SUBSCRIBE TO THE PODCAST

The A of the ABCDEF Bundle is for “Assess, Prevent, and Treat Pain”. How do we truly master this tool and how does this impact patient outcomes? Can we assess, prevent, and treat pain while simultaneously striving to have all possible patients awake, autonomous, and even mobile? Joanna Stollings, PharmD, shares what the A of the ABCDEF Bundle really means and how to master it for each patient.

Episode Transcription

Kali Dayton 0:00
Hey, I’m Joanna, welcome to the podcast. Can you introduce yourself to us?

Joanna Stollings, PharmD 0:06
Hi, my name is Joanna Stolling. I’m the medical ICU at Vanderbilt in Nashville, Tennessee. I also work with our critical illness brain dysfunction survivorship center. And I also work in our post ICU Recovery Center at Vanderbilt.

Kali Dayton 0:20
I am so excited to talk to you I’ve heard so many people sing your praises as a great expert on the A to F bundle, the PADIS guidelines, tell us about your discipline, and you know, what your role is with the bundle?

Joanna Stollings, PharmD 0:35
So I have been really fortunate to been involved with the bundle for a really long time. And so proud how I initially got involved with it is that a brand upon lead a quality improvement project, which included over like, 15,000 patients, and implemented the A through F bundle, nationally. And so I was one of the overall like on the the board for that.

And so we essentially implemented that in multiple 68 different centers. And we showed that if you do that ABCDEF bundle. Essentially, it’s like a dose response. And that people spend less time on the VA, they have less delirium, and they have a less use of restraints, they’re less likely to be sent to a facility.

The only thing we found, or the other thing we found was very interesting is they had more pain, and says I’m talking about the letter A today, I think it’s especially important to bring up that point is just we think that the reason we found more pain in these people is essentially that because we were looking for it, and we had not been looking for it before. So that’s how I initially got involved.

And then I was fortunate enough to be a co-chair with Jaspal Singh of the ICU Liberation committee of SCCM. So that was really, really fun. That was during COVID. When unfortunately, utilization of the bundle, we were having a lot of problems with that. And we were really doing some backtracking just because we did have a lot of drug shortages.

And people were obviously scared. And so it was a really good opportunity to, to do a lot of things to really implement or to remind people how important it was to do the bundle. And so I’ve spoken about this topic a lot like nationally and internationally. And so my most recent adventure is actually got to go to the Ukraine, and to teach about ICU liberation, for two weeks. And that was one of the most rewarding and amazing experiences that I’ve ever had.

Kali Dayton 2:32
Wow. And especially to be talking about pain management for so many horrific trauma victims. Sorry, I get emotional. Thank you for doing that. That’s really exciting, I’m sure, really, really needed. I know Chris Permai went with you as well. And I’m planning on doing an episode with her dedicated to that. Pain is such a prevalent thing in the ICU, whether it’s in Ukraine, or even in our ICUs, especially our trauma ICU is I think we have some mandated elements of the A in our charting system, CPOTs, pain scale, things like that. But I think we are falling short of really mastering the eight. So tell me what is the A of the bundle? And how does it impact patient outcomes?

Joanna Stollings, PharmD 3:19
So A stands for assessing, preventing and treating pain. And so Wes Ely, who’s essentially like The Godfather of this whole bundle, and his wife, Kim, who’s just this wonderful lady, she was like, why don’t you make the A analgesia? And we’re all like, oh, yeah, we should have this kind of funny so that you can think of it as analgesia or you can think of it as the other.

But essentially, what we found, or what we have found over and over in studies, not just ones that we’ve conducted is, if you don’t look for pain, unfortunately, you’re gonna miss it. And it’s not just the trauma patients or the surgical ICU patients or the burn patients that were it’s like, more obvious that they have pain sources, like this happens all the time in our medical ICU, because maybe they come in and they have sepsis, and you’re like, oh, they don’t really have a source of pain.

But that’s not true. Like I wouldn’t want to lay in one of those ICU beds are being intubated or have an endotracheal tube or a chest tube or a Foley catheter or getting my finger prick to get my glucose check. There’s multiple sources of pain that we don’t think about in our patients every day. And unfortunately, if we don’t treat pain, guess what happens?

They get agitated, and then they can quite often get delirious, which I’m sure you’re gonna have somebody talking about the letter D, and we know all the horrific outcomes associated with delirium that they have long term cognitive impairment, they spend more time in the hospital, and they have higher mortality. And so it’s just really, if you don’t treat pain when it’s indicated, then you can really send the person the patient down a road that they don’t need to go down.

