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What does the ABCDEF bundle look like in neurocritical care? When patients suffer conditions such as intracranial hypertension that necessitate sedation and immobility, how does the ABCDEF bundle apply? Neurointensivist, Dr. Neha Dangayach, shares with us her team’s strong ABCDEF culture and practices in the neuro ICU.

Episode Transcription

Kali Dayton 0:06
In a recent conference I attended, I heard the comment. We have a lot of neuro patients. So the ABCDEF bundle doesn’t really apply to our unit. It had me dumbfounded. I am excited to discuss this further with an incredible neuro intensivist Dr. Neha Dangayach who is a bold advocate for the ABCDEF bundle, particularly with neuro patients within her specialty. Dr. Dangayach, thank you so much for coming on the podcast. Do you mind introducing yourself?

Dr. Neha Dangayach 1:07
Thank you so much, Kali for having me. My name is Neha Dangayach. I am an assistant professor of neurology and neurosurgery for the Montana health system. Systems director for Neuro emergencies. Management and transfers are nemat program, and I’m the Research Director for neurocritical care and recovery. It’s my honor and privilege to be here. Kali.

Kali Dayton 1:26
Thank you so much. And I’m really excited to talk about how to apply the ABCDEF Bundle into neuro ICU. I have worked only one travel contract in the neuro ICU. I did see exceptions in which sedation and mobility were essential. And you know, a lot of the podcasts we talked about COVID, ICU, MSICU kind of patients, but the ABCDEF Bundle is very flexible, very adaptable for patients in any specialty, with any kind of exception. So as we get away from this “conveyor belt ICU care”, how does the ABCDEF bundle apply to the neuro ICU? And why is it so important to implement?

Dr. Neha Dangayach 2:07
Kali, why while a lot of the studies that informed the evidence-based practices for the ABCDEF bundle, may not have necessarily included patients with different kinds of acute brain injuries. Like you said, this bundle is very adaptable. And perhaps in a neuro ICU setting, it may be even more important to humanize the ICU, and to implement this ICU liberation bundle for various reasons.

But the most important being there are so many of our patients are not going to be able to speak for themselves. Even as they’re getting liberated from mechanical ventilation. They may have multifocal stroke, or aphasia, there are so many structural reasons why they lose their agency and that feeling of being human. So whatever we can do to humanize the ICU, it is imperative for all the teams taking care of patients in a neuro ICU to do that.

What do I mean by adapting the bundle to provide care for neuro ICU patients? So when we think about spontaneous awakening trial, spontaneous breathing trials or choosing the right analgesic medications, so choosing the right sedative agents titrating them appropriately, early mobilization, delirium, screening and prevention, having loved ones or family at the bedside, I can’t think of a single element of the bundle that is not applicable to a neuro ICU patient population.

There are, you know, going a little bit into the reasons for why we sedate people in a neuro ICU patients who have different kinds of severe acute brain injuries, why will they need to be sedated? There are those those general critical care type reasons where you’re going to treat that pain, they’re going to need to be able to tolerate being on a mechanical ventilator, or they have different kinds of shock, and you’re trying to reduce the metabolic demand of the body, so on and so forth.

So there are various reasons why just like you would in a general critical care population, then there are these neurocritical care specific reasons you may need to sedate and use analgesia or analgesic drips in patients, for example, ICP crisis, or patients who have Status Epilepticus, or patients who have ICP crisis and severe ARDS or patients who have refractory ICP crisis, even after having undergone for example, decompressive surgery.

So there are these neurocritical care specific reasons why you may need sedation and analgesia in addition to the general critical care reasons. But the bottom line is we’re trying to when the brain is injured, and while that primary neurological injury is recovering, we’re trying to prevent secondary neurological injury. We’re trying to quickly diagnose and treat secondary neurological injury as well as supporting our patients to recover from their primary neurological injury.

And that cerebral edema, that ICP cry Ss are Status Epilepticus or ventricle, itis meningitis, things that are happening to them after their primary neurological injury may need some sedation and analgesia. But it’s super, super important to recognize Yes, there will be times when we need to reduce the cerebral metabolic oxygen consumption, there will be times where we need to modulate the cerebral blood flow.

But at the same time, there’s the central equation of CPAP cerebral perfusion pressure is equal to mean arterial pressure minus intracranial pressure, we’re going to uphold that both as we’re escalating somebody’s sedation and analgesic trips, but also very intentionally thinking about when can we begin to de escalate? When can we start waking our patients up every single day, asking ourselves when we round on these patients?

When is that the end time, the appropriate time to begin to de escalate to peel away the sedation so we can begin to see how our patient is recovering? What what manifestations are we beginning to see from that underlying structural, structural brain injury? Because that’s going to really begin to guide or unravel the mysteries of prognostication. So yes, we’ll treat but then we’ve got to start moving into this realm of prognostication as well. And one of the key things for prognostication is also what is your patient’s clinical examination?

