Hello, everyone, and thank you for joining us for this session. My name is Ashley Hawthorne. I am a clinical ICU pharmacist and also assistant professor of pharmacy practice at William Carey University in Biloxi, Mississippi. And I have with me today, I have our two presenters. I have first Dr. Bridget Krom. She is an ICU clinical pharmacist at Duke University Hospital and also the PGY-2 residency program director there. And she also serves as assistant professor of clinical education for UNC Eshelman School of Pharmacy. So we're very excited to have her. And then we also have Dr. Kunal Karamshadani. He is an associate professor of anesthesiology and critical care at University of Texas Southwestern Medical Center, and also the medical director of anesthesia and critical care advanced practice provider program at UT Southwestern as well. So our topic today is titled Breaking the Habit, Addiction Management in the ICU. And after discussing with Bridget and Kunal, we have kind of decided that there's two different ways we can kind of approach this. So the first way that we're gonna start with today is talking about those patients who come into our unit who already have an opioid use disorder problem and how to manage pain and sedation in those patients. And then the second approach that we thought as well could be what about those patients who come in who are possibly opioid naive? And we put them on inalgo sedative regimens and maybe they develop an opioid dependency while they're in the hospital. So how do we approach transitions of care and avoidance of the chronic use of opiates? So I'll go ahead and turn it over to you guys. I think as we discuss, we'll start with talking about those patients who come into our units with opioid use disorders. And both of you have a little bit different practice areas. So Bridget is primarily in the medical ICU, whereas Kunal is primarily in the surgical ICU. So I'd like to hear, what are you guys perspectives on the management of those patients in your units? I think I'll start. Yeah, I think that this is definitely an added facet of complexity for these patients. I think typically we really try to get a good medication history and review outpatient refill records, or if they are a patient who is on methadone at home or received it from a clinic that we're actively seeking out those doses and making sure that we restart it at a bare minimum, those baseline doses that the patient is receiving at home. So if it's a chronic cancer patient who's on OxyContin, for example, we're making sure that we fractionate that for the intubated patients so that we can administer it via tube and make sure that we're at least giving them what their basal is. And then accounting for the fact that this patient may have more pain from the ET tube or whatever procedures they may be undergoing and kind of increasing it or augmenting that regimen from there. Oftentimes our medical patients maybe not have, they do still do experience pain, but definitely don't have all of the complexity that the surgical patients do that Kunal will definitely talk about, but we also try to think about multimodal analgesia as well. And so we're thinking about things like ketamine or lidocaine and are those adjuncts that we could potentially use to at least overcome that acute illness phase for the patient. Thank you, Ashley, for the kind introduction and thank you, Bridget, for bringing the MICU part up. Now, as we all know, opioid use disorder is just a version. I mean, it's the number of patients that are having this disorder is going up, increasing almost every year. So as a result, we're seeing more and more of these patients coming to the ICU, whether it's the medical ICU or the surgical ICU. Now, I think I'll agree with Bridget. The first part, even in a surgical ICU is to calculate their home requirements, what they are taking at baseline and make sure you at least provide that, especially in a surgical patient or a post-operative patient, we want to make sure we at least provide that regimen to them and then add on top of it. One of the things that is confounding in our surgical patients, especially someone who had an abdominal surgery is we cannot use their GI tract. Usually if they have a colorectal surgery or some kind of a surgical oncology procedure, we're waiting for that bowel ileus to resolve and so on. So we don't have that luxury a number of times to put them back on their enteral medications. So what we traditionally do in that setting is try to convert them based on the morphine equivalents that they're using at home and then switch it to an IV formulation. So that's usually the first step. And then we look at other options for multimodal analgesia as Bridget had mentioned. The only thing that we may add on in our surgical patients is some kind of a regional analgesia, right? For example, if someone had an abdominal procedure, we have an option of either doing a single shot duromorph in the spinal space. We can do an epidural catheter and run an epidural infusion of a local anesthetic along with an opioid. We have an option of doing, if it's a peripheral surgery, we can do nerve blocks. And now with facial plane blocks coming up, things like serratus anterior block, erector spinae plane block, and