Episode 152: C- Choice of Sedation and Analgesia with John Devlin, PharmD

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Is the C of the ABCDEF bundle only for avoiding benzodiazepines? How do we fully practice the “C” of the bundle and how does this impact patient care and outcomes? If we are automatically starting sedation without evaluation, are we truly practicing the ABCDEF bundle?

John W. Devlin, PharmD, BCCCP, MCCM, FCCP joins us in this episode to share his expertise on best sedation and analgesia practices in the ICU.

Episode Transcription

Kali Dayton 0:00
A very common statement I hears is, “We’re practicing the bundle. We’ve really cut down on our benzodiazipine use lately!”. I absolutely celebrate that important step as benzodiazepines consistently worsen almost all outcomes. Nonetheless, avoiding benzodiazepines is a key but small part of the C of the bundle. The C is for choice of sedation and analgesia. That choice is not just what kind of sedation, but whether or not to give it- whether or not there is an indication for it. As well as what doses to give and how long to give it. John Devlin joins us now to share his expertise on the C of the ABCDEF bundle. yourself to us?

John Devlin,PharmD, BCCCP, MCCM, FCCP 0:07
First of all, thanks very much for having me on your podcast, I really enjoyed the presentation you delivered at the recent annual meeting of the American delirium society. And it’s really great to meet you in person, and to participate in your podcasts. I’ve been a critical care pharmacist for almost 30 years now.

And currently, I’m a Professor of Pharmacy at Northeastern University, a critical care pharmacist in the medical ICU at Brigham and Women’s Hospital. And then I have research appointments in the pulmonary critical care division and Harvard Medical School.

And so I’ve kind of seen it all, you know, from first rounding as a pharmacist in the late 1990s, early tooth, early 1990s, sort of rounding in the ICU in the early 1990s, where, you know, patients were just incredibly deeply sedated, they weren’t mobilized, you know, we didn’t even use sedation scales, if you can believe it, they really hadn’t been invented.

And, you know, people would just sort of wake patients up suddenly trying to wean them, we didn’t really do daily wake ups or sedation. You know, as pts and an ever be, we would be surprised when the patients had had ICU psychosis, we didn’t screen for delirium, we did screen for pain.

And patients would, when they had ICU psychosis, the word delirium really wasn’t used at all, it hadn’t really even, to be honest, really been invented. And we would just get boatloads of haloperidol, it was crazy.

And we never really thought about where patients were going, like, we just thought about, you know, if they survive their critical illness, that, that that was really the big goal of care, which is, you know, obviously, if you talk to any patient, they do, they do want to survive.

Um, but we were really thinking about their pipe post ICU trajectory, and then it’s really funny families had little engagement, you know, they would be invited to the ICU for a few minutes, but they weren’t really engaged at the bedside. And they certainly weren’t, you know, physicians would give them updates.

But, you know, they, they didn’t have a lot of contact with rest of the members of the interprofessional team. And, and I think everything was very, very physician led, and, and driven. And so in an academic centers, where I’ve always worked, um, this could actually lead to a lot of changes in care patterns, even between different attending intensivist, that might be covering a medical ICU for a week or two.

That just sort of wasn’t all these things happening. It was really everything was people were just waiting for the physician to say to do things. So I mean, there’s just so many barriers and problems with the care the model and our approach to everything we were doing. But you know, I think people knew there was issues, but we, you know, 30 years ago, we just didn’t really know what to do.

Kali Dayton 3:18
You’re one of the early pioneers, you’ve watched this all unfold, and even one of the leaders and this and you’ve been president of American delirium society, you have been participating in this research, you’ve really gotten your head above water when it comes to sedation practices. So what inspired your recent article in The Lancet journal that you co authored with Dr. Dale Needham, and who is the other author?

John Devlin,PharmD, BCCCP, MCCM, FCCP 3:45
Oh, is Matthias Ackerman, who’s a anesthesiologist. Both Dale and Matthias are just fabulous researchers in their own right. And it really changed the paradigm for practice in the ICU, with all their great research, and you I think, you know, for years sets, you know, really, I would say 2009, JP Kress’ landmark daily interruptions, say this published the New England Journal of Medicine.

You know, it really had a profound effect in the academic world, because people saw that you could just, you know, wake people up, reduce sedation, and it didn’t really affect outcomes, either bedside safety, or increased cardiac ischemia, or any of the things that we always would feel if we reduced or stopped sedation would happen.

And, you know, the, the long and short story of all this is that it it got a lot of traction in terms of people reading it, but then when people tried to do this, in their individual ICUs on a large scale basis, it didn’t really fly and you know, there’s just a lot of barriers and I think what happened is we now Never really thought about how ICU teams work how important the ICU professional team is. What goal what are really the goals of sedation?

Like just because someone’s mechanically ventilated doesn’t mean they need continuous sedation? We never really, yeah, we never really thought, yeah, we always just thought, you know, oh, the patient’s intubated, going to be intubated or intubated, we need to get, you know, midazolam, or propofol, or dexmetatomidine, we need a continuous sedative. And often, they must be in pain or discomfort. So why don’t we just throw in a continuous infusion of fentanyl there, and then we don’t have the there’s no way the patient will, you know, be in pain, they won’t remember things which we realize ICU memories are really important, they won’t be afraid.

