Hi, everyone. I'm super excited to be here. I'm honored to be among these esteemed presenters. I'm a pediatric intensivist at Vanderbilt University Medical Center. I am the upcoming co-chair of the ICU Liberation Committee, and I was in the PANDEM Guidelines Group. So I'm going to focus on the implementation of the A through C elements and talk a little bit about our recent guidelines. So today, we'll review the PANDEM Guidelines. And as Safna referenced, the new Pediatric Vent Liberation Guidelines as well. You can't talk about the B element without talking about those. And then we'll discuss some methods to implement the A through C bundle elements. So we've talked a lot about the ICU Liberation A through F bundle. And this was always intended to be a way to implement the guidelines. So when we were doing the PANDEM Guidelines, we really wanted to be synergistic. And so these things work together. I'm only going to talk about A through C, but it's a bundle, and everything interplays. So it's very hard. So you'll see there's some overlap. And I will try not to speak too much about D, E, and F, because my colleagues are going to talk about that next. I also want to highlight our website, which is on the bottom. It looks a little small, I'm sorry. But if you Google ICU Liberation, you'll get to our website. Over the past couple years, we've made a conscious effort to increase our pediatric content on that website. And so there's each bundle element has a separate page. The scales that I'm going to talk about today are in there. So I encourage you to take a look. So the last year has been super exciting for pediatrics. We've had two huge guidelines published that are very important for our patients. And so the first was the clinical practice guidelines on prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill patients, with consideration of the ICU environment and early mobility. I'm just going to call those the PANDEM guidelines from here on out, because that's a mouthful. And we were chaired by John Birkenbosch and Heidi Smith, who were wonderful, and I know John's here today. And then I also want to bring up the International Practice Guidelines for Pediatric Vent Liberation, which came out of the POLICI group, which is also very, very helpful as we talk about the B element. So the PANDEM guidelines is a really large document. It was a lot of work over several years. I actually got added to the group after they had already been working for a very long time. It was a large group of people put in a lot of work to look at all the data. And so it's a little overwhelming when you first look at it, and we moved a lot of the information into supplemental digital content. So as I talk today, there's not a lot of time to get into the nitty gritty, but I encourage you to go check that out if you're interested about exactly what studies and what the data was. But I do want to point out that figure one in that document was meant to help with the approach at the bedside. It's not covering everything, because it's impossible to have it all in one clean figure, but this is the high points, and this was meant to help you when you're implementing this in your unit. So this is a blown up, this is taking a step back and looking at it all together, but I'm gonna zoom in on a few portions of this today as I talk through the bundle elements. So A, A stands for assess, prevent, and manage pain. In the PANDEM guidelines, our recommendation really is the analgo-sedation approach. So Savna talked about this too. Treat pain before sedating your patient. That is imperative. And so to assess our patients for pain, we need to use reliable, validated scales. Self-report is the gold standard. So if your patient is able to self-report their pain with the scales I'm gonna show you in a second, that is what you wanna do. If they aren't able to self-report, don't rely on just vital signs. That's not, it's not accurate, and we want you to use validated observational tools, because remember, sedatives can change vital signs. So here is a list of the self-report scales that are validated in pediatrics that the PANDEM guidelines recommends, and then the observational tools, the FLAC and the Comfort Behavior Scale are the ones that we recommend for that. As far as frequency of pain assessments, this came up when Savna was showing her data. There's no recommendation on the frequency, but I will encourage you, at our institution, we do every two hours, but if a patient's having a procedure, or if their pain is rated high, and we're doing something to treat it, we monitor it more frequently. I would recommend having some sort of policy or protocol in your unit to standardize how often you're doing pain assessments. So for treating pain, the pharmacologic recommendation for moderate to severe pain is IV opioids. There's actually moderate evidence for adjunct NSAIDs in post-operative children for reducing pain scores, and then a small amount of evidence for adjunct acetaminophen as well for post-operative patients. And then for NSAIDs and acetaminophen, there's a low level of evidence that when you use them as adjuncts, they will reduce the opiate dose that your patient needs as well. And then non-pharmacologic, please, please publish what you guys are doing, because I know that people do lots of non-pharmacologic pain management in their units, but there's just not a lot of data. Interestingly enough, there's moderate data for music therapy