SUBSCRIBE TO THE PODCAST

We know that sedation causes and worsens ICU delirium, post-ICU PTSD, post-ICU dementia, and ICU-acquired weakness in adults. The research is vast and compelling. What does this mean for children? What does research reveal about the harm children suffer from drug-induced comas? Is there a different way to treat our children? Can we preserve their futures by changing our practices in the ICU? What will it take to protect our children? Dr. Kudchadkar shares her life-preserving research and practices.

 

Episode Transcription

Kali Dayton 0:00
All right, we are 67 episodes into this podcast about improving critical care. And I am finally including a really important special part of our community- pediatrics. It has taken me far too long, not because they’re not a priority. At the very beginning of my journey, I had a nurse leader reached out and asked me if these principles applied to pediatrics as well. I could barely even go there. I can’t even ask my friends that work in pediatrics about their jobs.

I couldn’t handle thinking about sick kids, let alone imagining delirium, PTSD, cognitive deficits, and ICU acquired weakness and children that have already suffered life threatening illnesses. It makes me go unhinged. So I’ve been focusing on the research that is readily accessible and adult that can speak for themselves.

Then a few months ago, I found myself running through the doors at the ER with my own limp toddler and respiratory distress. Looking in the eyes of the ER physicians, I could see them contemplating intubation. And panic struck my heart not just because of the idea of a ventilator, honestly, helping my daughter breathe was top of my priority list.

What terrified me was the thoughts of her being lost in a world of terror and isolation. So far from me, despite holding her hand, I was not going to risk her cognitive and psychological safety without a fight. Fortunately, we dodged a ventilator that day. Yet, with my with my daughter’s global hypotonia, we could be right back there during the next respiratory season.

So I had to know: What does sedation and immobility do to young, sweet brains? How does it psychologically affect them? Do they also struggle to ever return to their physical baseline? I am grateful to a bold pioneer in the critical care world that has dared to ask and study these exact questions. Dr. Sapna Kudchadkar, I am so honored to have you on the podcast. Can you introduce yourself and tell us a little bit about your course?

Dr. Sapna Kudchadkar 2:37
Absolutely. Oh, my name is Dr. Sapna Kudchadkar. I’m a pediatric intensivist and anesthesiologist at the Johns Hopkins University School of Medicine. In my courses that I always knew I wanted to be a doctor, but wasn’t sure where I was headed until I did my pediatric rotation in medical school. And it was clear that my skill set and what I enjoyed most was the both patient and family centered interactions.

As you all know, pediatrics is where it’s at with regards to patient and family centered interactions. And then I thought it was going to be a general pediatrician. And then I came to Johns Hopkins for pediatric residency and immediately recognized that my my love for caring for acutely ill children in the ICU environment was what drew me to pediatric critical care.

I just love that I had the opportunity to take care of such a wide spectrum of patients and different ages and diagnoses, and be there in the most highly acute phases of their care, but also be a part of those, as you know, so integral conversations, very difficult conversations often and be there for families at the most difficult time in their lives, which is having a critically ill child in the ICU.

So that’s how I gravitated to the ICU. And I decided to do anesthesia as well because I had many colleagues at in our institution who practice both and it’s turned out to be really wonderful being part of the perioperative home for patients who are cared for in the operating room and the ICU. I also get to take care of healthy kids every once in a while, which is which is nice, but I wouldn’t trade what I do for the world.

Kali Dayton 4:15
Well, I had my daughter in the ICU back in October, she was on the verge of needing to be intubated. Okay. And I’ve been doing this podcast for at least 10 months or so. And I was really engrossed in a lot of that avoiding sedation and early mobility within the adult world.

Dr. Sapna Kudchadkar 4:36
Sure.

Kali Dayton 4:37
And I recognize that Pediatrics has a lot of unique challenges to it, but when it came time for my daughter to potentially be on a ventilator, I got really panicked because she has a neuromuscular disorder. She’s almost two years old, she’s still working on heading car control, and her cognition is strong and one of her most functional features. I knew and or assumed that if sedation can hurt a brain could hurt a pediatric brain. And so what led you to start researching into what we’re doing with pediatrics as far as managing them on ventilators?

Dr. Sapna Kudchadkar 5:17
Oh, thank you for sharing that story. And I think it, it perfectly illustrates exactly what led me down this path. So when I was a pediatric critical care fellow, I actually had very little intention of pursuing a research career at the time, I figured I’m going to be an anesthesiologist, and I’m going to be an ICU doctor.

And I’ll have plenty to keep me busy and value to a health care system. So research wasn’t in the cards. And then because of my anesthesia had actually taken care of kids in the operating room giving them general anesthetics, right to tolerate surgery and minimize pain, etc.

I came to the ICU and I’d be standing at the bedside on rounds, and the bedside nurse or the resident or even the attending would refer to a child who was on a benzodiazepine infusion and an opiate infusion with their eyes closed and this fluorescent light above their head and a million infusion pumps beeping and the, you know, ECMO circuit going off and their eyes are closed, and they’d say, she didn’t sleep very well last night.