Kali Dayton 4:55
And it can be really difficult to treat pain when you can’t, either See the symptoms of it or discern what you are seeing. So I always suggest that it’s easier to adequately treat pain when patients can tell us what they’re experiencing. Agree, I worry that we take away that opportunity for many patients in which they could have had the opportunity.

Many situations in which case patients don’t necessarily have an indication for sedation. But because they’re intubated, boom, they get sucked into this vortex of sedation, opioids immobility, right, and they don’t get the opportunity to wake up and tell us, I have pain, it’s not adequately treated, or I don’t have pain, I don’t need opioids. So how do we best screen for pain for those that can report it and those that cannot.

Joanna Stollings, PharmD 5:38
So if you can report pain, and we want to recommend using a numeric rating scale, so that’s where you would have a pain or a patient tell us, you would say the patient on a scale of zero through 10, where 10 is being the worst pain you can possibly imagine. And zero being no pain, like what is your pain to get a more a better grasp of what their pain is, and to better understand like how we should treat that, versus if they can’t verbalize the PAD guidelines that pain education to learn from 2013.

And then the POTUS guidelines from 2018. So not only pad but also early mobility and sleep would suggest to use the C part which is a critical care pain observational tool, or the behavioral pain scale. So the c part, for example, or the BPS are for people that can’t verbalize. So if you were going to perform a C PA and your patient, you have to take into account their facial expression.

So they get a score of zero through two for their facial expression. So, for example, if like the patient is grimacing, then they’re going to get a higher score than if they’re smiling. And you take into account their body movements like are they rolling around in the bed indicating that they are in distress, and they’re also their muscle tension.

So are they like resisting you that would also indicate that they’re in pain, and then either their vocalization or their compliance with the ventilators the fourth part, so for each of the four parts, they get a score of zero through two. And if a patient has a score of three or more, that would indicate that they’re in pain, but obviously then verbalizing their pain is the best way to do it. But when they can’t, using either the c pot or the VPS is the way to go.

Kali Dayton 7:10
And this can be really tricky when you have patients that have delirium, agitated right now systematically, we’re not stepping back and saying what is causing the agitation, still get responses to increase sedation, when there can be so many different causes. Here’s an example is a trauma patient team reached out to me a little bit ago they had a patient that is a poly substance abuser, and just had probably had some withdrawals on top of everything he had been in a car accident had some rib fractures, which to anyone that is excruciating and painful. And he was intubated.

And so they kept on giving him verset pushes, eventually put them on a reset, drip, everything kept escalating, because he kept coming out agitated. He was getting some opioids, but it was really hard to know what’s withdrawal, delirium, pain, right? navigate that.

Joanna Stollings, PharmD 8:05
I mean, honestly, like so the approach I always take in that situation is always think about pain first. So if I’m presenting this on a PowerPoint, I put it literally like in a circle, and say pain is beside delirium is beside agitation. They’re all interrelated. And if you don’t treat pain, your patient can get agitated or get delirious.

And so in that situation, that person had an avert source of pain, you know, and so I would absolutely recommend that we use pain meds to treat that and hopefully work on the delirium. And so I like to treat this isn’t necessarily about pain. But this is all interrelated. The pneumonic Dr. Dre, like the rapper in Atlanta, and we’re the first DR is like disease remediation. So you’re thinking about diseases or diseases we think about will be heart failure, or COPD, or sepsis.

And the next one being drug removal. So stopping bids or days means stopping opiates if they’re not indicated. So in other words, if you did assessment for pain, they’re not indicated not using them, right. Or dragon weevils. So using like Anticholinergics in the ICU that aren’t indicated to like somebody’s home, allergy med. And then lastly, the environment. So thinking about like, trying to be quiet at night, not coming in and waking patients up to draw wives or giving them medications in the middle of the night, like if they don’t need them, or putting glasses on patients or their hearing aids or mobilizing patients.

So once again, like if people are going to the doctor tray, then part of that they’re going to be like, hey, wait a minute, this patient has pain. So maybe that is why the patient is delirious. We also know that benzodiazepines in themselves are very delivery agentic. And so even if the patient didn’t have pain, and we were trying to treat agitation, we shouldn’t be using visit as a pain. So we’re kind of as we’re going to worsen the whole entire problem.

