Pratik Pandharipande, MD, MSCI Department of Anesthesiology

1. Pratik Pandharipande, MD, MSCI Department of Anesthesiology Vanderbilt University School of Medicine VA TN Valley Health Care System Teamwork and Multidisciplinary Approach to “Wake Up and Walk Implementation of the ABCs of good sedation practices in the ICU

2. Need for Sedation and Analgesia 1. Prevention of pain and anxiety 2. Decrease oxygen consumption 3. Decrease the stress response 4. Patient-ventilator synchrony 5. ? Prevention of psychiatric illnesses– depression, PTSD Rotondi AJ, et al. Crit Care Med. 2002;30:746-52A. Weinert C, et al. Curr Opin in Crit Care. 2005;11(4):376-380. Kress JP, et al. J Respir Crit Care Med. 1996;153:1012-1018.

3. Pitfalls of Sedatives and Analgesics Sedatives and analgesics may contribute to Increased duration of mechanical ventilation Length of intensive care requirement Impede neurological examination May predispose to delirium Kollef M, et al. Chest. 114:541-548. Pandharipande et al. Anesthesiology. 2006;124:21-26.

4. The ABCDE approach of good sedation and delirium management • AB- Awakening and Breathing Coordination • C- Choice of Sedative • D- Delirium monitoring and management • E- Early mobility

5. AB • Awakening and Breathing

6. Daily Interruption of Sedatives 100 80 Ventilator time reduced by 2.5 days Adjusted P<.001 60 Patients Receiving Mechanical Ventilation (%) 40 Control (n=60) 20 Protocol (n=68) 0 0 5 10 15 20 25 30 Time (Days) Kress JP, et al. NEJM. 2000;342:1471-1477.

7. The ABC Trial(Both groups get patient targeted sedation) Control Intervention Girard TD, et al. Lancet. 2008;371:126-134.

8. Benzodiazepines 70 Usual Care + SBT 60 SBT + SAT 50 40 Daily Dose of Benzodiazepines 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Study Day

9. Successful Extubation 100 SAT + SBT (n=167) 80 SBT (n=168) 60 Patients Successfully Extubated (%) 40 20 Mean ventilator-free days, 14.7 versus 11.6 days 95% CI for the difference, 0.7 to 5.6 days; P=.02 0 14 21 28 7 0 Days Girard TD, et al. Lancet. 2008;371:126-134.

10. 100 80 SAT+SBT (n=167) 60 Patients Alive (%) 40 SBT (n=168) 20 Hazard Ratio=0.68 (0.50-0.92), P=.01 0 60 120 180 240 300 360 0 Days Improved 1-Year Survival in ABC Trial Girard TD, et al. Lancet. 2008;371:126-134.

11. Implementation challenges and multidisciplinary approach to overcome barriers

12. Sedation Safety Screen Components of the Awakening and Breathing Coordination FAIL PASS- Sedation Cessation SAT Trial FAIL SBT Sedative Restarting Criteria

13. Safety Screening Criteria • Why have a safety screen? • Does it have to be tailored to different populations/ICU or can you have one? • Key Question: When is it not safe to stop sedatives?

14. Spontaneous Awakening Trial Screen

15. Key players to get involved • Approvals from unit specific physician and nursing leadership • ICU Director or designee • Nurse educators and charge nurses in each ICU • Respiratory therapists in each ICU • Champions in each unit (nurses, NPs…) • ICU Team for reinforcement

16. Allay Concerns “I think that, to get nursing staff buy-in (especially in the CVICU where hemodynamic swings can be devastating), it is important to clearly define hemodynamic instability.” “If we start with what all consider to be reasonable, then we have more likelihood of additional patients included later. If we start with criteria that the nurses consider to be “dangerous”, we will not get buy-in.”

17. Allay Concerns “Is there any more specific definition for hemodynamically unstable – including a timeframe from a last major intervention to get them stable? (Example: If the patient is now at target for their blood pressure, PA pressures, or heart rate, but they have only been there for two hours after a raucous 12 hour chase, are they now hemodynamically stable and eligible for SAT?)” “Do you want a nurse to determine hemodynamic instability or cardiac ischemia. We have some new nurses in our ICU” “Surgical patients have pain. I don’t want to stop analgesic infusions.”

18. Responsiveness to concerns: modified SAT screen 1. Active seizures? 2. Active ETOH withdrawal? 3. Ongoing agitation (RASS ≥ +2 in last 4 hours)? 4. Paralytics or a RASS order of -4 or -5? 5. SpO2 ≤ 88% and FiO2 ≥ 0.70 ? 6. Myocardial ischemia (troponin ≥ 0.2 µ/L) ? 7. Hemodynamic instability in previous 4 hours?* 8. Abnormal ICP (≥ 20 mm Hg)? 9. Open abdomen or similar contraindications for wake up ? • *Use of 2 concurrent vasopressors/inotropes, or > 7.5 µg/min of norepinephrine or epinephrine or > 7.5 µg/kg/min of dopamine or dobutamine