And that statement started to bother me because I said to myself, “sleep”, like why are we using the term “sleep”. I couldn’t wrap my head around why it bothered me so much other than the fact that I know that sleep is a natural restorative activity that human beings need to function, right, none of us can function without sleep.

And here we are in the ICU environment, which is the most artificial environment with regards to technology, and all of the things we’re doing to patients to keep them alive to save their lives, which is incredibly important, obviously. But we’re using this very natural action to replace what I thought was sedation and general anesthesia. And then it really hit me that these kids are in the most impactful and rapid phases of their neurologic development.

As you know, the majority of the children that are in the PICU, for longer than three days are under the age of three. So we’re caring for kids at the most vulnerable time of their brain development. Yet, we’re administering all of these medications and doing these interventions that we have no idea what they’re doing to their brains, and we have no idea whether they’re experiencing natural restorative sleep that is integral to brain development.

You know, there’s a reason that babies sleep all the time, and they have no circadian rhythm. And over time, you know, a two year old is taking naps in the data in the daytime, maybe one nap a day and at night, they sleep through the night. And there’s a reason that their sleep patterns change so rapidly, because it’s, it’s literally a reflection of their rapid brain development.

Kali Dayton 7:54
Right.

Dr. Sapna Kudchadkar 7:54
So the way your sleep changes is how you and I, our sleep patterns don’t change because our brains aren’t developing anymore. They’re step they’re, they’re in their phases, right. And so that’s, that’s when it hit me that something wasn’t being addressed. And I couldn’t get out of my mind. And I figured that this is something that I needed to think about further, which made me do my first systematic review on sleep and the critically ill child, which really had not been explored in any sort of focused way.

Kali Dayton 8:24
What did you find?

Dr. Sapna Kudchadkar 8:26
What did we find? So we found that this was the most basic systematic review search ever done ever. I decided I was going to look for the word sleep, and the words pediatric intensive care unit in the same paper, that was all I that was the only exclusion criteria. And we found a total of nine, I can count them on two hands nine studies.

And three of them were from the same randomized control trial in burn patients looking at Ambien zolpidem versus haloperidol. To see look at sleep. So again, a pharmacologic agent, right to impact sleep. And all of the other studies were subjective studies looking at basically, are their eyes closed, or are their eyes open in the ICU?

And I was, I was flabbergasted. I was like, “Wait, this is all we’ve done about sleep in the pediatric ICU?”. And then I looked at my NICU colleagues and what they’ve done, and in the neonatal ICU, they’re all about the sleep, they understand that sleep is important to me and adult development. And yet we take care of infants through age 25 in our PICU at Hopkins yet, we weren’t addressing sleep in any way, shape, or form. So that that was astounding, and that’s really what cemented for me that this needed to be potentially an area of research focus for me, and hopefully I could develop a niche in that area.

Kali Dayton 9:46
So what was your next step? What do you think?

Dr. Sapna Kudchadkar 9:49
Great, a great question. So I think my my journey is a good example of you know, the trials and tribulations of developing a research journey, but also listening to where your journey takes you.

So after I determined there was a knowledge gap, right? Anytime anyone starts a research program or journey, you have to see if there’s a need for the research. Is there a knowledge gap there? Which clue there was so then I was like, well, maybe we’re not studying it, but maybe our colleagues are all practicing it.

So then I did an international survey, looking at sedation, sleep and delirium practices across the world, through the World Federation of pediatric intensive and Critical Care societies with PICs as the short name. And we queried over 300 intensivists across the world, and less than 2% of them were doing anything related to delirium screening at the time, and that was in 2013.

And we were almost universally using opioid and benzodiazepine infusions as our first line for mechanically ventilated kids. Like, if you got a breathing tube, you automatically got started on an opioid and a benzo. And then with regards to sleep promotion, I mean, most of the most basic things like earplugs eye masks, but even just do you have a quiet period at night where the lights are dimmed? Or do you make an effort to have a period of time where noise is minimized? And the answer was almost always “no”.

So that identified a significant need from a clinical perspective to identify that and at the time, I need to mention, we weren’t talking about early mobility in the PICU at all, it wasn’t even on the radar. However, my colleagues, for example, dill Needham at Johns Hopkins and many other colleagues across the world, were starting to investigate the importance of mobility in the adult ICU population. So that’s why that first survey didn’t include anything about mobility because it wasn’t even on the radar. This is just seven years ago. So the obviously the story is going to evolve I imagine over our chat, but that’s that’s where this all started.

Kali Dayton 11:48
So not much is going on in the peds world. And you’re identifying the problems. So then how do you really expose it and then address it?

Dr. Sapna Kudchadkar 11:57
Yeah, great question. So I had a big problem and question in front of me, because clearly, sedation, sleep and delirium were not being explored in pediatric ICU care. Clearly, I think anyone who works in the pediatric ICU would agree that we had a problem with that, like that that was an issue, because these are all things that could impact children’s neurologic development, potentially, and have both short and long term implications for their outcomes.