Kali Dayton 9:50
And that’s where they were reaching out to me because they were panicked. They said, this is a mess, right? We don’t know what’s causing what and so we troubleshot a lot of different probable causes withdrawals, we put down some clot up into the feeding tube at a lower dose, maybe ward off some benzodiazepine withdrawal.

Oxycodone down the feeding tube to make sure there were no opioid withdrawals, but also to manage the pain we ate and kept a little bit of fentanyl going so that we can had some continuous coverage. It would have been great to have an epidural on him. Absolutely. He could have mobilized and maybe worked through that delirium. But when they did those things, and they went back the medazepam they started to use their expert nurses, they made sure that the right nurses had him for the next following shift.

And they figured out he wanted to use the bedpan. Wow. And then use the bedpan and he had calmed down, they were able to keep them on some low dose precedents and start to mobilize him some more and really figure out how is his pain and what they actually need. And they were able to navigate and adjust things with his engagement. And that to me, I thought that was a really good example of the A, it’s not so I’ve had people say, well, we can’t avoid sedation in our patients because they have pain. And to me, that’s a huge red flag, right? That we need.

Joanna Stollings, PharmD 11:06
100% agree with you. Yeah. And that’s I mean, that brings into another topic, which is an algo sedation. So essentially, now though, sedation is using opiates, not only for their opiate properties, but also for their sedative properties as well. So Thomas Strom and is kinda he published one of the first studies on this.

And so he essentially showed, he did a study comparing patients that got propofol to intermittent doses of morphine, and people spent like less time on the ventilator like I think it was almost nine days, if they only got the intermittent doses of morphine as compared to the propofol. So it really shows we use a lot more fit now than morphine, obviously, just because of a lot of our patients have renal dysfunction or that hypotension. So can’t use a lot of morphine. But really just shows that if your patient has pain, and that you can use opiates, not only for their analgesia effects, but also for their side effects as well as well.

Kali Dayton 12:00
Absolutely. And that should be the first thing that we go to rather than sedatives that ended as a pains. All this plays into having patients be as awake, communicative and engaged as possible. I personally know that when I’m in labor about to have a baby, I’m really in a place to talk and communicate, and tell everyone obviously, it knows what I need. It’s very obvious what’s what’s happening with what the cause is, right?

But I just think about when these patients are in excruciating pain, but we don’t necessarily know what’s going on, we need to treat it so they can actually tell us then they can calm down enough to communicate and express their needs. One podcast listener told me a story of having their patient awake on a ventilator, and they reported chest pain.

And because they got that cue from the patient that had a chest X ray, they found a large pneumothorax as they’re looking at the machine, the patient arrested, and I’m gonna get exactly what caused it. So pain is such a vital sign. It’s such an indicator of something changing something going on. So what are your thoughts about automatically starting fentanyl and every patient that fentanyl drips on every patient that’s on a ventilator? Is that really practicing a is that what we need to do?

Joanna Stollings, PharmD 13:13
So a couple of thoughts on that. So initially, so when you intubate somebody, we’re going to give them a set of usually a Terminator, ketamine, and we’re gonna paralyze them. So because we paralyze them, they’re gonna have to, they’re gonna have to be a target RASS and negative five for a few hours to give time for that paralytic to wear off because one of the worst things I can’t imagine this like, would be to be paralyzed. And to remember it, you know, so that’s so scary. So initially, we have to deeply sedate everyone and give them analgesia, but that’s only for a few.

Kali Dayton 13:45
It’s a procedure, procedural medications.

Joanna Stollings, PharmD 13:47
Exactly. But after those few hours go away, then absolutely, we shouldn’t be giving fentanyl drips to every single person in the ICU, we should be doing appropriate assessments like the C pod or a numeric rating scale. And we also need to think about so if you look at the pack gallons, why not again, once again, like you’re thinking about like, it’s gonna say opiates are number one. That’s what we should be using in the ICU for most of our patients, but we can’t forget and the PAD guidelines did a fantastic job going over this multimodal therapy. So multimodal therapy essentially means like, don’t just give everybody opiates.

You have to give them agents that act by different means as well so we can decrease our utilization of opiates. Because if I was going to name the top five questions that I got when I was in Ukraine, it was like What about opiate withdrawal? My patient just because they were concerned about that because their patients do have so much pain so really going over multimodal therapy with them as well, for example. So what are options for multimodal therapy?

