Analgesia & Sedation in #pedsICU feat. Jayashree Muralidharan

This is pediatric or intensive as season three. PICU based rehabilitation, guest edited by the amazing Karen Chung. Pediatric intensiveists and research from McMaster University in Canada. We should not be sending patients out who are not neurologically stable. And we said included in that are patients who are at risk of withdrawal and patients who are at risk of delirium. I think it's hugely important that we do specify both aspects of the medications that we often blur the lines between. And having all these if-then-do that plans aren't always the set up for the most success either, right? That's things change. But I really do wonder if the balance is tipped a little bit too far in terms of oversupplying these drugs and not weaning them fast enough. As soon as the patient stabilizes, the talk should be more about the de-escalation. The involvement of the parents has been a game changer in my practice. It's not about the best sedative but the best approach. My name is Greg Kelly. I'm a pediatric intensiveist from Sydney, Toronto, South Federal Network. Hi, my name's Sharon DeCivo and I am a ICU nurse from Hamilton, Ontario. Hi, I'm Jay Shrivoglidhara. I work as a pediatric intensiveist at the Advanced Pediatric Centre at BGH-Chandiger, India. My name is Jonathan. I am the PICU Pharmacist here at Big Master since I guess 2016. I'm Peter Alexander. I'm a pediatric cardiologist and an intensiveist at Boston Children's Hospital in the US. I'm very excited that this episode is going to be focused on sedation practices and critically ill children because it is a very controversial topic. I'm very excited to have Jay Shrivoglidhara, who is a world expert on this topic, joining us today with Sharon, who is a very experienced pediatric intensive care nurse, helping us understand the nursing perspective. It's also great to have Jonathan and experience PICU pharmacists around out the team. This episode we're talking about, Anjou Sedation, which is something that we do for the vast majority of our patients to keep them comfortable, reduce anxiety, and enable nursing and medical therapies. However, despite it being such a core part of what we do, there's massive variability in what we do around the world and emerging evidence that some of these drugs can cause harm to our patients in the short and possibly the long term. Are we really going to go with Anjou Sedation? Can't we just say "Anjou G'sia" and "Cedation"? Why don't we call it what people usually understand it as in sedation practices? The only thing I would say about that, which I just want to be careful about, and I think is in the literature of it sometimes, and certainly in practice, is that people can flake the two. And there are some patients that definitely need Anjou G'sia, but have no reason to have sedation. And then my residents say, "Oh, should we wean the sedation?" I'm like, "Hang on, no, this patient doesn't need sedation." They have a painful thing. They've got a broken femur from their accident. They don't need any sedation. My population's mainly post-operative. That's the crux of the matter, is because we still do lump them together. And I'm quite sure that in our conversation, we will start to distinguish between the need for pain control, the need for anceolysis, and what is sedation really at the end of the day. And then that, I think it's really important to tease out that it is different. Karen, you've talked before about the importance of precision medicine, and we certainly talked about that a lot in our single ventricle season, about really trying to identify, not saying this patient is struggling, but saying, "This patient is struggling because they have AVVL very good and atrial hypertension." And I think it's exactly the same, trying to be really precise about what the patient needs and therefore what we can do for them. And I think the conflation of analgesia and sedation that we all do, actually isn't as good as we could be for our patients. I think we have patients in the ICU who just need analgesia. They have a painful chest drain or they have a broken femur. And then we have patients who don't have anything painful, say again, that patient with left-atrial hypertension, but they do perhaps need some sedation to help nurse their physiology through. And of course, some of our analgesia drugs are sedative, and some of our sedative drugs are a bit analgesic. But I think trying to be really precise about what the patient has, and then what we can do to help them is a really good way to get more. Out of the drugs and the therapies that we already have. You've brought up some really important points, and I started out the introduction using the term sedation practices. Because really the challenging population is the mechanically ventilated child who cannot verbalize. Patients who can verbalize or articulate or have a parent with them who may be able to help us understand what they need, can articulate whether those needs may be pain, or whether it is ancillitis, or whether it is hunger, or they need their diaper changed, etc. I think this is particularly clear in the mechanically ventilated patient, where the concept of sedation has bridge not just those different aspects of pain, control, and ancillitis, but also the challenging aspect of safety. At the end of the day, you don't want the patient to pull out their tubes. And so I think when we think about precision medicine now, is trying to tease those things apart. Like when we talked about in the Delirium episode, being able to use tools to distinguish between why the patient is agitated, whether it is because they're in pain, or whether it's because they're delirious, or whether it's because it's withdrawal. We now are equipped with the ability to try and distinguish. And so it shouldn't really be just about sedation. It should be about what is the most important thing first. It is comfort. Therefore, that you will increasingly hear the term not sedation practices, but analgo sedation practices, or analgesia first. Practices when you're managing a mechanically ventilated child who cannot communicate, or articulate their needs. Sharon, maybe we'll go back to that point and to get your perspective, because sedation practices, I find, is one of the most challenging areas to really collaborate with with the nurses, because you have a different perspective than a physician does. And each nurse will have a different perspective. Yes. And then you have a variety of nurses. But it always comes from a place of you want to do the best for the patient, but you are trying to keep the patients safe, and you're trying to nurse the patient, and you have to be able to leave the room when necessary and respond in a very quick way. So perhaps I'll start by asking you, where do you think, at least in the unit that you practice it, in where do you think the nursing mindset is with respect to sedation practices, or analgesia first, or analgo sedation practices, and mechanically ventilated children now? Do you think it's evolving? Do you think there's a different mindset, or do you think it's still stuck in tradition? I think as you see the newer nurses come in, you're starting to see an evolution of change, but I still feel like trying to get some of the older generations who've been around to change a bit is still a struggle. And I feel like that's comes from experience, and I feel like everybody's experience plays into that, right? Like if you have only ever had sedated patients where you're over sedating them, then you're going to be fearful to take that away. And until they see that change, they're going to continue to have that mindset. What do you experience in your units with respect to the collaboration between nursing physician staff and nursing staff? Where are the ones that write the orders? Ask the nurse to do something and get them on board and get the buy-in, but I find it, you