And, and we just felt that, you know, the patient really didn’t have they were too sick to participate in their own care. We didn’t even really even think about mobility. And I mean, we knew ICU car weakness was an issue, but we’re just like, What can we really do here, you know, so patients generally would just be in bed and restraints. And what’s until they’re extubated, and far down their critical care trajectory that we would, you know, get them moving and move to a chair and do all those things.

But there was days. And the other thing is we use a lot of continuous neuromuscular blockers. So, you know, that was another reason that would even drive more, you know, sedation strategies, there was a little bit of a fear, too, that, you know, really bad things would happen, even though JP crush showed that it wouldn’t in his studies, and, you know, the ICU back then there was a little bit of a, you know, there was a lot of pressure put on nurses, not for bad things to happen.

And so nurses, you know, might see the benefits of, you know, more of a more wakeful patient, but they also were clearly aware of the potential, you know, sequelae that would happen if their patient actually self excavated or fell out of bed or, or any of these bad things. And so, there was a lot of pressure put on nurses, I think for them to, we didn’t really give them the ability to keep patients wakeful. And right,

Kali Dayton 7:21
We still had this automatic sedation, and then we were trying to move nurses into turning it off sooner. So the nurses got to deal with the delirious patient that are at risk of all the harmful events. We never would still we’re not really giving nurses the chance to have a patient that is awake, strong, calm, compliant, free of delirium. We still lock them into this, what Dr. Ely calls delirium factory. And so it increases everything for the nurse.

John Devlin,PharmD, BCCCP, MCCM, FCCP 7:49
You’re absolutely right. And the other thing is, we never really asked nurses what they really wanted to do. Like I did some research really looking at barriers to daily interruption. And, and with nurses and you I really found out some surprising things. And, you know, and the other thing that we were sort of realizing is that nurses wanted their patients to sleep at night.

So there was a real, very diurnal variation where nurses, if they were going to wake patients up, it was just a temporary thing, during like the daytime, they would be much more deeply sedated at night. And then, you know, generally it was just the focus on let’s just wake them up to try to do an SBT.

And, and what we realize is I was involved in a Canadian crowd for trials group study where we did hourly sedation protocol, with or without daily interruption. It was a large study. It was published in JAMA about 10 years ago. And what we really found through this study, and you know, I enrolled about 60 patients in it and talking to the nurses, they actually really liked the protocol and nurses were quite willing the protocol really involved nurses keeping the patients at the goal RASS, which was generally light sedation.

So we’re asking minus one minus two, which is actually you know, in this day and age probably too sedated for most patients because they don’t even need to be sedated. Back then…

Kali Dayton 9:11
Thank you!

John Devlin,PharmD, BCCCP, MCCM, FCCP 9:12
That was that was a that was probably a reasonable goal. And most patients were kept in a coma. And nurses actually didn’t mind making small changes. So basically, they would increase or decrease the protocol by like 10 to 20. mcgs per kilogram permitted every hour until they reached the goal RASS and and so patients are and nurses, and we really worked with our night nurses, and it was amazing how nurses day and night had really no problem.

Sometimes they would read it right off, which was fabulous. Other times they, you know, they’d keep the patient at 10 mics of propofol but the patient was very arousal, you know, you could just stimulate them or you could just turn off and they’d be wakeful within a few minutes. And so we really found that the patients did much, much better on the morning SBTs they were awake.

We were able to, the families would come in, they’re like, “Wow, I love the patients and families who would love to be with each others.” And we actually started doing as we brought more physiotherapist in 10 years ago, we started doing a lot more mobility and just everything. Everybody was happier.

And, and it’s funny, patients would actually tell us when they’re intubated, they would tell the nurses,”Don’t re-sedate me again, or don’t make this deep sedation. Again, I love being able to engage.” You know, very, very rarely a patient would say, “Can you sedate me a little more? I’m kind of scared, I want to have a nap or something.”

That would happened. But most of the time, it’s like they don’t resuscitate me. And so that really was an important paradigm that that really thing. And then obviously, we’d COVID And you know it that’s set us back a little bit, I think. And now we’re kind of getting back. And with the A to F bundle.

In terms of wakefulness, we’re realizing with, you know, great research that’s been done in Denmark, and many other places that probably intermittent sedation are very short courses, as sedation are probably all that’s needed for the majority of patients. I think it’s also important to think when we’re talking about this is like the majority of patients, I mean, you’re always going to hit a busy 20 Bed ICU are always going to have a day where one or two patients need deeper sedation for either, you know, ventilator synchrony or, or they’re having open abdomen or something’s going on with the patient that day.

But it’s important to separate those patients out, that’s probably less than 10% of the patients on 10% of the days, right. So most patients, that could just be, you know, you don’t need this continuous sedation. And, and so that’s kind of what really led and then we we realized, you know, what I was having all these great discussions that Dale Needham and Matthias Eickermann as we were, you know, really thinking about the messaging we wanted in this invited Lancet commentary.