So one of the first drugs that the Pattas guidelines go over is acetaminophen. So Acetaminophen is a great drug to use and people who have been Okay, so we think about people who have had fractures or people and had bony metastases like schedule that and put that in the background, just so that we can decrease utilization of opiates. Now if you if your institution has obesity manifests in which a lot do not because honestly, it’s really expensive.

And then sometimes it gets misused when we could use oral we’re not have to worry about a little hypotension. But essentially scheduling like oral our per tube, acetaminophen in the background is a great way to decrease utilization out yet. The next option you could consider insets. Right? So thinking about like ibuprofen or couture lack now, these are not for everyone and the pad is guidelines, don’t recommend them. And it’s not that it’s bad. It’s that you have to consider the side effects. So once again, if and I work in the NICU, so tons of our patients have renal dysfunction.

We have patients that have heart failure, we have patients admitted with GI bleeds like those are not the patients, you give NSAIDs. But once again, there are patients that have bone pain that you can put this in the background and it will help decrease utilization of opiates. So one of the hottest drugs out there in the ICU is probably ketamine. Right? So ketamine, once again, if you look at the Pattice guidelines, it would say to consider low dose ketamine in surgical ICU patients.

So once again, you can run that in the background and help decrease utilization of opiates. But we shouldn’t be using that and our medical ICU patients, just because it can be diarrheagenic. It’s a PCP analog. So just remembering that other things. So why to cane infusions are not recommended by the patent guidelines. Once again, it’s not that they’re bad, per se, but literally there was like, there’s like one study, really, that has evaluated that.

And because of that, there’s just really not enough evidence to recommend it. But once again, it’s not that it’s bad. We usually don’t use those routinely in our medical ICU unless the pain service is on board, but you can use that for a couple days and have good results. The other things to consider are like neuropathic pain. So a question I’ve gotten before is like how do you know if a patient has neuropathic pain? So once again, like if you have diabetics, or COVID patients, these people have tons of neuropathic pain. So on the PADIS guidelines.

Actually, if you have a CV surgery patient, it says to essentially give it to everyone. But if it’s not if it’s like a medical or another type of surgical patient, it’s specifically for neuropathic pain. So looking at those risk factors, and considering either pregabalin or gabapentin, I personally wouldn’t recommend carbamazepine just because there are so many side effects associated with it a lot of drug interactions.

So won’t necessarily do that. But Gabapentin and pregabalin, either one depending on the background, also can be super helpful. So when I think about multimodal, I’m thinking about all those different agents and kind of what can happen in the background to decrease my patients utilization of opiates.

Kali Dayton 17:55
And that just goes in sync with my experiences and in the wake and walk in ICU. Very few of our COVID patients even had fentanyl drips, very few COVID or patients that were on ventilators in period that had fentanyl drips. It’s not that it was a no No never. It was just we were able to know what they needed. Because they would tell us we also utilize everything you’ve described before getting there.

And that doesn’t mean that we just sit there and let them languish, we’d give until pushes. We try to buy some time all these other things, lay the foundation of pain management, and then saw what we needed from there. And these patients were awake, calm, compliant, mobilized. This is not what people expect that they’re thrashing languaging in excruciating pain, I really felt confident that we were adequately managing their pain, and not just masking it with sedation.

When I talked to some survivors, they describe how much pain they were in. And it was untreated. And they couldn’t tell me about it. They couldn’t report it, they couldn’t get relief. And they were psychologically left alone with it while locked into delirium. And it was all incorporated into their delirium, they thought that a snake had bit them and that the worst thing that happened, their brain was trying to make sense of the pain that we’re having.

Even some of the more mild discomfort in their intertrade from the endotracheal tube. It all exacerbated the trauma of the delirium because they could not get enough relief from the pain and nobody knew it. From the outside. I’m sure they were had a very low CPOT. Right? We were still and no signs of pain were seen. So as a pharmacist, I’m hearing you were just this fountain of knowledge. How do you bring in mastery of the eighth element of the bundle to your team? What is your role in all of this?

Joanna Stollings, PharmD 19:45
So my role as a pharmacist is like so I’m going on rounds every day. And so our nurses actually present the A through F bundle. It’s one of the first things they present on rounds. And so just listening and it’s like okay, so what is their C pod or what is your new grading scale, what have we put on for pain? And so absolutely like, I don’t think that we could complete this like podcast without saying like Tim Girard, when he published the ABC study, right, that showed coordinating the spontaneous awakening trial with a spontaneous breathing trial.