know, you have to choose your words carefully, you have to spend some time educating, and then if you come across a nurse whose inferness quite experienced and opinionated, I myself find you have to tread carefully and listen to their perspective as well. I think, yeah, I also find that with approaching the doctors as well, to be honest, we have these algorithms, we have these educations, we have these teachings, and I can go with them and say, this is what I'm seeing, this is the scoring for that, this is what our algorithm says, and yet I still am met with fear for them to actually write these orders. And I don't understand that. We all have to be in a team and if you want these things to be done and you want to have the evidence for that, I struggle with sometimes being able to get the orders that way. It's really interesting because in our unit, it's almost the opposite of what I think I'm understanding from yours, where we have a group still of very senior nurses who've been bedside forever since before dectimate automating was available to extubate patients on it, just keep everybody quiet. And then the ones that I know I can shut off whatever of a sedation they're on, shut off the morphine and medazolam infusions for the two-year-old and they're going to keep that kid quiet until I come back at 12 noon and extubate them. And similarly, they're the ones who'll say, you know, the withdrawal is really not that bad. Why don't we make it a Q8 reduction in deximate automating infusion for the next few days and just see where we get to. We'll just see where we get to. And they're confident enough in their practice and in their ability to assess and rescue. And their ability to get one of us to the bedside who's going to believe their assessment and they're a bit really the rescue. And that makes a big difference, I think, in our unit. Whereas the more, you know, people who are newer to the team, don't necessarily have that confidence that their assessment is going to be believed and action immediately, that they're going to have the ability to effectively rescue if they get it wrong. And so everybody moves with much more steps early on. And so, you know, as we lose that group of senior nurses, we're really going to notice it in our unit, I think. I think you've just touched on a really important point though, is the trust between the two of you. So if you don't have that trust, so say the newer residence coming on or the lack of confidence for whatever reason, maybe it's because of the new practice, then you're not going to want to. And you are going to push. And I think that that's what we see with some of our more seasoned nurses that the confidence isn't there because it's new. And they don't have the confidence that's going to work based on what they've seen. And they don't maybe have the trust that if we do get into a crisis situation, that we're actually going to get the rescue medications that we need because there's such a viewpoint of no, we're not doing any of those things anymore. And the lack of rescue medication, there's fear for that. You know what I mean? They're fearful. The residents are fearful to order these things because of they don't want to make to Leria Mourney of that. J. Esher, how interested to hear what your perspective is in terms of sedation practices and the interaction between the more physicians and nursing staff? Our situation is a little different. India being a low-villain country. Over decades, nurses primarily have been kind of, what should I say, that they have been the team who have been following orders of physician. So this is a kind of mindset which has changed largely now over last decade in India and especially intensive care setups where people have moved from vertical teams to horizontal teams. So nurses are getting more and more empowered evolved. They are into the treatment, whatever is going on for children. So we are seeing a change which is a very welcome change. But still in our ICU, even though we have horizontal teams, the orders are physician driven, especially with respect to an algo sedation. The orders have to come from physician. The nurses of course, they are able to pick up the at-risk children, pick up withdrawal symptoms. So they are very, very like quick incoming and reporting to the physicians or the residents, fellows and consultants. But they cannot take a decision of top-up polars or increasing the infusion unless it is endorsed by the physician. So one of the change which I see as compared to setups like what you people describe is that we are getting there and I'm very hopeful and optimistic that we would be in a situation where there would be many things which probably would be the nurses would be drivers as compared to physicians. And one example is the infection control which has been completely taken over by nurses. They are the drivers. So I'm sure that an algo sedation also as a practice is going to become that way very soon. Pida, you talked about very experienced nurses being comfortable with the decisions to change sedation or reduce sedation. Your guidelines nursing led or pharmacy led titration protocols? So that's a great question actually. We were I think the primary, the pilot side for Martha Curley's cardiac restore protocol. And so for those of you not familiar, it's very much a nursing led, nursing titrated protocol. The biggest criticism that I've heard about it as not an expert in this area, I'm not going to claim to be one of Karen's expert panel. But the criticism is that it's Madazzleam heavy dexmenitomating light basically. So first line opiate, second line benzone and then titrate in a dexmenitomating later. But the primary principle is very much that the bedside nurse who is managing the patient for the entire shift does have the opportunity to titrate up with bolstosing. And after three bolstoses to actually increment the dosing schedule for the infusion for any any of the agents, whichever they believe is making the biggest difference. Now the physician team obviously orders the medications and the infusions, but the decision making around titrating is heavily influenced and indeed directed often by the bedside nurses. So they are very much our team is very much empowered to be decision making and heavily involved in the decision making around that. I think that's huge. I feel like I can see how nursing having the autonomy to make those decisions would allow people to be more comfortable titrating down because they know that if they do get into trouble, they can titrate back up. And I believe that having that and that trust that you do know what you're doing makes a huge difference in people following along and following pursue. They understand why they they feel that you they're being trusted to make these decisions versus having to go back and argue we still need sedation or know this isn't pain related. This is likely more of an anxiety driven component or vice versa. And being able to be trusted to make those decisions, I think is a huge part of why your program is successful in that. I'd I'd hate to make anybody think that our program is a particular nirvana for sedation restriction practices because that is not not the case. But but certainly there is shared decision making around what's required at the bedside. As I listen to you talk, there is no doubt our PIC and nurses are extremely experienced in titrating many agents. And I think the challenge with respect to a nalagal sedation or analogies your first sedation or sedation practices however you will is that the targets vary. With respect to titrating Ina tropes, you're the ones that should be doing it just as much as the respiratory therapist should be titrating ventilator management because you're there. It's real time you can titrate up and down. And that instance there's no controversy. You know what a blood pressure target is you either go up or you go down. The challenge with sedation is that