Episode 191: Insights from SCCM Congress- Current State of Affairs
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This is the Walking Home from the ICU podcast. I'm Kaylee Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we'll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution.

Last month, I was at SCCM with ISU clinicians from all disciplines and from across the United States and even the world. It was an inspiring atmosphere to be with bright, driven, and compassionate experts that have dedicated so much of their lives to the saving of the lives of others. My experience presenting there was a huge contrast compared to another large conference I participated in last fall. I had the incredible honor of joining a panel presentation with the

Dr. Wes Ely, Dr. Dale Needham, and Heidi Engel, who are all world-renowned leading experts and founders of ICU Early Mobility and the ABCDEF bundle. I struggled to wrap my mind around Dr. Wes Ely and Dr. Dale Needham being in the same room together as they are both involved in so many things throughout the world and are in very high demand. They both flew to Boston basically just to present

and then to turn around and fly out. I was pinching myself at the opportunity to listen to them and present beside them. Then we went to present and it was on the last hour of the last day. The room was almost empty except Dr. Marie Pavini and her group from HD Medical that make refraint devices and VR goggles about delirium and who are all

already powerful revolutionists, and then there were a few other wonderful people. It was a little deflating. No one really knows me, but to have so much wisdom and knowledge about how to save and preserve lives in the ICU through the other three experts there, and there were only about 10 to 15 people in the room. I didn't know whether to laugh or cry. So going to SCCM, I was bracing for the same experience when I got to present with Joanna Stallings from episode 149, Petriek

Pandari Pandey, who has been huge in delirium research, and Heidi Engel, the legend. It was really moving to see the hall full, people standing along the sides, lines out of the door, and unfortunately, people turned away due to maxed capacity. It wasn't just the volume of bodies in the room, but the sense of eagerness, humility, excitement, and even desperation to revolutionize critical care medicine.

If you had told me five years ago, while I was hiding in my closet with the cheapest mic I could find and feeling like I was talking to a wall, that someday I would be surrounded by such greatness in that room at that moment, and that they would actually want to know about awakened walking ICUs, I would have really struggled to believe it. Yet part of me isn't surprised. I

I always had this unfounded glimmer of hope that felt like a knowledge that there were so many good people out there that were willing to work hard to change and learn how to do the right things for patients. Feeling their energy in that room helped me realize that the revolution is about to make some big leaps in the next few years. You're actually out there. You're doing the work and making a huge difference out there. After Joanna Stallings and Dr. Patrik Pandari-Pandi debated

deep versus light or no sedation. Heidi Engel asked the audience to raise their hands if they used light sedation in their units. Almost everyone raised their hands. She then asked, do your patients actually open their eyes to voice and make eye contact with you? The hands raised dropped by about a fourth to half. I later showed a slide reflecting the spectrum of compliance with the bundle. Heidi asked the audience which level of compliance their team practiced.

When she asked, who practiced at level A, the lowest level that captured deep sedation despite light sedation orders, the SATs and SBTs only happening toward extubation. Only two people raised their hands. Turns out they were from the rehab team from a large, renowned hospital.

that has published on mobility protocols and is a, quote, model ICU liberation facility. They later explained that though their team thinks patients are a RAS of negative one, when they as PTs and OTs try to work with the patients, they are closer to a RAS of negative four. It is a huge challenge as they were the only people from rehab disciplines in the room. They suspected the other providers may not really be looking at RAS objectively. Then

Then Heidi asked who practiced at a B level, meaning that the team automatically sedates patients somewhere between deep and moderate, but does daily awakening and breathing trials. About 10 to 20 people raised their hands. She then asked who practiced at a level C, meaning patients are lumbosacral.

lightly sedated with daily SAT and SPT and the majority of the room raised their hands. She asked who practiced at a level D in which patients are awake with no sedation after intubation and two people raised their hands. In regards to level E in which all patients are awake and doing their highest level of mobility promptly unless contraindicated, no one raised their hands.

People came to the presentation because they have a passion for the ABCDEF bundle. I am sure many to most of them had been working diligently on it in their teams for many years. Yet, it was astounding to realize how new and surprising the information we shared was. It was received very well, and yet, I wondered why, in 2025, these pictures, videos, and case studies of critically ill patients being awake and mobile was

was so surprising when Polly Bailey published her study showing it was safe and feasible to walk intubated patients with a median PF ratio of 89 back in 2007. The ABCDE bundle came out in 2013, and we've had dozens of early mobility studies since then.