in specifically post-operative patients, and then non-nutritive sucking, what oral soup creates for infants during invasive procedures, which I know we all know, but when you're doing guidelines, you have to go with the literature, so I encourage you to publish what you're doing. So now that brings us to the B element. So the B element stands for both spontaneous awakening trials and spontaneous breathing trials, but I grayed out the spontaneous awakening trials. This is where we really differ from the adults. So the PANDEM subgroup that looked at this, there were five pediatric studies looking at daily sedation interruptions, or DSIs. Four out of five of those had a high risk of bias, and then there was one that had a moderate risk of bias that was an RCT that actually saw increased mortality in the group that got DSIs. So with that, we didn't really have any data to recommend this in children, and so our recommendation is using goal-directed sedation. So using sedation scales, setting a goal, and everybody working towards that goal. There also is a period in our PANDEM guidelines where we talk about the periexubation period. So this is a time when you're reducing sedation because you're planning on exubating your patient, and this is where we often have unplanned exubations in this time period. And so the recommendation was to have a target depth of sedation and increase your frequency of monitoring their sedation level. And then consider a sedation weaning protocol. I'm gonna talk a little bit about that as a formal recommendation, because patients who wake up who are agitated and withdrawing are at higher risk of losing their ET tube. And then having unit standards for how you secure your endotracheal tubes and restricting nursing workload, which is really hard. But in this time period when you're reducing your sedation, if your nurse can be in that room with that patient, that will protect them as well. So for the spontaneous breathing trials, I am gonna reference the guidelines for pediatric vent liberation here. They had 14 recommendations in their document, and the first three were considered core recommendations. So the first one is use a protocolized screening method to assess when your patients are ready for an exubation readiness test, or an ERT. So we're humans, and to Jerry's point about waiting, you don't wanna wait until you recognize that your patient's ready for it. Have a screening method to when they should get an ERT. And then use a protocolized ERT bundle. That should include an SBT. Other things that might be in your ERT bundle, and they outline this in their document, are things like what are your patient's secretions? Do they have a leak? Are they at risk of post-exubation airway edema? Things like that. What's their muscular strength? All of those things can play into your ERT bundle. And then the other recommendations, the four through 15 recommendations, I don't have time to go through all of them, but they're wonderful, and I encourage you to look at it. But it's things about how much pressure support should we be using? And they really unpack what we have evidence for and what we don't. So that brings us to C, the last element that I'm gonna talk about today. And that's choice of analgesia and sedation. So again, these all interplay. We already talked about analgesia in A, so I'm not gonna talk a lot about that. But I wanna talk about sedation drugs and monitoring sedation scores. So we recommend using a validated sedation scale. So the two that have the strongest evidence in literature in children are the Comfort B and the State Behavioral Scale. There's a conditional recommendation, though, for the RAS as well, which is what a lot of adult ICUs use, and there's some pediatric data for that as well. But the biggest thing is set a sedation goal. Everybody should be speaking the same language, working towards the same sedation goal. And then when it comes to protocolized sedation, the PANDEM subgroup that looked at this, there were 10 pediatric studies at the time, when we reviewed the literature, looking at sedation protocols. And when they pooled all the evidence together, there was a low level of evidence to support using a sedation protocol. So we talked about analgesia already in the A, and so now I'm gonna talk about the actual drugs for sedation. So in the PANDEM guidelines, we did recommend alpha-agonists as the first-line agent, so dexmedetomidine is usually what most people are using, at least in the U.S. And there's very good literature in post-op cardiac patients, especially those that you're trying to fast-track on extubation, that dexmedetomidine is superior. As far as other critically ill children, there's a low level of evidence for the use of dexmedetomidine over other sedatives. For second-line therapies, the recommendation is ketamine, propofol, taking into consideration the risk for propofol-related infusion syndrome. So actually talk about minimizing your dose, minimizing your duration. There's actually a fair amount of evidence to support, if you use it carefully, that it is safe in children. But we definitely need more data in this field as well. And then benzodiazepine exposure. So I think most people know that benzodiazepines in higher doses and longer durations are associated with development of delirium in critically ill children. But when used thoughtfully, they can be good sedatives as well. So just taking that into consideration. As far as