optimal sedation is a moving target. And it goes back to what we were talking about before. If your patient is agitated, what is it? Is it pain? Is it they need to change their diaper? Is it that they're you know, missing their parent? Is it that they're anxious? Because nobody really needs sedation. Because it's analgesia, anxiolysis. Otherwise sedation is chemical restraint. To me it's not the issue of are you are nurses able to manage that? You are well equipped to manage that. The challenge is the variability of a sedation target if you will or a level of consciousness target. And that's why I really liked your RCT J.S.S. REE because it was about targeting to a wakefulness and interruption of sedation. So you you made a leap. You know we in our an an algo sedation algorithm encourage decrease every day to target wakefulness or whatever sedation target that you want depending on the type of patient. And we've actually given some guidelines with respect to that because not all patients are the same. There are patients who you might want to ensure that they're well sedated for example, if you must relax in them. that you want to rest their breathing, for example. So we try to encourage daily assessment of those level of consciousness targets and to decrease every day. But in your trial, you took a leap. It's daily intervention. I'm going to stop sedation every day. How did you manage that? How did you find that? Yeah, that's a very good question, Gary. But this concept of intermittent sedation, I must say that it basically stemmed from the fact that in our ICU, we have very limited ventilator beds. And there is always a huge demand. So we often face this supply demand mismatch in terms of resources, especially ventilators. That's one. And second issue, as I said, is that we have a lot of issues with staffing ratios. So our unit would function with a nurse patient ratio, which would be maybe one is to one and a half or one is to two. And sometimes like right now, currently with COVID pandemic, where our nurses get posted in different pediatric COVID facilities, the nursing ratios within the non-COVID-PICU is something like one is to three. So they are extremely overburdened. And so very often it becomes kind of easy for them if the patient is sedated and not much of things to monitor. So there are there were two aspects which made us actually plan this study. One is that we needed to reduce the duration of ventilation, get an increased turnover so that we can accommodate more patients for ventilation. And second, that we needed to work in terms of restricted staff ratios and empower nurses that higher sedation is probably not good for the children. So this was in the background on which we kind of planned this study, trying to drive home this point that less is more and that we need to look at something which is probably much better for the patient and probably in terms of cost effectiveness in a resource limited setting. And we were successful in this as you just said that the intermittent sedation definitely reduced the length of the mechanical ventilation, duration of mechanical ventilation as well as the length of the PICU stay by about three days which is a huge thing for us because at any given point in time we have at least three or four patients waiting to get into PIC. That's the kind of rush we have from our emergency department. And we continue to follow. So this was about eight, nine years back that we did this study and we still continue to follow this practice of interrupting sedation daily between now we just changed the time to seven to nine in the morning. And we we quite happy with it. There's hardly any body some critical incident or unplanned extubation that occurs. But however we don't do it in children who require deep sedation like those with active raised intracurricular pressure or those requiring high pressures like an a rds ventilation. But for all other patients who have ventilated it's a protocol in our unit that at seven their sedation is switched off and then they are monitored for the spontaneous breathing trial and their glass cocoma score and their reflexes and their awake, wakefulness and so on and so forth. So we are quite happy with this practice. But as I said, the premise was not for patient related adverse effect, but more for cost effective strategy and see how to reduce the ventilation duration so that we can accommodate more patient in the PIC. That's how we began. But subsequently I think the patient effects probably also took over our precedence. That's almost like the counter to that we're talking about how easy it is to turn things up. So they just say we actually need something strong that goes in the other direction and you know, every morning we turn everything off. I really like that as a concept and it's amazing that you've been able to continue it for so long and have such good results. It's fascinating because it's dependent on the driver for practice change and in your instance, the driver is resources where we are in our unit where we are resource rich, the driver for culture change and practice is, I would say, opinion based first. So having to convince staff with respect to the evidence is a lot more challenging because as we talked about earlier, these practices are steeped in tradition. So while it is on our agenda, I don't think we would have been as successful in changing our analogous sedation practices if we said, okay, in addition to restricting your use of benzodiazepines, I want you now to stop all of your sedation. I think we would, that is our next step because it has I think increasingly the data is in the right direction, including I think the last study out of Boston as well with the daily interruption of sedation and in other areas as well, suggesting that it leads to reduced duration mechanical ventilation. I find it very interesting to you that even within our own organization, the adults, they do, every day have interrupted sedation periods. It's not a time thing, but their sedation goes off so that they could do a thorough neural examination and how flipping through, I was so nervous at the beginning because this has changed to my practice, but they didn't have a set time. It would just be when they were awake enough to do a full exam and then they turn it back on. And it is just interesting how the practice changes so much within the same organization, adults versus pediatrics. It's so interesting that they would turn it back on once they had their neural logic linked with them. Well, they were always good neural exams. Well then we're back to why they agitated, right? In terms of practice changing, my practice has changed more from the last two conversations we've had than from probably anything else I've done because it's just really made me think a lot about what I do every day for every patient. And I guess two of the ideas that have kind of really come up as we're talking about, this is the one that we talk about what we're trying to do for a patient and we should say that we're trying to keep them comfortable, reduce anxiety and enable medical and nursing therapies. And obviously you can achieve those things with drugs but there are many other things that you can achieve them with. And I think again, once you start to be really precise about what you're trying to do with the patient, you can then be much more precise about how you're going to get there in a range of ways, not just through drugs. And the other thing that I, and obviously how much of it is drug depends on what the rest of your team looks like. So if you've got a really comfortable experience nurse and a really comfortable experience physio, then you may be able to mobilize that patient with minimal analgesia, whereas if they're more anxious, then that may need more drug to do the same thing. And I guess the other thing I wanted to talk about with the doctors and the nursing issue is that we talk about targeting