This information shouldn't be surprising, right? So I thought this SCCM conference would be a good opportunity to get a sense of where the mentalities, beliefs, perceptions, and practices were in this group of conference participants from so many different facilities. I had a suspicion that I could learn a lot by reframing my inquiries to make it about what treatments

they would want if they were personally in the ICU. So I approached people in the hall and asked if I could ask a few questions for a podcast. I didn't tell them who I was or what the podcast was. I told them it was anonymous, candid, and that there were no wrong answers. Everyone I approached was wonderful and willing to participate and were very interested to learn more after they had answered the questions. So this is how it went. What's your position in the ICU?

Well actually I work for the pharma industry so... Okay if you were intubated on a ventilator in the ICU would you want to be awake and moving or would you want to be in a medically induced coma? Right I think I would like to be in a medically induced coma. How come? So I've been working as a medical doctor myself

And I've seen patients and my feeling at least one particular case I have in mind that she didn't really feel well while being awake because she felt very tatted. People would do things with her. But I mean, it's a case really that I have in mind. So I don't have any scientific basis for this. And since you don't work in the ICU and this is kind of an unfamiliar intervention environment for you.

If the doctor explained to you before having that breathing tube placed that if you were in a medically induced coma, you'd have high risks of a brain injury, acute brain failure that could belong to cognitive impairments. And you might have hallucinations, which would increase your trauma and your fear. And you might lose a significant amount of muscle function and mass that would change your ability to sit, stand and walk after that coma. Right.

How might that change your decision making? So I don't know this data, but if the data was clear like this, of course it would change my decision making. Do you feel like patients have a right to be informed of those risks involved? Absolutely. Absolutely. 100%. Must be informed. Thank you. What is this for? You guys are all ICU clinicians. If you were intubated, would you want to be sedated and comatose? Yeah. Yes. Why?

I've been under anesthesia before and have woken up during the surgery. And so I have a firsthand experience of what that might feel like. And I can imagine that for days upon days. And so. Yeah. So you experienced severe pain, were unprepared. I mean, it wasn't supposed to happen. Correct. Okay. That was really traumatizing. The physical impact of being on a ventilator, being in that environment, the loss of control.

Just all of that to me, I would want to not have to be consciously aware of it and kind of skip that to when I'm ready to wake up, get up, get going, get better when I can actually do something about it. And what have you heard from patients that you've treated about what they experienced while sedated? I think that depends on the patient. There are some patients that have either had that experience before or not.

are more cognitively intact prior to the intubation, that they have more of a experience of let me get better, where there are other patients that don't recall any of it,

So it just, it really varies from patient to patient. How do patients usually come out of sedation? When you go to do an awakening trial, you guys, I'm just, okay. So you're the ones turn off with sedation. Are you so excited about turn off sedation? How do patients usually come out? No, it depends on the patient. I mean, we found with the younger population, it's a little bit trickier when they're coming off. Why? I think it's the way they metabolize the medications.

So I think that they are ones we always look out for, or more cautious, I should say, because of what kind of reaction they have. They can just bounce right out of sedation. One minute they're comatose and you shut it off where the average person would probably take a minute and then boom, they're wide awake. So...

Could their strength have something to do with it as well? Absolutely. Absolutely. We actually have a being new to the ICU when I was, I was warned like we're doing a spontaneous breathing trial. You just stay with those patients. If those are the ones that are going to throw you for a loop and try to self-excavate or because they are strong and you metabolize those medications.

And what does it do to your stress level when you have to do awakening trials? And you've heard maybe from the previous nurse, they were rodeo, they went wild, right? What is, as you're approaching that, how do you feel as a nurse? How does this impact you? Initially, I used to get nervous and I used to get like worried. And I've learned as my experience grew to get excited for the patient. And once I came into the room with that excited energy, you could see the patient kind of flip

in their response to being extubated. I love that. What if they don't pass their breathing trial? On your unit, what's the normal next step in terms of sedation? You don't pass the breathing trial, is sedation resumed? Or does the patient stay awake? It just depends on the patient. It depends on how they do during their awakening trial. So if they do well with the awakening trial, we try to limit the amount of sedation that we're giving them. You know, we try to give them a little bit more of it.

and try to give them some freedom, I guess you could say. Some autonomy over how they... What defines doing well? Being able to follow command, being able to stay calm. Sometimes they freak out and they're thrashy and they're usually restrained, so they're pulling on the restraint. So as long as they can stay calm and cool, we just try to limit the amount of sedation that's given. Okay.

What are some of the main causes of that kind of restlessness, impulsiveness, confusion, especially for these patients that you see? It's just the change in environment. They probably went under one circumstance and they're waking up under a different one.

