therapy with with awake patient, and both doses of morphine and see how it turns out because we were sure that it had an effect on length of mechanical ventilation. So we we put down a protocol and in 2006, we randomize the first patient and that was not without problems, to do a trial in a unit who had been dealing with awake patient for almost seven years at the time.

And patient were you know, admitted to the ICU for the operating theatre in the morning woken up and were mobilized and awake but still on hyvin setting and we that time needed the patient to x skipped the trial, of course relatives, and we have awake patient accepting to be enrolled in a trial. And when they draw sedation, we have, you know, nursing standard, we’ve crossed arms saying you can do it. It’s inhumane patient, it’s unethical permanently.

And the colleagues were also saying this is unethical. And but you know, we did it. And if you could say, still, at that time, you know, this was an open label trial. So either they received sedation or they received no sedation as bolus dose of morphine so that there were no placebo or anything. And we did in the control group, we did a daily wake up try and we try to do recce minus two minus three and a daily wake up trial.

And we randomized total of 140 patients 70 in each group. And in the late 2009, and I started 2009, we randomize all patients, and we looked at data. So we were, we put together the manuscript and submitted it for Lancet in late in the autumn 2009. That, that, that that was actually an amazing just a review process of putting in Serato submitting a manuscript, doing an intervention that no one in the community could believe that we’re actually amazing.

Because, you know, a lot of reviewers and comments, there’s some, some of the important what, they didn’t assume that they assumed all the reviewers that we use restraint and without, and they just put out, okay, what, what kind of restraints to use, and that didn’t, you know, start the sentence with what do you use restraints?

When if, yes, what kind of restraint they just assumed, okay, wait patient, the least they do is they tied the patients down, but we don’t. And then they hammer out a lot about the nurse patient ratio, because in our unit, we have a still have a one to one nurse patient ratio. And that’s a little, you know, awkward for this guy. I think in the US you have one nurse normally take care of two patients, is that not correct?

Kali Dayton 12:25
Ideally, at baseline, and during COVID? It’s been a different story. Unfortunately, it’s been one to three, one to four. It’s been terrible. Yeah.

Dr. Thomas Strom 12:35
Yeah. Yeah, in many ways, we can talk about that later. But the COVID has hammered us back, you know, with this walking in the ICU, but we can we can touch on that later on. But, so so. So we, we had a review process. And while this paper was out, I was PhD student at the time and, and did a, a tour with my family in the US for weeks in California and our camera.

Yeah, well, that was great. And then a week in Pittsburgh, at the University of Pittsburgh, I was a, you know, visiting observer. And I was given the chance to give a talk about our science trial and in Denmark, and I put forward our results. And that was, you know, I think all the doctors there was sitting with their arm crossed and saying, okay, awake patients, where they dig up that guy and what planet did he flew in from? It was? Yeah, yeah, what rock is he on? Because it truly awaking what I don’t know, look, whatever, there’s it. And I think that that was also because I think, you know, in visiting the US and service, I’m afterwards, I think, I’m being a anesthesiologist.

So I don’t, you know, mind removing the two by accidental extubation. But I think for many doctors who has no anesthesia training, working the ICU to handle tube and stuff like that, I think that’s a stressor in a way also, because we do it all the time here. So that’s not a problem. But I think and then this as a me was talking about just wake up the patient if they accidential remove the tooth, no problem.

They’re all on spontaneous ventilation and stuff like that. So well, and actually, after that week, I think at the Saturday where we were heading on to New York, me and my family, the the paper was accepted for the Lancet. And that was a huge turning point because that make the community aware that okay, there’s some guys in Denmark, believe it or not, who has a wake patient?

And but that was also an opening to have an open fairly discussion about what is right for the patient, and I think it was very, fairly received. And we had a lot of discussion when we in the unit, we were invited a lot to attend conferences, we have had a lot of visiting observers and stuff like that. And I think in general, that people are interested in the method. But it’s about culture and tradition to make the jump into awake patience.

Yeah. So so so that was sort of the beginning of the story. And then just to stay a little bit of science, I hope it’s not too too boring. But there was a lot of comments about okay, now you prove it in your unit. But would it be fair to do a multicenter trial and perhaps include units not used to this method?

And can you accomplish the same results. And so, some years later, we had the funding to do a multicenter trial, where the first trial ends to trial 100. For inpatient we, we reported a reduction in mechanical time of mechanical ventilation reduction in length of ICU stay and a reduction in total hospital length of stay, and then a tendency to towards a survival benefit by by having a weight patients. So based on that, we did a power calculation and plan A. And we conducted a multicenter trial with 700 patients. And we started out in 2015, mainly send us in Scandinavia, but unfortunately, also send us mainly senders who had in some way adopted the awake patience method.

And we think it took a little more than three, almost four years to finish off the randomization. And it was published a year ago in New England Journal of Medicine. And so the story is that, that, that the problem with doing a strategy who you believe in and have send us believing in awake patient tends to you know, and doing it, not blinded in the, in the study number two, we could see that that the level of difference in sedation, were not that that pronounced as in the first trial.

And and it was also the impression from from the center here in ordinance that that there were even more resistance of doing yet another trial. Now we prove and once that, that the method worked. And so so the team said, Okay, when it a patient was randomized for sedation, when can we when can we get out of sedation, and we said, okay, when the vent settings are low, PEEP of five, 40%, of oxygen. and then they hammered them out of the mechanical ventilation and turn off sedation, also during nighttime, and that didn’t happen in the control group, the intervention, whatever, in the awake group.

So when you look at the data and compare the two trials, then in the lens of trial, we have a very good separation between, you know, the level of sedation, the weight group in the Lancer trial and how to rest just rest minus a half a whole week. And the other group, the satanic group was recce, managed to to monastery for a week. And then you have the New England Journal trial 700 patient and you didn’t reach for start that deep level of sedation, and the lion sort of, you know, they didn’t separate they come to came together.

So we didn’t have I sometime compare it and we’d have been discussing that like doing the ARDS trial, you know, six versus 12 milliliters per kilo, if we were to do a trial saying eight versus 10. And you could do a fluid reverse trial with no difference in results, the Mr. Amount of resuscitation fluid, and I think that was, you know, our problem. In the second trial, we didn’t have separation, and I think it’s multi multifactorial, but but that’s the end of it.

So in the end, we didn’t report any difference in in difference in mechanical ventilation or length of ICU stay in or mortality, which were our primary endpoint. There was a more days free of coma and delirium in the awake group. But, you know, that’s a difficult we didn’t you know, kind of power the that was not our primary endpoint. So that should be treated with caution.

