all very much. Other questions, comments, experiences from the audience that you'd like to share, please. Hi there, Nick Ettinger from Texas Children's. First of all, great talks, everybody. Thank you very, very much. One thing I've always found really interesting is that the spontaneous awakening trial piece is really the piece that hasn't translated from adults to kids. And I was curious what your esteemed experienced opinions on that are. Is it just that two-year-olds are little monsters, and it's impossible to try and awaken them for that kind of thing? Or do you think there's something physiologically different about kids compared to adults? Actually, I think it's the opposite of kids being monsters. I think it's that the spontaneous awakening has been shown to work in units where the adults, for the most part, were very deeply sedated. So it is better to be woken up briefly once a day than it is to be deeply sedated throughout the entire course of your mechanical ventilation. However, by the time we got around to testing this in pediatrics, happily, we were not snowing our patients routinely anymore. So when one compares sedation interruption to a protocolized approach to sedation that prioritizes a low level of sedation, the sedation interruption is actually there is a trend towards harm. When you have a kid who's lightly sedated over the entire course of the mechanical ventilation, that kid tends to do well. They tend to communicate pain. They tend to interact. They tend not to develop withdrawal or tolerance or delirium. If instead what you have is deep sedation, you hold the sedation. This poor child emerges from sedation. They wake up agitated. You then have to put them down again using more sedation. What the pediatric studies have shown is that the sedation interruption group actually is exposed to greater, higher cumulative doses of sedation over the course of the ICU stay and tends to spend more time on the ventilator. There was even a statistically significant, though perhaps not causally related, increase in mortality in the sedation interruption group. This was a really well-designed RCT. So I believe the reason it doesn't work is because it's not going to work in adults either. If they're going to keep their adult patients as awake as possible over the course of their mechanical ventilation, they'll do better than if they snow them, wake them up, and then put them down again. Does that make sense? Thank you. All right. Next question. Go ahead. Hi. Thanks, everyone. Kate from Boston. Wonderful talks. And more of a comment or a challenge question, I think one population that we're really struggling with are these babies with pulmonary hypertension. And I really see it as they don't get touched for months. They're so sedated. Everyone's afraid to touch them. They have a pulmonary hypertensive crisis when you try to change their diaper. I mean, similar, like the super hemodynamically unstable patients. It's really, really challenging. And when I try to talk about positive touch, I get a lot of speculation. Or what's the word? Anyway, but I think positive touch is something I would love to hear more about if anybody has ways to kind of operationalize that at the bedside with nursing. Can you predict what the difference in a trial between a continuous escalating infusion of midazolam versus a bedside nanny who held that kid and rocked him most of the day might be? Yeah. Thank you. Comments? So again, I don't have empirical evidence. But positive touch by a family member, ideally, I do not believe has the same adverse response in terms of pulmonary pressures. I have not seen that. It's the therapeutic interventions that seem to have that major response. Continual positive touch, completely anecdotal, but I've certainly seen a positive response in pressures to have someone that is always there, that is always touching, that the child is aware of. And we do allow holding, even children with serious pulmonary hypertension, we do, in fact, encourage active holding in the parents' arms and therapeutic touch from the family members. Brenda's spot on. And I just wanted to add, I think it's really the familiarity of the person who's doing the positive touch. And so on the flip side, we interviewed a teenager recently who was intubated forever. And her biggest, I think, traumatic event was being touched constantly by people she didn't know, and bathed, and all of these different activities that we kind of take for granted because they have to happen. And she really said that she wished that someone had communicated to her that this was going to be part of the ICU care, to have unfamiliar people touching all the time. So being very thoughtful about how to integrate that. I don't think we have the right answer for these different age groups, but it's definitely something we need to be thinking about. So if I can just jump in as well. You just made me think there. So another part is the active participation of the family in those routine caregiving procedures. So yes, some of the medical interventions, it would not be appropriate for the family to do. But the family can bathe their child. They can dress their child. They can turn the child with assistance. It becomes a completely different experience when those activities