And so, and time has gone by, they don't know how much, or it might seem like a blip in time. And so, I mean, just confusion. I think that is the biggest one, especially with the, like we were talking about the younger patients who have the more strength, but even the older who have met, have dimension stuff on top of that and are just truly confused about where they're at. Yeah.

Absolutely. Role does delirium play in this? The whole problem. It depends on how long the patients spend there. Because even our young ones can have that, you know, we call it the ICU delirium, where it makes all this, as far as the spontaneous and extubation, very challenging.

And as nurses, when you've got a patient that has ISU delirium and they're scared and they're anxious and they're confused or they're trying to self-extubate and they failed their breathing trial, maybe it was from delirium, right? Maybe they were sick because they were delirious or whatnot, right? Maybe they just are too weak to breathe yet, right? So we're not going to extubate them. And now they have delirium. What tools do you have in your toolbox?

to manage that delirium and help them better from it. Here's like on the medications we're using, maybe Rolcamot, Busby, fentanyl and propopropan, butopressin X, where we can still activate, but help them transition through. I've seen that. Seroquel is always an option as far as medications go to kind of help with that as well.

We tried to like do the day and night thing where like during the day, make sure I didn't have all the lights on, make sure we had the blinds open. And I like, you know, start to get out and try to have them flip into regular normal. You guys sound like day nurses. Okay. Okay. Well, okay. It's a good mix though. Honestly, tell me honestly from both ends. Does the station go up at night?

Yes. They need to sleep. They need to rest during normal circadian rhythm hours. I think that is more beneficial. Would you be surprised to learn that propofol, especially, as well, inhibit REM cycle three and four? I've read that. But is that commonly talked about in your unit? Are you, as nurses, equipped with that kind of knowledge? No, it's not talked about.

Yeah. So then turn on at night and then the day shift gets to try to keep the patient calm. Right. And a patient that's maybe arrested plus one or plus two. They have delirium. They're confused. They can't be extubated yet. Now, let's say you're in rounds. The physician says, let's mobilize. How do you feel about that? Just tell me just totally honestly. I'm sorry. I'm always excited. You're my style. I love it. But how about the rest of your team? Like what's a normal kind of response?

I would assume that most of them would go, oh my God, how am I going to do that? And when am I going to do that? And how is the patient going to respond? How's the family going to respond? So I think it would be a challenge. Maybe I just like challenge. I don't know.

Yeah, any other thoughts on that? I think it would definitely be very beneficial for the patient to start the mobility process, even though they're intubated. Like Ruth said, it would be a challenge because we would have to get like therapy on board. We would have to get RT like prepared for us to start the process. And of course, I just make sure everyone on the unit kind of is aware of what's going on. It's like a daunting thing to orchestrate. And it sounds like it's not something that's been done or is done.

commonly done in our unit. That's not something that you do. And its own physician was like, go do it. But our patient population is different. And that's one thing I've noticed coming from a trauma center to our little community hospital. Our patients are different. We did mobilize our trauma patients where these are generally the patients that are intubated are pretty sick and wouldn't have mobilized even if they weren't on the vent.

And so I feel like our patient population, we might have a few patients that we might be missing the mark on, but it's not a big population of patients that we have that they'd be a good candidate to mobilize even though they're vented. So most of your patients have been bed bound all leading up to the ICU admission? A lot of them. And how do you feel like the ABCDF bundle is going in your unit? I think it works well. I see trends and I've

see things improving and when the patient is improving. So I think it's working well. Awesome. Have you guys ever heard of a verticalization bed that can stand for your bed bound patients? Yes, we actually saw those downstairs. Yeah. Yes. That sounds like a big gift for your team and make it easy for everyone involved. Thank you so much. Yes, it was. So as an intensivist, if you were intubated, would you want to be sedated and comatose? Yes, I would like to be sedated. How come? Um,

It's like drowning. If something is in your throat, you may feel like you're drowning. Absolutely. So I'm completely fear of such situations. So I wanted to be sedated. I don't want to remember anything. Okay. And what have your survivors told you about what it was like to be sedated and comatose? Patients, honestly, I interviewed some patients about being sedated or being intubated.

And they said they don't want to be intubated again. About sedation, they did not remember anything. So I don't know how they felt about sedation. They don't remember anything about the ICU? Did they have any other experiences? Experiences. They did not feel hungry. But some of the patients told me that they want to drink again once extubated. Yeah.