comfort but I think oftentimes we're treating the comfort of clinicians looking after the patient. And for doctors it's really easy because we can just walk out of the room. If we get uncomfortable, we can just walk out of the room and when you've been around a while, you sometimes see a patient that might be have a lot of pain or have really bad to lean, but it's not until the doctor is there at the bedside when that's happening that they're like, oh my god, this patient's in agony and the nurse is like, yeah, I've been saying that for 24 hours. And so I think that there's almost this unit of patient nurse or nurse other providers. So the nurses are their most of the time end parent. And in a sense we've got anxiety and all of them. And if we can, and obviously we treat through the patient, but I think managing the feelings and the expectations of parents, I think can really sometimes help to use analgesia and sedation judiciously in patients as well. And I just wanted to throw those ideas out there and see what people thought. I think you said some really, really important things. And while we talk about the nurse's physician interaction, ultimately the nurses know the downside of sedation. It's not that they're really trying to over sedate their patients. They know the downsides, operationalizing that balancing that with safety is challenging. And I think that's why I really enjoy this conversation because sedation practices, and again, I'm isolating this to sedation now, is a very emotionally laden practice because of let's say a certain, well, let's say it's distressing to see a patient that is, you perceive to be uncomfortable, but there are certain myths we talked about this before. Crying does not always equal distress. Babies cry all the time. It is normal, but we perceive it to be distressing. And so that is perceived. as a need to provide comfort. Adjitation is equated with distress, is equated with under a sedation. And the other myth is that sedation helps you sleep, and the opposite we know is true. So there are a lot of myths, and that's why I think that while we talk about very experienced nurses, and I'll say this with the deepest respect, is that the very experience is very, might be the ones that are most challenging to get by in because of what their tradition of practice is. Those are the ones that you have to slowly work together with, provide them with a different perspective, because maybe they came from a perspective of we used to use chloral hydrate. Why don't you use chloral hydrate? It works. Of course it works. It's a very, very powerful drug that is very difficult to titrate. So experience comes with different perspectives, and are driven by different things as we heard from J.A. Shreen in your instance. It's driven by resource utilization. And I think or uniformly I can say that it's driven by the discomfort in seeing a patient in distress. And I think that's really what our goal is has been in our anaegocidation practices. It really is outside of trying to reduce delirogenic drugs. It's not about finding the ideal drug. Once you target analgesia, you reduce delirogenic drugs to me. The biggest objective is to get on the same page with respect to what do I want to achieve today. I want to allow this patient to wake up. And allowing it is not just about the drugs as you talked about. It means I want the lines up. I want natural lighting. I want the TV off. I don't want them to nap during the daytime. I want them to get out and mobilize and exercise, etc. It's very much a complex juggling act that can be subjective in a sense too. And what I find helpful in our units with some of our experienced nurses, like Karen had said, who are used to a habitual practice or are comfortable with a level of sedation with some other patients. Sometimes it's helpful having a very unified, goal-directed stepwise approach to what you're trying to achieve. And circling back to what Greg was mentioning, I do find that the nurses are great people to use as your anchors for some of the decisions because they're in there 24/7 and probably the closest to the patient at all times at the day. So what I have found successful in terms of problem solving has always been if we do talk about decision-making, it is always as a group. And to see if the nurses are feeling comfortable with that decision because ultimately if they're going to be executing some of the orders that the team puts forth, they're the backbone for that. And they're usually more receptive, I feel, to collaborate with that decision-making, but also just to see if they feel comfortable in executing that game plan and if not, we can work our way around it in some sort of problem solving fashion. Yeah, I think for me, it wasn't until I started talking about targets using the scales, like a rast or something else that it begins to make sense because otherwise what happens is that you come into a room, you've been on for a couple of days, you've come into a room, and then this day that the nurse comes up and goes, "Is this patient climbing out of bed? They need more stuff." And you're like, "Hang on, but they've been okay for the last couple of days." And then it's not until you realize, "Oh, this nurse, because they're different background and different training and different experience, has a different idea about how this patient, who's the same patient that they were yesterday, how sedated they should be." And because we're not talking the same language, people tend to use quite, they know they need to get people's attention, so they'll say things like patients climbing out of bed or they're, you know, pulling out lines, whereas if we can say, "No, this patient, who's got this particular condition, they should have a rast of negative one to zero," and that's what we're targeting. Then we can actually all speak the same language and the nurse can say, "Hey, you know, you're targeting negative one to zero, they're actually, you know, more like plus one to plus two, how are we going to get to the target?" And Karen said something like this a few months ago and it really stuck with me and it really has changed the way that I practice in a really meaningful way. Going back to what Peter was saying earlier about experience, nurses being very comfortable with titrating sedation. I think our greatest success is empowering our nurses not to titrate something but to actually define the target. And more and more, our nurses, we're trying to encourage them to give us the sedation target, not us prescribe it. And that's why we have the glass door and encourage the nurses to, you know, you tell us what sedation target you think this patient should have. And I think proud as moments are hearing when we are aligned when the nurse says, "Yep, you know, I think it should be a rast of zero today." And this is how we're going to do it. And I don't want to, you know, be overly critical of nursing staff because I just going back to what Sharon was saying earlier on, where we have sedation guidelines but it is, and I was a sedation guidelines but it is, we do have to write the orders. And I do hear you when you say, you know, "Why hasn't my doctor written this order yet?" And I think what you're dealing with is with the culture of physicians where there is also variability in opinion, even though we have sedation guidelines, it may not be their main objective in terms of, you know, managing the sedation piece. And then you have junior staff who are driven, the orders, the time at which they write something is dependent on what they think or anticipate that their staff person might want. So I do find that it is challenging for nurses when the physician, when you've made a recommendation for a goal and a target and then your physician hasn't written that order to help you achieve your target. I keep hearing, you guys say, nurses comfort level. And I don't know how accurate that is because there's been a lot of times that