That made people spend like three or fewer days in event for a few days in ICU for a few days in a hospital on a 14% reduction in one year mortality, that he not only people had their sedation turned off, but they had their analgesia turned off, too. We can’t forget that. So anyway, so but I’m looking to make sure that we try to do that every day, and patients when is appropriate, based off their c pot score to turn off their analgesia. And I’m also looking if that’s not appropriate, like, “Hey, what happened to this patient? And what can we put on in the background to get rid of that fentanyl drip?”

And if they’re only on low dose fentanyl, can we give intermittent boluses effect now to essentially like, get them through? And then kind of what you were highlighting before about the guy that needed to use the restroom essentially, like made sure they have a bowel regimen to like people forget about that. And they’re on high dose opiates for days, we especially had problems with this during COVID.

If you were going to ask me today, my top 10 drugs I had to have during COVID to help patients and most it will be r&r can, because honestly like we had these patients on MiraLAX we had them on Santa and they were still getting really constipated. So we would give them oral Narcan. And it didn’t affect did not affect the effects of IV opiates, but it allowed the patient to have a bowel movement.

So I think that’s something else to remember. So my job is not only during rounds, like answering all these questions and trying to like facilitate decreased utilization of opiates when possible, but also like anytime we get new patients helping to figure out like what is the best pain regimen for this patient. Last thing I’ll say, which is also important to remember is when patients are have any kind of transition of care, because thinking about like people that are going to have addiction potentially to opiates, because I live in Tennessee, right?

And we’re one of the number one states with regards to the opiate epidemic is making sure much like stress ulcer prophylaxis, or not so much anymore. But antipsychotics when we used to think they work for delirium, but also opiates, do patients need the ease when they go to like to the floor, for example, because we don’t want patients to be on them when they go to the floor or even indefinitely, unfortunately, and just thinking about that too, because it is a problem.

Kali Dayton 22:32
Wow. And I am thinking about some teams that I’ve worked with on site and work into pharmacists. I’m going to definitely send this episode to them. I try to empower the pharmacists to jump in and have these conversations to assert themselves, especially when it comes to pain management and sedation stewardship. But you’re also bringing in this big picture of what are the bells doing?

And then I know with my pharmacist, what are they sleeping, what’s causing the delirium, what’s causing the agitation really digging into the root of it and making suggestions, especially for pain management. When I tried to empower the pharmacist, especially to bring up sedation, they feel really nervous. They feel hesitant because they think, well, sedation is the nurses realm, I can’t dare step into that landmine.

But this is within the pharmacist stewardship. This is how you really make the biggest impact as a pharmacist into the ICU team. You’re not just there to fill meds to check orders. You know, obviously, that’s a huge safety net and makes a huge difference. But how do we empower pharmacists to really take the a by the by the horns, as well as the C and a D. And

Joanna Stollings, PharmD 23:46
I like to take to two things to think about. So I have this slide that sometimes I like to present and like the ABCDEF bundle is all about a team, right? So like think about like, if everybody’s working in their own little silo, right and not talking to each other man, “like that’s the nurses job.” “That’s the PTS job,” you know? “That’s the pharmacist job”, we’re not going to be near as effective.

So some people like to say, “hey, the letter C choices IV sedation and analgesia that’s a pharmacist job”, but I like to empower pharmacists that they can help with every letter. So thinking about the letter A right so like helping like with what we’ve talked about, like assessing pain, and making sure those are performed and performed correctly, and also like helping select analgesia.

And then same thing with the letter B every single day on rounds. If the nurse or someone in the team does not bring up about turning off that sedation or LTC, I ask every single time and honestly like I think that the pharmacist just needs to empower themselves and realize that they are like a very vital member of the team and that they should ask, “Hey, can we try to turn this off? Hey, can we whiteness up maybe it’s not appropriate to completely turn it off, you know?”

And because that’s gonna we know that based off the ABC study that like that’s gonna help extubate the patient more quickly. And that’s gonna lead to a decrease risk of complications like ventilator associated pneumonia, etc. You know, the letter C is our letter, like, I feel like most pharmacists feel comfortable with that, like, Hey, I’m avoiding visit A’s pains thinking about dexmedetomidine and approval for the letter D.

I mean, delirium is why we do a lot of these other letters, right. So no benzos and treating pain appropriately, you know, and making sure that the cam is appropriately reported on rounds and avoiding antipsychotics to prevent and treat delirium because we know they don’t work. And so and people will think this is crazy, but I even get involved with the letter E.