How much of the coma that your patient is suffering from is coming from the iTero genic implementation of sedation and analgesia? And how much of this is coming from that underlying brain injury? So I know he said a lot of different things. But in my mind, you cannot bifurcate humanizing the ICU from providing care in the ICU. If it’s care in the ICU, it has to involve humanization.

Kali Dayton 6:52
Absolutely. And when you have vulnerable brains that are already injured, it should be of utmost priority to prevent further injury to the brain, but sometimes does require some sedation. And I love that you talked about choice of analgesia that that’s when we just because someone’s on a ventilator doesn’t mean they have to be blasted with midazolam. We have to think about what are we doing that will improve the harm that’s already been done and not cause further harm, especially to the brain.

And just because they’re on a ventilator doesn’t mean that they have to have sedation? I love that approach of every rounds, every shift every hopefully, throughout the shift. That question has always been asked, do they still have a clear mandatory indicator for sedation. And once they don’t, that it’s time to roll with the wake and breathing trials and trying to get it off?

That was one of the things I was most impressed with, I guess shocked by when I became a travel nurse is that I couldn’t do a neuro exam on my patients. And that didn’t seem to be concerning. Even before I understood the harm of sedation. When I was just shocked by the mere sedation and immobility culture. The reason I wanted to get sedation off initially was because I wanted to do a neuro exam that was so normal to me to check to make sure my patient was following commands and oriented and you know, all those things that you can do when a patient is awake even on a ventilator.

I couldn’t do. And it was weird to me that the staff didn’t think that that was concerning. They said, Well, they’re on a ventilator. And I kept thinking, but then how do you do a neuro exam? Isn’t that still important? Don’t we still care? And when I’m hearing about COPD patients coming out with strokes that are not new, that probably happened days, two weeks beforehand, it it hurts my heart?

And I mean, how do you…. in my mind, the patient’s awake and walking on a ventilator? You’re gonna know if they’ve had a stroke, you’re gonna know if they’ve had neurological changes? And how do you tell? Because Larium has so many different presentations, it can be profoundly comatose or agitated. How do you know what’s a brain injury from the first problem? And what’s delirium?

Dr. Neha Dangayach 9:04
You’re asking some very, very important questions. So one central principle that guides us and something that we try to uphold every single time we’re taking care of our patients is time is brain. There are lots of things that we need to recognize rapidly, both for this this sort of rapid recognition of the primary neurological injury, knowing that our patients are going to be vulnerable to developing secondary neurological injury, how do we treat and prevent both the primary neurological injury and the secondary neurological injury like those are those are very, very fundamental principles of providing neurocritical care.

Having said that, I think the the challenges that come with performing a focused neurological examination in a patient who’s sick for various reasons and needs to needs to have sedative and analgesic drips or an algo sedative drips, I think Recognizing that a patient needs it and what are the reasons and verbalizing those reasons very clearly. This patient needs it because they have refractory ICP crisis this patient needs to be needs to be on a midazolam drip a high dose midazolam drip because they have Status Epilepticus so verbalizing.

The utility of your sedative and analgesic drips are an algosedative drips, making it very clear. “This is why we’re using it”. Once those reasons are gone, or once, as soon as it is safe to start peeling things back. And I’ll give you an example of how we can start being very intentional about the use of these these trips in our in our patients who already have acute brain injuries. So verbalizing that reason, knowing what the trajectory of the primary and secondary neurological injury is going to be.

Sometimes there are certain types of injuries where we know okay, for example, a patient who has half their brain is suffering from a stroke, and they’ve developed swelling. So what is called as a malignant MCA stroke. So, you know, when more than half that territory in the middle cerebral artery is involved, we know that these patients will swell. We also know that the most the peak of the swelling will happen in the first 24 to 48 hours, some patients will continue to swell up to seven days.

But we know that decompressing them, the appropriately selected candidates is the right treatment for them. For younger patients, even after having their skull removed, or half their skull removed, and they’ve undergone this decompression, they’re still going to continue to swell. So anticipating that they are going to continue to swell and what is it that I’m using to monitor that kind of swelling, whether it’s invasive, non invasive, monitoring, verbalizing how frequently you’re going to check all these different parameters, whether it’s pupils, whether it’s, you know, pupil, ometer, whether it’s an EBD, ICP monitoring, optic nerve, Shaddai, meter, ultrasound, etc, etc.

