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Kali talks to Dr. Wes Ely, sub-specialist in pulmonary and critical care medicine, and creator of the cam scoring tool and the ABCDE F bundle.
Episode Transcription
Kali Dayton
Today, we’re going to be talking to Dr. Wes Ely. Dr. Ely is a sub specialist in pulmonary and critical care medicine, and has been a busy researcher at Vanderbilt University. He is the creator of the cam scoring tool and the ABCDE F bundle. We have all likely heard of and even used these tools. We are honored to discuss his work with him today. Dr. Ely, thank you so much for joining us today.
Dr. Wes Ely
It’s my privilege, Kali, and thank you so much for having me.
Kali Dayton
Can you tell us a little bit about your career and what’s led you to this point this far?
Dr. Wes Ely
Sure. I was trained as an internist who was fascinated by cardiopulmonary physiology. And that led me to pursue critical care. So I finished a fellowship in pulmonary and critical critical care medicine. And what I started noticing was that people would come back to clinic and be unable to tell me that they have returned to work. They said that they were retiring early, and I started noticing that they couldn’t remember stuff and being embarrassed by that and becoming more and more reclusive, which led me to the brain even though I’d started out primarily interested in the heart and lungs.
Kali Dayton
And what did that lead you to do about it?
Dr. Wes Ely
Well, at the time, I was also the medical director of lung transplantation at Vanderbilt University I had trained elsewhere have a come here because my wife was a pathologist. And so in following my wife, I got this job as a medical director of lung transplant, I’d gone and done a lung transplant fellowship at Barnes Jewish in St. Louis. And in the clinic for the transplant patients, I just saw all these patients that were supposed to have been all fit because they got their new lungs, they had good oxygen levels, and yet they had ongoing problems with cognition.
So it may be first think, well, these may be related to the transplant the operating room, or even immunosuppression. But we should study this. And since I was a general in intensivist, as well, and attending in the NICU, it led me Kaylee to start doing research to develop a way of measuring delirium in the ICU, which to that point, had not really been done in a valid fashion.
Kali Dayton
So you seem to be the man to explain what we’ve heard thus far on these podcasts. We had a Susan he said, THREE TIME ARDS survivor tell us that she is not afraid of ventilators, ARDS, but she’s terrified of sedation, and that she had legal documents drafted protecting her from sedation in the future. And then we’ve heard a number of patient testimonials talking about their hallucinations, and how traumatizing their experiences under sedation work. Can you explain to us what exactly happens and what they’ve experienced?
Dr. Wes Ely
Wow, that’s a great anecdote, this woman who would be more willing to go on a ventilator than to receive sedation, right? That’s quite alarming. And it goes against the grain of what most of the world thinks, which is, you know, hey, sedation is a good thing. Sedation would be protective, it would make me not remember, and yet this woman is telling us wait a minute, it’s, it’s the devil, you know, and the devil is in the details.
Of course, what is happening is that, under the guise of benevolence, we in the ICU, have thought that it was the right thing to do to give people these extremely robust, potent psychoactive medications. And to do it without limit, so that patients can get as much of these drugs as we want to give them to keep them without movement with no muscular movement at all. And to keep that bed tidy and the sheet drawn clean with no wrinkles, etc. You know, that’s one of the things that nurses used to be taught was that you’re measured by how clean and tidy your room looks.
Maybe we should be measuring people by how complete of a recovery the patient receives after critical illness. And when people are worried about them waking up and remembering something, maybe we should be more worried whether or not they’ll ever walk again. And whether or not they can think clearly on the back end of critical care. I mean, this would seem like a much more worthy place to place our concerns than how tidy the room looks during their stay in the ICU.
Kali Dayton
That’s amazing. And so tell us more about this ICU delirium. What causes it? Can it be prevented?
Dr. Wes Ely
I see delirium is a problem whereby the brain is undergoing, basically an encephalopathy. You could think of encephalopathy and delirium as synonymous terms almost. And the brain at the cellular cellular level is Having a problem such that neurons can’t fire and communicate to one another, and therefore the person is unable to pay attention, in fact, in attention is the cardinal feature of delirium.