And the very first time I asked, I was like, “hey, hey, can we do PT?” and a medicine resident looked at me and said, “This patient isn’t on warfarin,” because they thought it was like a prothrombin time. And I was like, “No, no, no, I’m talking about physical therapy!” You know?

So once again, like physicians and advanced practice, providers are so busy. So pharmacists, in general in the ICU have to empower themselves to be the drug police, for lack of a better term, you know, and to really just to micromanage those medications to make sure that patients are getting the most effective therapy and as little things like PT that fall through the cracks, because everybody’s so busy. And the same thing with like the family, like I told you before I work in our post ICU clinic.

So not only educating like family members and patients even about that, that really just like, we have to make sure that the the nurse and that the family, like are invited to rounds every day, and that they know like we find them as we go to each patient. So just little things like that are things that the pharmacist can help to facilitate, to really make sure that the ABCDE F bundle is being applied to every single patient.

Kali Dayton 26:53
I’m just my hands are up right now. I’m just so excited about everything. Because this is exactly what I have experienced as part of an interdisciplinary A to F bundle team, this exact role that I want pharmacist to play. I mean, obviously, the A applies to everyone. The PTS OTS need to be aware of A before the mobilize a patient nurses need to be obviously very in tune with what signs are seeing addressing the causes of the symptoms, things like that.

But pharmacists are not just there to check the orders. Exactly. I love that your goal is to minimize the drugs used not just to run the drugs. Absolutely. And you would never let us give antibiotics without an indication. Never. Because you have antibiotic stewardship. And I would love pharmacists to have standardized sedation and opioid stewardship, you would never let us give you should never let us give sedatives or opioids without an indication.

And then just like with antibiotics, while you’re watching the in time, you’re saying, is it the right antibiotic still? Is it? Do we still need it? Can we downsize it? Can we turn it off? Can we? Or do we need to keep it going? You’re part of that conversation, you take a lot of stewardship, I would love to see the whole team take the same approach with sedation and pain management moving forward. And now add to the conversation.

Joanna Stollings, PharmD 28:17
No, I 100% agree with you. Like I just think that it’s important that everybody takes a role in this and that this is a huge part of patient’s care, just because they got P we’ll have to be educated about the long term manifestations of this. So like the consequences like post intensive care syndrome, like I like I said, I work in our post ICU clinic. So when you see these people come in, and they have cognitive impairment, right?

We know delirium is like the number one risk factor for that. So once again, taking a step back, did we treat their pain correctly? Did we give them the right sedative, we have to think about long term consequences of these decisions were making. And I think that in itself is the most empowering thing for people to know to really get involved and want to help with this.

Kali Dayton 29:03
You bring that into rounds, do you help with the education and bring in the post ICU information into the immediate decision making?

Joanna Stollings, PharmD 29:12
Absolutely like I honestly like we’ll bring that up on rounds. And I also am like the person that’s looking for patients that are high risk for developing this if people have been on the vent for a long time those that have delirium those that have ARDS or sepsis. I’m actively screening for these patients to go to the clinic too.

Yeah, like is I even mentioned some of these papers is like we were talking today and like when a paper comes up like that around you better I send it, I’ll send them a picture of like the Dr. Dre, I’ll send them Thomas Strom study on like an algo sedation or Tim Girard’s ABC study just so that they can see it for themselves to see they understand why this is so important and why we think about this every day.

Kali Dayton 29:52
I love it. Bringing the evidence into the intimate bedside clinical Critical Thinking decision making As a team I, that’s exactly what this information should be used for. Thank you so much for everything you’re doing for the critical care community throughout the world. Now, stay tuned for more episodes with more elements and do and I look forward to learning more from you in the future. Thank you!

Joanna Stollings, PharmD 30:15
Thank you so much.

Transcribed by https://otter.ai

 

Resources

ABC study by Dr. Girard:
Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W., Schweickert, W. D., Pun, B. T., Taichman, D. B., Dunn, J. G., Pohlman, A. S., Kinniry, P. A., Jackson, J. C., Canonico, A. E., Light, R. W., Shintani, A. K., Thompson, J. L., Gordon, S. M., Hall, J. B., Dittus, R. S., Bernard, G. R., & Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet (London, England), 371(9607), 126–134. https://doi.org/10.1016/S0140-6736(08)60105-1

Decreasing ventilator days by 9 through no continuous sedation by Dr. Thomas Strom in episode 91:

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

PAD/ PADIS guidelines: https://www.sccm.org/iculiberation/guidelines

SUBSCRIBE TO THE PODCAST