We realized that we should be really focusing on the problem, which is agitation, and how to reverse a treat that rather than the sedation bit, so I think we were kind of getting it wrong, and what we, you know, it there’s a lot of causes for agitation, and we kind of felt that bedside nurses and whole ICU team, you know, working together weren’t really thinking about the common causes of agitation and treating that.

And usually, most of the, when you you know, kind of go through our table, many of the common causes of agitation are, you know, it’s really non pharmacologic interventions that need to be used, or it’s things that aren’t really related to giving more sedation. So you know, for example, patients can be really constipated in the ICU. This is just an example.

And we know that, you know, we try to use bowel protocols, but we don’t really aggressively use them. So you could have a patient hasn’t had a bowel movement for three days. And they just might have such a dominant discomfort, but they can’t really communicate that. And they could just be agitated from that, right, it can be really frustrated that like a family member hasn’t arrived that day.

Now, they’re probably just really frustrated for still being intubated. We don’t use the right communication strategies and intubated patients, I think, to communicate, especially if families aren’t around. And we found that in COVID, and then there’s, you know, language issues, there’s many patients that don’t speak English.

So I mean, there’s just a whole list of things that could be causing the agitation, these patients, and if you systematically think about that, and treat that it’s amazing how you can, you know, safely manage the patient and treat them treat their agitation. And you don’t really need to give any sedation, sedating medications at all. So

Kali Dayton 13:39
That was so validating, to read in your article, because that’s been something that I’ve been on my soapbox here on the podcast for a long time, I haven’t worked in an awakened walk and I see we’re hardly anyone was sedated. That’s where I started, I never had considered that sedation would automatically be given upon intubation until I worked outside that ICU.

But when I looked into the research, you know, there’s Dr. strums study, looking at no sedation, there are a few things out there. But there’s not a lot of clear communication saying straight point blank, mechanical ventilation is not an indication for sedation.

John Devlin,PharmD, BCCCP, MCCM, FCCP 14:18
Absolutely, absolutely. And you know, it’s, you know, the actual intubation probably you need to be but that’s, that’s RSI for most patients, and it’s only for an hour. And then then you kind of wake up the patients who need to see to evaluate them, but we don’t usually get the patient a chance post intubation to declare themselves and figure out what they’re about.

People now know a lot of the things if they’ve chronically been taking them to these pains or opioids, or if they have a lot of anxiety, baseline, you know, it takes a while to collect all that data from any patient. So that’s, I think, another problem too. We don’t always know a lot about the patient and

Kali Dayton 14:55
We don’t give the patient a chance to provide that information to us. They can do metrics, they can do lots of things, usually, if we allow them to be free of delirium, right after intubation and throughout their course on the ventilator.

But we deprive nurses, especially of that experience, and then we expect to unmask that delirium or unmask the agitation that they’re having. But I love that in this article, it wasn’t just, we know sedation is dangerous. It’s not even every patient of ventilator, but you guys took it a step further and said, Here’s some alternative tools to use. Instead of having to run back and mask the agitation that you’re seeing, let’s really treat it.

John Devlin,PharmD, BCCCP, MCCM, FCCP 15:36
No, you’re absolutely right. And I think it’s I think the other thing that’s really important, which the eight F bundle does, and particularly the c component, which is choice of medications, and it’s not necessarily, you know, what’s the date that this patient needs sedation, their whole ICU status?

Or are we going to use a Dexmetatomidine in our protocol, it’s really, it’s really looking each day at a minimum, but even more often, like it should be thought about on an afternoon rounds. What does the patient need these? When I talk about medications, I really am talking about sort of like psychoactive medications, which is a broader group of medications than sedative.

So this would include opioids would include, you know, other like nice psychotics, and basically any drug that has a sedating effect. So that can be a larger group, because we use these quite liberally in our patients. And I think it’s, it’s so easy to add on these medications, and rarely do we really try to aggressively take them off.

And I think that’s a big role for Kroeker pharmacists, but the whole interprofessional team is to continuously question why are these medications being given and there’s lots of practical strategies you can use, I think the big thing is, is, you know, really figuring out the patient’s level of pain aggressively using you know, non opioid analgesics, you know, so, acetaminophen.

I mean, all these basic medications, you know, for, you know, patients with major surgery, major pain, you know, maybe just very low dose ketamine might be useful for a couple of days, but it’s really low dose. So we ended up using ketamine at sky high doses, and, and you see a lot of delirium, and we’re not really using ketamine, we’re trying to use it as a sedative.

And it’s, it’s really, to me, most of the evidence is using a very low infusion doses for for pain. You know, opioid symi are really nasty, and they don’t really work very well, they have a lot of side effects. You know, I published recently, a large analysis in the blue journal, really showing the strong association between opioids and delirium.

And I think it’s important that we don’t, you know, kind of circling back to sedation that we don’t think about opioids as an analgesic sedation. So we’re giving opioids for sedation, I think opioids can be very useful for helping you know, acute pain because people do have pain. And but again, most of the times, it should really be boluses. I, you know, I always try to get patients away from, you know, clinicians from using a continuous infusion, because that kind of goes on autopilot.