I mean, there’s a bunch of different things that you can do to use as surrogates for that raised intracranial pressure use as surrogates for that worsening cerebral edema. That won’t be the kind of patient you’re going to then say, Okay, now let me do a wake up exam, you’re not going to stop there sedation, you’re not going to stop their analgesia because you know, what the underlying trajectory is, however, you’re using a lot of surrogates to monitor what is actually happening to this patient’s brain, right from the bedside assessments of their pupils, or ultrasound examination of their optic nerve sheath diameter, transcranial Doppler, periodically, you will send them down for radiographic imaging etc.

So knowing that you’re not able to when somebody says sedation off, you’re going to have that many more different ways of getting a window into what is going on in their brain, right. However, for our patients who are on ECMO, or who are on L Bad’s and they’re on ECMO, and CDPH, and a bunch of different devices and mechanical circulatory support, there are different reasons or they have refractory shock, and you can’t stop there, sanitary or analgesic drips, the least you can do is check their pupils. Right.

These are patients who can bleed into their brains when they’re on anticoagulant drips, etc. So while there are patients in other ICUs, or mixed medical surgical ICUs, who may be at risk of developing underlying neurological injury, in whom you may not be able to do dedicated or focused neurological exams for various reasons, also being intentional and saying these are the reasons why I can’t when they’re sedation and analgesia of the least I’m going to ask our bedside nurses to do then his check the pupils, look for any abnormal movements say somebody is not paralyzed, but they’re sedated you begin to see the few segmental myoclonic jerks.

So just observing your patient every single time you go in, know, letting them know that you’re there, no matter what their depth of sedation analgesia, their paralytics, just letting them know that you’re there, that you’re going to be assessing specific things. It also reminds you that there is a human being behind that patient when you do that. So just addressing them by their name, letting them know what you’re going to do. And even if you can’t peel oxidation for doing that, the hallmark of neuro ICU stands to be this key when our neuro check, right? So in those patients in whom we can’t win their drips off, at least having other ways of monitoring and the least if you can’t do anything else, at least check their pupils.

Kali Dayton 14:35
Oh, so many good points when you contact with myoclonic jerks, I think and other specialties. Sometimes if you see any movement, that just means you turn up sedation. We’re so afraid of any kind of movement rather than evaluating what does that movement about what a seizure

Dr. Neha Dangayach 14:48
right or a new onset seizure. So instead of just ramping up your sedation, observing that movement and trying to make sense and if you if you’ve seen abnormal movements or one side of the body or the other agenda realized abnormal movements. Also knowing Who who are you supposed to ask for help at your hospital? Is it the neurology console team? Or do you call neurocritical care? Who do you call for help? Who can also lay eyes?

Sometimes, you know, we don’t, particularly for seizures of abnormal movements. For the non expert, or somebody who is who hasn’t seen these kinds of movements before, they may not be able to describe it, when you have an expert at the bedside. So then your expert may not be able to diagnose what that problem was. So sometimes, you know, even making a video, a brief video of the movement that you’ve seen, and knowing that this was recorded on this smart sedation. So despite this maturation, despite this much, you know, fentanyl or whatever, analgesic drugs, despite that, were seeing these movements. What could this be?

Does this look like a seizure? Or is this a movement disorder or not? So I think, being a steward, it doesn’t take that long, every time you walk into titrate, your drips, if you if you said hello to your patient, address them by their first name, and just observe what is happening to them before you begin to titrate your drips, for example.

Kali Dayton 16:13
I think sometimes we misinterpret anxiety or agitation as pain or we just, we get so worried about movements, because we don’t want them to be agitated. But when you cause delirium, you’re at higher risk of having agitation and often that’s from the the sedatives and your patients, when they probably needed sedatives at some point, you’re pulling it back. Now you have acute agitation. And, you know, historically, we’ve been saying you can give these medications for agitation.

But the irony is, it’s not going to really fix the agitation because it’s causing the agitation. So how do you go through that process of working through delirium, as well as primary brain injury, without causing more brain injury with more station, but still having real agitation and likely in patients that you’re not going to be able to quickly reorient? And how do you initiate early mobility during all of that? How do you move forward?

Dr. Neha Dangayach 17:12
So first, let’s talk a little bit about delirium. And there were several societies who put together a consensus, you know, statement about delirium and thinking about, you know, acute thinking of delirium as acute brain failure. When we talk about organ failure in patients who don’t have, you know, underlying organ injury, we are clearly you and I were chatting briefly about, you know, acute renal failure or acute liver failure.

So delirium is akin to acute brain failure. Now, if we think about acute brain failure in those patients who don’t have underlying structural brain injury, so they came in with seemingly normal brains, they were, they did not have any problems with their brains. But just as their underlying disease process, whether it’s sepsis, whether it’s ARDS, just as that underlying disease process is affecting different organs in their body, the brain is perhaps one of the most vulnerable organs in the body, when it comes to trying to maintain perfusion, we don’t have good tools to measure that kind of brain injury on structural imaging.