Absolutely. And where do you practice? In Japan. In Japan. Yes. This is kind of not a topic, but the Japanese culture, if patients had had hallucinations and they were very traumatized, would they feel comfortable telling other people or a physician they saw demons in the bedroom or that they were in another alternative reality? Would that be culturally acceptable to talk about those things? Yes. Yes.

And have you ever heard that from patients? Talking about patients that had hallucinations. Uh-huh, hallucinations, yep. Yes, we had some patients. They're able to talk about it? Yes. Would you ever be willing to mobilize your own patients? Do your intubated patients get up and stand up at the bedside while intubated? I try to, with the help of rehabilitation. While they have the breathing tube? Yes.

Okay, so they're not comatose. They're not in a medically induced coma. No, we do not mobilize patients who are comatose. But you have a lot of patients that are awake. Yes. While intubated. Yes. On the ventilator. Yes. Stand at the bedside. Walking? Sometimes. But only a few meters walk. Okay. But you personally would like to be comatose rather than demobilized like that. So you mean that you want to sit it?

to the level of comatose. Yeah. You personally? No. Okay. I like to feel something, but I do not remember something bad. So you feel like some sedation. Yes. But you still like to be awake and mobile. Be able to get off the ventilator. Yes. The tricky balance, right? Thank you so much.

As an EM doctor, if you were intubated, would you want to be sedated in the ICU? I would 100% want to be sedated. We intubate people in the ER frequently and send them off to the ICU. And one of the things that I find personally is cruel is to not start them on sedation when we intubate them. So that's something I'm personally very cognizant of and very

very passionate about is if we're intubating somebody, I want them to be sedated for their comfort and everybody else's comfort as well, safety, everything. And what kind of sedatives do you usually use? It depends. So we see so many different kinds of patients. So if they're septic, that's obviously going to make things a little bit different because they usually have the soft blood pressure. That's when I usually, ICU doctors will cringe at this, but EM docs love ketamine. So that one works great.

fentanyl works great. And then if they have an okay blood pressure, good old propofol always works. And have you ever talked to survivors that have been sedated for prolonged periods of time? I have, yes. I work, the project I'm presenting is with survivors of the ICU. And I've also talked to people once they've been extubated in the ICU and their memories of

getting intubated and waking up afterwards and stuff. And it's a very traumatizing event. We have those few patients who are very calm and chill, and they actually do just fine letting them out of sedation. They are able to look around the room and interact with their family without having issues. But if we start doing that sedation and they're not doing well with it, we turn it back on and we don't want them traumatized from that event.

What role do you think delirium plays in them not doing well when sedation's coming off? Delirium definitely plays a role. It's kind of a chicken or the egg. Is the delirium causing them to not do well? Or is the trauma of waking up and having a tube down your throat contributing to them developing delirium? So I think they're kind of tied and I don't know which one comes first. So would you want to be mobilized on mechanical ventilation if you were in the ICU? I personally...

Don't think I would. No, I think I'd like to be asleep through it. Perfect. Thank you. As an intensivist, if you were intubated, would you want to be sedated for prolonged periods of time with an altered level of consciousness? For the procedural intubation or any other procedure which might involve pain and suffering, then yes. And intubation is one of those procedures. So that's why sequence intubation will require that sedation. And if, for example, those patients who cannot tolerate that level of sedation, then conscious sedation, my level of sedation to finish the procedure successfully.

Would you want to be able to write on a clipboard text, be informed and make decisions while you were intubated? Yes. If my clinical condition is getting better and keeping me awake does not impair my clinical condition and doesn't worsen the situation, then waking up on a daily basis will definitely be appropriate. And the same reason mobilizing on a daily basis, if my clinical condition doesn't worsen with that,

And we asked about walking around the ICU if my clinical condition doesn't get worse because of the walk-in, and yes. Would you want to be sedated overnight with a daily awakening, like an interruption of sedation for these things, or would you want to be awake continually? Well, even when I'm best of my health, I don't stay awake at night. So to maintain that diurnal variation in the ICU is very important. So sleeping at night,

With the help of medications, definitely will be helpful. And then waking up in the morning, if my clinical condition doesn't impair me waking up and waking up in the morning on a daily basis to see my readiness for extubation. What would you want to have given overnight on yourself? Light pain medication will be effective if I'm able to sleep with light pain medications without sedatives.

Okay, that's a test. And are your own patients awake and walking while intubated as a normal occurrence? If clinical condition allows and their overall trajectory is getting better, then yes, we do spontaneous awakening and breathing trial. And with that, if those patients who are not able to get extubated because of a varied number of reasons, then they are mobilized out of the bed and walk.

