Pratik Pandharipande, MD, MSCIDepartment of Anesthesiology
Vanderbilt University School of MedicineVA 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
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.
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.
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
ABAB•Awakening and BreathingAwakening and Breathing
Daily Interruption of Sedatives
Kress JP, et al. NEJM. 2000;342:1471-1477.
0
20
40
60
80
100
Pa
tient
s R
ece
ivin
gM
ech
an
ica
l Ve
ntila
tion
(%
)
0 302010 155 25
Control (n=60)
Protocol (n=68)
Adjusted P<.001
Time (Days)
Ventilator time reduced by 2.5 days
The ABC Trial(Both groups get patient targeted sedation)
O U TC O M ESd e lirium , LO S , 1 2 -m o N P S tes tin g , Q O L
S p o ntan eo u s B rea th ing T ria l (S B T)ve n tila to r o ff
sa fe ly m o n ito red
O U TC O M ESd e lirium , LO S , 1 2 -m o N P S tes tin g , Q O L
S p o ntan eo u s B rea th ing T ria l (S B T)ve n tila to r o ff
sa fe ly m o n ito red
S p on taneo us A w aken ing T ria l (SA T)tu rn se d a tio n /n a rco tics o ff
m o n ito r sa fe ly
M e d ica l IC U o n V en tila to rS u rro g a te In fo rm e d C o nse nt
ControlControl InterventionIntervention
Girard TD, et al. Girard TD, et al. LancetLancet. 2008;371:126-134.. 2008;371:126-134.
Study DayStudy Day
Da
ily D
ose
of B
enzo
dia
zepi
nes
Da
ily D
ose
of B
enzo
dia
zepi
nes
11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 1818 1919 2020 2121
00
1010
2020
3030
4040
5050
6060
7070Benzodiazepines
Usual Care + SBTUsual Care + SBTSBT + SATSBT + SAT
Successful Extubation
00
DaysDays
77
00
2020
4040
6060
8080
100100P
atie
nts
Su
cce
ssfu
lly E
xtu
ba
ted
(%
)P
atie
nts
Su
cce
ssfu
lly E
xtu
ba
ted
(%
)
1414 2121 2828
SAT + SBT (n=167)SAT + SBT (n=167)
SBT (n=168)SBT (n=168)
Mean ventilator-free days, 14.7 versus 11.6 daysMean ventilator-free days, 14.7 versus 11.6 days95% CI for the difference, 0.7 to 5.6 days; 95% CI for the difference, 0.7 to 5.6 days; PP=.02=.02
Girard TD, et al. Girard TD, et al. LancetLancet. 2008;371:126-134.. 2008;371:126-134.
Improved 1-Year Survival in ABC TrialP
atie
nts
Aliv
e (
%)
Pa
tient
s A
live
(%
)
00
00
2020
4040
6060
8080
100100
6060 120120 180180 240240 300300 360360
DaysDays
SBT (n=168)SBT (n=168)
SAT+SBT (n=167)SAT+SBT (n=167)
Hazard Ratio=0.68 (0.50-0.92), Hazard Ratio=0.68 (0.50-0.92), PP=.01=.01
Girard TD, et al. Girard TD, et al. LancetLancet. 2008;371:126-134.. 2008;371:126-134.
Implementation challenges and multidisciplinary approach to
overcome barriers
Sedation Safety ScreenSedation Safety Screen
PASS- Sedation CessationPASS- Sedation Cessation
SBTSBT
Components of the Awakening and Breathing Coordination
Sedative Restarting CriteriaSedative Restarting Criteria
SAT Trial FAILSAT Trial FAIL
FAILFAIL
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?
Spontaneous Awakening Trial Screen
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
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.”
“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.”
Allay Concerns
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
CC•Coordination of Awakening and Coordination of Awakening and
BreathingBreathing
Timing of SATs/SBTs
• Night shift?
• Day Shift?
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
Sedation Safety ScreenSedation Safety Screen
Sedation CessationSedation Cessation
SBTSBT
Components of the Awakening and Breathing Coordination
Sedative Restarting CriteriaSedative Restarting Criteria
SAT Trial FAILSAT Trial FAIL
FAILFAIL
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
Involve Nursing in Morning Report: Mandatory Documentation
Neuro Status 7am 7pmSedation RASS/CAM: ____/____ _____/____ SAT screen Passed/Failed If failed why? SAT trial
In progress/Passed/Failed If failed why?
