Hey guys, I'm Stacy Williams. I have worked with Christina now on with delirium and the PANDEM guidelines and also Pete, so it's actually nice to actually be able to see everyone in person now. I'm going to talk today about non-pharmacological prevention and management of pediatric delirium. So a little bit about me, I have been at Vanderbilt Children's now for almost 12 years and I have been a part of the PANDEM guidelines and also on the ICU liberation committee. Obviously my passion of research is delirium, early mobility, sedation, really if it has to do with ICU liberation, I'm all about it. So my disclosures are I am a co-investigator for a study that's funded by the NIH and then also there are a lot of pictures and videos in these upcoming slides and all the families that you'll see, the kids, they have all consented. I know normally it's just a given but there are a lot of pictures so don't let anybody think that we did. So really the objective is to review the non-pharmacological prevention and treatment strategies. So introduction is really what Dr. Butters talked about was why do we need this? Well because we have poor outcomes associated with delirium. So really what we need to do is we need to take it back to the basics. So the first thing we need to do is if you don't monitor for delirium you need to start because you can't prevent something that you're not monitoring for. Then you need to start with the strategies that don't require medication first because those are the easiest ones to implement. So the key to delirium treatment is actually prevention. Why do I say that? Well because one, it's easier to prevent something than treat it that you're already in the thick of it but also a lot of the prevention strategies and treatment strategies are the same. I keep going the wrong way, sorry y'all. So this is a mnemonic that was created by Dr. Heidi Smith et al and this is just a way to help you remember some of the causes of delirium and so for this talk we are going to focus on the patient atmosphere, immobilization, and awake. So this slide is super busy, I know this, but these are the five suggestions that were put out by the PANDEM guidelines and the reason that they're so important is because if you look at the strength of recommendation it's all conditional. The quality of evidence is low. Why is that? Because there is a lack of literature out there but the guideline team thought that it was so important to include these because the risk is so little that we wanted to include them as suggestions and those things include optimization of sleep, interdisciplinary rounds, family presence, and family being in not just present but actually involved being present during procedures, and environment modifications. There's a ton of literature out there for adults talking about environment modifications, however in pediatrics it's very little but what it does show, what little data is out there, it does show that it can modify the environment, can actually reduce the actual rate of delirium but also the severity. So we all work in the ICU, really our big thing is critical illness. We want to heal our children but sometimes we get caught up in that and we miss the little things. So does our patient need glasses? Are they anxious because they honestly can't see anything happening going on around us? Also do they need a special pair of shoes that might help motivate them to walk down the hall? Do they need any hearing assistance? Do they like to sleep with a fan at night or any noise like a white sound machine? Do they have a special blankie that potentially can help calm them? Do they have one levy or maybe 20 that helps them? And then going on to early mobility which we'll talk about in a minute, do they need assistance in performing these things? So this is why we'll talk about family too. Family are the ones who can give us this information. We do not know these children at home and the families are the ones that have this information for us. Okay the slide's doing it again. The background. So what all this is saying in the background, I don't know why it's doing this, it fixed it earlier. So what is early mobility in pediatrics? That's really one of the questions that we get asked all the time from our adult friends. Really early mobility in pediatrics can be anything from just a kind touch because our children experience so much negative touch in the ICU, to moving an infant over to their mom's arms, to sitting up on the side of the bed playing uno with our therapy dog, or even getting up and walking. The data out there for early mobility in relation to delirium is very scarce. Again a lot of the research out there right now shows is going out because they want to show how safe it is for early mobility because everyone is terrified of it. And so that's the focus now. But there are two studies. One was a 22-month study that looked initially it started with a sedation protocol and then they rolled out early mobility and it showed a reduction of 40% of delirium in their ICU. The other one was a quality improvement initiative that they implemented early mobility in their unit and it didn't show it. It was not statistically significant but there was a difference in delirium rates. So barriers. Everyone's terrified of it. This is the first thing that everyone is afraid of is what is going to happen. Are we going to lose an endotracheal tube? Are we going to lose a catheter? Really there's all the research shows that there is little to no adverse events when you're doing early mobility. There's actually a study that Dr. Batters did looking at pre and post survey after our implementation and the views completely changed. So after early mobility was initiated the providers really the worries of