I want to thank Karen for that absolutely fantastic presentation. Hopefully she's convinced you that we owe it to our patients to implement the data that we know is going to improve their outcomes. We are out of time, so I'm just going to take two minutes to kind of put this all together for you. We're going to run through a case scenario twice. We're going to compare and contrast the traditional approach to our mechanically ventilated children with the ICU liberation approach. So we're going to start with a six-year-old previously healthy boy. He doesn't exist, but I've named him Alex. Alex was admitted with influenza virus pneumonitis and acute respiratory failure with superimposed bacterial pneumonia. He is quite ill upon transfer to the ICU. Within two hours, he requires intubation for hypoxemia. The unit gets him settled, and he's now on moderate ventilator settings. His PEEP is eight, his FIO2 is 55%, and his hemodynamics are stable. Now here is where two roads diverge in a wood. Traditional approach. The initial sedation plan, Alex is started on fentanyl and midazolam infusions. He awakens from sedation and appears agitated. What should be done? Well, he gets bolus doses of fentanyl and midazolam, and the infusion rates of both drips are escalated. The cycle repeats itself multiple times over the first 24 hours. By day two, his fentanyl, this is a previously healthy kid, so he's not kind of opioid exposed or habituated. This previously healthy child is on a fentanyl infusion of three mikes per kilo per hour and a midazolam infusion of 0.3 milligrams. His bedside nurse notes that he is, quote, impossible to sedate. And she, in all distress, says, I'm afraid he will auto-extubate. Oh no, this is a big trigger for our unit practice. He is then placed in restraints, and his drips are increased. The mom, when the child wakes up, goes over to his bedside, and the nurse says, no, no, I just got him quiet, I just got him still, don't touch him, don't stimulate him. He has some hypotension that is associated with the sedation, and he requires several fluid boluses over the next several days. His AA gradient increases for about three or four days, and then it plateaus. At this point, one would be inclined to wean him, but despite the high dose sedatives, he has these periods of emergence agitation, which require, actually, intermittent doses of paralytic. He's now edematous and bed-bound four days into his ICU course. So by day seven, we were able to start some diuresis, we're able to wean his sedation a little by addressing some of his delirium, his chest x-rays better, his PIP is improved, and we begin to wean the ventilator. That's day seven. However, whenever we decrease the sedation, the patient's agitation, which had been pharmacologically masked with the high dose sedatives, emerges. We then note that he has hyperactive delirium and opiate withdrawal. So it takes three more days to kind of organize his sedatives and wean his ventilator, and he's now ready for an extubation trial. We'll contrast this with the PICU liberation approach. Alex is a six-year-old previously healthy boy who comes in with influenza virus, pneumonitis, and a superimposed bacterial pneumonia and pretty severe hypoxemic respiratory failure. He's intubated, same ventilator settings, about two hours later. The initial approach is different than the traditional approach. He's prescribed acetaminophen and ibuprofen around the clock, TNT, it's dynamite, in addition to morphine every two to three hours. The goal here is optimal pain control and minimal sedation. He is given a RAS goal. Our RAS goal for Alex is zero, and the nurse has the ability to titrate to that RAS goal. So if the RAS goal is zero and Alex's sedation level is minus one or minus two, he needs less sedation. If his RAS level is plus one or plus two, then he needs something to address that agitation. He, just like the first Alex, awakens several times over that day. He's given several extra loading doses of morphine and he calms. But the cycle repeats itself two times over the next several hours, where he wakes up, requires more morphine, wakes up, requires more morphine. Does he have opiate tolerance? Because I've heard that, oh wow, this kid's really tolerant, right? He clearly just needs higher dose opiates. He doesn't have opiate tolerance, he's never seen an opiate until today. So it's highly unlikely this is opiate tolerance. What this is likely is just that he needs extra loading doses of morphine, but no increase in the standing dose. He still appears anxious, and he deserves something for his anxiety, right? It's not his fault he's six with respiratory failure. So a dexmedetomidine drip is initiated and titrated to effect. He's earned his sedative. It wasn't given to him as a party favor. Welcome to my ICU. Here's your endotracheal tube and here's your sedative. He's shown that he requires sedation. We've also reassured ourselves that his pain is very well managed before we added on that sedative. He's able to sleep for a few hours, but then he awakens and he's able to communicate pain when his nurse sections him. So a plan is made for preemptive morphine to be given about 10 minutes prior to any scheduled sectioning. Despite moderate ventilator settings, he's awake. He's reasonably cooperative. He's mobilized. My ICU's not so fancy, so we didn't have enough staffing. It was a Sunday. We didn't walk him, but he's mobilized in his bed. It's turned into a chair. He's given a handheld game to play. He's interactive with his parents and his staff, and he sleeps for five hours that night. His mom kind of rubs his feet, and he had watched a football game with his dad earlier in the day. Twice daily delirium screening occurs when his delirium score begins to rise, so we don't wait until his kind of CAPD score reaches that threshold of nine. The medical team looks for what they can do, what might be modifiable that could be contributing to his delirium. They review his medication list. They discontinue some unnecessary anticholinergic medication that had been started two days earlier. They also remove his Foley catheter. His subsequent delirium score is improved. Despite this excellent care, his AA gradient does increase over the first three days. His pneumonia is blossoming. So his RAS target, which had been zero, is now changed to minus one. We now want him drowsy to facilitate patient ventilator synchrony. Several boluses of dexmedetomidine are used, and an increase in the infusion rate achieves target sedation. By day four, his chest x-ray and his peak pressure is improved. His sedation target is raised again. His target is now zero. We want him less sedated. His medications are weaned accordingly, and his ventilator begins to wean. Since he has been spontaneously breathing and he's been exercising for most of his ICU stay, he has not experienced significant deconditioning. He has not experienced severe agitated hyperactive delirium, and he quickly weans and is successfully extubated on day six of invasive mechanical ventilation. So obviously, this is an overly simplistic case. I did that to make a point, right? My point is that, as Albert Einstein so eloquently stated, intellectuals solve problems, geniuses prevent them. By using the quality bundled approach to care that we have shown you is effective, safe, and sustainable, we can avoid the problems, the iatrogenic problems that we cause in the course of providing critical care. This is a ripe opportunity for quality improvement. Not only does it improve the quality of care we provide to our patients, it's also good for their parents, and it's good for our hospital staff. Our ICUs have gone from looking a lot like this, where you kind of were default intubated, deeply sedated, while critically ill, and then you kind of looked dazed and confused on the back end, to ICUs that look like this, where children are awake and alert while being critically ill and interactive with their staff and their family members. To conclude this session, we can shift our historical approach to sedating children to an analgesia-based approach. There's a large body of evidence that shows it's safe and effective, and by preventing delirium, mobilizing patients, and involving families, we can likely improve outcomes in critically ill children. But there is so much work to be done. To quote the philosopher William James, as a community, we pediatric intensivists, compared to what we ought to be, we are half awake. Working together, I believe we can change that. We're officially out of time, but whoever wants to stay before lunch happens, I'd just like to invite the panelists up here, so you guys can ask any questions that you have. I thank you very much for your attention.

mechanically ventilated children

ICU

traditional approach

PICU liberation approach

sedation-based to analgesia-based approaches