You know, also opioids have real patients because it can become quite tolerant to opioids, they can develop chronic pain syndromes. And then, you know, there’s always a risk, we still do, there’s lots of data showing how long patients continue on opioids actually leave the ICU of the hospital. So, you know, once we started, we have to make sure there’s plans to stop these drugs, you know, hopefully daily, but for sure there’s a plan before they leave the ICU.

So opioids are kind of nasty, I think the other thing that we also need to do is, you know, if someone has a single period of acute agitation, and they need something now to control the patient, you never know, right? This these things, I always make sure that these patients have a low dose midazolam ordered PRN.

And so really using PRN meds and so I’d rather have a patient with say, one to two milligrams IV push Q four h or Q six h of midazolam and not have the patient on appropriate Waldrip. So the nurse knows that if the patient has an acute agitated event, they can give a little push midazolam, figure out using our you know, our Lancet, agitation algorithm figuring out “well, what can be reversed? What can you do?”

Because it buys a little time. And then I’m thinking about what the strategy is. I mean, maybe there could be a small group of patients that do need to go back on continuous sedation, but usually not and, and I think people are really paranoid that “Oh, we can’t ever give a milligram of midazolam in in the ICU”, but yes, I’m not saying we should be using infusions or regularly giving it scheduled but it needs to acute situation, it can really be, you know, a kind of a life saving strategy for nurses to deliver once and you know, once every two or three days or if there’s

Kali Dayton 20:09
Like, procedural, or…

John Devlin,PharmD, BCCCP, MCCM, FCCP 20:11
procedural exactly, things like that.

That’s and it makes nurses feel more comfortable with avoiding the protocol going. So I think that’s really, really important. And then I think the other thing is, is we need to we can be really aggressive in it doesn’t mean we have to stop everything. Let’s try decreasing things by 50% and see what happens.

I’m working with a Community Hospital, and they’re actually pretty good with the A to F bundle. And but what they found is that they at night, they really end up ramping up a lot of their sedation and psychoactive medication. So they’re using a lot of a psychotic patients have delirium.

Kali Dayton 20:51
It’s not just them. That’s a very shared practice throughout the community.

John Devlin,PharmD, BCCCP, MCCM, FCCP 20:55
So we actually developed a whole nocturnal protocols, we found that the things at night, it’s a little bit different, because people are very focused on sleep. We have a non pharmacologic sleep protocol that’s kind of you know, quiet time and noise and offering IMS for light and stuff. But we found that patients were still getting far too much sedation at night, and because they wanted patients to sleep and of course, you know, it’s not sleep, it’s absolutely not a if you put any EEG on patients, it’s completely different. It’s really quite disorganized. sedation, and it’s not, it’s very disorganized sleep.

Kali Dayton 21:32
We’re depriving them of sleep.

John Devlin,PharmD, BCCCP, MCCM, FCCP 21:34
I’m absolutely better. And then, you know, obviously, some of the other things that we’re really looking at are circadian rhythm, things in the daytime, like bright light. wakefulness is really important. Being upright, being upright mobilization and wakefulness is, so if you’re wakeful it, you can soak in the light. And it these are all the big, they call them like Ivers that really drive your circadian rhythm.

And if you can maintain patients with some bright light, wakeful, allowing them, you know, some prime allowing them to nap for an hour or two, depending on the patient. I mean, that’s kind of reasonable. And then you’ll make sure you’re mobilizing them. It’s amazing how this Acadian rhythm retrains itself. And they get back on a normal schedule, and they sleep much, much better.

So these are some of the kind of the more new innovative things but I think getting back to the basics, it’s having that pharmacists in the team thinking about every drug, why are we using it, both daytime and nighttime and making sure nurses feel comfortable but not using the drug, or at least having a PRN if, if there’s an unexpected situation where they don’t have anything ordered, because I think that can be bothersome, especially at night.

And then I think the other thing is, you know, if we do find some of these medications need to be chronically used, getting them off IVs. And so using the gut, you know, most patients, if they’re tolerating tube feeds, you could start putting down some of these medications, almost all of them through, you know, with the exception of things like ketamine stuff through their gut, and that’s a great way to transition them out of the ICU faster.

Kali Dayton 23:09
Right, and even, you know, talking about agitation, I’ve loved low dose Klonopin on the feeding tube, and that they have hyperactive delirium, or it’s just real anxiety that does need to be treated. And so we can help, you know, chemically restrain them a little bit without sedating them.

And you in that article, you define sedation as administration of sedating medication to impair consciousness. Right. So when I talk about sedation on the podcasts, that it really is what I’m, what I mean, you know, it’s not that sedation is always bad, but when we sedate patients is usually to alter their consciousness, but we can use sedation without impairing their consciousness.

John Devlin,PharmD, BCCCP, MCCM, FCCP 23:51
Absolutely. And that’s really important. And if you do need to give some more aggressive sedation temporarily, you should only be impairing their consciousness temporarily and allowing them to have all this time to engage with their family and clinicians. And

Kali Dayton 24:05
What are some of those indications? I mean, when we talked about impairing consciousness right now, throughout the community as a standard, that usually happens upon intubation, without even questioning whether or not it’s necessary. So if we’re going to question whether or not sedation is necessary, when is sedation to impair consciousness necessary? What are some examples?