And this is all happening simultaneous to the fact that our mortality rates in the PICU have dropped massively. That’s a beautiful thing, right? Our mortality rates are at an all time low. However, as we save more children’s lives, what we started to recognize at the same time I’m doing this initial research says that there are more children living with short and long term morbidities that are a result of their technologic dependence, or the interventions they received in the ICU.

Kali Dayton 12:55
Right

Dr. Sapna Kudchadkar 12:55
So we’re saving more kids lives, but we’re also causing more downstream challenges. So then studies by for example, my colleague, Karen Chu, and Canada, and others started to demonstrate that, you know, these aren’t just short term problems that go away that post intensive care syndrome that was described by our adult colleagues. In 2010, I believe, is also something we should be thinking about in pediatrics, especially in children who have longer lives to live.

Kali Dayton 13:23
Right!

Dr. Sapna Kudchadkar 13:23
So, you know, it’s, it’s very different for someone who’s 75 years old to have post intensive care syndrome, as tragic and hard as it can be, what about a 12 year old with post intensive care syndrome? What are the implications for their long longevity, the quality of life moving forward.

And as this whole was all very daunting to me as an early faculty member, and you know, trying to like I felt like I was like taking on the world. But then I decided were and so I decided at this point that if I was going to make any change, I needed to start locally, right?

So let me not try to take over like trying to fix this problem internationally, let let me focus in the place that I have the most input, the most interaction, and let’s focus on my own unit. So let me focus on my own unit. So what I did was essentially sit down, I grabbed an interprofessional group of people who had very, were very like minded and recognize that we probably were not addressing sleep sedation, we weren’t screening for delirium.

All the kids were in bed and immobile, that we weren’t making active efforts to get our rehabilitation team colleagues into the unit to actively engage our patients early. So how do we even try to tackle this? So we had a nurse champion, a nurse practitioner champion, a Respiratory Therapy champion, a child life specialist, a physician, and a social worker and a pharmacist, and or PT and an OT and SLP.

And we all got together in a room together and said, “we have a problem. How are we going to how are we going to challenge this? How are we going to fix it?” So that is when PICU UP! was born. So we actually sat for an hour just coming up with a name for this thing that we wanted to do.

We knew that ICU liberation was a hot topic in the adult world. And we were convinced that it’s just as important if not more important in the pediatric world, but we didn’t know where to start, because you can’t just take the adult liberation bundle and just slap it on the kids and call it a day.

Obviously, the PICU is the most heterogeneous place in the hospital system. But you know, the same nurses caring for a two week old in one bed spot who came off ECMO, and then an 18 year old who had a methadone overdose, like those are two very different mental frameworks to be dealing with on a 12 hour shift.

So we just said, “We need to take this in a stepwise fashion.” And we looked around, we did a systematic review on mobility in the PICU, and saw that there were some studies, but they were all all over the place. But universally, they said it was safe and feasible to do, regardless of the population.

So that gave us the green light to say, “Okay, well, let’s think about it this way. How do you get a kid out of bed early in their PICU course?” Well, they need to have minimal sedation onboard, they can’t be delirious, because obviously, it would be dangerous to get a delirious child out of bed and mobilizing, and they need to sleep well, you know, I don’t think you or I feel good doing a workout the next day after we haven’t had a leg asleep at night.

And so we need to try to optimize their day night rhythms. So clearly, we had this massive need for culture change. And in order to effect that culture change, you needed interprofessional champions who are dedicated to the cause. And so we sat together in a room for one hour every single week, talking about how to make pick you up whatever that was going to be happen. And that’s how we created this interprofessional tiered, systematic approach to mobilizing critically ill children.

Kali Dayton 16:55
So how would you describe or how, look, I’ve never gone through the protocols of PICU UP! So tell me how to start.

Dr. Sapna Kudchadkar 17:03
So so the goal for pick you up was to create a shared mental model for every single person who worked in the unit. So essentially, we wanted to make sure that a everyone had a focus on sleep hygiene, even for the sickest patient in the unit, right. Like, no matter how sick you are, you can still open the shades during the day. And you know, turn off the turn down the lights and close the shades at night, minimize noise at night.

And so basically, it’s a tiered system. Level one is the sickest patients in the unit. And Level Three are the patients who are poised for transfer out of the PICU. And all of this is available in the piece of sandpaper and open access it from 2016. If you just Google PICU UP!, you’ll find it. And then so those are the levels, and then we had activity levels that match those levels.

So activity level one are the sickest patients where sleep hygiene, for example, TV watching, so how often have we as healthcare workers walked past a two week Olds bed spot with the TV on 24/7 Hit 24 hours a day? Right? I don’t think that two equals getting much benefit out of that TV watching. But again, it’s hospital routine, it seems like an easy thing to do to distract children.

So that American Academy of Pediatrics as a two, you know, has a limitation on how much TV a child should watch, for example, so we try to incorporate those guidelines in the even for the sickest children, we ask that every child be screened for delirium twice a day, and that we set sedation goals, and we try to meet them, and we discuss them on rounds.

The other big thing we noticed was that our nurses were documenting the state behavioral score on a shift on a cue for our bases, but the medical team wasn’t talking about it. So it’s really hard for anyone to buy into documentation when it feels like no one cares what the documentation is.