But, but I don’t know, was it a failure to do it? I don’t know. I think we needed to do it. But But I think we all need to learn when we can be planned trial. We need to be sure that that there’s a difference. So should we have done it we should probably have put an effort in using senders. Who didn’t adapt to the awake method? I think we should have done it another way. But that’s a different story.

Kali Dayton 20:06
No, I’m so glad to bring that up because that that study has been waved in my face so many times, right? They’re like, No, look, there was no difference. And then I had to bring in the methodology, which I didn’t have all that insight. I didn’t understand the culture, and the facilities where you were doing it. But I did notice the methodology that the the RASS is we’re not different.

And the interventions just weren’t that different. So of course, it wasn’t different. I also noticed that there was no factoring in of mobility. I definitely had some questions about that trials, that really clarifies it. And, boy, I know so many places here, where we could do a really effective trial, where there’s a plethora of patients Rassie, negative three, negative four on medazepam, proper false tonnelle. And then we could do it our way with a with a little group, I think that would be a very a much more effective trial. So I have big plans and dreams, but I think you’re totally right. We, it needs to be done somewhere where it is new. And it’s it would be a very stark contrast with standard practice of the states.

Dr. Thomas Strom 21:15
Yeah, yeah, definitely. And then and then the next question is when you give talks, because you’re gonna interview, it seems ICU teams in the US, and they say, “Okay, you do it in Denmark, you have a one to one nurse patient ratio, what can we learn?” I’ve been giving some talks in South America in Argentina, and then, you know, we have a fair, fair question.

From the audience nurses asking, “Okay, I look as you described during the COVID,, and after four patients, what would you…. would you still do it?” And I say, Well, I don’t know this is this is very difficult. But what we can learn is that a tube or being being on a ventilator, invasively mechanical ventilator doesn’t necessarily need…. You don’t need sedation, as you know, like gravity or something like that. You need to realize you can do without it. But I think the culture and the understanding of the concept is very important.

When we were designing the second trial, the New England Journal, we were having a discussion with colleagues from Peter Saki in Karolinska, the capital of Sweden. And we were keen on getting them on board to but they say we can do it, and they have once one nurse patient ratio. But they have a set standard at that at the time, I hope it has changed. But they had sedated patient even though they had a one to one nurse patient ratio, they have a strategy about having the sedation on daily basis, but it often went back.

And so my point here is that it you need to have the, in order to succeed with this awake and walking and mobilize patient and getting rid of standard sedation, you need to get the whole team aboard and and it’s a culture. It’s not that one member has this great idea saying oh, now we do that you need, everyone needs to think that this is this is a great idea. Otherwise, you won’t succeed.

Kali Dayton 23:21
A lot of people have experienced and they implement protocols, but they don’t really bring in an understanding. They don’t understand what patients experience under sedation, they don’t understand the repercussions of it. So you have a few and leadership that tried to work down these orders do certifications, which I think are more difficult than than your approach what a lot of is going on in the state of start sedation to start Midazolam, and then try to take it off or give it a break a few days later, see how it goes. And it doesn’t go well.

And that’s where we get this concern about safety. Because you give patients delirium, then you unmask it, then you have two patients and you have to be in another room, but you have a delirious patient unattended. Whereas what I’m advocating for is more of your approach is- Don’t start it. Don’t make them crazy. Let them wake up after intubation, then you have a calm, cooperative patient that is much safer that’s less likely to self extubate, that doesn’t need restraints a lot of the time. So it’s refreshing to hear that that’s been your experience as well

Dr. Thomas Strom 24:27
yeah and just to touch on that because when when you get used to the method I we can we can touch on the nurse patient ratio but that’s a that’s a you know such a sharp yet but we can bring in some facts. Because just you probably know the same because on our unit here, when I talk to nurses and ICU doctors and, and physiologist, you know your physiotherapist, I think I think one of the things that is important to realize is that: You do it, or you don’t do it.

You know, the you know, “comfort sedation” of the patient – it often goes wrong. And in Denmark we have, you know, sedation for tube tolerance. And that’s a scary thing because if you have an awake patient, he the patient is most most likely breathing on his own. And and you can you can actually talk with the patient is okay you have the tube, it gives you a oxygen, it’s not comfortable, we can deal with that. Please feel it. And you know, but please, please don’t pull it out. And you can make an agreement.

The patient is coughing, or whatever. You can do intervention suction, give the bolsos the morphine and make them comfortable and adjust the ventilator and the patient accepts it. But the patient who has been, you know, lightly sedated, and whatever that is, and then suddenly they wake up, and they don’t know what what’s going on. And they have the thing in their mouth, and they put it out. And then the take away the drive that makes them breathe. And then you have a semi sedated patient with very superficial respiration. And you have this near arrest scenario.

Where if a patient who’s awake, breathing on their own, pulls out the tube, you have a mask you can put on give them oxygen and make a decision whether or not to put back the tube. And I think in our unit we always say “If that we don’t have accidental extubation, we oversedate.” and yeah, that’s that’s the easy part. If you don’t pull out a tube now and then and if you accidentally go out, we over sedate.

And and the situation is not. It’s not very dangerous. Of course we have patient prone ventilated, paralyzed, that can if the tube goes out there. But in the end, when you when you see your patient in the ICU most patient is on moderate settings on the ventilator and stuff like that they it’s not dramatic if they pull out the tube. I’ve been working with ICUs where they you know, have one nurse taking care of to patient and you know, lightly sedated, weaning from the ventilator.

And I haven’t seen as many dangerous situations semi sedated patient without a tube. It’s killing patients. It’s it shouldn’t be allowed. Either you use you make a statement saying this patient because of you know, some end thing in the throat deeply sedated. Severe, it is prone ventilated. We take a decision now we need for a few days to be sedated or turn it off. I think and we discussed it before you say okay, we will Is it safe to sedate patient and we take it as a standard?

You know, I think I would go all the way in say, okay, standard, we need to do low sedation, we need to bring the patient comfort, bought some analgesia because the tube is not nice. I haven’t met a patient who want another trip on mechanical insulation. But we can do it and it’s usually a comfort. And if that doesn’t prove right, or you have some other circumstances saying we need to sit then you can sedate. You wouldn’t give antiarrhythmic to a sinus rhythm. You wouldn’t do it.

Kali Dayton 28:23
Oh, thank you. Yes, absolutely. And you wouldn’t treat tachycardia with a beta blocker. You know, we see patients that if they delirious- we give them sedation–which causes, prolongs, and exacerbates delirium. And it’s all this huge misunderstanding. And we just do it in the hardest way. But I’m noticing it’s done in the name of “safety”. So we think that a patient’s safer, but in the research, the more sedation you give, the more likely they are to self extubate. But it’s interesting.