John Devlin,PharmD, BCCCP, MCCM, FCCP 24:24
Yeah, I think, I think patients that, you know, are, are not tolerating the ventilator, the orders to synchrony where you’ve made ventilator adjustments, you’ve maybe tried giving a bolus of an opioid and you just can’t, you know, you can’t match. You know, they’re inspiratory and expiratory drive and they’re just not touring the ventilator. But there’s a lot of steps that should be done. Right.

Kali Dayton 24:48
Right.

John Devlin,PharmD, BCCCP, MCCM, FCCP 24:49
Can be a lot of reasons. Absolutely. So there’s a lot of steps that should be done before you say they need to deep deeper sedation. And sometimes, you know, you might give them a bolus of Have first and then maybe you need to give a single bolus of a neuromuscular blocker as you make all these adjustments. But again, that’s only an hour or two, it’s not a it’s not a permanent thing.

I think, I think procedures as you alluded to is really important. Patient there’s painful procedures and procedures that are, you know, pains complex, it’s, it’s, it’s related to arousal, the actual pain stimulus at the settings, I think people need to use a multimodal approach, while before they’re doing what, like putting in a chest tube or doing a bedside surgical procedure. People have a lot of variability.

I mean, some patients could just lie there, while central lines being in and other patients, you know, they’re just going to be out to do it. Yeah. And so you need to provide some more sedation, then, but then again, it’s usually more of a multimodal approach. Again, I think patients, you know, in our in the pad is guidelines that I chaired, we asked, we had patients and families really involved in the guidelines.

And, you know, we did have our patient, who was like, I was just tired that they were always trying to keep me awake every single day. And they never asked me if I ever wanted a little break. And if I was frustrated, because he had been ventilated with meds at Johns Hopkins for about two weeks. And so we have one little statement in there like, you know, ask the patient what level of sedation they want.

You know, as I said at the beginning, you know, people we’ve had people with laptops, right, do not sedate me. Uh huh. Yeah. And then had he but he was like he was someone asked him, because he actually there was one afternoon, he was very frustrated, and he would have liked to have been stayed a little bit more just temporarily.

Kali Dayton 26:41
And when we say patients for surgery for a few hours, yeah. They don’t report the same hallucinations, trauma, they really don’t develop that level of delirium. It’s been sedation that goes on. I mean, sedation slash sleep deprivation goes on for days to weeks when we really start to be in a dangerous zone.

John Devlin,PharmD, BCCCP, MCCM, FCCP 27:03
Well, that’s right. And I think it’s ways and I think it’s sort of the medications we have, like they’re all fairly short acting like dexmedetomidine, the benzodiazepines like you’d regret or profile for giving them intravenously, even opioids. So we have this idea where we wouldn’t just give a bolus, we want to continue to longer because this could come up again and be a problem. I think that’s an issue.

I think there’s some new strategies, you know, either here or coming down the pipeline that are going to be helpful to you. There’s a new formulation, a sublingual formulation, that dexmedetomidine It’s not indicated for the ICU, but I mean, it can be easily used in the ICU, and it’s a little patch that lasts for about four hours. It’s it’s only like, I think it’s 180 micrograms. So the brand names are kami. And, you know, that could be a strategy for patients that are, you know, a little bit agitated.

They want to be chilled out, but they don’t need at dexmedetomidine infusion because sometimes we have trouble with these patients, getting them off IV dexmedetomidine gain terms of the floor because they’re agitated, they’re withdrawing, and all of these things, you know, I’m involved in in multicenter study here in the United States using inhaled isofluorine for sedation, and our nurses really like it because it’s instant on an instant off.

And so we’re actually able to, you know, turn it off and the patient’s wake up right away, and, and then if they need it, we can just turn it on, and they’re hooked up. It’s just a real breathing device. And it’s a Syringe Pump that delivers the isofluorine,

Kali Dayton 28:30
Does it cause the same levels of delirium. Do you know yet?

John Devlin,PharmD, BCCCP, MCCM, FCCP 28:32
Well, we’re, we’re that’s what we’re studying right now. We think it could be lower. Certainly, inhaled gases in the OR, are associated with reduced postoperative delirium. And so, you know, our nurses have actually kind of liked that, because they can do much more assessment just to date the patients when they need it, and then wake them up into like, Sproat breathe us so quickly. So that’s it.

There’s, you know, some interesting strategies that I think are more titratable, because I think we’re gonna get to the point, with all the great work you’re doing, and I guess all of us are doing in your community is we’re gonna get to the point where, yes, we are going to have days where patients do need some sedation, and what are we going to use, and I think gone are the days where we are using propofol infusions and DEX infusions, we need short and short onset short offset medications that don’t, you know, have the prolonged effects and the effects on cognition. And if you are going to interrupt consciousness, it’s just a very brief, you know, period.