So it was the small incremental changes of taking what was already being done well, and capitalizing on that into a systematic approach. So every morning we call it every kid every day on rounds, we talk about all of the components of the ABCDEF bundle, which are part of the you know, SCCM ICU liberation initiative.

We cover pain, we cover breathing trials, we cover minimizing sedation, delirium, monitoring, and management, early mobility and family engagement. All of those things together, the nurses report what they think is possible for the day, and we set a minimum activity goal for the day.

The other key tenant of pick you up as we get our rehab team colleagues to the bedside By day three of admission at the absolute latest. So if you know a kid’s going to be in the unit for longer than three days, you cancelled on day zero, our rehab team comes to the unit early they engage with the nurses. And what’s really happened now is it’s taken the physicians largely out of the mix in terms of moving forward the stuff has is happening organically on its own because our rehab team and our nurses are partnering together to optimize the child’s mobility and liberate them earlier in their hospital course.

Kali Dayton 19:59
And that way, you’re really allowing your therapists to practice at the top of their license and use their higher education rather than moving flaccid limbs. They’re really assessing, evaluating and hustling the kids.

Dr. Sapna Kudchadkar 20:14
I love that, “hustling”. I think that’s perfectly put- hustling the kids. It’s true. Because, you know, our culture was to consult the rehab team when all of our acute resuscitative stuff was done. And we’d run out of things to talk about on rounds. And usually that’s like, day 10 day 12. Like, that’s too late.

Kali Dayton 20:31
Right.

Dr. Sapna Kudchadkar 20:32
And, you know, a rehab team colleagues were thrilled to be invited to the PICU early, they’re the ones often when I get called from other institutions, it’s the rehab team that’s calling me to say, “hey, we want to get into the PICU. How can you can you help us make that happen?”

And so really, it was shocking to me how much they have to offer that we weren’t capitalizing on. And valuing the fact that there is no kid, this is a major take home, there is no kid that’s too sick, to be evaluated by a rehab team specialist. You know, no matter how sick you are, they can assess the baseline, they can look, you know, they can start to evaluate and get to know the child so that when the child is ready to be mobilized, they can make that happen.

Kali Dayton 21:14
That is such a powerful statement. And it goes along with some of the things I’ve been talking about on the podcast. When PT ot was removed out of the adult ICU with COVID. I was in hysterics, because you can’t do that. They have to be there! I think, you know, at least by day three, but preferably on admission. That’s one of my first admission orders I ever put in because that these patients should be on their radar right away.

And I always appreciated the rehab services. But once I have once I started doing therapies with my daughter,

Dr. Sapna Kudchadkar 21:44
of course, yeah,

Kali Dayton 21:45
Watching how powerful their assessments are, they noticed every little thing they I, I can’t even I mean…. this is why they are the experts in it. And so she was admitted in October for respiratory failure from the rhinovirus and then been admitted, again to do an EEG and some other things.

So she’s been admitted a few times since then. Every time- that’s my first demand- is that we get PT and OT in there, because I didn’t know how long she was going to be in there. But I didn’t want time to be wasted. She does therapy five days a week to maintain and keep progressing with what she’s got.

Dr. Sapna Kudchadkar 22:17
Absolutely.

Kali Dayton 22:18
So if we leave her for 10 days.

Dr. Sapna Kudchadkar 22:20
It’s amazing how much is being missed. Right? Yeah.

Kali Dayton 22:23
And she’s gonna end up with a trach.

Dr. Sapna Kudchadkar 22:25
And so that and you know, I think that that’s, that’s, that’s, that’s so telling, because often, our rehab team colleagues are the ones who will come pull us aside and say, “Have you guys screened this kid for delirium?”

And the reason they recognize it before often the rest of the team is because they’re actually actively engaging with the patient, right? So they can recognize immediately hypoactive delirium- this kid has inattention. And that’s why, you know, it’s so incredibly important to engage them early and often, and use their guidance because every single person has a skill set.

And now what’s so cool about in our unit is that are you know that they wear maroon scrubs in our in our hospital. And they’re everywhere. It’s so cool to see like them just walking through the unit doing their thing. And by the time we start rounds, often, the nurses who know pick you up well, and who’ve been in the unit, they’ve already called the PT for the day and said, “Hey, when are we going to get Sarah up and out of bed today? She has an MRI at 10 o’clock, she has to go down for her swallow study at four. So can we do it at 2?”

You know, I and it’s that coordination that pick you is such a complex place. There are so many things happening. It requires coordination, and the rehab team is busy. But the nurses are at the bedside all the time. The rehab team is happy to coordinate with the nursing team and the medical team to determine when best to do it.

And I just wanted to highlight what you said about advocating for your child and getting a PT OT to come see your child, we noticed that it’s the parents who have had children in the medical system who have come to the PICU, who know to advocate for that.

