David Oxman, MD
Assistant Professor of Medicine
Pulmonary & Critical Care
Thomas Jefferson University Hospital
July 19, 2013

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• One day cross-sectional study of ICU clinicians
• Conflicts perceived by 72% of respondents
• Physician-nurse conflict most common at 32%.
• Most common conflict causing behaviors
– Personal animosity
– Mistrust
– Communication gaps
Azoulay AJRCCM 2009

Interdisciplinary Communication in ICU
• Bad Communication associated with:
– Job dissatisfaction
– Burnout
– Misperception of patient care goals
– Medical errors
• Tools to improve interdisciplinary communication in
ICU
– Creating safe atmosphere to speak up
– Willingness to listen
– Leveling Hierarchy (Interdisciplinary rounds)

Role of the MICU Fellow in Promoting
Good ICU Communication
• At center of daily activities of ICU
• Can foster good communication between disciplines
• Often aware conflicts first.
• Set an example for the residents

Nursing
Respiratory
PT/OT
Patient
Pharmacists
Physicians

A Multidisciplinary Approach to the
Mechanically Ventilated Patient:
The ABCDE Bundle

Changing Paradigm of ICU Care
When I was resident Now

Why an Integrated approach?
We Need Coordinated Care
• Many tasks and demands on critical care staff
• About aligning the people, processes, and technology already existing in ICUs
• ABCDE bundle is interdisciplinary, and designed to:
• Improve collaboration among clinical team members
• Standardize care processes
• Break the cycle of oversedation and prolonged ventilation

AB
C
What are the components of the
ABCDE Bundle?
Awakening and Breathing Coordination
Choice of Analgesics and Sedatives
D
Delirium Identification and Management
E
Early Exercise and Mobility

Daily Awakening Trials
Why Is Interruption of Sedation Effective?
• Less accumulation of sedative drug and metabolites
• Less sedative medication used overall
• Opportunity for more effective weaning from mechanical ventilation
Sessler CN. Crit Care Med 2004
Kress et al. NEJM. 2000

Results
• Shorter duration of mechanical ventilation
• Shorter ICU LOS
• Fewer tests for altered mental status
Kress et al. N Engl J Med 2000; 342:1471-7

“SAT + SBT” Was Superior to
Conventional Sedation + SBT
Extubated faster Discharged from ICU sooner
P = 0.01
P = 0.02
Girard et al. Lancet 2008; 371:126-34

Spontaneous Awakening Trial (SAT)

Spontaneous Breathing Trial (SBT)

C

Using the Right Drugs is Important –
It’s a Balancing Act
Dangerous agitation
Agitation, vent dyssynchrony
Pain, anxiety
Calm Alert
Free of pain and anxiety
Lightly sedated
Deeply sedated
Unresponsive
Spectrum of Distress/Comfort/Sedation
Self-harm
Caregiver assault
Stress
MI
LOS
Dost
Delirium
VAP

Consequences of Suboptimal Sedation
Inadequate sedation/analgesia
• Anxiety
• Pain
• Patient-ventilator dyssynchrony
• Agitation
– Self-removal of tubes/catheters
• Care provider assault
• Myocardial ischemia
• Family dissatisfaction
Excessive sedation
• Prolonged mechanical ventilation, ICU LOS
– Tracheostomy
– DVT, VAP
• Additional testing
• Added cost
• Inability to communicate
• Cannot evaluate for delirium

C Choice of
Analgesics and Sedatives
The Ideal ICU Sedative
• Rapid onset of action and rapidly cleared.
• Predictable dose response
•
• Minimal drug accumulation
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• Minimal drug interaction
• Cheap
1. Ostermann ME, et al. JAMA. 2000;283:1451-1459.
2. Jacobi J, et al. Crit Care Med . 2002;30:119-141.
3. Dasta JF, et al. Pharmacother.
2006;26:798-805.
4. Nelson LE, et al. Anesthesiol . 2003;98:428-436.

Assessing and Targeting Sedation
Richmond Agitation Sedation Scale
Score
+4 Combative, violent, danger to staff
RAAS Description
+3 Pulls or removes tube(s) or catheters; aggressive
+2 Frequent non-purposeful movement, fights ventilator
+1 Anxious, apprehensive, but not aggressive
0 Alert and calm
-1 Awakens to voice (eye opening/contact) >10 sec
-2 Light sedation, briefly awakens to voice (eye opening/contact) <10 sec
-3 Moderate sedation, movement or eye opening. No eye contact
-4 Deep sedation, no response to voice, but movement or eye opening to physical stimulation
-5 Unarousable, no response to voice or physical stimulation

TJUH Pain and Agitation Algorithm

C
Choice of
Analgesics and Sedatives
The choice driven by:
 Goals for each patient
 Clinical pharmacology
 Costs
Key Points on Sedation
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•
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Assess and target.
Bolus first and then consider continuous infusion.
Daily interruption

D

72% of ICU Delirium Undiagnosed??
Gets our attention “Ideal patient”

Delirium Kills
Duration and Mortality
Kaplan-Meier
Survival Curve
P < 0.001
Each day of delirium in the ICU increases the hazard of mortality by 10%
Pisani MA. Am J Respir Crit Care Med . 2009;180:1092-1097.