so on. So that's something that we try to add on along with the astaminophen, the lidocaine, the keramine, and all those drugs. So I think in the surgical ICU, this multimodal analgesia is a little more comprehensive involving regional. That being said, I think I've read a few studies where in MICU for these acute pancreatitis patients, there has been some data to show that epidural infusions might be helpful. Again, this is an area that needs to be explored a little further, but that's something that has, has some kind of preliminary data behind it. So that in a sense would be how we would manage these patients with opioid use disorder coming to the surgical ICU. I think too, I wanted to also touch upon a kind of illicit drug use or illicit opiate use when we can't really quantify what they're taking at home. That's a lot more challenging for us. And so I think we, at least on rounds, or as we're admitting the patient, we really have thoughtful conversations about monitoring for signs and symptoms of withdrawal and kind of using a symptom-based management approach for those patients, just because we don't know what their baseline requirements may be, and just trying to minimize the withdrawal symptoms that they may feel in that acute setting. But that's also, I'm sure, something that you deal with in your trauma unit or your surgical unit as well. Do you guys use a similar approach or? I think so. I mean, most of the times, it's like our go-to drugs are dexmedidimidine in these patients where we're not sure what their requirements are. For example, a trauma patient. I mean, there's no way you can take a good history. And a lot of times, as you said, they may not fill the prescriptions at the same place. It's hard to do a good medicine reconciliation when they get admitted. So in those patients, I think to be on the safer side, we do put them on dexmedidimidine infusion. Again, if their hemodynamics tolerate that, and then switch them to entylclonidine when we can. So I think that part of managing these patients probably remains the same, whether it's a patient that's admitted to the medical ICU or the surgical ICU. In the trauma patient population, the only thing you have to do is you just have to keep adding more. Again, another area which I think I'll ask you to comment on is what about those patients who are on Suboxone, or that's a patient population that's extremely challenging to manage, especially when they have incisional pain, they have rib fractures, they have long bone fractures. I think in those areas, we tend to do a lot more regional so that we don't have to kind of give them extra opioids because of the Suboxone that they have been taking. They have developed this kind of tolerance, for the lack of a better word, for opioids. So I think I would like to hear what you guys do for these patients who are on drugs like Suboxone. That does come up, maybe more infrequently right now, because we're in the midst of COVID, but on occasion that certainly has come up. And it's tough, right? I think our approach, both in the surgical and medical population has been to continue the Suboxone in the kind of acute setting and not really sort of taper back or withhold it while they're intubated, for example. But it's always a thoughtful discussion with the team. We're actually really lucky. We're very lucky at Duke that we also have what we call the Comet team, which is a specialist team who manages specific opioid use withdrawal. So they help with our Suboxone management while these patients are acutely in the hospital. We don't typically consult them in the ICU because a lot of our attendings are so comfortable with managing this patient population, but it's also a really great resource for us to consult with them. They end up writing a lot of the orders themselves, which we are a closed unit. So kind of from a logistical standpoint, it becomes a little bit more challenging. So we just want to make sure everyone, well, the cooks in the kitchen, we're continuing to talk to each other about the management of the patient. But I think we're very fortunate and I would really advocate for most centers to have such a great resource if possible, but we generally continue it in the acute setting. That's been our practice, both in medicine and in surgery. Nice, nice. I kind of want to expand a little bit. This was something we kind of touched on in our private conversations, but substance abuse consult teams in the ICU. Do both of you have experience with those and does it differ in places where you may have like an open versus a closed unit or what do you guys experience? Yeah, so we are a closed unit, our medical ICU is, but the Comet team is very accustomed to writing their orders for their patients when they are consulting on them. And so kind of as the pharmacist, I see all the orders before they're verified. So it's very important for me to go and make sure that the Comet team has touched base with our team directly because our team may prefer to write the orders and may prefer the Comet team to speak with our team and then we would write the orders, which may be different than a floor-based patient or someone in the surgical ICU, which is sort of a half open, half closed area. So I think it presents logistical