He talked about the respiratory drive and the safety of if they do so let’s debate and the ABCDEF bundle study that was put out in 2019, they had the same amount between the control groups of self-extubation, but an ABCDEF bundle group, they were more successful. Meaning, they did not have to be re-intubated because they could breathe on their own because they had less sedation on board.

But in the other “Awake and Walking ICU” come from they went over two years without any self extubation is before COVID Because patients in their right minds don’t pull out their lifeline and that’s the difference. So it is safer. But we also if you do have a delirious patient that is trying to pull their to when we think about safety in that moment, obviously we need to restrain them, but do we need to sedate them?

Because we also need to consider the safety of their cognitive function of their physical function of their their psychiatric well being. We don’t discuss, “Hey, is it worth the risk of disabling them the rest of their life because they’re confused in this moment? And because they’re confused at this moment they’re at higher risk of having cognitive impairments, so should we exacerbate that? So we’ve definitely signed them up to have lifelong impairments and suffering?” we don’t think about it that way. And that should be relevant to our discussion about safety. So I get fired up about that. So I appreciate that you have had the same experience that it is safer to have patients awake right after intubation and clear.

Dr. Thomas Strom 30:22
I just wanted to mention another thing, because we, during our trials, we have discussed we have we have met and you know, interview patients afterwards. And in the end, we have very few even we do sedation and light sedation. We have very few patients with with with traditional Post Traumatic Stress Disorder. But but but I think it’s very interesting, since we talk to the patients afterwards, I think in many way, we would have discussed it with colleagues and say, “Okay, we need to follow up on the patients and treat them afterwards.”

I have a I have a different perspective, I think the most interesting thing about talking to the patients afterwards is to learn- What can we do better when they are in the ICU? Because I don’t think you can actually afterwards say, “I’m sorry, I’m sorry, we heavily sedated and strapped down:-, I think that’s too late, then the patient has a problem.

I think we need to go back and do a better job when they when they are in the ICU. And sometimes we you know, we had colleagues say “Okay, it’s unethical to have a wake patient because, you know, they fighting for their life, you know, that they’re there, and they, why should they know that they perhaps they will die?”

And I think we need to shift it around and say, “Why shouldn’t they know, you know, what you take away, you know, the patient’s ability to fight the disease, and work with it by just putting them out?” And, and, well, sometimes, have you ever had that, you know, you have to after a night shift, you go home to have a few hours of sleep, and then you wake up just for a brief second. You don’t know where you are, you know, try? You know you are?

Kali Dayton 32:07
“What is it? What am I?”

Dr. Thomas Strom 32:09
Yeah, yeah, “Where am I? What did I forget? I need to rearrange is okay, okay, I’m after, you know, night shift, and I’m here, everything’s good.” I imagine some times that, that that’s what we do with the light sedation, because we keep patients there for a week. And I don’t know, I think that would be very stressing, I will go into delirium in a few hours. And I would be heavily delirious.

And my point is that we talked to some some patients and I know it was very few we could talk to the first trial because we were very late on but I remember a patient who has a younger man who had a car accident trauma patient, and he were with us and he was sedated, and he had a day to wake up trial and stuff like that, and he was discharged from the ICU. Then he came back for this follow up and and we talked with him, he couldn’t remember the ICU at all.

And at that time, he had been, you know, daily wake up, and he has been extubated. And when he was ready, he was discharged. But the first memory is what was from the stationary ward. And then he had these nightmares about when he was in the ICU on a daily basis. He was sort of, you know, lifted up, like in the heaven, and you know, the, the sky Oh, and then and he thought, “Okay, I’m gonna die and meet God or whatever.”

And, and when he was almost there, almost there, he was lowered again. And he said, “Okay, make up your mind. God. Take me up there. Leave me This is This is awful.” And I think what was really going on and we could discuss with him was that he had some fractures and then he was you know, on a daily basis lifted you know, I don’t know what you call it in English, but you know, you had this so he could flat be lifted up and you could you know, change the bed linen and push him up on the bed.

And and then and then back in. And I think that was the delirious mind trying to make some sense there. But he had, “okay, this is awful.” And then we’re discussing, “okay, that makes sense. But wow, that was and he still had these bad dreams about it.”

And then we had another young trauma patient who has been awake and he remembered the ICU. He remembered how awful it was to be mechanical ventilated, but he could very clearly said that he was aware that everyone around him were on the edge of their toes to do the best job to come forward, reassure him and give him morphine or whatever and, and, and so he said, Okay, it was awful… But he was reassured that there was always someone around him to look after him he could remember had visited and stuff like that.

So my point is, I don’t think we, I think we take away so much from our patient by doing sedation, we don’t relieve them. It’s not the right way we introduce nightmares and stuff like that. If the patient are fighting for their lives, I think I think I think they need to be there, if ever possible to know. And also when you have awake patients….

Let’s go back. If you have a sedated patient during midazolam, doesn’t wake up, we say okay, is this the best interest to continue active therapy? You would never that to, to have a discussion about just ending therapy is very difficult with an awake patient, because you need you need to take you won’t to it. So I think you take me you take away so much for the patient, if you sedate them. So I think we need to keep the patient’s awake for so many reasons.

Kali Dayton 36:04
That is so validating to hear because that is exactly been my experience. Personally, if I was going to die, I’d want to say goodbye. I’ve had patients, a one man didn’t know he had cancer, and until he was intubated, it was terminal. And he wouldn’t allow for the extubation until he had signed his pension paperwork. He knew his wife was taken care of. They gave him a moment to say goodbye to everyone and no one had to make the decision whether or not he wanted to do treatment, prolong things.

I mean, that’s been a repeated concept. Like I’ve had people say, I’m done, pull the two or I want, they just say what they want to say I want a Slurpee from 711. When you self activate me, I want this music going, I want these people here and everyone gets closure to say goodbye. It’s just as more humane. And also, they get to process it with their loved ones, as it should be. And I I feel extremely strongly about that. And literature supports everything you’re saying that Post ICU PTSD is more related or closely connected to sedation.

But for some reason, culturally, we have not processed that. It’s just one of our myths or misinformation within the ICU that we’re sparing them trauma when we are deeply sedating them. But I think part of that is reinforced by what we experience during sedation vacations when they come out, and they’re agitated, and they’re thrashing. They’re panics. But we don’t understand from the patient side that they think that there’s a snake in their throat. They think that they’re being kidnapped, they’re watching babies burned, I mean, that’s what they’re experiencing.

So of course, they’re wild and trying to get out of bed. And then when you have a two to one patient ratio or more, it’s not feasible. Whereas if we did all the way, like you’re saying, and just did a write and just really let them wake up after intubation, and keep their coping mechanisms with them, they’d be safer, the carrot would be easier to you’re granted, your nurses probably have not experienced it the US way, or the traditional way of deeply sedating and having delirious patients, but do they feel like it’s easier for them?