So once they're stable, like what's the highest ventilator setting that you would allow a patient to mobilize on? In fact, that question will tie up with the highest ventilator setting at which the patient can wake up and do the spontaneous breathing trial. And that will be the minimum ventilation. And that can be anything between 30% to 50% FiO2 and between 6 to 8, depending upon the body habitus.

And that's just because that's not, they're usually not awake before then, right? No, I would answer that question in a different way. It is because their lungs are not ready before that. Their whole body is not ready before that. Just that's the reason they're using FIO2 more than 50%. And that's the reason they're using PEEP higher than that.

at minimum standard of the B. Is that your hospital policy, those platelet settings as parameters? We put that in our spontaneous breathing trial policy that this much settings should be there and overall clinical conditions should be getting better. And that is evidence supported as plethora of the evidence is there in which spontaneous breathing trial readiness should be done with clinical condition improving and specific indicators of clinical conditions have been very

clearly marked in a good quality evidence. So the breathing trial parameters applied to the mobility parameters as well. For sure. Yeah. All right. Thank you so much. Perfect. Well, thanks a lot. As an intensivist and respiratory therapist in Panama, if you were in the ICU, would you want to be sedated or awake while intubated? I prefer sedated. And why? For best control to the situation, a more dynamic stability for the patient.

for the best cure to the end of the patient. Have you ever spoken to your patients that have been sedated for days or weeks and have they told you what it was like? I talked with the patient before they were sedated and the family for the requirements to the sedation, to the ventilation and I say how many days, I don't know. It depends on the patient's response and the clinical proof to the situation. And then when they're

clinical picture has improved and they're extubated or have a tracheostomy, do you get to talk with the patient and hear about what it was like while they were sedated? Yes. What have they said? The patient's person does not remember the situation. It makes comfortable with the stay. In few particular cases, they remembered voices. Any voices, any messages.

If you stay, for example, today is Thursday. If you stay in the ICU, if you improve better, don't worry. We are careful. You, your family stay here. And some patients remember that. The major population, major people,

No remember anything, no have pain, no have discomfort. Stay good. And they're able to tell you that after they've been intubated. They said, I don't experience anything. I never had pain. I was good. No, yes. No, no pain.

And if you were intubated, would you want to be mobilized? Would you want to stand and get out of bed and walk? Yes. No walk, but mobilizes, yes. Physio, acting physio, yes. Rehab, acting, yes. But if you're sedated, that would pose a challenge, right? Sit in the bed.

Sit in the bed and move the arms, move the legs. Like have the nurses and physios do the moving for the patient. Yes. While they're sedated with their eyes closed. No. Passive movement. Only passive movement.

And does your team practice the ABCDEF bundle? It's bundled, yes. Every day? Great. And do you ever have patients out of bed standing while intubated? Not standing in or ICU. It's not working with them. Okay. No. So everyone is usually laying in bed with their eyes closed? Yes. And how is your team worried about delirium? Delirium?

Delirium, it's not half delivery in the ICU or patients. Okay. We put early dexmed for prevent and management delivery. That's great. And so your nurses are screening for delirium. Everyone's checking it throughout each shift. The nurses is not, it's only the medical team. Okay. The doctors, the fellowships and the attending. Okay.

So it's, oh, so that's the doctors that are doing the CAM-ICU and everybody. Yes. Only doctors. Oh, wow. Nurses. Okay. Thank you so much. I know you.

If you were intubated in the ICU, would you want to be awake or sedated? Sedated, definitely. Why? Because it's easy to intubate. So sedated for the procedure of intubation. And after intubation, would you want to wake up right on the clipboard while you have the breathing tube or would you want to be...

with laying there with your eyes closed the whole time? Depends of the parameters of the ventilator. Okay. Because if the parameter is down, I try to awake the patients. I try to use the Presidex, Texmetomidine, to awake the patients soon.

So if the parameters are high, if ventilator settings are high, the patient needs more support from the ventilator, you feel like it's important to have sedation going. Yeah, I try to use totally blockade and I use midazolam and fentanyl. On drips, like for days? I try to...

Done a lot of long days because that increase the mortality and it's not good for the patient. But depend on the condition, because if the patient have RDS, it's not easy to awake. It's not recommended to awake because you have to achieve RDS.

goals, you know, perfusion, oxygenation goals. And you feel like sedation helps enable that. I try to use the common sedation and, you know, midazolam, fentanyl, and when as soon as possible, I try to

use the bridge with precedex in order to awake the patient. And when you awake the patients, it's because you're looking towards extubation. Yeah, yeah, yeah. I prefer to use support pressure to extubate the patient. Once they can be on pressure support, now you're looking at extubation. Have you talked to your survivors that have been sedated? Yeah. What have you heard about what they experience while they're sedated? It's bad. For a long time, it's bad.

because they don't have a good awake. They are very agitated, you know, have a big problem and very bad experience for them. Yeah. Is midazolam then a common sedative in your ICU? Yeah, because I work in a public hospital and that's very common. Yeah.