challenges that are kind of important for the pharmacist to be a part of those conversations and just make sure everyone's communicating appropriately with each other. But I think that those conversations are still excellent to have. And we may have a different approach to management than the Comet team may have. And so I think it's just up to the providers to have those conversations. So adding on to what Bridget said, I think if you have that option of utilizing a resource like that, then it's great. Unfortunately, not many institutions have that. I remember when I was at Penn State, we had an addiction medicine team, but very limited in their resources. So most of the times, we call them only when we absolutely needed someone to follow a patient that was being transitioned from the ICU to the floor, not so much in the ICU because we didn't have that. They didn't have the bandwidth to do that. And to Bridget's question, I mean, I think one of the big differences between MICU and SICU comes about that closed ICU kind of model, right? And as Bridget alluded, a lot of surgical ICUs have some kind of a semi-open or semi-closed, depending on whether you see the glass half full or half empty model. So for me personally, I've worked in a surgical ICU for almost nine, 10, maybe 11 years now. I think for me, if a surgical ICU has orders being placed by only one team, that is good enough for a closed model for a surgical ICU, because then there is a mandatory discussion between the various teams because the orders are being placed only by one team. And they have to come to a consensus, whether it's the surgical team, whether it's the ICU team, whether it's the consultants that are being involved. So on that note, I have been fortunate that the ICUs that I have worked in, even though they are semi-open or semi-closed, the orders have been put in by just the ICU team. So when I'm rounding, if the surgeons have any requests, then they are bound to talk to us and let us know that this is what we want, and if you can put those orders in. So in that situation, if we have any confusion or if you're not agreeing to something, we can always clarify that at that same time, which avoids patient harm. Because the worst thing is, when I'm rounding in the ICU, I put in a Lasix order for 40 of Lasix, a surgical resident on the floor thinks, no, no, this patient needs fluid, I'm gonna put in a liter of crystalloid. And then now you have an order of a liter of crystalloid and 40 of Lasix, and it doesn't make sense. So I think that's, in my view, as a person working predominantly in the surgical ICU, is the key. And coming back to the point about addiction medicine and staff again, same principle. When we ask them, they talk to us, we come up with a plan, and then the orders go in after we have kind of formulated that plan. So again, it's a whole multidisciplinary, multispeciality approach that makes critical care what it is and helps improve patient outcomes. Awesome. Do either of you have, and maybe this is what the addiction management team does as well, but do either of you have opioid stewardship teams at your hospitals? We do not. We have an inpatient pain service, and we also have a palliative care service. I would say they require consult from the primary team, but I would say both of them would wear that hat at my institution. Okay. Yeah, I don't think we have an opioid stewardship model, just like we have antibiotic stewardship models. I think I would agree with Bridget. Most of the times what we have is a chronic pain team that we can consult. And we do get them involved. In fact, recently, we just had a meeting about our spine surgery patients where we were so concerned because these patients are invariably on a lot of opioids when they come in, and then they have their back cut open, and postoperatively, it's a nightmare managing them. So we're trying to get into a model where we, after the first post-op day, get chronic pain specialists involved to help manage pain, especially when the neurosurgeons are managing them on the floor. In the ICU, not so much, since we're pretty comfortable managing the post-op day one and two pain. But that's something that we're trying to envision and trying to build in. So I think that's where we probably need to focus. And I think there's some data that's come out about these teams that help manage, especially transitions of care, which I think is the next area that we should probably discuss, is in the ICU, yes, we do infusions, we do whatnot, but the challenge is when we are transitioning them to either a floor or sending them to a skilled nursing facility or a long-term acute care hospital. And I'll have Bridget comment on that first, and then I'll say what we traditionally do, but I would be interested to hear what Bridget has to say, because I know she's published a lot in this area where transitions of care are- You're very kind. I think I've published once or twice, but it's something that I love talking about. I think I completely agree with you that inpatient transitions of care has become a little bit of a black hole. I think we have a lot of pharmacy processes, for example, or pharmacy literature is based on inpatient admissions and med rec and things like that. And now we're