increased sedation delirium and dislodgement of catheters decreased significantly. Really the barriers then became lack of staff, lack of equipment, and difficulty in arranging everybody that needed to be there and every item that needed to be there for it to happen. And then 90% of the study participants actually said that it actually helped their patients. So here is a video. This is kind of on the higher end of early mobility. And so you'll see here our team. What you'll see is she is on ECMO. You see we actually if one of our patients is on ECMO doing early mobility we have two ECMO specialists. One that is the bedside specialist and then we bring in the lead. You have your nurse manning all the lines because every person has a role. If the patient was intubated we would have respiratory therapy there and then she stepped out of the way for the video but our physical therapist was there. Oh now it comes up. There you go. So sleep hygiene and schedules. As medical professionals we all know how important sleep is. The lack of data in pediatrics is astronomical. It's crazy. But the data in the adult population and in neonatology is outstanding. And really sleep hygiene is implemented in most delirium bundles but there's no multiple studies showing that it actually decreases the rate of delirium. And most delirium bundles are besides sleep hygiene include like noise reduction and things like that. But nothing is really studied one-on-one in relation to delirium. So here are some suggestions. Really promote natural sleep-wake cycles. Promote healthy sleep conditions. So minimizing noise, light and stimulation. And there are some studies that do look at minimizing noise and light but not in relation to delirium. Natural light exposure. Level of stimulation more during the day. This is where early mobility can come in because it is cognitive stimulation and it helps kind of helps them sleep better at night. Asking the family how do they sleep at home. Do they have certain ways that they like to sleep? Do they have certain things they like to sleep with? And then a schedule. How many of you guys have kids, have nieces, nephews that are younger toddler age who had a schedule and you didn't stray from that schedule because everyone involved was so much better? Our ICU patients shouldn't be any different. They should include PTOT. They should include a time for rest. They should include a time for just a time to themselves because they're again they are overstimulated. So family presence, empowerment, engagement. Really in pediatrics we know that it's not just our patients we have to care for. It's the entire family. And we don't define who the family is. The patient and those close to them define who is family. Getting them involved in rounds is imperative because you have to, it's a two-way street. We can give them information about their child. They can give us little tidbits about their child that can help us in the care. Also there was a study showing that families who are in the ICU are new to the ICU environment. It's really helpful after rounds kind of in the afternoon to like have a provider circle back and they're more apt to understand what's happening and answer questions. Whereas those who are kind of unfortunately frequent the ICU, they are in rounds, they can answer the questions, they can ask, they understand. But also having them involved decreases their anxiety and their stress levels and it gives them a sense of still being the child's parent because we strip that away from them a lot of times in the ICU. They feel helpless and this gives them a little bit of empowerment. So we need to educate our parents too to encourage them to do mobility. They can be, they are just another team member. They can change their baby's diaper, massage, and then also they are what's familiar to the child in the bed, the crib because, and this is what we stress with delirium, is have things that are familiar to the child. We are not what's familiar. The mom's voice, the mom's touch, the dad's voice, all those things. And then last but not least, other helpful resources. Again, there's very little data. Music therapy and pet therapy really focus on kind of the comfort scores and the families feeling like their patient or their child's more comfortable. Pet therapy though does actually include, like shows that there's more active engagement and more movement. This is actually our therapy dog, Squid, who can actually play Uno. I mean, how can you not be happy with that? Pet therapy also increases the mood of the ICU, which we could all use that. And then massage. Massage therapy is super easy. There's very low risk and it does show that it helps with the family engagement and also them feeling like their child is getting more comfortable. And then there was one study that actually did show that implementing massage therapy did lower the amount of benzodiazepines the children did get. So where do we go from here? Well, if you don't already monitor for delirium, you should start. And then we need to add in the prevention strategies. We need to educate the staff and the families. We need to remind families too that this is not forever. This is just a point in time of their child's care because it can be very scary. And then we need to publish. It was eye-opening, the lack of research out there that we, again, you saw that everything was conditional and very low quality of evidence. But we all do this. We all have sedation practices. We all have pain management. And there's just little data. So we've got to start publishing. And then here are all the references. And then there's my email if anyone has any questions.

Stacy Williams

pediatric delirium

non-pharmacological strategies

PANDEM guidelines

early mobility