Kali Dayton 29:29
Oh it’d be amazing to have that kind of synergy between a changing culture, true mastery of the ABCDEF bundle where we really expect patients to be awake, communicative, autonomous, mobile, unless there’s an indication for sedation and when there is an indication, it’d be really nice to have safer options that have are less damaging and are easier to use.

John Devlin,PharmD, BCCCP, MCCM, FCCP 29:53
Absolutely.

Kali Dayton 29:54
Because it’s hard. I mean, as a nurse, I experienced that when I was a travel nurse. It’s hard when you start sedation and It goes on for a few days, then taking it off is a whole roller coaster. And that’s one of our biggest barriers. And that’s what people imagine. When I say “Awake and Walking ICU”, they imagine what they see, when you turn sedation off.

After a few days, they mess up, patients are coming out, thrashing, agitated, delirious. But if we really mastered what you guys were talking about in your recent article, that sedation is not necessarily for every patient on a ventilator, and rather, it should be the exception.

And here’s an alternative strategies. If we really mastered that one principle, the rest of the bundle, I think, would be much more attainable, we could really assess for pain family could actually be engaged, patients would be ready to mobilize we’d really prevent and treat delirium it and then breathing in awakening trials would be I mean, awakening trials, especially would be in the minority.

John Devlin,PharmD, BCCCP, MCCM, FCCP 30:52
Well, absolutely. Because we’re just we’re, yeah, we’re setting ourselves up for failure, because we’re creating this oversight data and monster, and we’re always fighting that when we don’t need to overnight, as you said, we’re not feeding the cars in most cases. So yeah, there’s, it’s just total mindset.

And it really takes it’s the whole team that needs to be thinking about this. And, you know, a lot of it starts with the physicians, you know, you need a, you know, that you need the attending leader to make it okay to do this teaching hospital, this goes all the way down from the fellows to medical students that this is the way and that’s going to change practice.

And it’s okay to in talking about experiences and what’s happening. And I think some of these interventions happen in, you know, the morning, they should happen the morning, but sometimes nurses aren’t even on bedside rounds, we’re not talking about the symptoms patients have, like, we might know what the current RASS score is, or if they, if their most recent CAM is positive or negative, but we don’t really know about the symptoms, what patients are experienced in their care.

And we just quickly skip over all these medications. And then if we do try to make a change, often they’re not really formally evaluated. And I know that’s kind of with this, you know, this community hospital project is really making sure what’s talked about in the morning, continues on in the afternoon, and then continues on throughout the night. And that’s that’s a big transition. That’s important. And physicians have to really support that.

Kali Dayton 32:20
Absolutely. Can you imagine how powerful would be if physicians were all very well trained and delirium in ABCDEF bundle. And when it comes to the sea, that they took stewardship over that, as they’re the ones writing the orders or the APS. And if they asked, Does this patient have an indication for sedation? If that’s what the C really meant to our community? But I think that’s probably what it was intended to be not just to use benzos or not?

John Devlin,PharmD, BCCCP, MCCM, FCCP 32:50
Well, it’s more use versus choice. Absolutely.

Kali Dayton 32:53
Right. Yeah. Is it actually needed but if physicians really took stewardship over that, and if pharmacists felt comfortable asking, Does patients still have an indication for sedation, if nurses were asking themselves that every every shift, or throughout the shift, this is patients who have an indication for sedation? I mean, it would just turn this around, and the whole bundle would be much more feasible.

John Devlin,PharmD, BCCCP, MCCM, FCCP 33:15
You’re absolutely right. And I think, you know, nurses are amazing. But they’re a very heterogeneous group, at least the nurses I’ve always worked with, and done research with and practice clinically with and, you know, you there’s gonna be nurses that are afraid of change, and they’re always afraid of bad outcomes.

And then there’s nurses that are, you know, real, they’re like, Absolutely, as patient doesn’t need sedation, they’re good, that they’re going to be pushing the team, to be more wakeful and just or just do it on their own and realize, but I think what we need is, you know, the physicians and rest of the team have to give the nurses more support, yes, or this and say, “It’s okay, I’m realizing, you know, there could be something that happens, you know, it, if you have a patient, it shouldn’t, especially if you mobilize them and are really looking for things, but, you know, there is probably a risk of someone has a RASS minus one that, you know, they couldn’t self-extubate or pull out a line. But that’s probably okay. You know, it’s, it’s not the end of the world.”

Most patients, I mean, a lot of times, you don’t even need to re-intubate the patient. And if they need the line, maybe they didn’t even still really need the central line, you know, all these things kind of go hand in hand. And that’s okay. Because you’re it’s a small risk. But the benefit is that you have this awake patient that can be mobilized and probably have reduced delirium and be potentially do better on SATs.

Kali Dayton 34:36
And I would defer to I think, Episode 117 on unplanned extubations, where I break down the research behind that showing that the real risk lies in the sedation and immobility for most patients versus the unplanned acts to patients. But a team that really matters, the ABCDEF bundle, they understand that they’re really weighing out the risk versus benefit before starting or continuing sedation. and they have a culture in which nurses are supported.