I've been very uncomfortable with the plan, but I have trust in the team that like Peta said, like there's trust that if we need that emergency medication, we're going to get it. And I think that that's sometimes a big component with some of the new people coming in and some of the relationships between staff. If you don't have trust in that nurse's assessment and you go to the bedside and you're like, I don't see this. What do you, I've been here for five minutes and they've been fine. There has to be that trust between the two to make all of this work. There has to be a trust in the assessments that you may not see it at that time because that patient's up and down and around the corner. Trust that the nurse has done other things before going to sedation. Trust that they have done massaging if it's a bath time or that they've tried to comfort them, that they've gone through different techniques with the parents and having the parents comfortable with the nurse as well, going through things like you, you can hold the, if he gets upset, hold his hand, talk to him. So that all of us are on the same page. I think what you've said is so important because the family at the bedside can see what's going on. The team doesn't trust each other and if you have a discrepancy and you're not on the same page, it makes them anxious. And I find that sometimes those conversations happen in the room. Excuse me, you want me to do what? Or why haven't you sedated this patient because he's really, really anxious right now. I think sometimes we just have to be more aware of how the the family perceives these conversations in front of them. And I think a lot of this is similar to the early mobilization. I bring everything back to early mobilization apologies, but only because our journey with respect to our delirium algorithms and protocols and sedation followed after instituting early mobilization. So I bring it all back to that, but we started with, you know, what's the target? I want to get this patient out of bed. What's the sedation target? Oh, I want this patient awake. What do I need to do to make that happen? It was really about getting a lot of buy-in from a nursing staff because it's not just about the drugs. As you said, Greg, it's also about, can I untie this patient? Can I untie this baby? Can I untie this patient with developmental disabilities and allow them to awaken when I actually don't know what their baseline is? I think that's what is really impressive now is that increasing evidence in pediatrics. As there's no, those patients are no more dangerous when they're awake than other patients who can verbalize. And I think that's really, really important and really convincing evidence that's really going to move the fields forward in pediatrics. J.A.S.H.R.E. maybe I cannot ask you a question. What was your history in your unit? I noticed in the trial you used the Ramsey score and there I think there's so many sedation scores that are being used now in pediatric ICU does get confusing and perhaps challenging. Yeah, I think that's a very, very important question, Karen. As you rightly said, we used the Ramsey score for the RCT that we did comparing continuous and intermittent sedation. But over the years somehow we have not been very comfortable with the Ramsey and lately we have shifted to the comfort B. So we use the comfort scoring. Having said that, I think there are many scores. It can be very confusing and especially when we want to empower nurses, it's important that we kind of keep it minimally confusing for them so that it becomes easy for them to become part of shared decision making. But somehow over the years, maybe about four, five years, the whole team seems quite comfortable with the comfort scoring and that's what we have been using lately in our ICU. Another point which I wish to kind of emphasize, I was just hearing the interesting conversation that was going on. It's important for all of us to kind of emphasize to the team. As soon as the patient stabilizes, the talk should be more about the de-escalation, whether the de-escalation is related to fluids, whether it's related to ventilated requirements, the ways of active drugs or the analgo sedation. The team should get kind of tuned to the fact that once the stabilization has occurred, which may be few hours into ICU, the talk should be more about when we are going to decrease everything. This way, I think the team starts looking at a different perspective and probably at the lower end of the spectrum where it's important for them to realize that decreasing is as important or probably more important than simply escalating things, whether fluids or antibiotics or I think pretty much the principles apply for most interventions that we do in ICU. So we kind of stress that. There is a daycare sheet which denerses and the doctors together fill up and that has a mnemonic at the end of the daycare sheet. I'm sure many of you must be aware, which is the fast hugs bit. So one of the S there stands for sedation. So it's important that they kind of recount what is the sedation and then the immediate question is that can we bring it down, can we kind of take off, is the child really requiring it. So these that kind of reminder there every day, once in the morning and once in the evening, when the sheet is seen thoroughly, I think it kind of keeps ringing the bell that we need to come down. So I think coming emphasis on the coming down part is probably very important for all ICU interventions and same for the analgo sedation. And the other important thing about parents perspective that we I just heard you guys talking about, our set of parents is very different. At least I would say that more than 50% of the parents, they come from economically weaker section and they have no idea of what is going on for the patient and so they have kind of completely surrendered to the treating team, the nurses and the doctors and they have full faith on whatever is being done for their child. But we have a system where the parents stay with the child in the ICU 24 into seven. So the presence of the family member, whether mother, father, grandmother or any uncle aunt, whatever, by rotation, I think that's a huge help for the nurses and also plays a huge role in the psychological well-being of the child. So we are kind of like we can motivate the parents to keep talking to the child and probably the non-pharmacological interventions that is coming up in such a big way as far as an algo sedation is concerned. I think something that we obviously need to improve upon it, but we have the parents presence probably is a very important factor for us there. That's a different perspective in our unit as compared to what we discussed in the other units. Yeah, I really liked what you said in terms of, you know, it's similar to active de-resuscitation and de-escalation. And I think for us because we see the sedation and algo sedation practices very much as part of rehabilitation because ultimately the objective is to improve functional recovery, just as much as any other organ system. It should happen as soon as your patient has being resuscitated and that it should happen in parallel and in integrated into practice and not in series, not as an afterthought, not, you know, at the tail end or the back end. And we used to we used to use fast hug and now thankfully we have a couple of letters in the alphabet that we can think of with respect to A to F bundle. And I think that's I think people can remember ABCDEF, perhaps at least easier in our unit. And A can stand for many things and for in our bundle, I think reminding people that A means allow awakening. Very much also helps us remember, I think the sedation scales that we were talking about and we simplified it. And I think Jonathan will remember this. We reviewed all our sedation scales and really what we were using at that point in time was comfort, which is I can't remember how many