neuromuscular blockade, we do have some guidelines on that as well. We know that neuromuscular blockade has negative consequences for our patients. It increases their risk for ICU-acquired weakness. It takes away our ability to assess them for pain. It takes away our ability to get a neurologic exam. And it takes away our ability to see how well they're sedated. So we don't love using these drugs, but we also know that there are clinical situations where we need to use these drugs for physiologic reasons. So if you are using it, use the lowest dose possible and monitor your patient closely. This is another area where there's a real lack of pediatric literature. But we do recommend using train of four to monitor the depth of your neuromuscular blockade. And then consider use of an EEG to assess your patient's sedation state underneath the neuromuscular blockade. Of course, make sure they have adequate sedation and analgesia, which is easier said than done, I think, in real-life practice. And then eye protection. Save the eyes. So remember, these patients are at real high risk for exposure keratitis. So making sure their eyes are moisturized, using eye shields if their eyes are open. As far as iatrogenic withdrawal syndrome, recommend using a validated screening tool for that in children. So the WOT-1 or the SOFIA observation scale for opioids and benzos are recommended. And the guidelines actually call out to remember that even if your patient's been on sedation or analgesic drugs for less than five days, if they've been on high doses, they're still at risk for withdrawal. So don't forget about those patients and screen them as well. And then the other thing I want to point out is that these tools aren't validated for use in dexmedetomidine withdrawal. So my fellow Chiara Velez actually did an abstract on Saturday. We've been taking a deeper dive into our data trying to define what does alpha agonist withdrawal truly look like. And we need a validated tool for this very badly. As far as alpha agonist withdrawal, I will say we mentioned looking for unexplained hypertension of tachycardia because that has been described in case reports as a sign of withdrawal from that as well. And then a standardized sedation weaning protocol. In the past few years, we've had some good literature come out showing that this improves outcomes in pediatric patients. So I would encourage you that as part of the guideline recommendation, I think we're building data on that as well. We're doing a cost analysis right now on our sedation weaning protocol. So that was a lot of data in a short period of time. So I'm just gonna hit the high points for you as we're closing out here. So for A, use validated scales to assess your patients for pain. And self-report is the gold standard if your patient can do that. And remember, treat your patient's pain before sedating them. For B, we don't recommend a spontaneous awakening trial on children at this time. That could change if the evidence changes over time. But for right now, no SATs in children. But we do want you to use protocolized screening for ERT readiness and spontaneous breathing trials as part of an ERT bundle on your pediatric patients. For C, use validated sedation scales. Set a goal. So we're all speaking the same language. And use a protocolized sedation in your unit that everybody's on the same page as far as what your goals are. And then don't forget to monitor your patient for atrogenic withdrawal symptoms. So this is a lot to do in real life practice. As we already see, we're struggling to implement these things. There are many, many barriers. And I want to give you guys some resources. So again, the ICU Liberation Committee, we've been working hard to build our pediatric resources. So I want to point out, if you go to our website, there's an implementation toolkit that's for peds and adult. And as part of this, which you may hear about, there's something called the MDS or the minimum data set that you can track your compliance. But we have also recently, over the last couple years, we've been working with Epic and Cerner to create ICU Liberation builds in the EMR. And those are officially released for the pediatrics versions as well. They do take some IT support to build into your EMR. So if you're interested, go to our website, talk to me, I'm happy to help with that. But again, sustaining some of these things, if you can build it into your EMR and track compliance, that will help you with sustaining the implementation. And then lastly, just bringing it all together. So it is hard work, and I want to remind you why we do it. So these are some of my patients reaping the benefit of PICU Liberation. So the first one's a young man with acute onchronic renal failure and ARDS, secondary to histoplasmosis pneumonia. And he is coloring dinosaurs. He loves, loves dinosaurs. One of my favorite patients ever. The middle patient's a post-op cardiac patient who is doing developmentally appropriate activities while she's intubated in a tumble form. And the last patient was a young lady with end-stage pulmonary hypertension who's on BVECMO. And she's in our garden drinking a milkshake on BVECMO. So this is why we do it. It's not easy, but remember this. As you're going forward with this and you're meeting barriers, this is the point of it all. Thank you.

pediatric intensivist

ICU Liberation guidelines

PANDEM guidelines

assess, prevent, and manage pain

spontaneous awakening trials