I’ve seen in ABCDEF bundle-mastered units. This is discussed the risk versus benefits of sedation or are understood and discussed for each patient before starting or continuing sedation, and they really support their nurses. They don’t see unplanned extubations as the worst case scenario that could ever happen.

I’d refer back to a couple episodes ago with Dr. Bellucci. He led his team as a physician to become a minimal to no sedation unit and an implant extubation happened and the patient didn’t have to re re intubated. But the nurse was so distraught by the visits this and sat down with a nurse and said, “Look at their outcomes. They’re not re-intubated. They’re not delirious. They’re strong. They’re going to discharge to the floor in the morning there. This is a total success. And it’s because you did well with avoiding sedation!”

That’s the kind of culture that needs to happen. Another podcast listener, had a patient in high ventilator settings. He was not delirious, but he had some psychopathology going on. He promised on the whiteboard, I won’t feel effects debate, the nurse managers, were saying, “Sedate him. Sedate him!” and the nurse said “No, he does not need sedation. We need a sitter.” And they wouldn’t support her in that.

So she went to go check on her other patient really quick and got the two out. They bring intubated, and he was fine. But she was about to get into so much trouble for her management. And that attending came in and said, “She’s practicing better evidence-based medicine than the rest of us. She’d better not get any heat.”

John Devlin,PharmD, BCCCP, MCCM, FCCP 36:47
Oh, good. So that’s really good to have that in that that’s what needs to happen.

Kali Dayton 36:50
Right? We need to be saying, “Okay, so he was fine. But what was the circumstances? He should have had a sitter versus sedation.” Sedation wasn’t safe. And we need to support that nurse and making a good evidence-based practice and decision in that moment. So I hope that that’s as we really understand the bundle and this see, we find more liability and unnecessarily sedating patients, then these other events that could happen that are less likely to happen if they’re not sedated.

John Devlin,PharmD, BCCCP, MCCM, FCCP 37:18
Yeah, and you actually need a culture of and you know, of patients being under browsable deeply sedated. And that’s the goal, that should actually be a never event. That’s, to me, that’s more important. Never events, so dangerous, than accidental device removal.

Yes, in some instances, because that’s kind of the really severe risks of sedation. So yeah, it’s gonna be interesting, you know, and there’s a lot of research coming down the tube I’m involved in at large and North American study. The results aren’t, I don’t know the results yet. But it was a mat a large, randomized study, looking at twice daily versus once daily, spontaneous breathing trials with her with and then comparing T-piece versus CPAP SBTs.

And, you know, I, we hypothesize, obviously, that the more frequently you screen, a lot of these patients twice daily, that you’re going to lead to, you know, it, let’s say obviously don’t meet the SPT screen, they potentially, you know, could be exported less. And there’s all kinds of downstream effects of that. But if you have, you’ve are only focusing on this morning wakefulness and rest of the day, we’re not you might not be able to deliver an intervention like that, which could be hugely beneficial to patients.

Kali Dayton 38:33
Especially when a lot of times these SATs are happening at five in the morning with one lone nurse, no family, you know, PT and OT OT, to reevaluate later and say, “Now that we have the gang together. Let’s try another one. Let’s look at you know, this article with these all these tools provided to treat the agitation if we see it as we do in awakening trial.”

Brenda Pun says in that 2019 ABCDEF bundle study that the objective of the bundle is to have patients that are more Awake, awake, engaged, interactive, communicative, physically active, in order to facilitate patient autonomy and the ability to express unmet physical and emotional needs. So that was like our guiding or star when we’re navigating station practices, then you’re right, it would be a never to hardly ever event that someone would be consciously impaired.

John Devlin,PharmD, BCCCP, MCCM, FCCP 39:29
You’re absolutely right. No, you’re totally right. And you know, and I think that you’re from that 2019 study, which has evolved with the, you know, what a really important message too, is that even if you do some of this with the ADF bundle, you’re still gonna really improve outcome and it’s incremental.

The more you do, the better the outcome of the patient is. And I think it’s, you know, I worked with Brenda and Dr. Stallings and a few other people on kind of the, you know, a big part of the ice liberation effort with the bundle was was role modeling and really focusing on team dynamics and how people communicate with each other responsibilities and who does what and how you run rounds.

And, you know, I think sometimes our current rounding structure leaves a little bit less desired. For example, like I do a lot of teaching with healthcare pharmacists, and, you know, yeah, they can talk about the list of sedating the neuroactive medications and the sedation they’re on. But you know, that pharmacists, they have time while they’re rounding and in between things, they can do their own RASS scores, and they could do some patient evaluation.

And, you know, they could talk to the nurse, like, you know, the, and so they could be another nudging point, I guess I could say about when they see that they could do a RASS. Or they could see where it’s at that is too deep. And like challenge the nurse, like, “why are we? Why are we doing this?” and because they’re a consistent presence. And it doesn’t have to be this, you know, combative or bad. And we’re behind the scenes and trying to get people in trouble. But it’s just, it’s just these additional nudges, to get people to think about ways of better caring for the patients on a 24/7 basis.