And you know, a lot of functional imaging hasn’t made it from the realm of research into our bedside care. And oftentimes, these are not the patients who are stable enough to even move back and forth for different kinds of, you know, neuro imaging, but when they

Kali Dayton 18:33
Like if delirium came up with a lab results every morning, then we would care, right?

Dr. Neha Dangayach 18:36
Right? Absolutely. That there would be no question. Why is this person person not behaving like they would? Well, we think about these fluctuations in attention and this confusion and agitation, and then the more difficult into diagnosis hypoactive delirium, it’s so much harder because we’re relying on clinical assessments to give us the answer.

While there are well validated scales in patients without structural brain injury, when you have a patient with underlying structural brain injury, so it’s almost as if you’re adding insult to injury. So there’s already structural brain injury, their brains are already vulnerable, that everything else that we do to them in an ICU setting, what is happening to their brains, when we’re doing all of those, those other things, whether it’s whether it’s, you know, sedative drips, or whether it’s immobilization or the lack of family visitation, or not being able to comprehend what is actually happening to them because of their underlying structural brain injury

. So that just that fear of loss of identity that fear of losing their lives, and they’re not able to verbalize it because they have a breathing tube down their throats like this. There’s so much to unpack there. So knowing my approach to agitation is very simple. And I teach this on my rounds always agitate Shouldn’t is a symptom of something else, like you have to get to the bottom of why is this person agitated? And just saying, Oh, it’s just ICU delirium, no ICU delirium is also it’s this, you know, it is the signature of a lot of other things that are happening either physiologically to this patient or as a consequence of the medications that we’re using, or just as a consequence of the of the care that we’re trying to provide to support them as they’re recovering from the primary from the primary reason that they came to the ICU.

Right. So we have to one is, okay, should you then do some symptomatic management of the agitation to ensure that your patient is safe enough, so you can buy some time to find that underlying reason for why they’re agitated? I think that that is appropriate. But at the same time, not. At and I’ll say this out loud, do you know that there are occasions when when people Yeah, you know, the person was agitated? So we put the patient on precedex drip? Yeah, then what? Did you try to do try to figure out- WHY?

Kali Dayton 21:09
One of my favorite case studies of someone that we were they came out from an outside facility, they were on medazepam, they came out as you’d expect agitated, she bid through her endotracheal. Tube, she was on high ventilator settings, we replaced the tube. But and we did we started propofol and fentanyl and precedex. And because we wanted to bridge to precedex. But we use that time and it was like only an hour or two, to get her down to a RASS of one or zero, get her own unprecedented thing, get her walking, and get her moving with family and connecting.

And we use that to bridge to that. You can’t walk someone when they’re on a RASS of three or four. But we didn’t just say that was a failed sedation vacation. Oh, that was agitation. Therefore she needs sedation, we panicked. And we said she seems to have acute brain failure. We need to implement these tools and precedex is going to enable that and shortly after we took her off of precedex. But we don’t have that approach. But if it’s not like oliguria wouldn’t say oh, no, it’s just from the acute renal failure. It’s okay. We just accept it.

Dr. Neha Dangayach 22:11
No, we’re gonna get to the bottom of it. But we’re going to also look at every single thing that is worsening that you know that acute renal failure. So why are we not approaching it viewed brain failure the same way? I’m sure I’m sure that if if we look at you know, preventing isogenic harm, and knowing Yes, a lot of these things are needed, but they’re needed that whole escalation and de escalation.

So I think this analogy with how septic shock should be managed and fluids, right fluids are also very controversial, like how much should you give? How quickly should you give and when do you begin to de escalate, but thinking about supporting every every organ in the body in a manner that is going to be cohesive? There are going to be different needs. But can we minimize it Jenny? Can we escalate, optimize, stabilize and then begin the escalation?

One of my friends Dr. Manuel brain talks about this ROSE concept for his published quite a bit for Rose concept for septic shock and fluid management, etc. And I think that concept probably applies to how we take care of, you know, different different kinds of injuries you receive, you know, you resuscitate, you optimize, stabilize and then remember to de escalate like that.

And we’ve got to do the same like if you thought about sedation analgesia, sure your patient is having ICP crisis or going back to that patient who’s young patient in his 50s has this middle cerebral artery stroke, it was a malignant cerebral stroke, and they need a decompressive Hemi trainee, despite the decompression or they’re continuing to swell, continuing to swell. And you know what the anticipated trajectory is? So yes, I’ll escalate along that ICP management ladder, I’m going to escalate maybe even even paralyzed this patient.