Right? So what about all the kids who are there for the first time and you know, so it’s on the medical team to advocate for it always, because not all parents are aware that they should be advocating for rehab, for example. And so we noticed in our park PICU study, for example, a point prevalence study of rehab practices across the world, that it’s the kids who have baseline functional deficits that were getting rehab consulted early, but it was the kids who didn’t have any baseline deficits that are missing out completely.

Because we probably just like with everything else, we have an implicit bias that you know, you were fine before you came in. So you’re probably not going to need anything, you’re going to be fine when you leave. And we know that is not the case. Karen Jun has done research looking at that. And it’s only about 60% of children who had no physical or cognitive deficits before they came to the PICU they get ARDS or you know, get a bad infection. Only 60% of those kids are back to their baseline six months later. So we were actually pretty good about the kid with chronic critical illness, that kids who have baseline impairments, it’s it’s the other kids that we often miss because we think they’re going to be fine.

Kali Dayton 25:08
Wow. And and I that was one of the questions is I assumed that kids kind of bounce back. They have more neuroplasticity…. I just… I didn’t know. And so, I always knew that I need to do pediatrics on the podcast, but I hadn’t yet and there was in the ER with my daughter who was having a hard time clean her secretions. And we’re all looking at each other. And I know what’s on everyone’s minds. And the respiratory therapist came in and I cornered them and I said, “Do you sedate kids here? Is that automatic?”

Like, I had already kind of accepted that maybe she would have to be on a ventilator. But the thought of having her have cognitive deficits or PTSD, assuming that that was the same in kids, was not a welcome outcome and my world worsen. So what do we know about that? Do kids have the same cognitive deficits and PTSD that adults do from delirium and sedation?

Dr. Sapna Kudchadkar 26:05
Oh, we’re learning more. We don’t have as much data in pediatrics. But there’s no question that there are children having cognitive deficits having psychosocial challenges as a result of invasive interventions, but often likely related to sedation and delirium.

So, you know, I think our typical teaching and dogma and pediatric critical care appropriately. So based on the knowledge that we had, was that children shouldn’t remember what they went through in the intensive care unit that we need to make sure they don’t remember. So that they can come out of it and not be traumatized by the invasive things that we did, et cetera.

But what we’re learning in the adult world and in the pediatrics world is that often it’s it’s really hard to make sure that someone doesn’t remember everything. And what often happens on an opioid and benzodiazepine infusion, and as we know, in adults, and now in children, benzos are an independent risk factor for delirium. And children, specifically, one major difference for those of you who aren’t pediatric folks aren’t listening to the podcast, children develop tachyphylaxis to the medications we give them much faster than adults.

So for example, if you start a child, a two year old on a fentanyl infusion of one mic per kilogram per hour, that very likely is going to be up to two micrograms per kilogram per hour the next day, and potentially up to four the day after. And that’s because the kids chew through medications, their metabolism is outstanding.

They they require more, but it also means that they end up dependent on these medications for long periods of time. And we have to wean them very slowly, it leads to longer ICU stays often some kids are getting discharged on methadone. They’re getting discharged on valium because of the massive amounts of drugs they were receiving.

And I think that people just assumed that that’s what we needed to do, they needed to be deeply sedated. However, we slowly started learning with delirium coming to the forefront, that these drugs can lead to increased delirium. And often the delirium will lead to this vicious cycle of giving more drug in order to make them safe and help them quote unquote, “sleep”.

And the drugs that we’re giving are all deleterious to sleep, opioids and benzos help you fall asleep, they don’t help you with the quality of your sleep. And what ends up happening is the doses just keep going up, up and up. So then with pick you up, we said to ourselves, Well, what would happen if we took some of the approaches that our adult colleagues are using, and saying analgesia first, focus on analgesia for the noxious stimuli of the endotracheal tube, and sedation only when needed only when needed?

So what does that mean? So we started with, you know, what we call the lowest hanging fruit. So we started with the patient, that seemed like the most straightforward patient to try this approach with. She was a 10 year old, you know, very smart with have a child who had had an actually had an airway tumor, and required an endotracheal tube for airway protection in the course of getting this airway tumor to decompress and not be an issue.

And we asked her and her mother like, hey, we were thinking that we would give you a morphine PCA, we’ll give you a button. And whatever you’re feeling any pain from your breathing to you push your button, and is that something that you might want to try and then you can be awake and interact with your mom, and we’ll give you a iPad and a whiteboard, and we’ll figure out how to help you communicate. This short, let’s try it. And she did beautifully.

She pushed her button. It gave her control. As we all know, preteens and teenagers love their sense of control. And really all of us need control, right? Yeah, we want to have control over our bodies and what happens to them. And she actually was the first patient we emulated with an endotracheal tube, because it was so well she went to the playroom she played with some Barbies. She came back now Keep in mind, she was only on 30%.

FYI, oh two, she was on low ventilator pressures. But it was a great first patient to start this with. And because she was lucid the whole time, and she wasn’t delirious, she came out and said, you know, yeah, it wasn’t great having a breathing tube, but she didn’t have any, any post implications of, for example, traumatic stress or PTSD. And she’s doing beautifully now.