And when we came up with a tool called the confusion assessment method for the ICU, or the cam ICU, which is a sister instrument and neurological assessment up against a consciousness scale, like the Richmond agitation sedation scale, these two tools together, the RAS and the cam, help us to realize when that brain is undergoing such a problem with with cognition, and what we mainly do cailli is figure out can the person pay attention to us for 10 to 15 seconds when they can’t. That is a cardinal feature of delirium. And that by itself is a marker of increased likelihood of dying, a length of stay longer length of stay, higher cost of care, and a much higher risk of long term acquired dementia after critical illness.
Kali Dayton
Wow. And I think as a nurse, initially, I just interpreted that, that as they’re confused I, I knew the term delirium, but I didn’t realize what it meant. And a big picture, I didn’t realize that I didn’t look at a patient that was delirious as a higher risk of dying, I just saw them as a lot of work.
Dr. Wes Ely
And so I can see why I can see why you would think of them as a lot of work because sometimes the delirious person is hyperactivity, delirious, and they’re pulling out lines and tubes. in no circumstances, Kali, I’m sure you felt like it was important to give them something, to control their agitation to keep them protected against self and protect them from her heart self harm and harming others. But the vast majority of delirious patients, Kaylee or Hypoactivity, delirious, and they’re just sitting there like a bump on a log, and they’re not minding, you know, causing anybody trouble. But that brain is very defective at that point, you can think of it as, as acute organ dysfunction of the brain, like hypoxemia is organ dysfunction is a marker of organ dysfunction of the lungs, and shock as a marker of organ dysfunction of the cardiovascular system. In this case, delirium being a marker of the organ dysfunction of the brain,
Kali Dayton
Can it be prevented?
Dr. Wes Ely
There’s a lot we can do to prevent delirium in the ICU, it can’t, it can’t be prevented in all circumstances. But we can reduce the onset of delirium or reduce the duration of delirium by about 25%, just using a non pharmacological bundle that we now call the A to F bond or the ABCDE F bundle. This is a bundle that we have developed, meaning we meeting people all over the world. Through the literature, there have been about 35 or 40, New England journal Lancet and Jama papers, which we put together in this very sticky, easy to remember bundle. And that bundle has taken the average rates of delirium on in ventilated and shot patients from about 75% down to below 50%. This has been a reproducible reduction in delirium. So we’re very thankful that in 2020, we have about 25% Less delirium in the sickest of the sick ICU patients than we had a decade ago.
Kali Dayton
And what has that done for their outcomes?
Dr. Wes Ely
Well, interestingly, we just published, we’ve got data now on over 25,000 patients 15,000, published with the SCCM ICU liberation program 6000, published from Sutter Health, and their ICUs in California, another 4000, published from New York. And then my Klapa is published in the CDC program, in the blue journal, another cup, another 5000, we have over 25,000 patients, showing that different variations of this, this very same A to F bundle, have reduced the likelihood of dying, reduced length of stay in the ICU and hospital, reduced reenter patients, and also ICU bouncebacks. And reduce nursing home transfers, in addition, of course, to reducing the amount of delirium and coma that patients experience.
So in general, the A to F bundle this program of just I just think of it as a safety program, and that she basically allows people to get through their critical illness, more hole faster, higher likelihood of surviving, and, and really surviving in a way that’s more efficient, effective and, and hopefully makes them happier and have a better quality of life. Although those latter two things happiness and quality of life haven’t been objectively proven to date yet. They just haven’t been studied in long term outcomes yet.
Kali Dayton
But that’ll be exciting when it does. Yes, I will have links on the blog, and to this study, as well as your IC delayering web pages. That study is really impressive. I mean, the numbers are amazing. 46% less likely to be readmitted to the ICU. I mean, that’s, that’s a big number. And it’s mentioned that this is dose dependent. What does that mean?
Dr. Wes Ely
Sure, exactly. Kali in medicine, one of the most convincing ways to, to make sure that what we’re seeing is real is Do you see a dose response. So if you increase the dose of a drug from low to medium to high, you see an effect on the outcome from low to medium die. And in this circumstance with the bundle, what we have seen now in two separate multicenter studies, is that even after you adjust for severity of illness, age, raise all kinds of other comorbid issues, we adjusted for actually up to 18 covariates.
In the ICU liberation analyses, and delete, and the percent compliance with this bundle was the strongest independent predictor of whether or not people were living or dying, getting out of the ICU earlier or not, etc. So that’s why we say that there’s a dose dependent relationship that if you comply with this bundle, at a 20% compliance rate, versus a 40% versus a 60, or an 80% compliance rate, that when you comply at those higher rates, you have a much higher likelihood of these good outcomes that we’re all seeking for our patients.