Dr. Thomas Strom 38:08
Though, actually, I think I think I can answer it and then differently because after we put out the the lancet trial, it was, you know, adopted in a national Danish recommendation or guideline that in, you know, as a standard, the standard ways to bring comfort, not sedation, you need to comfort the patient.

And as a last resort, they use sedation, but but comfort, morphine, whatever, and when setting and stuff like that, and only if you couldn’t manage with our way you would use sedation, and that was the standard and some ICUs of course. Because of lack of nurses and, and, and stuff like that needed to sedate the patient, and there was one hospitals in Denmark, where, where the nurses complained, you know, about their working environment, or what could you say.

This is not, you know, they were not comfortable by, you know, taking care of two patients, and needed to sedate both of them when they knew that, that that was there was another way. And then this story was leaked to the media’s and the national television and all kinds of thing, you know, dug into this story. And, you know, if if, let’s say you would recommend this, you know, as a standard, you would have said, “Okay, can we avoid a disaster”, you would go out and say, “Okay, this is temporarily we have been, you know, facing some, you know, lack of staffing, we’re working on it. We try our best to do it and stuff like that”, but and then the case wouldn’t have grown that big.

But they took a decision and saying “no, we won’t we won’t listen to this. It’s not shown that that that sedation is that difficult. They do it all around the world, we can do it too.” And it was, it was at the moment for a few days, it was a very huge story here in Denmark. And the ended that that, that that the hospital department, the chief of the department, were given, you know, a complaint official complaint about it, you know, from the from the Ministry of Health and say, “That’s not standard in Denmark, you can’t sedate the patient, because you don’t have staffing. You need to look into that.”

So it’s huge. It’s a huge case in Denmark, of course, from time to time, you know, full ICU, a COVID crisis and stuff like that. We lingered it, and I think you know, there’s a difference in Denmark also, which hospital whether or not the patient can be awake. But in general, we try we try to go towards as little sedation as as possible.

Kali Dayton 41:03
So that’s so interesting, because often I have wondered, what if the public knew what is the news knew that our standard practices increase mortality, infection time on the ventilator? lifelong disability suffering? What if they knew what if this became public knowledge, and the public health? The health care side liable for that? How awkward would that get?

But also, how much quicker would we change and be motivated to actually implement the support to make this happen, which looks like that happened in on your side? I’m not liking it to the media other than doing the podcast. But I don’t think anyone NPR doesn’t really care about my podcast, right? But it isn’t awkward should we think and we tell families that we’re doing everything possible for them to survive. And it’s awkward from my side, because I’m like, well, you’re giving them midazolam. And that clearly increases mortality.

So something’s not quite forthright, or honest or even, or even really knowledgeable in those statements. And yet, that’s just what we’re doing. It’s just normal. So we don’t question it. But I love that you bring up things like the renal failure and the accumulation of metabolites, and how that totally changes the response to the medications. I think that’s partially why we’re like, well, we use this in the O bar, it’s what we do during surgeries, and why not do it during the ICU over these two weeks, but then you have this necessity for vasopressors.

So in the “Awake and Walking ICU” during in COVID, they’ve been one of the main COVID units in Utah. Rarely are their patients on vasopressors, their COVID patients, yet in the rest of the country, almost every COVID patient is on a base suppressor, at least one. But how much of that is really to do with to do with the sedation, and then they end up on CRRT or renal replacement therapy. But in the wake and walk in ICU, they don’t they hardly ever, so it’s a really interesting time to prepare.

Dr. Thomas Strom 43:11
Yeah, I think I think also, if you look at the, if you look at the things we’re discussing, now, you know, parenteral nutrition, you should probably wait because our body isn’t built for for nutrition when you’re critically ill, you know, I like that idea. You know, what would the injured animal do you know, it was you know, it has a fractured leg, it will crumble in the cave, and hopefully that fracture will stabilize, and they can do some basic feeding and either the, the animal dies, or it’s survived, but in that period, it lives on the muscles, you know, whatever it has, and is skinny from the start. It won’t survive.

And now in the ICU, I think it’s difficult, of course, what would nature do here? Because we have an ICU with machines, vasopressors, dialysis, I don’t think nature has put in the ICU in the maps of evolution. But still, I think, I think you could you could learn a lot but what what would be the natural way? I don’t think the natural way would do to conserve the body.

You know, of course, there’s a period where your septic and you know, your vessels leaking and stuff like that. You probably can gain weight or muscle at that time, but that quickly changes. And I think we have an obligation as as as as a team in the ICU to you know, do it the patient on daily basis and say, Okay, what’s the problem? What’s the main problem here? What kind of infection did we figure out? What kind of disease you know, figure out the disease treated and the patient will recover?

It’s very I think intensive care therapy is very simple. Just find out You know, Where’s, where’s the, where’s the infection, get rid of it, and the patient will recover. But don’t call home make. Note and on the way don’t don’t do do know, do as little harm as possible, get rid of, you know, drugs, plastic machine, you know, get rid of it. I think that’s the main, I think one of the most things, one of the biggest thing you can fear as an ICU in the ICU is to overlook that the patient actually had recovered, and don’t get off the sedation, don’t get out of bed.

And you know what the patient who still lives in bed are the ones who don’t survive. Our physiotherapist in the unit say that, that we mobilize our patient, okay? He don’t he don’t take out the dead ones. But besides that all patients are mobilized. Okay, there’s, you know, intracranial pressure, some unstable fractures, but in a way, you know, you need to walk the disease.

So, yeah, you need to get out of bed, otherwise, they won’t survive. So, and then you’ll of course, individualize you start with passive treatment, get the patient out of bed, and before you know it, and the patient can stand beside the bed and walk. We don’t do a lot of walking, we do it from time to time, but if, you know, during, remember the dislike a trial from Chicago, and, you know, early physiotherapy, when, with the populace, that they had a lot of videos when they presented it, you know, patients doing, you know, hop in the ICU, and you have this elderly woman walking around the whole ICU.

And, you know, in my opinion, you know, okay, if we just, you know, get a little mobilization and use the effort is to pull out the tube, because he was ready for that. So you know, and you know, you have to spend your, you know, the physical needs, because we pulled out the two very early on, if you if we had this in doubt whether or not the patient can do without the tube, we stand on, pull out the tube, you know, daily wake up, that’s what you at least should do. But daily exploration, that’s the way to go.