Yeah, that's challenging. Do you ever have patients or would you, if you were intubated, would you want to be standing at the bedside, moving around, even walking while intubated? I think that is not possible, but I want to see that. Can you be willing to try?

Yeah, I try because I know that it's important to awake as soon as possible the patient. It's very important for decrease the mortality. Absolutely. How is the ABCDEF bundle going in your... Yeah, we try to use for pain only fentanyl, but it's possible acetaminophen. Mm-hmm.

Tylenol? Tylenol, yes. And we try to pass to the Precidex because we have a good experience with Precidex and we follow the guidelines with Precidex in order to improve the experience of the patient, avoid the painful experience.

And that's it. Do many of your patients have tracheostomies? Yeah, yeah. We have a lot of patients with tracheostomy. You know, we have a neuro ICU. Okay. A neuro ICU. A lot of patients.

We implement the early tracheostomy. Okay. For the injuries. Yeah. What about your patients that have other medical problems, respiratory problems that require mechanical ventilation? Do they have tracheostomies at the end? I try to avoid, but if the patient pass 10 days, 14 days, I definitely, I do the tracheostomy. Do you feel like respiratory muscle weakness?

is a common cause of not being able to get off the ventilator? Yeah, definitely. And the weakness of the muscles is have a close relationship with the upper doses to the sedate. Absolutely. Do you feel like your team is worried about sedation or delirium or the muscles? Is that a concern for your team? Yeah, yeah, yeah, definitely. Now we can try to change

quickly is possible to ketiapine and dexmethamidine as soon as possible. And use lower doses to fentanyl and midazolam. And that all depends on the ventilator settings. Yeah, yeah, yeah. I try to control by pressure or control by volume, but we try to change quickly to a pressure support as soon as possible.

And this is all in Panama, right? Yeah, yeah, yeah. Yeah, yeah. In Panama. Thank you so much. Thank you so much. As fellows in the ICU, if you were intubated, would you want to be sedated? Yes. Yes. Absolutely. Why? The early traumatic experience and then maybe the sensation of a breathing tube. I think in the abnormal pattern of breathing, that would be

uncomfortable if there's no adequate sedation or some sort of an anxiolytic. Yeah, I mean, I think I'm a little less worried as a young person of my delirium than I am of my remembering being paralyzed with a tube in my throat. Yeah, I just don't want to remember the intubation and RSI, really. Well, certainly RSI, that's a procedure. Paralyzer in that time requires sedation. And after that, once the paralytics are worn off,

Yeah, something so I'm not too freaking out when I wake up. But it doesn't have to be deep. Would you want to be mobilized while intubated? Yeah, I think my butt started itching or something. What would I leave? I don't know. At some point, yeah. What would you want your RAS goal to be? Depends on how sick I am. Early on, really deep. At least a three-ish, negative three-ish. After that...

Oh, physician RAS with a nursing RAS. Why do you say that? Oh, it's just a joke. We say 0, negative 1, knowing that it'll be negative 2, negative 3. I've done some manual audits that confirm that. Absolutely. Do patients feel endotracheal tube when they're RAS of negative 3 or negative 4 or negative 5? Not that I've ever been in that situation, but I don't think so. I think it's very hard to. I mean, they don't even fairly respond to noxious stimuli. They're de-placinated, so...

Have you been able to talk to survivors that have been sedated for prolonged periods of time about what they experienced? I can't think of one, anyone in particular right now, but I do remember people telling me that they remember. It's more around their RSI. But post-extubation, do you ever ask, how was your experience or can you communicate? Can you sit down and chat with these people or what are they like post-extubation?

Unfortunately, I feel like I get to see them at their post-extubation confusion state where they don't really remember much. But maybe once they're in the outpatient world, they might talk a little bit more about how traumatic it was. How do you feel like your team is doing at the ABCDEF bundle? It's almost annoying how adherent we are with our checklist and bundle board care. At least we check it twice a day at least sometimes.

And how many of your intubated patients are out of the bed being mobilized? Once. It's very difficult now because if they're deplacitated, we're not going to do that. Basically means they have something called a lung condition. But in our mid-key, usually if he's alert and oriented, we'll try to liberate him.