moving toward discharge for high-risk discharge patients, but this inpatient transition is just this bit of a lost, or maybe like a black sheep, I don't know, but it's- I'm with you there. Yeah, yeah, it's very interesting to me. And so, I mean, I think we started a ton of stuff in the ICU that we never intend for patients to go home on, but- So much. I mean, largely, we've done quite a few smaller, more pilot type studies, but I mean, 30% of patients, we start on scheduled opiates in the ICU, go home on them, both medical and surgical patients. We used to use clonazepam or benzodiazepines to wean from sedation for patients who were on them for long periods of time. 30% of our patients would go home on that. Antipsychotic, there's a ton of data that says, 20 to 30% of patients that we start in the ICU go home on those. Clonidine for dexmedetomidine weans, that data is the same, 30%. Midodrine, 30%. It's incredible to me. And then, understanding what outpatient provider perceptions are from these medications is really another area that I think we need to learn more about because, you know, does a patient's PCP, well, they're started on quetiapine while the patient's in the intensive care unit, or at Duke University Hospital, they started this patient on quetiapine. Does that mean I should intend that to be a long-term medication? Oh, sleepers are another one. I mean, with the release of the PADIS guidelines, we have noticed our use of sleep medications has increased, and similarly, our discharge prescribing of patients on melatonin, trazodone, antipsychotics, things like that for sleep, it's just really rapidly rising. We know sleep in the hospital is not, it's just incredibly challenging despite the use of these medications. So I think we have huge opportunities at inpatient transitions to start. Yes, discharge certainly plays a role when we have to, you know, think about that long-term medication use when the patient is discharged, but I think at inpatient, we've become learning a lot about these data and what practices sort of lead to continuation of these medications. We try really hard when patients transfer out of the unit to clean that profile up as much as we possibly can. We've largely moved away from using enteral opiates to wean from IV opiates because of that concern. We largely have moved away from antipsychotics because they don't really improve outcomes or decrease duration of delirium, so we typically don't use those very much anymore. We've largely weaned away from using enteral benzos unless the patient has significant anxiety or air hunger issues that we're having difficulty reconciling non-pharmacologically, but we're really taking a hard look at that medication profile and just understanding that literature has been huge for our providers as well and making sure that we take a more active approach. And we think about it a lot like stewardship as well. I mean, we may not want to discontinue something acutely, you know, on that day of discharge when the patient's still on high doses of things or the day before discharge from the unit, I mean, but we may put a taper on there, for example, or write that for the receiving team so that they know that our intention is for this medication to be short-term or to put a stop date on there. This kind of goes back to your opiate stewardship question. I would consider this to be a medication stewardship at inpatient transitions as well, and so we really take an active role, and that's really come about in the past five years, which I think is awesome, but I think another really big opportunity for institutions across the country. Yeah, I think I agree with Bridget. I think it's a big problem, and, you know, the reason I said that, because I think we published some data as well, but a lot of times I cite Bridget's studies when, you know, I write that manuscript, so that's why I know that she's been working hard in that area. I mean, one thing we recently found, we did a study where we looked at what was, you know, opioid prescription on discharge. One of the big factors was hospitalization after ICU stay. So the longer the patient stayed in the hospital after their ICU stay, the more likelihood of them being discharged on opioids from the hospital, and these were opioid-naive MICU patients who did not have a surgical procedure. So that makes me wonder, that transition of care that's happening from the ICU to the floor, I think that's an area of quality improvement and patient safety enterprise where we can look at the medications, make sure that someone knows what these medications are for, and taper them out before the patient's discharged from the hospital. I think that's an area that needs a lot of attention, and I think this would more likely be a multidisciplinary approach where we have the ICU team giving a proper handoff to the floor team, along with the ICU pharmacy team letting the floor pharmacy team know about these drugs and so on, whether it's opioids, whether it's clonidine, whether it's atypical antipsychotics, I think this is a problem that needs to be addressed at an institutional level, as Bridget said, and at a more multidisciplinary level. It's not one speciality's issue. It's an issue which involves predominantly, I would say, the