So that gave us the courage to continue to push the envelope and try with other patients. And what we quickly realized is if you’re not going to sedate patients deeply, you have to give them means to communicate. And that led to our Augmentative and assistive communication program and bringing SLPs on board very early, right, we usually are used to SLPs coming on board when they’re talking about swallowing, dysfunction and speech.

But now all these kids have breathing tubes, they need SLP help and love because we need to figure out a way to communicate. So our SOPs worked with Child Life and OT and the nurses. And slowly but surely more and more patients were awake when with endotracheal tubes. I want to make it very clear that pick you up is not designed to make sure every kid with a breathing tube ambulating that is absolutely not the not the goal. In fact, when we announced pick you up was being rolled out everyone in the unit thought that that’s what we’re trying to do. Oh my god, they want us to walk every intubated kid. I mean, first of all, the vast majority of our intubated kids aren’t ambulatory to begin with.

Kali Dayton 31:25
So my daughter wouldn’t be able to, but it’d still be really important to implement.

Dr. Sapna Kudchadkar 31:30
Exactly. We have so many young children who aren’t walking who you know, don’t have any functional impairments. And then we have many patients who are ambulatory at baseline, in general, regardless of age, like you mentioned your daughter. But there is so much that it’s critically important to optimize every other aspect of their care by optimizing analgesia.

We never want a child in pain, and and keeping them awake and alert to interact with their family and feel the zest for living. Right, like feel that survivorship that’s so important. And we learn more and more that the more delirious patients were, the more that they’re going to have traumatic stress, the less delirious they are, the less likely they are.

So we started testing it out with younger and younger patients. And we’re at the point now where there are infants with breathing tubes on a little morphine infusions, since they can’t push their button, but a low dose morphine or fentanyl infusion, no, benzo we use dexmedetomidine very sparingly, since it maintains respiratory drive and actually, potentially could improve sleep in a bit when there’s data that data is a bit mixed. But we avoid benzos at all costs.

For sedation, I want to make it very clear that benzos have an important role in the ICU for other reasons. For spasms, spasticity, et cetera, on seizures, of course, but not for sedation. And we say that only in the most important and needed circumstances, there are some patients that need to be on the oscillator and paralyzed because of the physiologic acuity of their illness. But only for those cases, it’s not first line for any of our patients. And we’re seeing a movement across the world to the same, which is great to see.

Kali Dayton 33:12
Which brings me so much peace. So that I keep on I especially wanted to talk about my daughter

Dr. Sapna Kudchadkar 33:18
right now, as you should I mean, you have this experience that I think that all of this resonates so deeply for you.

Kali Dayton 33:24
Yeah, my question for them was, if she’s on a ventilator, she is not going to be able to really get it that tube, I mean, we could slightly restrain her and she’s not gonna pull anything out. She doesn’t have that kind of strength. She’s not going to get that agitated. And also, I heard the survivors talk about their loneliness, their solidarity. And she’s at the time she was 18 months, and I and I thought 18 month olds are not supposed to be completely without human contact for days, two weeks?

And what kind of impact would that have on her cognitively, but also emotionally? Of course, and to kids? I don’t know if there’s any way to know but adults talk about they’re dealing with hallucinations and tears. But can 18 month olds also have that kind of experience? I know injures the brain, but do they have that kind of is there any way to know what they experience under sedation?

Dr. Sapna Kudchadkar 34:15
All in all indicators would say that, yes, they’re experiencing something very similar in their own developmental framework, because we’ve queried, you know, children who are able to verbalize, you know, around age four or five that have delirium, and they will tell you, what they what they remember and what they saw.

And so the the challenge is for an 18 month old, which again, your daughter’s age group was the age group of most of our intubated patients in the PICU. We know that 60 to two thirds of our patients are often under the age of two. So, you know, I think, assuming that that is the case that delirium could have a significant impact is the is the only way to go because that will force us to think about our own hospital routines.

And that’s the thing there’s so many things that we do In the hospital, that we can change relatively easily to minimize the risk factors for delirium and sleep disruption, and sedation need, for example, and one big cultural change that we made along with this whole PICU UP! initiative was daily X rays. You know, why do we still get daily X rays at 5am in the hospital? Because it’s convenient for me, right?

I want to round at 730. So if X rays are all done by 630, the techs or X ray techs are can leave for the morning, the nurses don’t have to worry about an x ray tech positioning their patient between seven and eight. And then the X ray is read by the radiologist by the time I start rounds. That is why we do that, right. A 5am.

X ray is probably the worst thing we can do for sleeping patients in the intensive care unit if we’re trying to prevent delirium. And the other thing I always talk about whenever I give grand rounds or speak on this topic is baths. When do we give bath in the ICU, we give back at two or three in the morning. Why? Because it’s convenient.

There’s not as much stuff happening at night, the daytime is busy, there’s all this stuff going on. So we take a baby out of their crib at two in the morning and put them in a bath again, and there’s I think it’d be great if someone would do the study, there’s increased risk potentially of physiologic compromised right in those situations where you there’s a stress response is at a higher risk for things like cardiac arrest, et cetera.