are performed by the family rather than a perceived negative health care intervention by a stranger. Good question and discussion. Thanks. Hi. Mallory Perry, ED, from UConn and Connecticut Children's. Great presentations. I had a question about, I've seen through all the presentations, that assessment of pain and assessment of delirium, especially pain, was pretty consistent across sites. Though, was it looked at the actual accuracy of the assessment? I know even working in the PICU, being a nurse myself, sometimes you have a patient who is neuromuscular blockade. And then you've got an SPS score on them, or you've got a pain score on them. So yeah, you're assessing pain. But is it done right? Because we know what goes into the EMR, if junk is in, junk comes out. So I was wondering your thoughts on that. I can speak. We recently published a QI study last year because we did this, where we went to the bedside to assess whether delirium assessments were being done. That's charted in the actual EMR at our institution. But were they being done accurately? And they weren't. And we had rolled out delirium screening in 2012. It had been in our unit a long time. We switched EMRs, we had a ton of staff turnover, and we recognized we had a problem. And so we went back to the drawing board and had to do a lot of education. We did multimodal education. We did Zoom sessions, we did handouts. But then what I spoke about on Saturday in my delirium session is we actually changed our flow sheets that built in the moment education into the EMR to help with the accuracy of assessments. And then came back and looked again. And that benefit, our accuracy went up and the number of assessments went up. And then we looked at it a year later and we still sustain those gains. So I think try and think out of the box about in the moment education because healthcare's changed and we're onboarding new people so frequently now too. Thank you for your question. Next in the back. Hi, my name is Nidhi from Dell in Austin. Step up to the microphone. Oh yeah. Sorry, my vertical challengeness does not help the situation. I'm Nidhi from Dell in Austin. Thank you so much, this was amazing. The bigger question I have is how do you continue to keep the cultural change and the momentum going with travel nursing? Because it feels like that's such a large population and so you invest all this time and the nurses you have get momentum flowing and they maybe move on to other opportunities. And it feels like you have a shift amongst what you've tried to accomplish. I don't wanna be here a long time. And maybe I'll just answer it by providing some thoughts to the previous question as well. I think when you make it an expectation and make it a standard and make it a nursing requirement, make it a clinician requirement and so on, the culture does change. And you were talking about how do you know you're doing it accurately? The same is true of any vital sign that we do. If you actually look at the research, the compliance with that is actually not great. And there's great variability to that. What we found is that the more you do and you more embed it, the more frequently they do the reassessments. And I think that's the key. The more you do it, the more familiar you are with it, the more you make it an expectation that it is in the syllabus for the trainees and it's an expectation for the clinicians to talk about liberation on rounds, the culture will change. And so when I did our earlier research, we found that it was difficult. And then ultimately, you come back and when you've implemented it and you actually, the qualitative research that we did, the feedback from the nursing staff was, well, what used to be difficult is now easy because it's second nature, because it's an expectation not just by one individual, one champion, but everybody. So it will happen. With regards to the travel nursing question, I just wanted to comment and don't automatically, and we all have a lot of travel nurses in our unit, right? Because of our staffing challenges. Don't automatically assume that the travel nurses aren't actually more advanced sometimes in this capacity with regards to liberation than even some of your own staff. They have a lot of experience. They've gone to multiple units and worked. And I have been the one who's surprised when they said, can I get this kid out of bed today? I'm like, wait a second, I've never seen you before. Been in our unit a couple days, but they're pushing the envelope. So utilize those champions. And potentially some of these travel nurses may decide to stay at your institution, end up becoming one of your liberation champions. So don't make the assumption that they are not on board. They may in fact be already ahead of the game. And so kind of tackle that and have a systematic approach for every kid every day. We're back over here. Yeah, hello, I'm Matt Borgman, San Antonio. So all of our data gathering for all of this is really limited to the ICU stay. How far are we from leveraging technology to have an app or something to give to every one of our parents that come in for following afterwards to follow up this PICS-P, post-traumatic stress, quality of life indicators, so we can have an idea of whether this stuff is having meaningful