But then I’ll verbalize to my team. If this patient goes without an ICP crisis for 24 to 48 hours, we were going to need to start peeling some of those things back and then what are we going to start with? So of course, in that situation, sedation is not going to be the first thing that I’ll peel paralytics may be the first thing that I’m going to peel off, and then see how this person is going to tolerate. Tolerate that. So knowing how we do these different things and verbalizing it being intentional using evidence based practices, where it’s available. And in the absence of evidence, at least having a consistent practice and measuring the consistency in our practice, educating our frontline teams, that these are all the things that we’re going to need to do.

And how are we going to adapt the A to F bundle so for us, so we’ve also implemented say relevance of the A to F bundled into our respiratory recovery pathway at Mount Sinai. And it’s built in into our electronic health record epic. And we got these ICU daily goal sheets, and the goal sheets need to be completed on rounds. And while they include you know, what are the top five things we’re going to do for this patient? They also have, okay, so what are we going to do about the sedation? What are we going to do about the analgesia? What scale are we using?

So yes, we’re using the RAS when using the CPOT, etc, etc. For early mobilization, the for knowing how much we can ambulate our patients? Or can we start with setting them up in bed so that they’re not, you know, losing their truncal stability and not getting deconditioned etc. Till we till we did not start using this, this whole respiratory recovery pathway is then ordered on every patient who goes on mechanical ventilation.

And because it’s all built in now, it’s essentially it’s a shared document between the medical team and the nursing team. So the medical team has to fill out what is the level of mobility, so on rounds, we’ll discuss it with our nurses, what do you think this person can do? And then we have to fill it into our ICU goal sheet and it gets populated on the nursing side. And when they finish their charting, only then that loop gets closed, otherwise, it doesn’t get closed. And you can visualize, you know, how much somebody’s somebody has progressed?

And are they meeting their goal or not. So those sort of visual cues and reminding, reminding the frontline teams about why this is so important. One of my neurosurgery friends, Dr. Christopher Keller says you know, any more than anything I can do as a surgeon, it’s the presence of family at the bedside, that makes a difference. And paraphrasing that the therapeutic effect of having family and loved ones at the bedside is much more than anything that we can do, as we’re providing care for our particularly ill patients. And to prevent the consequences of, of our treatments and of our support in the ICU.

We know there are these unintended consequences, this post intensive care syndrome, and this whole battery of problems that our patients and families suffer from as part of ICU survivorship. So one of the keys to preventing pigs is the implementation of the A to F bundle. So now that we know it, we know this works. We know that ICU survivorship is very, very hard. And there is this new state of normal that we can prepare our patients and families for let’s prepare everybody for success. So the least we can do is adapt and adopt the ABCDEF bundle. And Euro ICUs are no exception in my mind.

Kali Dayton 27:49
Oh, I love that. The ABCDEF bundle isn’t just in your EHR. It’s in your culture. It’s in your rounds. It’s in your process of care, because I think probably everywhere now has a cam score arrest score, see pot requirement in attorney system for nurses. But there’s not always that leadership. There’s not always that interdisciplinary collaboration and communication about here’s why we have sedation. That alone I think is powerful. I think we just automatically add married mechanical ventilation and sedation.

And there are no questions asked, there’s no justification of exact indicator. It’s just automatic. And that’s what I experienced as a travel nurse, I would say, Well, why are they sedated? And they say because they’re intubated. Like, like it was a dud, it was assumed and that wasn’t my first session. But breaking through that barrier to say, they are on a sedative because of this exact indicator that’s going to be temporary. We’re going to reassess every shift every rounds, and we’re going to talk about it that kind of leadership and education has to be so powerful in guiding treatment.

Otherwise, why would we change anything when it’s convenient to have people comatose? And for that moment, and then to have everyone involved in that assessment, that this isn’t a dictatorship? Everyone is weighing in the nurses at the bedside, who are the eyes and ears of everything are contributing to understanding the patient’s status and needs and that you talk about what you’re working towards. I think that is so powerful in every ICU specialty that that then we can really more appropriately triage the utilization of sedatives in the ICU and actually implement and have a culture of the A to F bundle.

And then when you have patients that are agitated, how do you keep them safe when you know they may have heavy cranial and they have, you know, these safety risks and you can’t have a thrashing? How do you work through that in the UK? How does physical and occupational therapy play into that?

Dr. Neha Dangayach 29:56
So it really takes a village in all aspects of care and caring, like you mentioned that multidisciplinary aspect, that collaborative care and coming up with a plan, and reassessing it and re evaluating. So at every step of the way, if our if we’re finding that our patient is agitated, despite having an adequate, you know, a plan in place, or something changed during the course of the day.