Kali Dayton 41:09
It’s a safety net, when we know this is a high risk intervention and medication. We’d better be doing safety nets. And I see the RAS is kind of like a trough. The pharmacist saw sedation management or took stewardship over sedation like they do antibiotic stewardship. One, they would never let us give vancomycin without an indication, the course they would say, “why is that ordered? is it still needed? What are the levels?”

So with sedation, they should be doing the same? “Why is it ordered? Is it still needed? And what are the levels?” and so I think it’s an excellent proposal, I like to hear from you rather than me. I’ve mentioned this on on-site. And I trained pharmacists on the RASS so that they can go in it. But it’d be nice to have a systematic check, everyone has an expectation the pharmacists going to pop their heads and assess the patient themselves and make sure that the rest is is within a safe parameter, just like vancomycin trough.

John Devlin,PharmD, BCCCP, MCCM, FCCP 42:05
You’re absolutely right. Yep, absolutely.

Kali Dayton 42:08
I love it. Anything else you would share with the ICU community?

John Devlin,PharmD, BCCCP, MCCM, FCCP 42:12
No, I think less is more and that, you know, these drugs all have really serious side effects. And some are some are predictable. And you know, these are widely used drugs, some of them aren’t, and we’re still not really sure they respond to patients, it’s quite vary between different patients of the elderly are very, very sensitive.

And, you know, if you see a patient with press, you know, that’s we use a lot of propofol still, and it happens in you know, one to 2% of patients. And, you know, so there’s some serious things that can happen with these agents that people just assume, while they’re safe, and they’re easy to use.

And, you know, I I just think, you know, the low the decreased level of consciousness and all the other, you know, expected unexpected side effects that these agents accumulate over time. And these are just, to me, they’re just such high risk medications, anything that psychoactive that affects the brain, on so many levels, and they you as you’ve already kind of mentioned, you just need a really good documented reason, you know, each day or each shift, “Why are we using these? And why are we using them at the current dose that we’re using them at?”

Kali Dayton 43:22
And each time it’s ordered! If the provider has to stay the drop down box, just like we do for an antibiotic? “What is the indication and mechanical ventilation?”

Mechanical ventialtion should not be one of the options.

John Devlin,PharmD, BCCCP, MCCM, FCCP 43:32
I know. We make it too easy.

Kali Dayton 43:37
And I love that you said in the article, “A common practice that ICU, which is sedation, due to traditions of clinical teaching, and other reasons that are not evidence based, and not necessarily patient centered.”

John Devlin,PharmD, BCCCP, MCCM, FCCP 43:50
And the patient centeredness is a big thing. Absolutely.

Kali Dayton 43:53
And that’s what the ABCDEF bundle is about. And true mastery of C will mean that we actually question whether or not it’s needed, and then have good stewardship from there.

John Devlin,PharmD, BCCCP, MCCM, FCCP 44:04
Absolutely. And then I think we need to talk about the family too, and which we’ve touched on and you know, family should be demanding, like, why, like, they have this concept that all they’re sick, so they need to be in this medically induced coma, which I think really reared its ugly head during COVID. But, you know, if families are visiting, and they can’t engage at all with their loved one, they should be demanding an answer from the nurse and the team have a why’s, why is this? Why is this necessary?

Kali Dayton 44:30
What if I told families before intubation or before starting sedation. So we should say, here are the risks of being sedated, maybe to the patient? And I guess give them an option, even though increase in mortality shouldn’t necessarily be an option ever. But if sedation is necessary, maybe for that moment, we do need to be clear and say, This medication comes with these risks and repercussions. If the family understands that then they’re going to be on them every day. Thanks. It’s still needed. Can we turn it off? Now? I’m worried about a brain injury, I’m worried about death, they can they can be part of that discussion, and they’re gonna be the ones that care about the long-term outcomes the most.

John Devlin,PharmD, BCCCP, MCCM, FCCP 45:10
You’re absolutely right. And I think it’s important for families to be aware that, you know, the memories that patients have during their ICU stay are really important. They’re protective of delirium. And, you know, obviously, they’re, they’re, you know, it’s, it’s controversial, but it absolutely is not going to increase PTSD. And, and I think the key thing is, is, is separating sedation, from comfort.

And I think families really want to make sure their loved ones are comfortable. That’s the key thing. And I think they sort of feel well comfort as part of this deep sedation in the center rouse ability. But I think it’s really important to separate it out. We are going to keep them comfortable, and through a combination of nonpharmacologic and pharmacologic strategies, but there’s no real reason to keep them deeply sedated. And I think if you separate that out, it helps families process it and realize the importance.

Kali Dayton 46:04
The teams first need to understand that in order to educate right when the teams are believing and calling sedation to be sleep. Right, it makes that very conflicting for loved ones. So I think good delirium education for clinicians can lead to better education for families, and improved practices all around. Thank you so much, Dr. Devlin, for sharing this expertise. Thanks for all of your research or leadership throughout the community and I look forward to your upcoming studies.

John Devlin,PharmD, BCCCP, MCCM, FCCP 46:32
Okay. Thanks very much, Kali, pleasure to talk to you. Thank you.

Transcribed by https://otter.ai