outcomes. We're working on that. I mean, the first question is, is an app the answer? We use them frequently for clinical care, day-to-day personal things. And we choose to use those because they meet our needs. But the biggest question is, do they meet the parents' needs? And we know that in terms of, well, certainly in Australia, mobile phones, internet access, we have excellent saturation. Even in our poorer, remote communities, they still have excellent saturation. And so they have asked for an app over a web page and things like that. But those sorts of things are coming. And I don't think they'll be too far away. Hi, my name is Neha. I'm a pediatric physical therapist here at UCSF. And I work in pediatric ICU. First off, I wanted to thank SCCM to organize such an amazing panel and for all of your outstanding clinical and research work, kind of paves the way for all of us. My question is more in context of rehab staff who are dedicated but with limited experience with that early mobilization, right, like implementing it in days and not weeks. And in that context, is there any talk or plan of maybe providing clinical hands-on training by any of your teams of rehab staff or, because I know there are didactics and research material but kind of that hands-on certification for especially our younger population? So I'm not familiar with the North American system in terms of certification. But certainly there are a number of workshops and hands-on teaching sessions that are held in different settings, including simulation-based training, where I think it's hugely valuable in performing simulation-based training, even just within your institution. I'm not aware, and I think my colleagues can address what is available in your setting. Our experience is that the rehab staff know a lot more than we do, the physical therapists, the occupational therapists. I learned everything about rehabilitation from our rehab staff. The other point is the majority of our patients are under two years of age, and the majority of clinicians who are providing the mobilization are actually the bedside nurse and the family caregivers. It's actually training them. And that's why we developed the safety guidelines. I will say the ICU Liberation Committee is building out a PICU liberation course similar to the adult ICU liberation course, and we are hoping that that will be offered as a pre-Congress session next year. It won't just be mobility, though. It'll be the entire bundle, and it's multidisciplinary. Lots of different disciplines attend the adult course. Kim? I just wanted to add, so if you haven't met Neha, Neha's one of the most passionate therapists in the world with regards to bringing this to her unit, and what you're referring to is making sure that we have competencies and practice-based competencies for our colleagues who aren't as experienced in the intensive care unit environment, and so you can train them to feel comfortable. Unfortunately, there isn't anything formalized like that, but our physiotherapy colleagues are definitely working on that. And also, to bring up what do you do after they leave the ICU, not just for parents, but on the floors, right? So we talk about the ICU, and then it's like, peace out, and then what's happening on the floor? Do you have activity mobility promotion programs there, too, where the therapists really are driving the boat, as opposed to the ICU, which is more nursing-based? Just want to reframe for a second. Early mobilization doesn't have to be walking down the hallway on ECMO. If you can take the 18-month-old and sit her up in bed and give her Play-Doh, you know, that's mobilization. It's play-based, and it's sensory. We really need to, not just with touch, but we need to appeal to all of our children's senses in therapeutic ways. It seems to be, we have nascent evidence that's emerging now, but kind of appealing to the senses in a pleasing way for children under two seems to be a great way to minimize amount of opiates and sedatives that are required for mechanically ventilated children. So you can reassure them that they don't have to walk the kid. If they can sit him up and play with them, that's mobilization. Thank you so much for all your answers. Go ahead. Hey, Eddie Hankins. I'm one of the clinical pharmacists in the PICU at Le Bonheur in Memphis. This was sort of touched on in the delirium talk, but I wanted to know if there is still a role at all for using atypical antipsychotics in really challenging delirium patients. So I'm not a physician. There is still a role. There is a small amount of not as strong evidence to suggest that you can use the atypical antipsychotics. But I might pass to one of my medical colleagues who would probably more likely prescribe it. But in our practice, we tend to reserve prescribing the atypical antipsychotics for children who have protracted delirium, where we've implemented all of our non-pharmacological measures. We've gone through brain maps, Dr. Dre, all those things, and where it's also very distressing for the child and the family. But in a sense, it just is a Band-Aid. It masks those symptoms. Yeah, I think that's exactly it. We do use it not to treat delirium because it doesn't treat delirium. We use it to Band-Aid the hyperactive symptoms of delirium