provider group and the pharmacy group, and they should work together to ensure that these patients are papered off, and when it's time to discharge, there has to be a discharge med rec as well, just like we do have an admission med rec, I think a discharge med rec where each and every medicine is looked at and, you know, figured out whether this patient needs to be discharged on this or not, and, you know, based on personal experience, I've seen residents do this discharge orders and stuff, and a lot of times they themselves are not sure what they are doing, and hence, having a pharmacist work with them on the discharge med rec as well would be important. I know it's going to need a lot of resources, and, you know, in my last job, I was the chair of the Pharmacy and Therapeutics Committee, so I know how stressed pharmacists are with, you know, a major amount of tasks that we let them, we ask them to manage, vancomycin, Coumadin, and whatnot, and we're adding another task to them, but you guys are our safety gatekeepers. I mean, you know, the patients are safe because you guys watch and keep a tab on what we're ordering and so on, so I think a little more proactive role on discharge med rec and transition of care med rec is something that I foresee is going to improve, you know, patient safety. It's really interesting because we did some single-center work looking at improving our transitions of care. We did a small study of antipsychotics particularly, so if the patient transitioned out of the unit on an antipsychotic, we proactively let the floor pharmacist know, and they would actively work every day to make sure that that medication was being discontinued prior to discharge, and it showed that it worked a little bit, but there was still a lot of pushback from the floor-based provider teams because, you know, I don't want to rock the boat. I don't want to change what's already working. I know that this patient's back to their baseline mental status, but I still think the antipsychotic is helping that or it's helping the patient sleep or things like that, so I think we can do our best, but I think that it still becomes like a wider understanding of what the ICU-based literature is for hospital-based or kind of floor-based services to understand why we would either start these things but why they shouldn't continue on the other side, so I think there has to be a really shared vision with from both provider teams and pharmacy-based teams for that, but I think it's 100% important. Yeah, I will just comment on that, so because we don't have the hospital that I currently practice at does not have a very big clinical pharmacy team, so I make it my purpose that before they leave the ICU, I put a taper or stop date or something on there, and even, you know, a lot of times the providers would be like, oh, we're signing off. They're going to the floor, transferring to the floor, so moving on to the next patient, I'm like, whoa, wait, before we go, can we please clean up all this stuff? We need antibiotic stop dates. We need to do something about these opiates. Yeah, 100%. Yeah, so Kanawha, just to kind of bring it back to the opioid topic, you mentioned something that I think we should talk a little bit about, and that is the patients who are opioid naive, and let's say they come into the MICU for whatever reason. It's not a surgical procedure, you know, maybe they're in here for COVID or something, you know, and they're an opioid naive patient, and we know that we should, per the guidelines, start patients on the ventilator on, you know, an algo sedation, and that's using an opiate, so you have the opioid naive patient and starting them on a fentanyl infusion, and what are your concerns about that, or do you approach those patients differently? Do you approach their sedation differently? I mean, you know, MICU is something, but, you know, I've looked at this in the VA population level where we published a research letter in JAMA surgery, and we found that a lot of these veterans who were opioid naive ended up being on chronic opioids after about 90 days, so that's a high incidence of, now, these are iatrogenic opioid dependents that we are creating based on that in algo sedation model, so I think it's something that needs to be addressed as to why, you know, and it's one thing leads to another. You start them on a fentanyl drip, they're on the fentanyl drip for three days, then we transition them to PO oxys, then they get transferred on PO oxys, and the story starts all over again. They get discharged on PO oxys. No one knows why they take PO oxys, but they're on oxycodone, and since they're on those for months, they continue taking it, and then we create opioid dependents, so, you know, I know Bridget mentioned that they have stopped using enteral opioids to transition from IV opioids. I would be interested to hear how their experience have been because, frankly, we still do it. I mean, it largely is culture. That was kind of an accepted culture for a long period of time to prevent withdrawal, and I think it's still advocated for in some patients, but I guess my answer to always is if you have a patient on fentanyl 50 mics an hour, that's a substantial amount of oxycodone a day. I'm going to forget the transition right