Patient Factors
Increased age
Alcohol use
Male gender
Living alone
Smoking
Renal disease
Delirium: What Can We Do?
Predisposing Disease
Cardiac disease
Cognitive impairment
(eg, dementia)
Less Modifiable Pulmonary disease
Environment
Admission via ED or through transfer
Isolation
No clock
No daylight
No visitors
Noise
Use of physical restraints
DELIRIUM
More Modifiable
Acute Illness
Length of stay
Fever
Medicine service
Lack of nutrition
Hypotension
Sepsis
Metabolic disorders
Tubes/catheters
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Medications:
Anticholinergics
Corticosteroids
- Benzodiazepines
Van Rompaey B, et al. Crit Care. 2009;13:R77.
Inouye SK, et al. JAMA .1996;275:852-857.
Skrobik Y. Crit Care Clin . 2009;25:585-591.

Diagnosis is Key !!
Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental status
And
Feature 2: Inattention
And
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
Feature 3: Altered level of consciousness
Or
Feature 4: Disorganized thinking

Diagnosing Delirium in Patient on
Mechanical Ventilation
Letter A test
• “SAVEAHAART”
• Say above 10 Letters
& instruct patient to squeeze hand every time you say letter
“A”
• Inattention PRESENT if
> 2 errors

E

E
Early Progressive
Exercise and Mobility
Early progressive mobility programs result in:
 Better patient outcomes
 Shorter hospital stays
 Decreased development of hospital acquired complications
The level of exercise and mobility is individualized and incrementally progressed

E
Immobility not beneficial and associated with harm
– Myopathy/neuropathy
– Delayed weaning from ventilator
– Delirium
– Infections
– Pressure ulcers

Early Exercise in the ICU
• Early exercise = progressive mobility
• Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation
Wake Up, Breathe, and Move
Schweickert WD, et al. Lancet.
2009;373:1874-1882.

Early Exercise Study Results
Outcome
Functionally independent at discharge
ICU delirium (days)
Time in ICU with delirium (%)
Hospital delirium (days)
Hospital days with delirium (%)
Barthel index score at discharge
ICU-acquired paresis at discharge
Ventilator-free days
Length of stay in ICU (days)
Length of stay in hospital (days)
Hospital mortality
Intervention
(n=49)
29 (59%)
Control
(n=50)
19 (35%)
P
0.02
2.0 (0.0-6.0)
33 (0-58)
2.0 (0.0-6.0)
4.0 (2.0-7.0) 0.03
57 (33-69) 0.02
4.0 (2.0-8.0) 0.02
28 (26)
75 (7.5-95)
41 (27)
55 (0-85)
0.01
0.05
15 (31%) 27 (49%) 0.09
23.5 (7.4-25.6) 21.1 (0.0-23.8) 0.05
5.9 (4.5-13.2) 7.9 (6.1-12.9) 0.08
13.5 (8.0-23.1) 12.9 (8.9-19.8) 0.93
9 (18%) 14 (25%) 0.53
Schweickert WD, et al. Lancet.
2009;373:1874-1882.

Early Progressive Exercise and Mobility
• All patients are candidates for mobilization if:
– No clinical contraindications to physical activity
– Pass a safety screen for participation
• Patients initially not eligible mobilization or who have had interruptions in exercise will continually reassessed for participation
• The level of exercise and mobility is individualized and incrementally progressed

Just Count Something
“No matter what you ultimately do in medicine a doctor should be a scientist in his or her world.
In the simplest terms, this means that we should count something…It doesn’t really matter what you count.
You don’t need a research grant. The only requirement is that what you count should be interesting to you.”
Atul Gawande

ICU Database
• Let’s us look above the daily grind.
• Illuminates random experiences.
• Concrete uses:
• Measuring utilization
• Measuring performance
• Platform for clinical research

MICU Database

MICU Database
• 95% of data entered by nursing/clerical staff
• Fellows responsible for:
– Primary MICU diagnosis
– Select comorbidities (yes or no)
– APACHE scores
• Coming to Methodist
• Regular feedback of data

ICU Infection Control
• Key Performance Measure for ICU
• Hospital Compensation from Payors at Risk
• Intensivist’s Bonuses at Risk!!!
Infections with Surveillance Programs
1.
Central Line Associated Bloodstream Infections (CLASBI)
2.
Ventilator-Associated Pneumonia (VAP)
3.
Catheter-Associated Urinary Tract Infection (CAUTI)
4.
Clostridium Difficile Colitis

Reducing ICU-Acquired Infections
• CLASBI
– Insertion bundle
– Avoid femoral site
– No blood draws through catheter
– Good catheter maintenance
– Remove when not needed
• VAP
– Shorten duration of mechanical ventilation: Daily SAT/SBT
– VAP Bundle
• CAUTI:
– Don’t place foley if not necessary
– Get Foley’s out when not needed
• Clostridium Difficile: Limit unnecessary antibiotics