numbers there are in that at least up to 30 or more and only applied in the mechanically ventilated patient. Really didn't allow us to apply assessments of level of arousal in all patients in the unit which we do need to because delirium management is dependent on that. And so it would be really nice to start seeing some consolidation of those scales across units to simplify things because rather than thinking about the number, the concept is awake and comfortable, asleep and comfortable, not agitated, pain free, not in distress rather than what number do you want to target because I think conceptually that becomes, there's so many scales that we use, it becomes very difficult. And so this concept of sedation stewardship I think is so important just like any other stewardship, just like antibiotic stewardship, we should be having that discussion every single day and how you do it depends on your unit. And what they're ready for, the concept should be, you know, how can I allow this patient to awaken whether it's by sedation holiday or daily interruption or reduction by a proportion, even we can achieve that go to allow that patient to awaken. Then I think we're really moving forward. Just as much as I think, you know, we're in this mindset of allowing awakening in the daytime, I don't think we focus enough on good sleep. And perhaps Jonathan, you can help us understand how we've evolved in this practice as well. We tend to load on nighttime sedation because okay, lights are out, maybe parents have gone home, it's nighttime, staffing may be different. And so I do think that we use more, I will say chemical restraint at nighttime. I understand the philosophy and I understand the challenges with respect to, you know, that what nurses need, how they need to nurse their patient. And I think in that case, we don't need to marry ourselves to a certain, the same drugs that we were using in the morning. I think you can rotate drugs or think about different drugs at nighttime that might facilitate sleep just as much as, you know, what we do in the daytime to facilitate awakening. Jonathan, what are your thoughts on that? Yeah, I think we've made a lot of headway in the last few years, kind of shifting towards that sedation stewardship. And I think that also applies at night too. Because I think we used to be quick to think of using benzodiazepines at night. Now we've flipped the switch so that we pretty much ask All our patients that have difficulty sleeping at night, whether or not we've tried melatonin or something as kind of a first line. And then we think to ourselves, I think just from a sedation standpoint, what agents might have more of a role or a signal and maintaining sleep architecture. So sometimes we do lean on press edX or dexmenatomidine, especially for the patients that have difficulty tolerating non invasive ventilation at night. And oftentimes we try to wean them to to high flow during the day and then we we might still be stuck on by a pep during the night. So we feel like our unit has kind of shifted towards that practice model, I think. And then also I think as we've gotten a lot more comfort in screening for delirium, but also managing delirium. Sometimes sleep issues and and and delirium symptoms coexist together. And and in that sometimes some of the agents that we use to manage delirium also help with sedation and sleep. So I think it's a complex situation sometimes. But I do I do feel like a shift in our unit has gone towards more of a situation stewardship when able mindsets and to be very thoughtful about what we use, especially at night as well. And while we are talking about, you know, the importance of de-resuscitation as much as resuscitation and stewardship, one of the things that I think has been a real practice shift in my still relatively short career has been this practice of incredibly slow reductions in doses in extra awake and extubated patients. And then sending them out of the ICU on often two or even three agents, you know, Benzo and opioid and alpha agonist. And you know, these are kids who have already had a long and complex stay often and have other morbidities. And I just something that really worries me for a couple of reasons, like I worry about sending sleepy patients to the water patients that would be more sleepy. I worry about whether it contributes to readmission and respiratory problems on the ward. I worry that the people we're sending them to don't know how to manage these drugs. You know, I've got asked to give a talk to our pediatric residents about how to wean triple agents on the ward. And I'm like, why are we sending patients to the ward on three things? I'm just wondering if, you know, this is other people's experience, how other people address that. Obviously it comes from a good place of not wanting to cause withdrawal in patients. But I really do wonder if the balance is tipped a little bit too far in terms of over supplying these drugs and not weaning them fast enough. Yeah, I think we in our ICU setting one of the things that we always think about earlier on too is the site from the situation stewardship is trying to liberate patients from their IV infusions. So I think in doing that and thinking about that earlier on, we were able to chop down on some of the doses quite significantly. Kind of leading up to their to their discharge from the ICU. But I do agree with you. It's a it is a little bit nerve wracking sending these patients. And I think that's one of these even if we create some of these tapering schedules, I often find myself having to really triple check some of these these suggestion orders and put down specific times for for when they're supposed to be given and if and having all these if then do that. And I think that's not always the set up for the most success either right as things change, but. But I'll have to say some of our our weaning guidelines do do help give us some guidance in in anchoring us and kind of explaining to the ward what we would do in certain scenarios if something was to come up. Yeah, our weaning guidelines will will kind of dictate the pace at what to wean and simultaneously even at some points and we're comfortable with doing that. So. And then also if we run into withdrawal issues, for example, then it kind of steers people into thinking about what we would do in that scenario, be it pausing the wean or maybe taking a step back. So I think with a resource like that, it helps both our pace team, which which follows up on some of these patients and helps with some of the problem solving in the initial transition to the ward and it also helps anchor people with what we keep at the forefront of our thoughts in the ICU with problem solving through some of these sedation weans. So I think what you said Greg reflects how we've evolved with respect to sedation practices in pediatric ICU and what is increasingly clear is that we should have best practice guidelines or algorithms or protocols that are tailored and customized to the unit. And that it's not about the best sedative, but the best approach and the data and the evidence is increasingly clear that it should consist of the following one analgesia first approach to reduce your deliriogenic drugs, three, a stewardship approach that allows you to reduce or deescalate sedation every day and for ad adjuncts. Part of that those algorithms include weaning algorithms or sedation holidays, if you will, and so on. And I think apart from the increasing data of decreasing duration of mechanical ventilation and a length of stay with the use of an algal sedation guidelines, we can reduce withdrawal and delirium. And we'll be examining our own local data soon, but I think we're also reducing polypharmacy by limiting the approach to focus on those principles. And the other aspect that you talked about in with respect to transferring patients out that the ward has to inherit and we've heard from the ward. And that the data is still