Kali Dayton
So would you say essentially, that the less sedation we use, the better the outcomes?
Dr. Wes Ely
I think that that having people I would say yes, generally having people awake and alert in the ICU, mobilizing them more, or another way of saying it less over sedation, and less immobilization has been very consistently showing us in the past decade, that patients do better, recover faster, and get out more whole than if we use heavier doses of sedation, and heavier amounts of immobilization.
Kali Dayton
And let’s talk about mobility for a moment. I think especially in the ICU, it’s really scary to see people on ventilators, innately we just process them as fragile, unstable, which they are in lots of ways. Why is mobility so important? Why not just wait until their lungs are better?
Dr. Wes Ely
Well, that’s a great question. When you go work out, do you think better afterwards, after you’ve worked out is your brain clipping, you know, firing off at a better rate than when you’re sitting there like a lump on a log.
Kali Dayton
That’s mostly why I work out.
Dr. Wes Ely
And I think patients know that to sitting them in this bed for days on end allows all kinds of bad things to happen to the body, the muscles begin to generate nerves get diseased, the brain itself gets pummeled with inflammatory mediators, which builds up when people are mobilized. And an Abbott, as opposed to catabolism, which is what I just described.
Anabolic circumstances when the body is building itself back are what lead to health. That’s why we break down and exercise and the muscle rebuilds. When when somebody is overtly sick and has leaky membranes and all kinds of, you know, toxins circulate through the body, that body needs to get up and moving. And the brain needs to be firing. And when we leave that person just tied down in a bed heavily sedated, etc. Now, we do it because we’re trying to be nice to them. But really, in the end, we now know that it is not nice. It is very injury provoking, and it’s very dangerous.
Kali Dayton
I hear a lot of survivors talk about their long term like aches and pains. Can you speak to that? I don’t know that I haven’t seen these studies really validating why exactly that is I’m sure it’s multifactorial, but I always wonder if it’s partially due to being stuck in the same position for so long.
Dr. Wes Ely
Sure that, you know, we were not meant to lie down like that we were meant to be vertical and to get up and move. And when people do lie down like that the muscles and nerves get extremely disease. You know, there are four main studies of early mobilization in the ICU. And what’s funny is that that adjective early is actually only applies to two of the four, two of them got people up on day two, or three. And those were highly successful randomized control trials.
The other two were negative studies, and they ended up mobilizing patients much later around day seven or eight. And so what we’re finding is that timing really, really matters. And it’s when you start moving people and getting them walking, or after a week in the ICU, you cannot make up for and it does not do the same degree of goodness, if you will, that that it does. If you get it going much earlier in the ICU even while they’re still on the ventilator.
Kali Dayton
Yeah, it’s really validating to what I’ve witnessed. In our facility. We usually walk people I mean, our to after their intubated, and they’re able to maintain that mobility throughout their intubation or the time on the mechanical ventilator. But when we get patients from outside facilities that have been in bed, it is so much harder to get them up. They come to us because they have gotten sicker as far as their lungs, and yet we get them more mobile bile as they get sicker, and so it’s just a different paradigm. But we’ve lost ground and that time that they weren’t moving, and it’s, it makes it so much harder and less safe to get them up.
Dr. Wes Ely
I love that point. And I do believe you’re hitting on the right, right truths here. You’re the people who work where you work, taught me that one of the things we do for patients who are large and high BMI is we say, well, there’s too big to move them. And it will be too difficult for us to move them well. These are people who have a lot of strength, they’ve been carrying that weight around for many years. And they are really at massive risk of of lifelong disability if they lose that muscle mass, because then they can’t get themselves up and do the recovery. On the other extreme of BMI. It’s a very low BMI, we know that frailty is a massive problem for those patients. So really, when you’re below 20, or above 30, BMI, that’s the people I’m the most diligent about about mobilizing early.
Kali Dayton
I think it’s really scary, especially for nurses to get up our little geriatric patients. Because, again, frail is the word, they look so frail, and it’s scary, and they’re on the ventilator, and it’s just, it makes you nervous. But in the big picture of things, what happens to especially our geriatrics when we keep them safe in the bed?