Because the most fear is what is the patient could do without the tube. And worst case scenario, we put a bag in, all patients have, eventually a tube, so they don’t aspirate, no problem. And we all train and it’s a shortage. So we just put back in the tube, that’s, you know, better give it a try. What is the patient could manage without it?

Kali Dayton 47:39
Yeah, and I, I love to see that, as the standard of the week, marking ICU patients will go on a walk, or sit in the chair. And they’re ready, they’re ready to just get the tooth taken out. You know, it’s not, I just can’t imagine what’s normal. And most other units where patients are barely awake, can barely open their eyes.

Don’t even know what planet they’re on. But they’re kind of taking some spontaneous breaths. They’ve done it for the last hour, so they’re probably good to go. And they pull the tube out after they’ve been deeply sedated for weeks. That is just that sounds like the perfect recipe for disaster. Now, I think during COVID, we’ve transitioned more from doing that to just tricking everybody. And just assuming that they’re going to have to rehabilitate, and attack another another facility for a few weeks.

Dr. Thomas Strom 48:24
Yeah, I think just an interesting thing, because you know, we have a lot of, you know, I think when you did your unit you need to do it’s like your ostomy in order to get the patient out of sedation. But but it’s very interesting, because if you use if you’re used to have awake, already intubated patient don’t have the need to do it. So here’s to me, because you don’t have to get rid of sedation, you’re already out of that.

And so I think in our unit in our first journal, when we did the Lancer trial, we immediate time of two weeks before we did a tracheostomy. I think we did we do it for selected patient but but after a week or so. But but if you read the literature and talk to colleagues around the world and say, Okay, if you need the patient to be waking up, he needs to do we need to do a tracheostomy, and that is not correct. I think there can be you know, sometimes we do it earlier because you know, some patient gag about the chew.

But if you use soft and large caliber chew, and you use to take care of patients use bolus doses of morphine to add impressive support. I think most patient in our experience can actually accept being orally intubated, no problem at all. And they can even eat an ice cream being orally intubated, it’s not a problem.

Kali Dayton 49:37
That’s that’s in my experience without the ice cream, but that they’re just they’re pretty calm and easy.

Dr. Thomas Strom 49:43
Yeah, of course some patient can and then you would in order to bring comfortable for the patient and move on to an early tracheostomy. But I think you can infer most patient managed without Yeah.

Kali Dayton 49:55
Oh, thank you so much for for bringing that up because that’s, I have felt like it Crazy person listening to all this critical care in the critical care world talking about just almost concentrate yes means for COVID patients, that’s few survivors. And when families reach out to me and have questions, they’re saying, okay, he’s been intubated for two weeks deeply sedated.

They want to do tracheostomy, then though, then they can wean down the sedation. Otherwise, they wouldn’t they won’t do it for the it’s the families are advocating for it. The team says, No, we can’t do that until they have a tracheostomy. And I’m just scouring the literature saying, Sorry, where did that come from? What study showed that it was safer to wake up a patient once they have their host their throat slit? Where compared to being intubated? Where did that come from? Why is that so widely accepted?

How was that humane, but and when they wake makan Ico again, has a COVID unit has hardly tricked anybody. And there were extenuating circumstances like end stage interstitial lung disease with COVID. But that’s a very different scenario than a 40 year old that came in, was deeply sedated, completely atrophied has no diaphragm left because of the deep sedation.

And then we have no concept of what it’s like to rehabilitate from that. It gets me fired up. And so that’s validating to hear from you that there’s no evidence, it’s not safer to mobilize someone with a tracheostomy versus an endotracheal. Tube, there’s no there’s nothing that shows anything. Any risks of mobilizing someone with an endotracheal tube? It’s all in our heads.

Dr. Thomas Strom 51:32
Yeah, but so many things. Just to be sure we touched on it, because I think, you know, the COVID. You know, it has we learned enough from that. But But I think it also made me realize that during the first wave of cobalt base, we had no unit, we also all know when when they get down here, we need to sedate them and prune them and stuff like that. And we did and we sedated just like you know, we, you know, we were hammered back.

And then during the second wave, when most of us had the vaccines and we get comfortable, as comfortable as you can in a in a COVID with all your masks and stuff like that. But we did as we as we normally did. And I think you need to realize once again, that, that, that if you do mechanical ventilation, and if you on top of that to control ventilation, you know, dictate how the patient breathes, the risk of complications, the vent settings goes up.

Because, again, it’s difficult to talk about nature but but that’s a that’s a reason we breathe on our own. So you can go if you have a patient or non invasive ventilation, very low setting, and you say, Okay, we intubate him, and then you use a date you doing anesthesia, you paralyzed the patient, put in a tube, and then you are 90% of oxygen and turn of P just because now you have to take care of the ventilation, and you take away, you know, the natural and spontaneous breathing, I think.

And during the second way where we use non invasive ventilation, there were a lot of patients who we did without invasive ventilation during COVID. And and I think we need to, we need to think about why is it is it safer to do for our area’s patient to deeply know paralyze them? And do control mechanical ventilation? Or should we up for them to at least breathe on their own? And if the patient because when when when I you know have a conversation about whether or not to do sedation then to say, “Okay, it’s unsafe on ARDS patient to breathe on their own?”

Well, it depends. Look at the patient! Because we have a lot of cases in our unit who have you know, they could enter whatever ARDS trial and they’re sitting, you know, intubated, reading a paper. And I yeah, I think to say, “Okay, I just read to go to that gentleman say, so you need to get back in bed. So I have this and you need to go back to ‘sleep’. And we need to increase the ventilation” and the patient will say, “Why?? Why should we do that?”

” Because that’s that’s the evidence!” and they say,” Okay, I’m here. Why sedate me?”- And I think it’s very interesting because you can have a lot of pro and con debate about do we have the area’s patient if we don’t do sedation and, and prone ventilation? I think, first of all, look at the patient. If the patient is comfortable, we need to go back and say, Okay, what does a ventilator do?

It buys us time while nature cures the disease and whatever, whatever we do with that waiting time, I don’t think because okay, if we have a non invasive failure, we intubate the patient, no harm done. And of course we have patients from time to time 80% of oxygen high setting the patient is distressed and have severe hypoxemia.

When you remove the mask, of course you need to sedate the patient and do whatever you do. But at least on a daily basis, try to go back and say, “okay, can the patient treat on their own?” perhaps some of them is high on carbon dioxide. But so be it. If the patient is comfortable, and some patient of course, high PEEP, it’s not nice. No patient go back and say, hold it. Can I have another round of that high PEEP thing? Please?

Kali Dayton 55:20
Yeah, yeah,

Dr. Thomas Strom 55:21
They won’t. And of course, sometimes you need to do comfort sedation. But it’s not the same as doing bringing the patient comfort that they necessarily be on a control ventilation, when data from our first trial in both groups, whether or not we did sedation are not within the first 24 hours, both group most patient was on spontaneous ventilation.