something that we have to analyze yet, but anecdotally, they're not having to manage the patients inherited with two, three types of classes of drugs on board. Part of it is because of our sedation stewardship and our weaning guidelines, but also based on the principle that we should not be sending patients out who are not neurologically stable. And that's included in that our patients who are at risk of withdrawal and patients who are at risk of delirium. I want to ask a burden question. Is how each of you manage in your units the use of restraints? And I mean, solve the constraints. Do you use them in your unit as it widespread? If you notice a change? And I'll buy it first. What was really interesting to me moving to Boston was that there was like 80 hours of net learning to be done before I could start work. And one of those hours was about the rules and regulations about the use of software strengths in patients. And it was probably the first time as a physician and an intensifist that I'd really thought about it because in my previous kind of environments, it had been used infrequently by my estimation. And was mainly a nursing decision. And yet one of my friends was in intensive care, having had a very part of him route. And her biggest PTSD associated with that wasn't nearly dying, wasn't nearly losing the baby. It wasn't the massive hemorrhage and all of the blood products. It was when she was waking up being physically restrained and feeling like she couldn't breathe. And she could talk about that so eloquently, but it really changed my perspective on it, even when I saw it by kind of passing. But moving to Boston, there are real protocols that say that every hour the patient has to be assessed by a physician and termination made as to whether or not the physical restraints are required. Now, I don't see that because obviously it's a frontline staff who do most of that. But since it's funny that we're having this discussion today because the first time I've seen physical restraints on a patient here for a very long time was last Thursday in an adult in a postoperative adult patient who was personally terrified of having delirium after his procedure. And so really was requesting minimum use of certainly the Lyria genocagins, but any conscious, what kind of any neurologically modifying agents. And he had softer strengths on in our unit. And I don't think I've seen it for the longest time, so I'm really interested to hear how different that is in your practice. Sorry, a long answer to a short question. We had, like I would say about maybe a decade back when we started ICU and we were getting used to the procedures, the nurses had the tendency of using soft wristrains in patient. But I must say that over the years this thing has kind of become very uncommon and only in very select few and that too when the sedation is being weened off, where there is a protocol and the sedation is coming down. That's when the patient is getting more awake and tends to pull out tubes and maybe an accidental extubation, the nurses are worried so there may be a soft wristraint. But I think I would say that maybe it's kind of 10 to 15% and dropped from when I don't have official figures, but I have seen it very often when I was a younger faculty and when I was a kind of resident, but now I hardly get to see them maybe very few. So I think that's a good change and probably patient being awake is better rather than restaining the patient. I think this particular sensitization has now come up in a big way. I would say they're actually very commonly used in our unit, which is something we do want to change. I've only been there for years. So I don't actually know whether that's a new thing or whether that's an historical thing, but I would say the majority of our patients would have soft wristraints, even ones that are awake. And yeah, I'm not sure the reasons that are driving that still. So I feel like we've came a long way with wristraints and I would have thought that we were using them a lot still. And then I went to adults recently and like you said, Peta, it was every single person who was intubated how to restraint. And it just took me back to some of my other practice when I was working in the shelters with some of the youth and they would talk about traumatic experiences they've had in the past and how that could be such a trigger waking up being held down and we don't know people's past and just thinking about that from a different perspective of what that restraint could mean to somebody really, I don't know, really hit me. I think that we've gotten a lot better using the restraints. We do things like we bundle the babies in a tight swaddle rather than restraint where we used to just restrain them as well. I think we've became more cautious about how we're restraining. We've loosened them so that they have some mobility when they're moving. Their hands meaning like they'll be able to hug their teddy bear but not enough to get up to their tube. So they have some movement but not total. But I can't help but feel like that is a huge driver into Delirium still. I think that having parents like you spoke about at the bedside is a huge thing that I think helps nursing feel more comfortable with restraining, with doing less restraints knowing that there's someone they're watching them if they do have to step away. But I feel like it's something that I'm hoping we can improve on. Yeah, it's impressive to hear Peter that it's rarely used in your unit. I would say we are perhaps more aligned with Sydney where the use is still common. And we do have policies and procedures with respect to restraint use but it is I believe liberally used. As insurance meaning I will see a patient who has the restraints on their wrist but not necessarily anchored just in case they need to anchor it quickly. And I would really like to see that change but I think we have come a long way. I think we had to decide which was the low hanging fruit to target first. And now that we've achieved some degree of sedation stewardship I think the next thing is just really highlighting the negative impact of restraints that restraints can have not just to the patient but to the family members as well. And I've seen even when parents are at bedside and I asked to remove the restraints because the parents can hold their hand on either side of the bed. There's still a hesitancy I think that's still steeped in tradition but it's really encouraging to hear that your units have evolved. I'm very much advanced and I think this is something again another variability in practice that we can work on. It's so interesting. I find the variability in practice that we don't usually think to ask about. It's one of the most fascinating aspects of talking to people from all over the world in this medium. We've found that with everything from the offering pre-singleventical surgery, ECMO or resuscitation to patients, we've found that with basically everything we've ever asked a group like this to just reflect what does your practice look like. Pre-cutting from where bypass steroids. The use of antibiotics in different conditions. It's pretty much everything. I had no concept that there would be so much variability in the use of restraints. I thought it had just gone. You've reminded me about, we've talked a lot about sedation titration and titrating up in de-escalation. Part of our algorithm is to actually ask why you actually need to start sedative infusions in the first place. We've evolved a lot. I think when our post-docs used to come and then the fellow would hand over to you and they'll tell you he's on two of this and two of that. You ask why and the answer would be because that's the way it's usually done. Now I think just asking the question makes them hesitate and try to rationalize that decision just like rationalizing anything else. If they need to start something and we talked about analgesia first, you don't need