19. C • Coordination of Awakening and Breathing

20. Timing of SATs/SBTs • Night shift? • Day Shift?

21. RN Staff (email from educator): We understand the reluctance to discontinue sedation on a ventilated patient first thing in the morning, when you haven’t seen your other patient. So, here is the compromise in step-by-step format after discussion with a large group of your peer nurses and physicians. 1. Complete your bedside shift report on all patients in your assignment (645-7 am) 2. Complete your assessments including SAT safety screen on both patients (7 am -730 am). 3. Start the SAT trial if the patient passes the safety screen. This should happen sometime around 730-8am. Notify RT 4. When the team rounds, you should address your progress on the SAT trial. Even if you haven’t started the actual trial, the team wants to know during rounds whether or not the patient is eligible for the trial. In short, communicate with the team about the status of the SAT. 5. Notify the team that the patient of the results of the SAT/SBT

22. Sedation Safety Screen Components of the Awakening and Breathing Coordination FAIL Sedation Cessation SAT Trial FAIL SBT Sedative Restarting Criteria

23. Sedation cessation-practical aspects • Once safety screen is passed, discontinue ALL sedative and analgesic infusions; prn analgesics OK • We stop dexmedetomidine UNLESS to treat delirium • Inform respiratory therapist to coordinate SBT • Sedative/Analgesics stay off until • Pass SAT/SBT and move towards extubation • Need for some sedation based on RASS target • Fail SAT (SAT duration >4hrs not a failure criteria) • Restart at lowest dose needed to maintain RASS target

24. Involve Nursing in Morning Report: Mandatory Documentation

27. Feedback and Auditing • Daily during rounds- attending or designated champions. We are using our NPs and pharmacists who are constants in the ICU • Weekly reports • Focus on education and not being punitive • Feedback from users • Electronic prompts/reminders

29. C • Choice of sedation (after analgesia and if needed)

32. Analgesia/Sedation Protocol for Mechanically Ventilated Patients • Bolus dosing prn with either • Fentanyl 50-100 mcg • Hydromorphone 0.1-0.3 mg • Morphine 2-5 mg In pain? 1 Yes No Yes Reassess often Controlled or anticipated control with < 3 bolus doses/hr No Analgesia may be adequate to reach RASS target • Fentanyl 50- 300 mcg/hr gtt • Fentanyl 25-100 mcg prn pain At RASS target? 2 No No Yes Over-sedated Under-sedated Hold sedative/ analgesics to achieve RASS target. Restart at 50% if clinically indicated Reassess often • Propofol 5-30 mcg/kg/min • Dexmed 0.2-1.5 mcg/kg/hr • (if delirious†/weaning) • Midazolam 1-3 mg prn‡ • (ETOH withdrawal or propofol intolerance*). SAT+SBTdaily Physical therapy CAM-ICU positive -Non pharm management - Pharm management CAM-ICU negative Reassess q 6-12 hrs Delirium ? 3 ‡ Midazolam 1-3 mg/hr gtt rarely if > 2 midaz boluses/hr and propofol intolerance * Propofol intolerance refers to propofol infusion syndrome, hemodynamic instability , increasing CPK >5000 IU/L, triglycerides >500 mg/dl or use >96 hrs .

34. PRECEDE Model for Improvement • Predispose • Enable • Reinforce

35. Predispose for Success • Must identify and understand current needs and barriers to adoption • Knowledge • Needs • Skills • Values

36. Address Knowledge Gaps • Address Knowledge Barriers Explicitly • Physician / Nurse / RT education • Multidisciplinary Educational Seminar • In Service Training • Grand Rounds • Journal Clubs • Posters • Readily Accessible Materials • Web-site development / Access

37. Barrier: Knowledge Gaps • Barriers to Sedation Protocol • Use may cause oversedation • Not appropriate for select patients • Possibility for undersedation • No proven benefit • Barriers to Sedation and Ventilation Interruption • Concerns about device removal • Compromising patient comfort • Lead to respiratory compromise • No proven benefit • Leads to PTSD Tanios MA, et al. J Crit Care. 2009;24:66-73 Devlin JW, et al. Crit Care Med 2006;34(2):556–7 Ely EW, et al. Am J Respir Crit Care Med 1999;159:439–446

38. Barrier: Unmet Needs Sedation Protocol and Sedation / Ventilation Interruption • Lack of physician order • Protocol not accessible when needed • Inconvenient to coordinate Tanios MA, et al. J Crit Care. 2009;24:66-73 Ely EW, et al. Am J Respir Crit Care Med 1999;159:439–446

39. Addressing Unmet Needs Make Protocol Accessible When Needed • Integrate with electronic medical record • Make available at charting area, bedside, and common gathering areas • Attach to charting areas • Attach to ventilators • Use pocket cards • Bedside reference book

40. Enable Success Optimize your environment: Resource support • Engage hospital and unit level leadership • Seek and provide administrative, financial, and professional support • Engage informatics and data management support for evaluation

41. Reinforce: Data audit and feedback • Critical to measure performance • Quantitative and Qualitative • Qualitative • Informal • Formal • Interviews • Focus Groups • Observation of processes • Process mapping

42. Reinforce: Reward and Recognize • Reward excellent performance • Display pride in job well done • Public display of performance improvement • Posters • Website / Blog • Newsletter • Recognition of leadership and quality improvement

43. Conclusions • Implementation must be • Interdisciplinary • Automated • Integrated • Monitored and Assessed with Data