now, but you're thinking that, you know, that's over 200 to 300 milligrams of oxycodone a day, so starting a patient on 5q6 or 10q6 to me doesn't logically make a lot of sense. It may make us feel better, but I think logically that doesn't transition into being equally analgesic dosing, so. Interesting point. Yeah, yeah, and so I think that's kind of been a big eye-opener for me, and, you know, those transitions, those conversions aren't 100%, right, but I think, yes, if you're concerned that this patient is at high risk of withdrawal and they're on 12 and a half or 25 of fentanyl and you're weaning off, I think that that makes perfect sense, but if you have a patient who's got a high infusion rate, the expectations that are we treating us versus treating the patient, I'm not really sure. I also, you know, we can identify patients with having opiate withdrawal pretty easily in a monitored setting, and so if a patient is experiencing opiate withdrawal, again, we can treat symptomatically, and so it's been pretty easy for us culturally to move away from it, kind of talking or taking a step back a little bit to what we were talking about before, opiate-naive versus opiate-tolerant patients at the time of intubation. That's also very challenging from a culture standpoint because it's always been this patient's intubated, start a fentanyl infusion, and so we've really started to educate our nursing staff a lot about analgesia- based sedation isn't always necessarily the patient has to be on a continuous or scheduled analgesic, and so when we intubate a patient, we have two pathways, a tolerant and a naive pathway, and our naive pathway starts with intermittent opiates for patients because we want to, again, keep them awake as much as possible, not transition to a continuous infusion unless the patient's really demonstrating a true need, either from a pain standpoint or a dyssynchrony or something like that. Culturally, it's been very difficult to implement that because it's just so reflexive, intubate, start fentanyl drip, so we do a lot of education, a lot of reinforcement at the bedside at that time, even from the providers, you know, our ABP staff, for example, very seasoned, very great, you know, but again, very accustomed to starting fentanyl at 25 and not just starting with intermittents first, and that patient really demonstrating a true need for a continuous infusion, so I think there's just a lot of work with culture that we are experiencing, but, you know, trying to, again, whittle away as we can. You know, that's two very different things, but... Two questions on this because this is something fascinating. So, first question I have is, you know, when you have someone on a mechanical ventilator, so you said you're going to do PRN opioids if they're opioid naive. Now, do you put them on a propofol drip or any kind of a sedation drip, or no, it's just PRN fentanyl or PRN Dilaudid, and that's about it. So, how do you factor in that? Is it time to move away from analgo-sedation and move to, like, drugs like propofol and dexmedinomidine, which are short-acting and so on? I mean, it's just an open discussion. That's the first point. The second point I have is, have you seen an increase in incidents of unplanned extubations or accidental removal of catheters because the patients are getting agitated, they're not on sedation or analgesia? So, those are two points that just came to me when you mentioned, you know, that you're trying to do this. I think it's all about how you interpret what analgesia-based sedation means, and I realize that's not really the topic of our conversation today, but we would—intermittent fentanyl with a propofol infusion seems very reasonable to me if you have a patient who has no pain, no dyssynchrony, but is just a little bit anxious or a little bit agitated, but I still think you're addressing and treating the patient's pain first because the patient is awake enough to be able to tell you I'm having pain or I'm not having pain, and I don't want to over-treat or over-prescribe opiates in that situation because we know that that's a risk factor for delirium as well, right? So, not under-treating pain and over-treating pain, I think, are both risk factors for delirium, so really try to move away from that. So, yes, it's not uncommon for us to have intermittent fentanyl with a low-dose propofol infusion. It's not also unreasonable for us to have a high-dose opiate infusion and a high-dose sedative in a patient who's dyssynchronous with COVID, and it's seemingly hypoxic, but we really try to use the individual patient assessments rather than the assumption of the assessments in these patients. I've already forgotten your second question. I don't have the data for that. I don't think it's any higher. I think we still have them occasionally. We remember them because they're always anxiety-inducing, particularly in COVID patients with unplanned extubations and things like that. We remember them, but I think we have probably the same amount, as been demonstrated in the literature, the same amount with light versus deep sedation. So, we just, again, try to use the assessments that we have and try to titrate to our goals. We call it like a goal-directed sedation. Shout out to Manny Rivers. So, how