So we need to, we need to really take a close look at our routines in the hospital and whether is this really about the patient to really need midnight labs? Or would 10pm labs suffice? What do we really need to like, you know, go get a blood pressure non invasively at four in the morning? Probably not, especially if there’s an art line. So think the things that we don’t talk about every single day, are they they’re not sexy, they’re not the exciting things.

But they’re the easy things that are probably going to have the biggest impact. And what Wes Ely is, you know, he tweets almost on a daily basis about how the pandemic really highlighted how easy it is to go back to our old routines.

So with COVID, right, it’s like we forgot everything that we knew about the ABCDEF bundle, all of a sudden, everyone’s getting heavily sedated. And I get it that you know, there was a huge, it was a huge event for the medical system. And we were overwhelmed. But all of a sudden, everyone’s getting over sedated. We weren’t mobilizing.

You mentioned that the rehab team was last priority to get into the patient rooms because of the COVID, you know, restrictions. Automatically, we kind of basically undid all this work that had been done in ICU liberation. And now a year later, we’re like, oh, let’s do that stuff again. And now we’re learning that that’s what these patients need. They need the same approaches.

So they call it the zentensivist, like, you know, the “less is more” philosophy of non pharmacologic approaches. And my PICU UP! trial right now is exactly that, like we’ve demonstrated the pick you up works in a single center, how now is a generalizable to other centers? And essentially, does it all come down to non pharmacologic team based approaches to change culture to optimize care?

Kali Dayton 38:09
And what kind of results? Are you seeing what have changed? What kind of outcomes?

Dr. Sapna Kudchadkar 38:15
I’m glad you asked. So the first thing we had to demonstrate in our single center study is that it’s safe. So we did, you know, in 100 patients, we demonstrated that that, you know, there was no adverse events whatsoever. And that’s because we have a system where everyone feels comfortable resting and reassessing and in ICU if there’s a potential for an event to occur.

And we demonstrated that we doubled the number of mobilization activities per patient per day. So that was a that was a huge change. And then we were also getting the rehab team to the bedside. So all that’s great, but what about the the hard outcomes like length of stay duration of mechanical ventilation?

So our pilot trial right now is definitely not we haven’t analyzed the data. This was in five centers. So that data is sitting there ready, many 1000s of hospital days. But the adverse event rate is essentially the same, we are not seeing an increase in adverse events. And what we’re seeing is that patients are using much less sedation, and delirium rates are going down.

So what the next phase of our analysis will be is to determine if it does impact duration and mechanical ventilation. My hope is Yes. And you know, even if it doesn’t, I think what’s so important to focus on here is like, what is it doing to the intangible things that we can’t put our finger on? Right? So I think minimizing sedation and optimizing sleep and preventing delirium, they all seem like really common sense things to do, right?

Like if we can do them easily and at a low cost. Why would you not why would you not find a way for a child to communicate with an endotracheal tube? Why would you not do everything you can to exercise? A critically ill patient because how I like to teach my mentees and my fellows here Is all of the things that we need as healthy human beings are needed in spades when we’re sick. We need to sleep when we’re healthy.

We need to eat good food when we’re healthy. We need to we need to exercise when we’re healthy. And if we don’t do those things, we feel like crap. And so why should that be any different in the hospital? And in addition to that, why don’t we try to normalize a kid’s routines? Why don’t we ask what time Bobby goes to nap at home and try to make him nap at the same time in the hospital? Why don’t we try to like ask these key questions about what’s happening at home so we can try to get them back to their home life as quickly as possible and not have this long phase of like convalescing to get back to their roots home routines.

Kali Dayton 40:46
I’m just wondering, are you evaluating tracheostomy rates as well? I think that’s been really under studied in the world. I have a special interest in that in the theatrical world, right? If my daughter ended up on a ventilator, that’s one of my main concerns.

Dr. Sapna Kudchadkar 40:59
Absolutely. Yes, that is one of the that is one of the variables that we’re collecting, what proportion of these patients are excavated next debated successfully versus what proportion of these patients are excavated and potentially re intubated and ended up with a tracheostomy, or go directly to tracheostomy and there’s not enough?

You’re right. There’s not enough data in pediatrics about tracheostomy decision making. And both short and long term like, are we tricking pediatric patients too late? Are we tricking them too early? You know, there’s pros and cons to both obviously, early tracheostomy as we’ve seen with COVID can minimize sedation needs, potentially if there’s a plan for potentially the tray coming out later on. I think there’s a lot for us to learn about tracheostomy and its role in the pediatric critical care patients care.

Kali Dayton 41:46
Yeah, definitely. What recommendations would you give to people that are in their own units wanting to make this change and transition?

Dr. Sapna Kudchadkar 41:58
Great question. I think first is to pull together the data that’s out there, you know, pull together the stories, the talks that you see online, these podcasts, to show the people who are working with you in the unit that you it’s not like you’re going at this alone, or this is like a new or novel concept are we know that I see liberation works in adults, we’re learning that it works in children, and convince people that it’s common sense, it’s common sense approaches to pediatric care is number one.