Dr. Wes Ely
Yeah, we keep them safe in the bed, we’re not keeping them safe. That’s the opposite. It’s a it’s a fallacy. And we what we have to do is make sure that we talked to the family and make an understand what the person’s baseline mobility level was. Now, if they were, you know, already, you know, contracted in the bed, that’s one thing, but if these people were walking, talking human beings with an active life, then we need to get them right back to that as soon as possible. And even if their lungs are failing, and their their oxygenation levels are no 92% on 60%. That’s a person I would have out of the bed walking, if they were, you know, SATs of 85% 88% on on 90% Oxygen, that’s one thing. And that might be you know, too early to do it. But as soon as we achieve some recovery and stabilization that oxygenation, they need to be getting up and moving.
Kali Dayton
And what does it do for the lungs to move, but we’re talking about general strength, the lungs, specifically, how does that benefit the lungs?
Dr. Wes Ely
Well, we need the long to take, we need the patient’s lungs to take large volumes. And using gravity by setting the patient up and getting them walking will help them to air rate and recruit lung volume, which is very good and ARDS, especially if you can do it on their own, rather than shoving air into generating high pressures from the ventilator, which just generates volume trauma and Barrow trauma. So this is a this is really important, by the way to link back in with sedation. Because you guess what’s the one thing you can’t do? You can’t mobilize heavily sedated patients? Yeah, they have to be awake to mobilize. So these things are inextricably linked.
Kali Dayton
Yeah, and it’s we have walked patients that are delirious, it’s not impossible depends on the type of delirium how bad it is. But it makes it so much harder. But I have seen that mobility helps their brains clear, you just kind of see the lights turn on, you know, they can barely open their eyes, they can barely put one foot in front, the other. But by the end of that activity session, they’re in bed awake, communicating on the board, they’ve woken up, at least for that time after activity they are with it.
Dr. Wes Ely
So that’s a very evidence based comment you just made. If you look at the original early mobility study by Bill Schweikert, and JP Kress, from University of Chicago, mobility cut delirium in half, very, obviously, half the amount of delirium when you mobilize patients early. And in addition, that’s been shown again and again. And other studies from Johns Hopkins beautifully demonstrated that the more you move less patients, the less delirium you had. So I think it fits that whole notion of when we’re on the treadmill working out, our brains are working better. Well, it’s even more true in the ICU for critically ill patients.
Kali Dayton
So interesting. And speaking of outcomes, I don’t, I haven’t found very much research validating this, I just wondered if you had any insight. What happens to the rate of tracheostomy is when we have patients awake and mobile on the ventilators?
Dr. Wes Ely
There are no data that I know of. But anecdotally, I will tell you that I’m a lot less interested as an intensivist in tracking my patient when I already see them walking because I can see the end in sight. So I think, you know, our trek rates are down generally in the world because of less sedation and earlier mobilization. And I’m pretty sure that that has been a contributor.
Kali Dayton
Yeah, very interesting. Sounds like you do a lot of work with patients on the other side of the ICU. Can you give us insight into what their life is like after I know, that hasn’t been researched yet, but what have you personally seen as far as cognition and even PTSD, if you can speak to it.
Dr. Wes Ely
Sure, we have a very active post ICU clinic here at Vanderbilt and the VA. We use ICU diaries during and then in the post ICU clinics, we go through the diaries with them, we talk about their life afterwards and their recovery, we get them physical therapists and cognitive rehabilitation as well. All of these things have led me to understand some of the suffering that my patients our patients are experiencing that didn’t use to understand. And it’s tremendous. It’s a, it’s an incredible amount of cognitive dysfunction, suffering from dementia, also suffering from post traumatic stress disorder and depression. In about a third of patients, I would say over half have the cognitive dysfunction, a third have the depression and about 10 to 20% have PTSD. So that’s a lot for people to carry. And when they especially when nobody else is, empathizing with them, and joining in with them on their journey, they kind of suffer in silence all too often.
Kali Dayton
That’s definitely what I see in the survivor groups. I think there’s such a disconnect from the ICU as to what happens after, and then there’s a disconnect in the outpatient side as to what has happened to them during the ICU. Um, when you talk to the patients about their PTSD, where where does it seem to be that that comes from? Is it from memories of procedures from the ventilator or is it from their hallucinations?
Dr. Wes Ely
Very interesting that it can vary, of course, but I think that a lot of patients miscategorized events in the ICU, such as if they were having their Foley managed in their peri area, they might think that they were being raped, they’ve put that into the wrong category of a good loving thing a nurse was doing into a I was being abused. In the ICU, we have lots of patients who have told us that many patients have scenarios where they feel like they were drowning. Underwater, that’s a very common description. And lots and lots of patients feel like they’re being attacked or persecuted, or under the threat of being killed by people around them when they delusionally are in a hallucinogenic fashion, thought that they were being taken care of by terrorists, etc. So all of these ramifications. All these scenarios have have serious ramifications on people’s long term mental health.