So I think I think, again, difficult to discuss nature, but but again, do as little harm as possible, try to go back to body’s natural, I think it’s natural to, you know, in an initiate your own breath that’s deep in your brain stem, you can you need deep sedation to take away breathing on their own and very, very few patients need that support that last measure before ECMO kind of thing. And, again,

Kali Dayton 56:14
it’s so contrary to what is so ingrained in our culture. I mean, I’ve seen protocols saying any spontaneous breathing, validates sedation, that is protocolized in our units. That is crazy to me. I mean, if we set a rate of, you know, 19, 20, someone’s breathing 25. Okay, great, good. That’s what they want to do.

That’s what they’re they’re comfortable with. But that makes many panic, because I think they’re gonna harm and I think I’m bold enough to say, I think the ARDS network needs to do some more studies and reevaluate their protocols and consider mobility and sedation into the outcomes of ARDS patients. I don’t think that’s part of it. And then we know we have research from 2016, showing that mobility decreases the neutrophilic response in the lungs. And yet that hasn’t been discussed during COVID. So we have patients that are higher risk of developing arity. Yes, and what do we do immobilize them, let them atrophy and field inflammatory response.

Dr. Thomas Strom 57:16
Okay, yeah. And you could say about about, you know, what, what would you do, if you, you know, when we, I think both of us are looks healthy, and we have, you know, severe flu, and, you know, coughing a lot, and, you know, and they feeling a little dyspnea? What, what, what do we do, we don’t, you know, lie in bed flat, we won’t do that, if you cough, you sort of sit up, stand up, whatever walk around, and what do we do with the critically ill?

Well, we put them flat in the bed. And and, of course, I know, prone ventilation is about recruiting other areas of the lungs, I think the natural way would be to sit them up and cheer. Because, you know, that’s recruitment, I think. And that’s why we do that a lot. And for most patients, we can avoid sedation, we can avoid the probe installation. We covered we had a little training and doing that, but but besides that many patients who fulfill criteria for severe ALS, they’re mobilized to sit in the chair, they do whatever.

And I think when you do sedation you, you miss with nature, in a way you don’t understand, you know, you mentioned the suppressors. And I think if you have a renal function just barely hanging on, then you put up sedation and increase the level of mechanical ventilation and peep, you take away the last resort of that kidney and you in a way startup dialysis, so whatever you do, try to do as little harm as possible and try to bring back some, you know, normal thing for the patients. And I think that’s, that’s what it’s all about. Yeah.

Kali Dayton 58:57
Do you see as well, that patients request to be in a chair? They prefer it oftentimes?

Dr. Thomas Strom 59:03
Yeah, yeah. I think when you’re first presented for the patient, you know, they are, you know, patients in the ICU, they’re severely ill, it’s not a fracture or anything, it’s severe need for for massive treatment, otherwise, you wouldn’t do it be in a modern ICU. So so when you present the idea for the patient, when you’re gonna get up in a chair, they say, okay, I can manage that.

But in the beginning, you could do it passively lifting the patient’s want a chair and I think most patient actually enjoys it. We use a rocking chair. For delirious patients, like they do in nursing homes. It’s an electronic rocking chair, but take it out and you know, rock them and you know, the shift. I think the worst case is to be lying flat and don’t know if you’re alive on or nothing good.

I think, like when we don’t often take them to shower but We we prioritize to take the patient to shower as soon as possible. You know, when you when you’re sick yourself and you know, when you’re, you know, out of here, you’d say, okay, the best thing now is to get a shower because you know, I’m on the leap of getting better and I can perhaps shower some of the disease. And I think you know, on the way you get you get out of bed, that’s the first part of fighting the disease and you’ll take a shower, you’ll get washed up and stuff like that. So I think the same goes for for our patients, get them out of the bed.

Kali Dayton 1:00:33
Oh, thank you. And when I was a travel nurse, I noticed that hardly any ICUs had a shower room, get the awakened walk in, I see where it come from how to shower room, and they not so much in code right now, because the circumstances are different. But they were putting extension tubing onto their intubated patients having the ventilator outside the room and showering their intubated patients.

And just you can see a massive change, they look like a different person, not because they’re cleaned up. But their morale, the orientation, everything is just better when they come out. And that’s something I would love to study. I don’t really know how to measure outcomes of how much better they feel other than inner surveys. But I think that’s very therapeutic.

But that’s interest that your team has also followed that same line of logic as you’ve taken off sedation, you’ve seen patients as human, you’ve been able to treat them as human, I never would have thought of a rocking chair. I think that’s a brilliant idea. But it’s led you to shower them and do more things that are just human and normal. And you’ve seen the outcomes are improved.

Dr. Thomas Strom 1:01:34
And yeah, and I think I think it’s very rewarding for our team to work with awake patient. And we have just a few weeks ago, we have two nurses and a doctor from the Netherlands visiting hours ICU and tried to learn the awake patient. And we had one patient who was already intubated on the suppressors and had been deeply sedated, we woke up the following day.

And we went through, you know, the waking up scenario where the patient is anxious and pulling out the tube. And he got oriented and everything was fine. And, and that the visitors from the Netherlands said, Oh, wow. And you know, we just doing a normal round and the nurse was just beside on, you know, answering all the questions I had. And we talked about the patient and she, the nurses went around, reassured him reassured now, that’s going to happen and now that’s going to happen now.

If you feel okay, we’re going to watch and get you out of bed and just talk to the patient in a normal way. And, and still, you know, what’s around the patient and you know, and we’re prepared for the, you know, anxious part and the patient has all got calm and it was very ungrammatically and the following day, the patient was what extubated? And the visitor said, Okay, wow, she just as normal routine just reassured the patient talk to him. Like he was a normal human being.

And yes, it’s a normal human being with demands. And, you know, all the fighting was because on our wants to try to do snakes out of the water, whatever. Yeah. But, and then, and you reach realize that you have awake patients, you need to, you know, coordinate the day with the patient. Okay, do you feel like getting out of bed? Do you feel like, now we worship or whatever you do? Or would they like to hear music or whatever. And that’s the next thing you need to, you know, in a way entertain the patient.

And that, if you come from deeply sedated patient where you just can do your routine, you know, now we wash, now we do medication, now we do, you can do that, because you have an individual, but that is so much more rewarding to have, you know, a patient and individual, you know, a family and, you know, it’s like when you you know, extra beta patient, they can say the first word or you can change to a speaking well, and, and the patient hear their own voice once again, if they had been weeks since since that, you need to, you know, humanize the patient as much as possible. Otherwise, not only the patient lose, but I think we lose that as ICU teams if we’re just, you know, taking care of objects that will be so empty.