Number two is make sure that people know that you recognize that this is an interprofessional strategy and approach and that you want their help you want every single discipline in your pick you to be at the table to determine how your unit best moves forward to change culture. So one thing we learned with pick you up, and we’re actively learning with our trial and implementation is every unit obviously is different. And every unit has very unique skills and strengths and very unique weaknesses and barriers. So you need to sit down as a team, and talk about what you do well, and where your areas of improvement are.

And then determine the best way to tackle those areas of improvement, but also capitalize on your strengths. So you know, for example, at Hopkins, our major strength was we had an incredible rehab team, our major barrier was that we hadn’t created a conduit for them to actively engage early in the process. So that was easy. We created order sets for automatic consultation of our rehab team by a certain time point.

And I created this program that laid out what the criteria were, what the restrictions were. And because one of the things that would come up was well, there’s no policy. So pick you up is now a policy, there’s a policy online, you go, you can, you know, go into the Hopkins system and look up, pick you up and you get all of the protocols there. And as you know, protocols mean a lot to people and they want to know that it’s documented that it’s okay for them to do X, Y, and Z. So that’s the best place to start. I’m always happy to be a resource.

I would also recommend, you know, following along on twitter, we have some really great hashtags, that cohort all of this information about ICU liberation, the three that I would follow if you’re interested in pediatric critical care, specifically our hashtag peds ICU, hashtag ICU rehab, and hashtag A to the number two F bundle A to F bundle. Those three will basically get you all the content that’s being shared online on literature focused on pediatric critical care, mobility and liberation. And, you know, thought leaders, people who are talking about this out there and sharing ideas.

I think the coolest thing about doing this PICU UP! trial is I’m learning everyday from these other centers and the cool things that they’re doing to optimize mobility. The nice thing is they didn’t have to reinvent the wheel, but they took what we’ve done and they’re adapting it to their center and coming up with even cooler ideas. And now the program’s like, it’s like burgeoning into this, like, basically this database of cool things you can do to implement mobility in your own unit and minimize station and optimize, optimize sleep, et cetera, et cetera, et cetera.

Kali Dayton 45:13
And I’m sure it was children, you have to get so creative.

Dr. Sapna Kudchadkar 45:16
That’s and that’s the fun part, though, right? Like so it’s so neat, because we even like little things like someone from our unit, Sean Barnes, one of my colleagues in the PICU, tweeted out, someone had created a hopscotch pattern out of blue tape on the floor in the PICU. Right.

And that was for one of the kids who was very mobile, and he did so was getting bored and needed something exciting to do. But the best part was, you saw, like, the adults like jumping on the thing. And like, you know, I mean, we all all could use a little joy, right?

And so that, I’m glad you brought that up, Kali, because the one thing that we have seen from these initiatives, as important as they are for patients and their families, one thing that we didn’t immediately recognize, and now we’ve learned through our qualitative work is that the staff. The staff gained so much joy and value to their day to day work by being part of these initiatives, because it’s that humanism side of medicine, that, that we don’t talk about it enough.

Like we come to work, and we do what we do, and we go home, and often, you know, a child has died or child has had a poor outcome and it hurts, it hurts. And we take that emotional, emotional work with us home daily. But if you also played bingo with a kid who was intubated and kept them awake and alert, and did you work your hardest to make their kid brighter, make their day brighter, that brings value to your day to day, I think that’s really invaluable. So our staff definitely are, have stated that that it’s hard work, but it’s, it’s good work. And we’re now learning that from our qualitative work in other states as well.

Kali Dayton 46:52
The last six months, I have been the recipient of a lot of expertise and care from the pediatric world. And I am just so touched and astounded by how good these people are, everyone gets into pediatrics, because I love kids. They have those special skills, abilities. They’re fun, they’re funny to create it. So I love this idea that they get to actually use those skills and that joy that they have, instead of just taking care of a flaccid body in the bed.

Dr. Sapna Kudchadkar 47:24
Their talents are maximally utilized with programs like this. And I that’s what makes their day fun. And it’s important, we all went into pediatrics for a reason. And that is to make kids lives as healthy and optimal as possible. But if you can add this little other dimension, I think to critical care, because obviously critical care is a calling. It’s a hard calling, but it’s a calling and to add this element to it. It’s just really cool.

Kali Dayton 47:50
Well, thank you so much for what you’re doing. You’re changing the peds world, when can we expect the results of this upcoming trial to be available?

Dr. Sapna Kudchadkar 48:00
Yeah, so the results of the pilot trial will likely be published in the next six to eight months. And then the hopefully soon to be fingers crossed funded trial. For the larger study, that’ll that’ll be a trial that takes about five years. But over time, we’ll gain a lot of information of that, and there’ll be a lot of literature to come out of that study. So a lot more to come. We’re always looking for collaborators and new and interesting ideas. So please reach out at any point.

And thank you to all your listeners for doing the hard work. I mean, I think the best part of my job is that I get to see this translated at the bedside, which I think is just so exciting to see people make this what they want. So I’ll leave it at that. Thank you so much. My pleasure. Thank you, Kali. Appreciate it.

Transcribed by https://otter.ai

SUBSCRIBE TO THE PODCAST