has the COVID pandemic changed your analgesia practices, particularly like with different waves, right? So, we had, especially with the Delta wave, we had a lot of our younger patients requiring tons and tons of fentanyl. And I'll just comment that I've, you know, never really practiced using like PO opiates to transition patients off of their fentanyl drips until the Delta wave of COVID, where people were on like 300 mics an hour of fentanyl and you just could not get them off without starting, you know, PO opiates. So, what has you guys experienced been with COVID patients transitioning from fentanyl to opiates? So, what has you guys experienced been with COVID? How has that kind of changed? Vinal, do you want to start? You want me to? Oh, you can start. I mean, I think we both would have probably similar stories to share because the Delta variant was, I think, the most brutal one for everything. So, I'll have you take the, you know, start and then I'll follow it up. Sure. Yeah, it's been a learning experience. I mean, right from the beginning with, you know, PPE conservation, extension tubing and pumps outside of the room and what drugs you can do with that, that these patients, yes, seem to require quite a bit more. They have the added barrier of the isolation and the difficulty throwing on the PPE in the case of the event would occur. So, trying to be sensitive with the nursing staff and allowing probably some levels of deeper sedation than maybe we would feel accustomed to because of that barrier with the isolation room. But I think over time as we've become more experienced with this, we've largely moved back towards, you know, standards of care and doing things for COVID patients that we should be doing for every patient. And there's been a couple of really nice publications about, you know, the effects of deep sedation on COVID patients and longer-term adverse sequelae. And again, trying to move back to making sure that we're doing standard of care and that COVID patients that, you know, still deserve the ABCDF bundle and that same approach. And I will say Delta was an anomaly, 100%. We used higher doses of sedatives for longer periods of time. We used more neuromuscular blocking agents, you know, for extended periods of time and, you know, the point where we were all feeling really uncomfortable with what we were doing. But we've also had a lot of really great survival stories and really kind of pushed us to, you know, it's really difficult to stay motivated and engaged and hopeful, I guess maybe is the right word, especially for these patients with these long periods of time. But I think we've started to have these survival stories are really helping to help us stay engaged. And again, returning to back to what we always do and what can we learn from these situations. So we've learned that we should be doing paralytic holidays every single day in these patients. And, you know, not only to assess are they ready to come off paralytic, but are they ready to, are we doing the right thing with sedation underneath paralysis, which for me has been a very interesting ways, you know, that's also variable across the country. And we can talk about that, but that's, you know, side street. But yeah, we're just using a lot more for a lot longer period of time. But again, I think we still focus on active weaning to help prevent dependence issues. And so we really, our sedation protocol really advocates for active weaning and daily SATs and SBTs and still holding true to those standards of practice to make sure that we don't create dependence for these patients as they leave the unit. And I think we've largely been successful with that overall. We're certainly dealing a lot more with anxiety and air hunger, particularly in, you know, our ECMO population and things like that. They've been a particular, and I can't imagine what they must feel like to have such low tidal volumes and difficulty breathing and what that must feel like. So I certainly empathize with that and want to make sure that we're treating those things symptomatically, but still allowing them to get up and do work with physical therapy and liberate them from the pump as quickly as we can. But again, just focusing on that, not all drug therapy all the time can fix all of these manifestations that these patients are having. So we have to focus on both pharmacologic and non-pharmacologic ways to manage a lot of these things. But I think we've been pretty successful in not transitioning a lot of our patients out on opiates and really having that active weaning process as a part of our standard. Yeah. So, I mean, I think I would tend to agree with Bridget, but going to a question about the different waves, I think the first wave, you know, there was issue of drug shortages as well. I remember we were short on fentanyl, you know, so I think the first wave was kind of challenging. I don't think the alpha variant was as bad and requiring as much sedation as the delta one, but we were short on drugs. And then we were still learning how to avoid, we were short on PPEs. We didn't know, you know, what to do and so on. So I think that was a period where we were still getting used to COVID. And I think that's when, you know, we had to transition to enteral