to default to an infusion and we encourage intermittent use. In fact there's a great RCT and love, I think by pink in the cardiac population that randomized to infusion and intermittent morphine and found no increase use in the intermittent morphine group of PRNs fascinating. Now I think when we talked about variability of practice, I think the presence of parents initially we always when we saw the units in the west and the resource rich countries where parents are not allowed to take part in the care of the child and it's all nurse-driven because they have one is to one stuffing ratios. We would be worried that we are allowing parents inside but now over the years we have actually realized that this practice is kind of very advantageous to us. It's a win-win situation both for the parents as well as the nurses. And the child. And the child, yeah, the child. So the psychological impact of the parent being by the side of the child, I think it's a huge advantage. A huge advantage. I think one of the reasons I think Sharon correctly pointed out the decrease in the use of soft restrain and I unit is because the mother or the father or the grandparents are around and kind of they can take care even if the nurse is busy and we don't have one is to one stuffing ratios. So I think family participation and care probably is one of the variability in practice. I think it's actually worked to our advantage which is what I'm realizing now when I kind of discussing with you guys because we always used to think that this is this may not be a good thing in terms of infection, visitation but then it has so many advantages. So it's kind of we need to balance it. I think that that's the best thing that you guys are doing. I can't say enough about it involving the parents has been a game changer in my practice, establishing that rapport, giving them things to do. Their anxiety comes right down when they know what they can do when they become comfortable with you. And that I feel like decreases the child's anxiety. Babies they feed off of each other. They feed off your emotions when you're anxious, they're anxious and when they wake up and they see their mom crying at the bedside versus this is what a versus a parent who's prepared for that. This is what this might look like. This is what you can do. This is what we found worked. Is there any songs that he likes to sing or she likes to sing? Here's your stuffy. These are things that I think are so important in comforting the child without any of the situations that we need to give or in Algese, these are things that should be first line. And then we'll be able to take off those things in my opinion. Having worked in the adult population, I would be interested to see the studies that come out of that. that with having no family at the bedside in the amounts of sedation that we've had to give and the restraint use because there wasn't the time and there isn't the time and there is nobody there. There is no familiar face reminding you of where you are or that you're okay or you're waking up in a strange room and again bringing back any past traumas in some of your older populations like Pediatrics up to 18, we've had children who have been abused or like horrific things have happened and the more that we can get those things and make them feel comfortable with us, making that trust between everybody, I think is so powerful before any of the other comfort measures that we can take. - Can I just ask, Jechery, you said specifically the language that you use and I don't want to misquote you but you said that the parents are participating in the care of the patient at the bedside, just to make sure that I'm not envisaging something that's not real, what sorts of care do the parents engage within the ICU, in your ICU? - So some of the daily needs of the child, changing of diapers, cleaning the baby along with the bedside nurse, it is sponging the baby, they in fact keep a tab on the numbers once they are educated and told, they see to it that all the lines, the IV, the drugs which are flowing are fine, they don't touch the lines but they always keep a watch. And of course, like for children who have started recovering, there would be videos that would be music, they've talked to the child, they read out stories for the patient. So in care, I would say basically the daily needs of sponging the child, cleaning the child, changing the diapers, they in fact even help the nurses, empty the urine bag, measure the urine and kind of tell it to the bedside nurse. And it's kind of a compulsion for us because our staffing ratios are not one is to one. So it's kind of one is to three, as I said, with this COVID pandemic or we function at one is to two. So the nurse is really very busy. So these are some of the tasks the parents help. So I feel that it's a kind of a symbiotic relationship, it helps the nurses as well as the child feels comfortable and cared for having a parent around. So a lot of the day. As I hear you saying that, I can remember, maybe five families who also got to that sort of point in our unit who had long term chronic critically ill patients who were in our unit, who would also say, oh, there's 64 CCs in that diaper or who would make sure that the trait was well positioned and the ventilated tubing was kind of all appropriate as the child was scrambling around in bed. But I don't, I just wanted to clarify, you mean pretty much every patient in your unit's family is measuring your own output and helping keep the line straight or is that also a small fraction of the patients but just the ones that care? - Every patient in the unit has a family member accompanying around the clock 24 into seven, they are there bedside with the child, the sponging, cleaning, changing of diapers, weighing of diapers for those who are not catheterized and of course helping the nurses measure the urine volume. This is pretty much done by every parent who's sitting bedside with the child. But the rest of the things as I said, like looking at the stats, looking at whether the lines are all fine, this is just visual inspection, no touching, they're not allowed to touch any lines or any tubes or anything, any monitors, they can't silence the alarms, nothing they can do. But yeah, for all patients, the rest of the health is done by the parents, they participate. - Wow, I think we've got lots to learn from you. - I think no matter what kind of setting you are in, whether it's resource limited or resource rich, family engagement is demonstrated to reduce anxiety, reduce pain, facilitate mobilization like we talked about. And it also helps them, not just empower them, but helps them gain some control, decreases their anxiety, decreases their anxiety, post leaving the ICU as well, there's data on that. I think this field is really going to move forward. I feel like we've really made a lot of progress with respect to analgesia and sedation practices and critical children. We're starting to think about not just different agents, but the principles, the algorithms, and thinking outside of the box, and it reminds me that we had a couple of patients, teens actually, that we used PCAs, and they weren't patients who were using PCA for pain, but we just administered PCAs so that they could give themselves their own analgesia while they were intervening, intervening. So I think lots of things to come. - Well, thank you all for being a part of it. It was really amazing panel line, such a rich conversation. Thank you very much to Sharon and Jonathan and J.S.R.E. for all making the time and the effort, especially for such an early morning, J.S.R.E. - I really enjoyed it. - It was great for us. I think the three of us from McMaster to hear about the perspectives coming from India and Boston and Sydney because I'm taking down notes for the next things to do that we can learn from you guys. It's been a great learning experience for me as well. I'm liking it. Thank you. [Music]