And then if we can, there's always some sort of a issue in deconditioning. And then, but it's very rare to see them walking, but maybe working with PT while intubated, but not walking and mobilizing that way. You feel like your team is worried about delirium. Are nurses concerned about delirium, like acute brain failure that doubles the risk of dying? Yes. I mean, in our institution, we talk a lot about

Delirium is a risk factor for adverse outcomes, et cetera. I don't know if we have, you know, other than generalized care and prevention, we feel like we can, outside of bundle, how much we can do for it other than addressing it when it's interfering with care and extreme, right, from a clinical standpoint. But yes, I mean, we, I think people are very aware of it as a significant barrier to improving getting out of the ICU. So my summary is,

On your unit, people are aware of delirium. They're fairly concerned about it. They are obsessed with the checklist. They're going over the bundle every single day. And very few patients are actually mobilizing early enough to be able to walk. That they get deconditioned to the point in which it's hard to get off the ventilator. They're confused after extubation. And yet everyone's prioritizing the bundle. Yeah, pretty much. Great. Thank you. All right. As a pharmacist in the ICU,

If you were intubated, would you want to be sedated? If I was intubated, would I want to be sedated? Absolutely. Why? Because I think it can be very uncomfortable just having a tube in your throat. Obviously, I would like minimal sedation, just enough to make me comfortable, though not enough to deeply sedate me and put me in so-called the coma state.

What would you want your RAS score to be? I would want my RAS score to be like a negative one, negative two at most. Would you want to be mobilized? Absolutely, I want to be mobilized. I want to prevent delirium in any way I can and mobilization can definitely help. So at a RAS of negative one, do you think you'd be safe to mobilize if you're conducting metatomidine and opening your eyes to voice, making eye contact?

Do you think you'd be ready to walk? Probably not ready to walk, but there's different other like rotational exercises that can be done, just range of motion, things like that, which I think are also definitely beneficial aside from just walking. What's the most common level of mobility done for your intubated patients in your ICU? I'm pretty sure we just stick to mainly range of motion, but I think it is definitely dependent on the provider and how aggressive they want to be. How deeply are your patients usually sedated? Not what's charted,

As a pharmacist, if you were to go and assess the rest and most of your patients on any given day, what is it actually at? I would say we mainly be at more like a negative two. And how is the ABCDF bundle going in your unit? How do we adhere to it? I think we adhere to it very well. Our physicians are very diligent with doing it, and especially with trying to include like families and kind of those later aspects of the bundle as well.

What's the normal timing for intubated patients as far as at what point do they get out of bed, bear weight? And I would like to say that we try to at least like get them to the chair within 24 hours of them like being extubated. We try to be more aggressive, obviously taking into consideration the patient's state. But again, we try to mobilize as early as possible. How are they usually placed in the chair? Are they getting themselves to the chair? Are they being lifted to the chair?

Yeah, so especially in that acute period right after extubation, typically they'll be lifted to the chair and just kind of like reoriented by the nurse. And then progressively each day will help assist them or eventually lead to them getting to the chair on their own. Excellent. Thank you so much. So if you as an anesthesiologist intensivist in Tanzania were intubated, would you want to be sedated? Yes. Why? I don't want to feel it. I don't want to...

feel the pain, the sensation of having something in my throat. And I want to be able to get the best out of the care that is being provided. I think I need to be sedated. I can't tolerate it without sedation. Have you ever had a patient be awake and texting to you or riding on a clipboard while intubated? Yes, not texting or something, but yes, somebody was awakened with a tube.

Yeah. Would you want to be mobilized? Would you want to stand and walk while intubated? I need to, maybe, yeah. If it's possible and I can mobilize and have all my other systems more watching, then why not? Yeah. Have you ever talked to any of your survivors after they've been sedated for days or weeks? Have you ever talked to them and heard what they experienced under sedation? No.

Not really. No, I can't really recall what they have said, but I've talked to people before and some of them are sedated, but maybe not fully sedated. And they remember some of the things. So yeah, I can say that. Yes.

No, it's not something that I focused on. Yeah, we're doing some research on patients, survivors right now and to see the experiences, not entirely just on sedation and intubation, but just the overall experience. So maybe we'll learn a lot from that study. But currently, I don't have really anecdotes on the issue. Yeah, a lot of times in the ICU, we don't get to talk to them after. And how are patients usually after they're extubated? Or do you see a lot of tracheostomies in your ICU?

We do quite a number of tracheostomies because we sometimes have to stay with patients for longer than a week or so and they're intubated. We don't have very good eye skills. So sometimes we end up with tracheas. And do you ever have intubated patients mobilizing? No, no, we don't mobilize them when they're intubated. Does your team practice the F bundle? Yes. And how's it going?