So, like we were discussing earlier in the conversation, where is that agitation coming from? And yes, we can do symptomatic treatment. But we’ve got to get to the bottom of why this is happening. See, I’ll also share with our teams that this this delirium is always going to be a diagnosis of exclusion, there are certain medications that may increase the risk of our patients getting more agitated, for example, levetiracetam levetiracetam, is, is used. It’s a very good anti epileptic medication.

But in some of our older patients, it may just cause them to become more agitated. So yes, they’re already at risk of developing ICU delirium. And then you add a primary neurological injury, whether it’s a stroke or brain bleed, whatever it is, you have that and that you’re adding, for example, Keppra as a, you know, seizure prophylaxis. So maybe it’s not the right choice in a patient who, who is demonstrating that they’re not tolerating it. So slowly peeling things back that we have already done to our patients, rather than trying to add another medication to treat the side effect of a medication that you started on the patient. Right.

So I think that is, that’s a common approach that I’ll use. I look at all the different medications, some of our brain tumor patients will be on very high dose steroids. They need it, they need it for the obesogenic cerebral edema. However, can we start doing a faster taper? So that’d be another another kind of approach, or there are some kinds of injuries that are going to predispose patients to more behavioral reasons for having agitation like by frontal injury, people who have a lot of edema in the in both the frontal lobes or because they had a big, you know, parasagittal meningioma or the light so we know that those patients will have a higher structural reason for being agitated.

So can we do some symptom management around the same time as they are emerging from the anesthesia or when they’re coming out of the operating room talking to the surgical teams and coming up with a plan for how are we going to manage their steroids because we know they’re going to get agitated or this is how they presented the last time they underwent their their surgery, and now they are undergoing resection of that recurrent tumor. So I think getting to know the patient’s history, preparing them for success.

If you already knew that somebody had agitation after they emerge from anesthesia for whatever reasons, whether they had structural injury or not, then what is your symptom management plan going to be? And making sure that all the different teams that are going to be managing this patient during different phases of care from the or to the ICU from or from the or to the pacu, from the pacu to the ICU, just making sure everybody’s on the same page in the ICU setting?

When we round with our nurses at the bedside, we’ll ask them you know, do you? What is your assessment of the agitation? Is it worse symptomatically? Is it worse as compared to yesterday, we’ve looked for all of these possible reversible causes. What else can we do? Then I will temporarily use you know anti psychotic medications like Seroquel. I’m using the words temporarily because it’s very, very important to not continue this medication at the time when these patients leave the ICU right.

I also I’m also very grateful to our teams that we work with in our critical care Recovery Clinic and we find you know some of these patients come back on on Seroquel and it’s not okay. So we have to be very thoughtful, just as we started therapy, when are we going to stop it? What are the reasons why we’re doing it? So I may use that I may use Seroquel or Zyprexa for symptom, symptom management rarely will end up using held all if a patient is not allowing for doesn’t have an you know, doesn’t have enteral access or is too agitated to swallow safely or they have dysphasia and they’re not able to swallow and they don’t have ventral access.

So we may end up using, you know, sublingual or im Zyprexa precedents, we do end up using precedente strips again being very thoughtful about okay it is going to be titrated to uracil zero to negative one. And when do we think we’re going to be able to peel off this president do we need to add for example, Seroquel, to be able to stop the the president drip and see how this patient’s doing? Because it also limits their ability to participate in physical therapy, occupational therapy, if they’re going to be on drips and over sedated.

So we don’t we want to break that vicious cycle. Another thing that the bedside nurses will always help us in assessing is do they need over Want to want to keep them safe, too, they need somebody present in the room, pre COVID, it was very easy to say, okay, you know, we’re going to get a one to one and this person can stay at this this patient’s bedside, we designed a new ICU in 2019 and new neuro ICU in 2019.

And we had this Family Zone patient zone nursing zone. And the idea was that a loved one could stay overnight, in the patient’s room. We also invite loved ones to join us or the surrogate or the person who is responsible for decision making or their health care proxy, we’ll invite them to join us on rounds, so they can hear and help us prepare a plan. Now, you’ll sometimes hear these little tidbits from families, you know, this person likes to be called this.

So then we’ll write it on the board, you know, we have these boards in all the ice rooms will write oh, this person likes to be called this, when you call them this, you know, they they will respond better, or they like this kind of music. And we’ll play that kind of music for the patients, you know. So I found it very challenging during COVID When we had limitations on family visitation, because I really missed having that partner in providing care. While the team was cut out, Oh, my God. They are the experts in their loved one.

We may try to be the experts in medicine, but they are the experts in this person. So we take that, and what do they like to be called? What is their favorite? You know what? This very interesting story, I should share this with you. So we had this patient who came in with a subarachnoid hemorrhage. She happened to be she happened to be a nurse and you know, nurse who used to work night shift. And we had no idea that she is sleeping a lot during the day and staying like oh, yeah, she’s developed ICU delirium.