Kali Dayton
That is so powerful. I previously mentioned, I know that nurses are so kind and compassionate, and that they do sedate with these good intentions. How can we share this perspective and this reality of what sedation is really like for patients?
Dr. Wes Ely
I think that we knowledge is power. So we have to listen, you know, listen in silence, have the exact same letters. So we need to remain silent. And listen to these people and let them tell their story to us. And we need to find in every ICU in the country, somebody needs to be a champion of this and find a patient who has survived and let them tell their own ICU their story, because they’re in will lie the truth of things.
Now it is anecdotal. But we can learn an awful lot from an anecdote, then we tack that story down with data. So these are my two steps to offer you stories and data. And that one doesn’t work without the other data is too dry. And stories are too anecdotal. So you have to use both. But the true strength, which is that anecdote, backed by data is what will make people listen learn change their habits, and improve care.
Kali Dayton
Any other insights or experiences that you’ve had with culture changing in the ICU around these facilities that you’ve worked with?
Dr. Wes Ely
Yeah, these changes are being seen in in 1000s of ICUs, around the country around the country and world right now, through the IC liberation program, this program sponsored by the SCCM, which I have no financial interest or anything like that. But it’s a great program that the SECM developed, the tool they use to implement the program is called the ABCDEF bundle. I love the fact that an evidence based bundle has found its way into the hands of the largest critical care society in the world.
And that this bundle, which you can read about, on our website, ICU delirium.org, again, nothing to sell you there. It’s just purely educational. This this bundle is a way of modifying the culture in the ICU. But the way to do it is through small tests of change. And PDSA cycles is not a thing where you walk in the ICU and say on April 1, we’re going to roll it out to the whole unit. No, that doesn’t work. Instead, what you do is you find one per one person, one patient, and get one nurse and model how to round with the ABCDEF bundle, how to say it out loud and have a conversation. And then the ICU will start to gradually transform its culture over time to the end game the end goal of having a circumstance For every patient every day, is rounded on where the nurses speaking first telling the team about the A to F bundle results and other aspects of their care. And this keeps things in check calibrates us towards safety, and towards having the patient’s awake, alert and mobile.
Kali Dayton
To me, it’s really exciting to think of the culture changing across the board. You know, that’s we’re in a field of evolution. What do you see for the future of critical care in this aspect? I know that, you know, historically postpartum part of moms were left in bed for weeks, knee replacements were left in bed for weeks, and that has totally flipped. Where do you see us heading? In 5-10 years?
Dr. Wes Ely
I think that we will have patients, what once the culture really does change, I can see that we really will have a circumstance where there are very few patients who are heavily sedated and immobilized. Or if they are, it’s only for one or two days in the ICU. In the majority of patients, there will always be some times, there’ll be exceptions to this where there’ll be somebody so sick that they end up staying a week on a ventilator sedated, but those will become the exception and not the rule. And what we’ll also have as will have a circumstance where essentially a more human ICU, a kinder, gentler circumstance where people are listening to one another, they’re talking they’re looking in patient’s eyes, they’re touching their hands to do the cam, and get their hands to be squeezing on certain letters.
In the past, we’ve been too focused on the beeps, and the buzzers and looking at the monitor, but what we’re seeing now is a turn of our face towards the patient and away from the monitor. Not that we want to ignore the invaluable data that comes to the monitor. But that that does not become the the rest of the tear of the whole point of the unit, the resident of terror is the person in the bed. It’s the human being. And that that degree of humaneness is where I think we’re moving rapidly towards.
Kali Dayton
I love that and I am so grateful that you would come on here and share that perspective with us. Is there anything else you would share with the critical care world?
Dr. Wes Ely
In the future as we’re moving forward, I think all of us want to have ways to measure the brains function on a more regular basis than just manually once every four hours or something. So right now, we shall be very thankful we have valid and reliable tools like the cam and the RAS. And even if you use the delirium screening checklist, this is a great tool as well.