stuff because we didn't have enough fentanyl. And then we had to avoid PPE being used because we didn't have, you know, we were short in short supply. The delta wave, I think, had its own challenges. And one challenge was the fact that these patients were younger, their lungs were so badly hit that every time they got this synchronous with the ventilator, they would desaturate and it was a nightmare. The second part to this was we had, we were kind of going short on nursing resources at that time. You know, we had drugs where we did not have as much nursing, you know, supply as we would have liked. And one of the biggest constraints was, and we were culprits, we had to go up on sedation because we did not want these patients to accidentally do something because it would take a long time for the nurses to get in there and act. So I think those were the logistical challenges which forced us to kind of deviate from our usual ABCDEF bundle, you know, even the sedation, you know, the spontaneous awakening, the spontaneous breathing trials became difficult just because of logistics, not because we didn't know that that was the right thing to do, but it was because we did not have the resources to make that happen, especially when the surges happened. I mean, we had like ICUs full of patients. We had staffing issues because, you know, people were getting sick. And at that time, yes, we all knew that we need to do this, this, this, but we just couldn't do it. So we had to do what we could to survive those surges. And as Bridget said, now, you know, that we have the surge kind of coming down, we can do what we should be doing for all critically ill patients who are mechanically ventilated is follow the ABCDEF bundle. So I would say, yes, we were all, you know, to be, you know, we were all culprits that we did not do that, but I think we had our reasoning. We had our own individual limitations that we had to deal with. So all said and done, I think, you know, going forward, if we have the resources that we need, I think the answer to this is follow what works for non-COVID patients. And 99%, it would work for COVID patients as well. If you have the resources, that that's the only thing I would like to add to what Bridget said. Yeah. A hundred percent. I couldn't agree more. Yeah. These are really great discussions. So we've got about five minutes left. I have enjoyed this. Like it went by so fast, but I've loved hearing from both of you. Any last thoughts from either of you? I'm just very grateful to be here. So thank you guys very much and really enjoy talking with you guys. I guess the big takeaways here for me are, you know, making sure that we have good transitions of care, both at inpatient for our patients with OBEs disorders and at inpatient transitions. So admission and inpatient and discharge transitions of care is a big opportunity, I think, for us as ICU care providers. So that would be my most important takeaway here is if you guys see opportunities in your institutions to be able to implement and advocate for these areas, I would certainly encourage it. Yeah. Same here, Ashley. I think it was a pleasure being part of this conversation today. I was hoping this was in person. We could have some live audience interaction as well, but nonetheless, I think this was a great discussion. And again, I agree with Bridget. The take-home points are the transitions of care are an issue where we need to address them. I'm looking for more data to come out, especially with regards to COVID patients as to how they are doing cognitively with opioid dependence with antipsychotic use after their ICU discharge and whether it's affecting their outcomes or not. Because, you know, frankly, for the lack of better words, we've thrown a kitchen sink at them when they're in the ICU, when we're short on resources. And, you know, we'll see what it leads to in the long term, because as ICU providers, most of the times we're not following up these patients. I know a lot of, some centers have come up with these post ICU clinics, but a lot of institutions, I would say 99% of the institutions do not have anything like that. So as an intensivist, still, I read literature until I figured out what's happening. I don't know what happened to my patient four months after they left the ICU. So true. And that's something I want to know, but unfortunately, again, in this, you know, we don't have resources to follow all these patients who's going to pay for it and so on and so forth. So I think that's an area that I'm looking for more research is as we call the post-intensive care syndrome, what happens to COVID patients with regards to their picks and whether what we do in the ICU, as far as their sedation and analgesia is impacting their long-term outlook. So I think that's something I'm looking forward to, but again, thank you so much for this very interesting discussion and we'll look forward to any chat comments that you guys have when you actually hear this during the meeting and we'll try our best to answer them, you know, when we get those chat messages. So thank you again. Yes. Thank you both. It's been a pleasure.

addiction management

ICU

opioid use disorders

pain management

sedation management

multimodal analgesia

methadone

Suboxone