We’re going to do something about it. Then her family shared with us. Yeah, you know, she’s used to sleeping eight hours during the day. Like that’s what she does. This is her normal routine.

Kali Dayton 36:54
That’s who she is.

Dr. Neha Dangayach 36:56
No, don’t treat it with medication.

Kali Dayton 36:59
Yes, I have heard from a lot of podcast listeners that they have really noticed that sedation use has drastically increased on families out there. Yes,

Dr. Neha Dangayach 37:09
Because they’re not there for reorientation, for reassuring, no matter. And having that familiar voice telling you it’s going to be okay, you’re getting all the care you need. That goes a long way in mitigating some of that fear, which may be contributing to do that agitation. And then we’re recognizing, we sometimes miss interpret that fear as delirium, because they can’t verbalize that they’re just scared.

Kali Dayton 37:36
Or in pain. So we need to go up in the narcotics or, you know, the pain. And just even the very concept of a deep, thorough assessment, evaluating all the contributing factors, just getting down to the root of why they’re having this symptom, instead of masking it, that can be universally applied in any ICU specialty, and can drastically change outcomes.

Because we are training our team whether outright or subconsciously or culturally, to just turn up sedation. Instead of asking, why are they having symptoms, why are they agitated, and then we don’t educate us to the effects of our medications that we give. So we give more at the thing that’s causing the problem often, or we’re missing addressing the true cause of the problem. And so we’re never really fixing anything.

And we’re causing this, as you say, a vicious cycle. We just walk them into this delirium ride, and we say, sorry, welcome to the ICU we run. This is the way it’s gonna be and how does this impact the team’s morale? Do you feel when you have this kind of focus? Because the perception is that the ATF model is more laborious that it right now in our staffing crisis, we don’t have the manpower, we don’t have the time we don’t have the energy to implement these interventions. How do you feel like this impacts workload and staff morale?

Dr. Neha Dangayach 39:04
The “why” behind the things that we’re doing and verbalizing those why’s are so important. And we don’t, we don’t necessarily, we don’t necessarily educate our teams, you know, on the on the front lines, particularly our nursing staff or our abps and trainees. We’re not necessarily being intentional about teaching them about the why, and also challenging.

You know, one of the things that I one of the first things that I learned in med school was you’re not here to worship what is known but to question it. And I am so glad that I learned that so early on, I’m so so grateful to all of my mentors who who have, you know, pushed me to to think about the why, and making sure that our frontline team so even when we were rolling this out, you’re absolutely right.

That whole documentation burden, and the the titration, and when when Joint Commission is coming by, you know —-what Why are you not titrating titrating, your drips, suppressors, you know, as rapidly as you’re actually escalating some of these? Some of those things need to be re-engineered, because we are taking away from the mission of providing care, when we create onerous…. when we tie that very, very important care to onerous documentation. Because then it then it becomes burdensome, when it actually should be a source of joy.

Because you are, you are not only providing care for your patient, you’re providing care for the whole person, when you implement, for example, the ICU liberation bundle. So making sure that we create avenues for dialogue, and we create avenues very intentionally, for why we’re going to be doing things a certain way. And are there are there opportunities for us to improve the implementation.

So there is nothing wrong with with this evidence based practice, but the implementation may need a little bit of reengineering may need a little bit of optimization. So I think it’s important to bifurcate, the science, the education, the implementation at the bedside, and that documentation piece, because if we don’t do that, we are then setting our teams up for failure.

So this mantra “set everybody up for success”, like I say this every single day. Including including our patients, our families, ourselves, our teams. Like if we don’t do this, then we are we’re doing a disservice. We’re doing a disservice to to our nursing staff, and then propagating that idea that, you know, we just, this is just for the for the sake of documentation, then it, it becomes its trivialization of something that is so meaningful, and so important to do.

So how do we simplify it, so making sure that our electronic health records become smarter, smarter at capturing some of this information, that the documentation doesn’t become onerous that you have, for example, you know, a nice flow that is built into your electronic health record that, that flows directly, for example, into your nurses care plan.

So they don’t have to type separately Oh, I titrated, this and I titrated, that you are already documenting it in one part of the EHR, so let’s not have them documented multiple times in multiple places. So there are easy fixes. I’m just giving a small example. But there are so many ways in which we can improve the implementation of a bundle that already works, the hard work of proving whether it works has already been done by by giants, like oh, you know, Wes Ely and team, like let’s just let’s just make sure that we can implement it implemented in a manner that our frontline teams don’t find burdensome, but it becomes a natural part of their care.