that are getting in the way of moving the child forward. So it's an off-label use. There is no drug approved by the FDA to treat delirium in any human of any age. In children, it's even more off-label because it's not even approved for use as an antipsychotic in very young children. But when the risk-benefit appears favorable and we have a kid who's miserable and where we can't wean the benzodiazepines and we can't move them forward because they're so agitated, in those cases, we use it as a very kind of directed, time-limited tool to enable us to get at some of the other iatrogenic causes of delirium that we can modify. And your question speaks to the critical importance of the pharmacist and also our psychiatry colleagues who are experts in the management of those medications. I think one of the challenges we have is sometimes our physician colleagues start these atypical antipsychotics and it might have been the right thing to do given everything you just heard from our team. However, who follows that after they leave the ICU? Who's going to continue to manage that? Stop it before they leave the ICU? Yes. So ideally- What is the time limit that you put on it? Well, so that's the big question and that's why we actually have an algorithm where we engage our psychiatrists exactly as Deb mentioned, after we've done pharmacologic things. But keep in mind, some of you may not have child psychiatry easily accessible. It depends on what resources you have. And I can tell you that our psychiatrist had no knowledge or interest in terms of ICU delirium when we started this whole process. So we brought them into the fray, educated them about the CAPD and all of the work that had been done and the PCAM and the PSCAM. And all of a sudden they're like, oh wow, this is our forum. We should be the ones who are helping you manage delirium in your ICU. And now they have an entire consultation team that's focused on that. They work with our pharmacists to determine what the ideal dosing is. And if there's a question, they reach out to the other experts. So it's been a really great collaboration. Just a very practical answer from me is if it doesn't work within 48 to 72 hours, stop it. For some kids, it's a magic bullet. But if you don't see an effect by 72-hour mark, I'm usually like, oh well, it was worth a try. And for what it's worth, I think this year there was a study published on adult critically ill patients that haloperidol had no effect on the trajectory of delirium. But not a similar, you don't have a similar study. That's exactly that. That's partly the reason for the question. Thank you. In the back. Hi, I'm Leah Lowry from St. Louis, pediatric intensivist. So my question has to do with navigating the day-night cycles, and you're all nodding your head. I think successfully defined success with a limited sedation regimen as, oh, I've got the kid up in the middle of the day and they're up and playing, and then it's 2 a.m. and I don't want my two-year-old up and playing, and neither does his parents. And we may have both fewer nursing staff because of traditional staffing models in the ICU and less experienced staff. So I was wondering how you all are navigating in terms of increased potential or decreasing their sedation scores to a minus one or something at night, rotating drugs, those kinds of things, just to get through that practical problem. Just to speak as a general pediatrician now instead of an intensivist, if they're awake and playing during the day, they're more likely to sleep at night. I wouldn't change my sedation target for the nighttime because that just makes them look like they're sleeping. Dr. Kujakar has some beautiful data showing that a kid on a benzodiazepine infusion might, for all intents and purposes, look like they're sleeping, and in fact, they're lying down, absolutely no restorative sleep. So I would do what I would do at home, use kind of normal non-pharmacologic bedtime, sleep-inducing techniques as able in a critically ill child rather than mess with my meds. So since you referred to me, I'll just add on that you're asking the billion-dollar question. This is a really, really hard thing to do, the day-night patterns and cycles. We didn't really even unpack that in very much detail. I think the normalization of routines piece that Deb touched on and really that we all focus on, again, what does the child do at home normally? And one thing we didn't talk about which should be an element we should discuss eventually in formal ways is nutrition and how we feed children. It's not physiologically or circadian homeostatically normal to be fed 24 hours a day. It contributes to your day-night cycle. So thinking about can we transition to bolus feeds during the day? What does this child normally do during the day? Is there any way we could give them a four-hour break from their continuous feeds at night that might help optimize day-night? So anything that you know impacts your day-night patterns and this child's day-night patterns, think about how we can translate that. And we need to find a systematic way to bring that into the orientation to the PICU, the nursing intake, and making sure that we do that consistently for every kid. Great question. I was just gonna add to that, sorry. In addition to, I