Kali Dayton 1:04:22
Yeah, no one intends to do it that way. It’s just the way that we’re trained. It’s it really is ingrained in the culture and doing webinars and consulting with teams that’s actually been extremely eye opening for me is that is one of their valid concerns. They’re not sure how to talk to patients, and what to say to them. And it’s a sincere concern because I never have. So I appreciate that that you’re reinforcing the idea that it is a skill set to have a patient’s that that’s delirious and not be trained to run back to the pump and just turn them off.

That’s a whole new skill set. But I think it comes from this understanding your team understands this patient still areas I can work from through that, and I’m going to have a much more cooperative, calm, enjoyable patient the next day, and I’m I am actually helping them. Whereas we’re trained right now to think that we’re helping them by turning on sedation, that if they look more comfortable, therefore they are more comfortable, we can just turn off the agitation, which is not the patient reality, but that’s what we believe.

Dr. Thomas Strom 1:05:25
No, no, no, no, I definitely, definitely think, as was discussed with the delirium, it’s about getting the patient back on track. We can’t do anything about delirium when it’s there, we can calm it, we can comfort the patient, but I think most is to get back, you know, a daily routine, you know, difference between light and day rear in the patient. And Nature needs to cure it, but at first time, we need to do as little harm as possible.

And I think that, that, that, that sums it up in a way, because what we do sometimes make make makes it even worse, because we have a patient, you know, on the edge of the lives. Sometimes, you know, as a severe septic patient is very calm, they are very, you know, when we have flu, we do nothing but sleep, so a little drip of morphine, well, it makes them very, very comfortable. And that’s all there is, then we need to focus on, you know, treating the underlying disease. And the least thing we should do in that area is to give them sedation, because, you know, it would be like, okay, he’s hanging on the edge of the cliff.

And we just, you know, pushed him even further out, and takes away the last thing he’s standing on, I think, I think we need to reinforce the fighting from the patient and not, you know, dipping them drowning with them with sedation. I think it’s a way to torture, I think it’s, we can do it. In general, in general, outliers. But but but I think we need to check it on a daily basis. Because also, we also have, you know, in our unit saying that, okay, the patient was all agitated, we need to sedate them he need probably need to be sleeping, you know, for for a long time. And I said, “okay, okay, he was just out of surgery, he couldn’t breathe he had pain. Could we resolve that? And start all over?”

And you do that! Also, you have from time to time you have a patient with a psychiatric history, and see my saying you can wake up a psychiatric patients? And is it okay, what, how long time do we need sedation to cure a psychiatric disease, because if anyone has data on that, I would love to have them. Because if it’s four or five days, and they out of schizophrenia, we can treat a lot of schizophrenic patients. So, you know, doing the kind of wake up kind of thing where a patient is anxious, when you wake them up, we need to do it, he will, the patient will have a psychiatric disease, what whatever time we wake them up, so we might as well face it from day one.

Because many psychiatric patients, it’s the same, they you know, reassure analgesia, presence of staffing and stuff like that. They do just fine. And of course, some patient can manage with that, too. They feel anxious. But you know, you need to individualize this kind of thing. And it’s very hard to predict which patient and you know, their family says, Oh, he’s very anxious. He don’t like, like hospitals?

No, I think the worst thing we could do then is to sedate him, he would hate hospitals even more. What we need to do is individualized treatment, you know, go go as you know, morphin and adjustment of the ventilator reassurance, and some patient this for a shorter period of time, could need some sedation to still be resolved, whatever. But we need to re evaluate on a daily basis. There’s no such thing as a patient can’t tolerate to be awake. Who invented that? That’s not true. You’re luckily things evolve. So yeah.

Kali Dayton 1:09:04
Oh, this is just reaffirms what I’ve been feeling as I try to train teams on this. Everyone likes to have a very clear cut black and white protocol. Because right now, that’s what we’ve done. You intubate used to date, you put everyone on the same ventilator settings, and you trach, peg, and send them out, very cookie-cutter very “factory-like system”.

And I can generally give outlines, like, “let them wake up, you’re going to have less delirium. Here’s some ventilator settings that will help here some approaches that are that will help.” But not everyone is the same. And so I really think that if we understand that the team has an understanding, we appreciate these concepts of delirium and mobility, we then we can critically think through each scenario in each case and understand what patients need and have a much more accurate thought process than what we’ve had.

And those are exceptions will be rare, which I think everyone right now expects an awakened walk in ICU to be delirious patients thrashing, trying to put their breathing tubes and your and their army crawling blue on the floor for mobility. And so I think some of that critical thinking comes after you’ve had experience like your team has, and a culture shape change, I mean, the fact that you’re trying to do a trial, and the nurses are trying to block the door, saying it’s inhumane to say, stay, my patients get that stuff out of here.

That’s really revealing of the level of critical thinking and humanity that your nurses have, because of the culture that’s been fostered in your unit, which is invaluable. Another last question I had, at least in the States, when we try to protocolized mobility, or sedation vacations, these ventilator settings creep in, I don’t know where they came from. So usually, it’s you cannot wake a patient up and you especially cannot mobilize them even set them up until their fit was less than 60. And their peeps less than eight. Where did that come from?

Dr. Thomas Strom 1:11:02
I don’t know not, not from here, I can assure you what I don’t know, if you have to sit standard who will fit all again, you need to set those high standards. And I think it’s wrong because we have mobilized patient 90% of oxygen and ad 18 of peep. So I think I think it’s difficult, I think you need to look at the patient and and and see what what what is the patient best interest because in our unit.

You know, it was not custom, you know, when when we started waking up the patient, we had, you know, very few ICUs mobilized patient on the continuous dialysis and we started doing that, because why not? What’s the problem? You can do it and you still have units who can mobilize patient doing renal replacement therapy, why not okay, you can have a catheter, you know, when you when you sit up the patient, the vena cava MCs or whatever mechanical problem, but you can solve that put and change the catheter or do it in the vena femoralis, and whatever you can do, but change it so the patient can be mobilized if if possible.

I think we start by looking at the patient and say, “Okay, can we do it? And then what?” And then we do it, I think it’s very difficult to have those standards, I think you should flip it and say, why not? Why can’t you mobilize the patient? It would be inhumane, if possible, then you can have a situation with, you know, when you just raise the head of the bed, and everything’s goes crazy and very unstable patient, well, that would be unethical.