Kali Dayton 43:00
Yes, I feel like some of our implementation has lacked the why. And therefore, it’s become very burdensome, we automatically start sedation on everyone because they’re intubated, and we create delirium, and then we leave it to the nurses to unmask the delirium. And then we don’t explain to them why we’re working on moving that direction, they don’t understand.

And nurses are extremely smart. And so I find it a little bit insulting to not provide that education and allow them tools for critical thinking that we just bark orders, or just put things into the ticketing system and demand that they feign unawakened breathing trial, but we’re not actually truly doing it. And they don’t get to actually experience the benefit of having patients be free of delirium. Having the human connection, having them get better and get off the ventilator and walk out the doors.

We’re depriving our teams have that kind of joy, because we’ve missed as you say, the why. And so I see what your team’s doing. And, and having that kind of collaboration and that constant communication about the why. So that everyone can be an active participant and understand the big picture, because that’s why we got into this, we want to alleviate human suffering and save lives. And that’s facilitated by the ABCDEF bundle. But until we understand that, then it just seems like another laborious thing to do.

Dr. Neha Dangayach 44:22
Absolutely right. And that team approach in how we provide care every single day that should flow into our culture. And our culture should flow into how we provide care. So I think that sort of interconnectedness, we can’t and we talk about burnout in medicine, and particularly burnout in the ICUs and so many of our nurses and watching some of our really amazing excellent nurses experienced that, that deprivation of joy and that sense of burnout and not having meaning and what they’re doing.

This is an avenue to give them back that sense of control. In a patient’s journey, because that’s why we all decided to, you know, like you said, take this on to to alleviate human suffering, and all this other stuff, whether it’s documentation, whether it’s billing, whether it’s, it’s, you know, work RUVs. Like, it’s it’s insane that those are the kinds of things that are becoming so prominent that we’re letting those things, rob us of the reasons why we chose to do this in the first place.

So while those things, whether it’s documentation, whether it’s billing work, our views, etc, yes, they’re, they’re important at some level. But these should not become the be all and the end all and who can prevent that from happening is us. Like, we’ve got to be very clear that we’re not going to let these things rob us of the joy of providing excellent care for our patients. And making sure that we we have the backing and support of leadership teams at our respective hospitals.

So when all the hospitals, you know, I know this has been a whole movement of wellness. And while this was not the theme of our, you know, of our podcast today, I should share that it we shouldn’t just be paying lip service to wellness, the implementation of care, like the ICU liberation bundle, the ABCDEFF bundle, that when we provide excellent care for our patients, that is the number one antidote to burn out.

So let’s do everything that we can, right from the knowledge to that knowledge, translation, implementation of high quality, evidence based practices, providing people with the right knowledge, the time space, the resources so they can, they can do right. And when when we help our teams do, right, that prevents burnout.

Kali Dayton 46:51
Oh, that’s profound. I am a deep believer of when it’s right, it feels right. And that brings peace and joy. And all these good things are good feelings. And that’s partially why there’s so much turmoil going on, because we’re not doing a lot of the right things. And we don’t have that inner peace.

But as we provide that human care that we’ve entered the field for, we can have that reciprocated joy and peace. And it will feel right and keep us at the bedside, and probably help resolve a lot of the other problems as we have more motivation and energy to do so. But when we provide poor care, everyone suffers.

Dr. Neha Dangayach 47:32
Everyone suffers.

Kali Dayton 47:34
Thank you so much for everything you contributed for this incredible perspective and these tools for critical thinking that I think apply to anyone at the bedside in the ICU. I thank you so much for everything you’re doing and I invite everyone to follow her on Twitter. She’s a powerful advocate for patient care and obviously an ABCDEF expert. Thank you so much.

Dr. Neha Dangayach 47:53
Thank you so much, Kali. Much appreciated.

Transcribed by https://otter.ai

References

ABCDEF Bundle in Neurocritical care:

https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.034023#.YhT7pmLLnm4.twitter

Claude Hemphill III, J. Improving Outcome After Intracerebral Hemorrhage: Maybe It is the Body, Not the Brain. Neurocrit Care 26, 157–159 (2017). https://doi.org/10.1007/s12028-017-0384-9

Oddo, M., Bracard, S., Cariou, A. et al. Update in Neurocritical Care: a summary of the 2018 Paris international conference of the French Society of Intensive Care. Ann. Intensive Care 9, 47 (2019). https://doi.org/10.1186/s13613-019-0523-x

Young, B., Moyer, M., Pino, W., Kung, D., Zager, E., & Kumar, M. A. (2019). Safety and Feasibility of Early Mobilization in Patients with Subarachnoid Hemorrhage and External Ventricular Drain. Neurocritical care, 31(1), 88–96. https://doi.org/10.1007/s12028-019-00670-2

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