You want to scrub IQ invented it and validated it from Canada back in the 90s, early 2000s. It basically the same year that we came up with the cam ICU, just find a tool, use it and monitor the patient. As we get more data, it may be that we can have a continuous brain monitor something like a pulse ox for the brain. But right now what we do have in the glasses, way over half full here is we have a way that simple and easy in a matter of seconds to measure whether or not the patient’s delirious, and if they are delirious, to then do something about it.
And the way that we handle delirious patients is we run through a thing called the Dr. Dre stands for diseases, drug removal environment, D dare, diseases, drug removal environment, and we think of what diseases are causing this person’s delirium, CHF, cirrhosis, infection, sepsis, or what drugs should be removed, instead of adding a drug, let’s remove a drug because antipsychotics don’t work. And lots of drugs cause delirium, have few of them treat delirium. So the main thing we want to do is remove psychoactive drugs. And then thirdly, the E the environment, we need to make sure that any delirious patient has their eyeglasses, their hearing aids, they’re getting the right kind of sleep, that we’re reorienting their day night cycles, that we’re getting them out of the bed and walking them.
And these things found in the Dr. Dre are more effective than putting somebody on specific drugs. So let’s let’s all work together to change this culture to do what we can to monitor, and that when we do find delirium that we run something like the Dr. Dre in our units, to effectively change the way that patients be managed to shorten the duration of their delirium.
Kali Dayton
Perfect. Thank you so much for all that you’ve done for patients and for our field, and for moving this forward.
Dr. Wes Ely
So, Kali, you what you’re doing on this podcast is excellent. We’re all going to be listening and learning from you. So thank you. Thank you. Bye, bye.
Transcribed by https://otter.ai
Resources Referenced:
Hipp, D., & Ely, W. (2012). Pharmacological and nonpharmacological management of delirium in critically ill patients. The American Society for Experimental NeuroTherapeutics, Inc., 9(1).
Morris, P., Berry, M., Files, D., Thompson, J., Hauser, J., Flores, L., Dhar, S., Chmelo, E., Lovato, J., Case L., Bakhru, R., Sarwal, A., Parry, S., Campbell, P., Mote, A., Winkelman, C., Hite, R., Nicklas, B., Chatterjee, A., & Young, M. (2016) Standardized rehabilitation and hospital length of stay among patient with acute respiratory failure: a randomized clinical trial. Journal of American Medical Association, 315(24), 2694–702.
Moss, M., Nordon-Craft, Malone, D., Van Pelt, D., Frankel, S., Warner, M., Kriekels, W., McNulty, M., Fairclough, D., & Schenkman, M. (2016) A randomized trial of an intensive physical therapy program for patients with acute respiratory failure. American Journal of Respiratory Critical Care Medicine, 193(10).
Pun, B., Balas, M., Daly, B., Thompson, J., Aldrich, J., Barr, J., Byrum, D., Carson, S., Devlin, J., Engel, H., Esbrook, C., Hargett, K., Harmon, L., Hielsbery, C., Jackson, J., Kelly, T., Kumar, V., Millner, L., Morse, A., Perme, C., Posa, P., Puntillo, K., Schweickert, W., Stollings, J., Tan, A., McGowan, D., & Ely, W. (2019). Caring for critically ill patients with the abcdef bundle: results of the icu liberation collaborative in over 15,000 adults. Critical Care Medicine, 47(1).
Schaller, S., Anstey, M., Blobner, M., Edrich, T., Grabitz, S., Gradwohl-Matis, I., Heim, M., Houle, T., Kurth, T., Latronico, N., Lee, J., Meyer, M., Peponis, T., Talmor, D., Velmahos, G., Waak, K., Walz, J., Zafonte, R., & Eikermann, M. (2016). Early, goal directed mobilization in the surgical intensive care unit: a randomized controlled trial. Lancet, 388(10052), 1377–1388.
Schweickert, W., Pohlman, M., Pohlman, A., Migos, C., Pawlik, A., Esbrooke, C., Spears, L., Miller, M., Franczk, M., Deprizio, D., Schmidt, G., Bowman, A., Barr, A., McCallister, K., Hall, J., & Kress, J. (2009) Early physical and occupational therapy in mechanically ventilated critically ill patients: a randomized controlled trial. Lancet, 373(9678), 1874–82.
A wonderful compilation of Dr. Ely’s published work.
When Should Sedation or Neuromuscular Blockade Be Used During Mechanical Ventilation?
Sedation has become an important part of critical care practice in minimizing patient discomfort and agitation during: rc.rcjournal.com
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