Pain ManagementPO IV
PCA EpidPO IV
PCA Epid
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
CC•Choice of sedation (after analgesia Choice of sedation (after analgesia
and if needed)and if needed)
First Author Year Population Outcome(s) improved
Benzodiazepines vs. propofolTrials finding better outcomes with propofol
Grounds RM 1987 Cardiac surgery Faster awakening
Aitkenhead AR 1989 General ICU More consistent awakening, faster weaning
McMurray TJ 1990 Cardiac surgery Faster awakening
Carrasco G 1993 General ICU More accurate sedation, faster awakening, lower costs
Roekaerts PM 1993 Cardiac surgery Faster awakening, earlier extubation
Ronan KP 1995 Surgical ICU Faster awakening
Sherry KM 1996 Cardiac surgery Lower costs
Chamorro C 1996 General ICU Better ventilator synchrony, faster awakening
Barrientos-Vega R 1997 General ICU Earlier extubation
Weinbroum AA 1997 General ICU Faster awakening
Sanchez-Izquierdo-Riera JA
1998 Trauma ICU Faster awakening
McCollam JS 1999 Trauma ICU Less oversedation
Hall RI 2001 Mixed ICU More accurate sedation, earlier extubation
Carson SS 2006 Medical ICU Fewer ventilator days
Trials finding no differences in outcomes
Searle NR 1997 Cardiac surgery None
Kress JP 2000 Medical ICU None
Huey-Ling L 2008 Cardiac surgery None
Trials finding better outcomes with the benzodiazepine
None
First Author Year Population Outcome(s) improved
Benzodiazepines vs. remifentanil
Trials finding better outcomes with remifentanilBreen D 2005 Mixed ICU Shorter duration of mechanical ventilation
Muellejans B 2006 Cardiac surgery Earlier extubation and ICU discharge
Rozendaal FW 2009 Mixed ICU Lighter sedation, shorter weaning time
Trials finding no differences in outcomes
None
Trials finding better outcomes with the benzodiazepine
None
Benzodiazepines vs. dexmedetomidineTrials finding better outcomes with dexmedetomidine
Pandharipande PP 2007 Mixed ICU More accurate sedation, more delirium/coma-free days
Riker RR 2009 Mixed ICU Lower prevalence of delirium, earlier extubation
Ruokonen E 2009 Mixed ICU Shorter duration of mechanical ventilation*
Maldonado JR 2009 Cardiac surgery Lower incidence and duration of delirium
Esmaoglu A 2009 Eclampsia Shorter ICU length of stay
Dasta JF 2010 Mixed ICU Lower ICU costs
Jakob SM 2012 General ICU Lighter sedation, fewer ventilation days
Trials finding no differences in outcomes
None
Trials finding better outcomes with the benzodiazepine
None
In pain?
Reassess often
Reassess often
Bolus dosing prn with either•Fentanyl 50-100 mcg
•Hydromorphone 0.1-0.3 mg•Morphine 2-5 mg
•Fentanyl 50- 300 mcg/hr gtt• Fentanyl 25-100 mcg prn pain
At RASS target?
Under-sedated Over-sedated• 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*).
Hold sedative/ analgesics to achieve RASS target. Restart at 50%
if clinically indicated
Yes
Controlled or anticipated control with < 3 bolus doses/hr
Yes
NoNo
No
Yes
No
2
1
Analgesia/Sedation Protocol for Mechanically Ventilated Patients
‡ 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.
SAT+SBT dailyPhysical therapy
Delirium ?3CAM-ICU positive
-Non pharm management- Pharm management
CAM-ICU negativeReassess q 6-12 hrs
Analgesia may be adequate to reach RASS
target
PRECEDE Model for Improvement
• Predispose
• Enable
• Reinforce
Predispose for Success
• Must identify and understand current needs and barriers to adoption
– Knowledge
– Needs
– Skills
– Values
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
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
Ely EW, et al. Am J Respir Crit Care Med 1999;159:439–446Tanios MA, et al. J Crit Care. 2009;24:66-73Devlin JW, et al. Crit Care Med 2006;34(2):556–7
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;24:66-73Ely EW, et al. Am J Respir Crit Care Med 1999;159:439–446
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
Enable SuccessOptimize 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
Reinforce: Data audit and feedback
• Critical to measure performance– Quantitative and Qualitative– Qualitative
• Informal
• Formal
– Interviews
– Focus Groups
– Observation of processes
– Process mapping
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
Conclusions
•Implementation must be– Interdisciplinary
– Automated
– Integrated
– Monitored and Assessed with Data