Well, I think I've not been in my ICU for some time. I'm doing a lot of research outside right now. I think it's a very good way of guiding them through the system of thinking and everything. Yeah, I think it's going well. I'm not sure I can really say as much. Thank you so much. If you've been listening to this podcast, you're likely convinced that sedation and mobility practices in the ICU need to change.

The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task.

How does this transformation start? It can begin with a consultation with me to discuss your team's current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation training, and bedside support. Let's work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

Now, of course, this was not a test. No one was graded or even judged for their answers to these questions. I am so appreciative that they were willing to talk with me and were candid and honest. Their answers reflected practices and beliefs that they have inherited, and I am confident I would have the same perspective if I had not spent seven years in an awakened walking ICU and the past five years diving deep into these problems.

Even during my two years and 11 other ICUs, I fell into the same culture and perspective, so I absolutely understand. This little snapshot reminded me of Junpei Haruna's publication this year with a one-day point prevalence setting in which they audited 135 ICUs in 54 countries.

and found that less than 10% of all patients on mechanical ventilation received early mobility. These wonderful participants that I talked with gave great insights into gaps and mentalities that I have seen throughout the country and world, from ICUs that I visited to the hundreds of clinicians that I have spoken to. These conversations captured the following common but erroneous beliefs and practices. One, mobility for intubated patients is passive range of motion.

Early and quote aggressive mobility is flinging them to the chair after extubation. Two, sedation is sleep and causes peaceful lack of awareness. It is comfortable, humane, and therefore the personal preference of ICU providers themselves. Three, since sedation is sleep, it is increased overnight to enhance the circadian rhythm. Four,

There are different RASs, physician prescribed RAS and nursing RAS. The nursing RAS is usually about two points lower than what is prescribed, but that's okay. It's just how it is. It's a running joke that we know about, but except as benign and a laughable reality. Five, it is best to be deeply sedated right after intubation, which is actually an independent predictor of mortality.

But that's the belief. Let's deeply sedate after intubation while we're really sick. That's the best thing. Six, awakening trials are just for extubation. It is best to keep patients sedated and comatose until the acute processes resolve, their lungs are better, and it's time to do an SBT. SATs and SBTs are to always be done together.

We wait until patients meet criteria for an SBT. If they fail their SBT, they'll probably get resedated if they're not perfectly still and calm. Seven, the agitation seen during awakening trials is primarily because of the endotracheal tube. Delirium is an afterthought and may even be caused by being aware of the tube. We sedate them so that they are not aware of the tube. Eight,

Sedation is essential for sick lungs. The sicker the lungs, the higher the ventilator settings, the more sedation patients need. Nine, the bundle is a checklist of things to document. The main point of it is to liberate patients from the ventilator.

And therefore, SATs and SBTs are the most important part. As long as we're checking the boxes of charting CPAP, RAS, SAT, SBT, CAM, early mobility screening, we're compliant. Patients don't have to be awake, communicative, autonomous, or even able to move their own bodies.

to be compliant with the bundle. Wasting number nine reaffirmed in the SACM Centers of Excellence program. The criteria for bronze, silver, and gold awards with the plaques that can be hung in the unit is based on compliance with charting. As long as screening for SAT is charted, that is compliant.

Even if the SAT is only a flicker of sedation off the pump and a prompt reception of sedation at full dose, a teen can get a gold star for compliance with the bundle. The entire ICU can be charted as bedrest for the early mobility screening, but as long as the ABCDEF bundle dashboard shows high volume of charting, the ICU will get their award. In the end, we can check off the box of the ABCDEF bundle as done.

but patients can still be deeply sedated, immobilized, and with higher risks of death, trauma, injury, and lifelong disability. But we will still be led to believe we are practicing the bundle because our charting looks good. I keep thinking about the cliche phrase, the truth will set you free. But here the reality is that the truth will set our patients free. If this is the first time you're hearing this podcast, lean into your own beliefs and practices with an open mind.

Go back to the previous episodes and listen to the survivors themselves. Check out my website, daytonicoconsulting.com and under the podcast tab for clinicians, you can find a category dedicated to survivors of sedation and immobility and a category for survivors of awake and walking ICUs. Listen to them.

Read the research, question your reality, and find the truth. It will change your practices and the lives of your patients. Welcome to the ICU revolution. To schedule a consultation for your ICU, as well as find supportive resources such as the free ebook, case studies, episode citations, and transcripts, please check out the website www.daytonicuconsulting.com.