mean, asking the family about what their normal night routine is and how they settle, we're very lucky in Australia that particularly if they're ventilated, all of our children are one-to-one nursed. See the eyes rolling. But the other thing is that in saying less is more, we're also trying to teach the nursing staff that if we say to do two delirium assessments a shift, if it falls in the middle of the night, and we have them at set times on our electronic medical records because it comes up as a reminder. But if it says 2 a.m. or whatever, or even 4 a.m., it doesn't mean that you have to do it at that point. So we're really asking the nurses to think judiciously about what they're doing and when. And some of them will just, you know, they're very good and they just follow task by task by task. And if it says do this at 4 a.m., they'll do it. But we're now saying to them, we want you to think about whether you need to awake a child to do those assessments or wake a child because of those assessments when maybe an hour ago you saw them moving around normally and appropriately in bed and they might have opened their eyes, looked around, and gone to sleep. You can base your assessment off that and not necessarily have to wake them specifically at that time. So it's also in addition to taking on those normal routines from home is de-implementing or strategically sort of deciding when you're going to do some of those nursing-based tasks or assessments or allowing people to come in. And other little things, for example, one of the things that was a huge disruption to our children and their sleep was the cleaners coming around in the morning and hearing the plastic bag being opened up and shaken and put in the bin. And of course, when we had communications with our cleaning team, they were horrified that they were doing this. And so liberation actually is not just collaborating with clinical staff, we've actually collaborated beyond that in ancillary staff. So everyone who comes into that, to our unit, knows that we're doing liberation and why and how everyone, clinical or non-clinical role, can be a part of that. Thanks, you covered some of what I wanted to say. But really, it's coming from a resource-constrained environment, I just want to remind people to get the basics right. Simple things like daylight, change, change the light, have exposure to natural light as far as possible. Have the child have familiar objects from home so that they can sleep in comfort. And then I think we have something to learn from our neonatal colleagues when they do it right, in terms of bundling of care according to the child's schedule, not your own schedule. And I think that's some of what's been spoken about here. But I do think we need to really look at some of the ICU processes so that it becomes child and family-centered, properly child and family-centered, and not really us-centered, yeah. Heidi Flora, University of Michigan. I'm sorry I came to the session late, but one thing that we had to consider at our institution is the timing of the excavation readiness test, because it worked out best for the RT if they did it at 3 a.m. And so we had to morph that. Honestly, it's not about what works out best for the RT. We used to bathe all our children at 4 a.m. Seems really stupid, it's hard to be asleep when you're getting a bath, right? So we no longer do. I think when we're goal-directed in our care, stuff like that, silly stuff like that, can be changed more easily than one might think. Does anybody still bathe their kids at 4 a.m., any of the units? Oh, God. There's some hands. There's nothing magical about a 5 a.m. CBC other than the fact that it comes back in time for the attending to round. You know, I think we've rethought a lot of that to be, as Brenda said, patient-centered. Well, first of all, I would like to thank the panel. I was wowed out of my seat. You saw me taking notes on lots of very interesting stuff, very practical stuff, too. And I wanted to thank the audience for sticking here, continuing listening, providing discussion. 35 minutes late, guys. I'm so sorry. And one last comment, selfishly for me, this thing on the bottom. There is a group of people trying to put together a non-RCT prospective cohort investigation enrolling a large number of children just like the adults did. And it will basically be, we now have the pallet guidelines and you heard three or four recommendations in there. And we have the pandem guidelines and you heard three or four more recommendations in there. And the study is gonna be really centered around B, C, and D but really the whole bundle. But the question is, do you do it or do you not? That's gonna be the research. If any of you or your other colleagues are attending the police meeting in Lake Tahoe in March, we're gonna try to begin the study design of this. I think there may be money to do this from PCORI. And we don't have all the details worked out, hardly at all yet. But if this is something burning in your soul that you might want to participate in, please get a hold of me and I'd like to talk to you. Thank you all very much and enjoy the rest of your day. Thank you.

PICU

spontaneous awakening trials

mechanical ventilation

positive touch

pulmonary hypertension

patient-centered care