But in most cases, you know, 70% of oxygen and an even higher level of peep, I think when when the when the patient, you know, especially when the patient is from spontaneous breathing, I think there’s a huge effort in mobilizing the patient, it would I think, when you first mobilize the patient, you could probably decrease most of that ventilator settings. So yeah, because you recruit much better. Because I think back to the sick patient, if you’re sick, you won’t live flat in bed, you would sit up, or what do whatever you could to mobilize the secretion or whatever you would do, why why shouldn’t your patient have the same? Same chance? So yeah,

Kali Dayton 1:13:27
Thank you, your patient. So much of what I’ve been trying to say throughout the podcast to say, I mean, when we’re sick at baseline, those are things that help our lungs, why when lungs are especially sick, do we remove things that actually help the lungs?

The ventilator is not there to do all of that it cannot mobilize the secretions, they can’t access the sick, we can’t access infection, secretions if they’re not mobilized, and yet, I was amazed. I mean, we treat a lot of ARDS patients in the past, before COVID. Again, they’re all walking, usually in pipes, high ventilator settings, and rarely, but sometimes that they have to be paralyzed and sedated for a brief period of time, but I did notice on one of the patients that was I think they were paralyzed for two days or so.

But they had not been able to really mobilize because of their oxygen consumption problem. Anyways, they they’re too caught it off it occluded. And when we removed the tube, I saw these secretions that were just some of them were bloody, but a lot of them were just secretions that had not been mobilized. And that’s one of my big eye opening moments was to realize how much mobility would have helped that probably, if they didn’t able to actually move those out. We didn’t actually able to section and how often that is that happening? Because of our mobility practices. I think one of the concerns I also hear is Oh, no, they’re gonna cough. And I thought,

Dr. Thomas Strom 1:14:50
luckily, luckily, they were cough. Yeah, yes.

Kali Dayton 1:14:53
I want them to cough. I want them to get that stuff out. But that’s, that’s an indicator for sedation. We don’t want them to cough. I’m not sure Again, where that came from, but there’s so many things. It’s nice to hear that your team’s doing this. I would love to have you as a resource of teams want to hear from other ICUs that have had success with this, if you’re okay with that?

Dr. Thomas Strom 1:15:10
Yeah, definitely. I would love to do it. Yeah. To participate. And yeah, definitely. And I think we just, you know, the basic point, I think, I think calving is good. We shouldn’t, we shouldn’t see it. As you know, as the patient is in stress, I think it’s a good thing, because the patient is trying to protect the lungs, it’s a natural thing.

I think the problem is if they don’t cough, because that we’re all the secretion. And we do a lot because then we use small tubes, and we sedate the patient. And then we some I don’t know, if you’re, if you’re in us, you use closed suction systems. And they’re a bad thing because you know, an immobilized patient on control ventilation, and then, you know, the suction catheter goes the same path every time and then suddenly closes and you you turn off sedation, you increase the ventilator, they’re just saying, okay, something is wrong here. And you should look down that tube, change it for a bigger and bring the patient back and spontaneous ventilation.

And if the patient is persistently coughing, well, it’s probably because that you should go out. And there’s a reason why the patient that coughing, and we should yeah, that’s, that’s a natural thing. I don’t, I don’t think we should be that afraid. But But, but you need to prepare to, you know, adjust your treatment for the patient, be ready to adjust, you know, the vents setting, wake up the patient, be ready to excavate. I hate, you know, sometimes, you know, you have a busy ICU and you have a patient who’s unloading setting the car thing, stuff like that.

And then you say, okay, either we sedate the patient, or we activate, then you need to activate even three o’clock in the morning, you need to activate the patient. That will be the great thing because you remove a stress from the patient, as they know he could sleep on propofol no way no way. propofol isn’t sleeping. It’s, you know, we could strap him down. There’s no natural sleep in propofol. Well, it looks nice to have nutrition and stuff like that. But the patient doesn’t go through a normal sleep pattern.

No, take away what’s bothering the patient, then the patient would fall asleep naturally. And that would be the best off. I know things. Not always is that, you know, clear cut button in general that that you should be the way to do for the patients?

Kali Dayton 1:17:37
Absolutely. I think if we understand mentality, then we wouldn’t get into the situation to which someone’s intubated because they’re sedated and sedated because they’re intubated. I mean, we we’ve locked patients into this roller coaster and say, you’re not getting out until I tell you, it’s time to get out. I know. It’s crazy, what we what we often do. So thank you for being the voice of reason, anything else you would share the critical care community?

Dr. Thomas Strom 1:18:02
No, I think I think we touched upon a lot of things, I think it’s very interesting to share these ideas, because the main thing is to do a better job for the patients. And I think that’s very important. And to be curious about how to do it. You know, it’s it’s, you know, it’s very interesting. And it’s very interesting to share ideas and thoughts and sometimes think out of the box, because otherwise we don’t evolve.

You know, we need to ask, “why are we doing that?”– but you need to constantly question, “Is this in the right?” you know, “Is this for the patient’s sake? Who say, are we doing this?” and I think we need to challenge that all the time and see are we’re doing the best for the patients? Not to fit in, if every patient and every, we don’t need to fit in a little box. It will be very boring if everything was black and white. Luckily, we got colors and change and said ups and downs, that boards makes life so great. Yeah.

Kali Dayton 1:18:59
And we can allow for nuances even in the ICU. We have protocols, but we can actually critically think at the same time. I would love to great like a network and an organization. I wish that some of our critical care organizations had more of this focus, I think they’re trying to, but I do have a Facebook group that I’m trying to have discussions collaborations going on.

But I think that hopefully down the road, we’ll have more people wanting to learn from your expertise and have more networking with you and I think that you’ll be a great resource moving forward. Thank you so much for all the good work you’re doing and for sharing it with us today. If you want to join in on the conversation, leave a voicemail at 801-784-0472 or reach out to me on Twitter.

Transcribed by https://otter.ai

 

References

Strøm, T., Martinussen, T., & Toft, P. (2010). A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet (London, England), 375(9713), 475–480. https://doi.org/10.1016/S0140-6736(09)62072-9

Olsen, H. T., Nedergaard, H. K., Strøm, T., Oxlund, J., Wian, K. A., Ytrebø, L. M., Kroken, B. A., Chew, M., Korkmaz, S., Lauridsen, J. T., & Toft, P. (2020). Nonsedation or Light Sedation in Critically Ill, Mechanically Ventilated Patients. The New England journal of medicine, 382(12), 1103–1111. https://doi.org/10.1056/NEJMoa1906759

Strom: A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Strom et al. Lancet 2010; 375:475-480. DOI:10.1016/S0140- 6736(09)62072-9

Strøm, T. , Stylsvig, M. , & Toft, P. (2011). Long-term psychological effects of a no-sedation protocol in critically ill patients. Critical Care, 15 (6). doi: 10.1186/cc10586

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