SCCM Pod-484: ICU Liberation in the Pediatric Setting

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The ICU Liberation Campaign aims to liberate patients from the harmful effects of an intensive care unit (ICU) stay. The campaign is expanding to include more resources for children and infants. Host Ludwig Lin, MD, was joined by Jerry Zimmerman, MD, PhD, FCCM, at the 2023 Critical Care Congress to discuss ICU Liberation and how it is being adapted to improve care in the pediatric ICU. Dr. Zimmerman is an attending physician in the pediatric ICU at Seattle Children’s Hospital and professor of pediatrics and anesthesiology at the University of Washington School of Medicine in Seattle, Washington, USA. This podcast is sponsored by Etiometry.

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Transcript:

This podcast is sponsored by Etiometry, where we believe high-acuity care teams deserve access to clinical intelligence to aid in care coordination. Developed within an ICU to meet clinicians’ most pressing needs, the platform’s customized visualization of hospital-specific protocols supports reducing length of stay and readmissions. See why some of the world’s top medical centers rely on Etiometry. Visit etiometry.com.

Dr. Lin: Hello and welcome to the 2023 Critical Care Congress edition of the Society of Critical Care Medicine podcast series. I’m your host, Dr. Ludwig Lin. Today, I’m joined by Dr. Jerry Zimmerman, MD, PhD, FCCM, to discuss pediatric ICU Liberation, PICU Liberation. Dr. Zimmerman is an attending physician in the pediatric intensive care unit at Seattle Children’s Hospital. He’s a professor of pediatrics and anesthesiology at the University of Washington School of Medicine in Seattle. Dr. Zimmerman has been involved with the PICU Liberation Network Group ever since SCCM launched this campaign in 2015. I would like to welcome Dr. Zimmerman. Before we get started, we’ll just ask Dr. Zimmerman to report any disclosures.

Dr. Zimmerman: Well, thank you, first of all, for inviting me. It’s an honor to discuss this with you. Conflicts of interest I don’t think are relevant. I have NIH funding for research, also some funding from Immunexpress in Seattle to do research, and I receive royalties for coediting the textbook Pediatric Critical Care.

Dr. Lin: Perfect. Thank you. Let’s get started in this discussion. I think it’s so daunting for us in the adult world to think about taking on pediatric tasks. I think, in a way, this is going to demystify this, hopefully, for our audience and also let us know what wonderful work the pediatric side of critical care has been doing. Let’s start with a general question. Which types of pediatric ICUs and which pediatric populations would benefit from adopting this ICU Liberation Bundle?

Dr. Zimmerman: That’s probably a good question to start with because the big answer, the 30,000-foot view of this, is that ICU Liberation is a care model that is applicable to every critical care patient. It doesn’t make any difference whether it’s an old lady with congestive heart failure or a child with bronchiolitis or even a neonate. These care principles focusing on this holistic approach are really applicable to anyone who’s critically ill.

Dr. Lin: That sounds really good. Do you recommend any adjustments to the protocol or the strategy for each particular age group when you are taking care of these kids?

Dr. Zimmerman: Well, certainly for assessment of pain, assessment of sedation level or agitation, and screening for delirium, the tools are different and they are developmentally corrected to be appropriate. So for an adult, you can say, how’s your pain on a scale of 1 to 10, and generally someone can help you. The patient can describe exactly on that scale where their pain level is. As you get younger, less developmentally mature, you don’t have that advantage, so you have to use other things like facial analogs of pain and other tricks of the trade. And if you get into the neonatal population, it gets even trickier and you have to use additional physiologic clues. So yes, there are different ways of assessing and monitoring for the various elements included in ICU Liberation, but the approach is really the same.

Dr. Lin: How do you empower your teams to be ready for these different age categories and to adjust their diagnostic tools?

Dr. Zimmerman: These tools for monitoring pain, for monitoring sedation, for monitoring possible transition into a delirious state are not unique to ICU Liberation. They are common tools that all ICU providers, particularly the nurses, who are the infantry on the front line, do as a matter of course. For example, pain is monitored by some method every one to two hours in most pediatric intensive care units, agitation or level of sedation probably every two hours, and the possibility of transition to delirium every four hours. That is part of usual nursing monitoring at the bedside for critically ill patients, both pediatric and adult. The tools that we use in pediatrics are different perhaps than in adults, but again, the intent is the same in terms of monitoring and it’s part of usual care.

Dr. Lin: Sure. As an adult intensivist, I think maybe for me personally, I’m used to the set of tools that I use, that I need. I think my colleagues, the nurses and pharmacists and everybody else do as well. It just seems, to be honest, quite intimidating to have these different age groups and to be thinking about it. But you seem perfectly comfortable. Let me ask you a follow-up about this.

Dr. Zimmerman: You actually hit on a critical point of practice of pediatrics and pediatric critical care medicine, and that is the importance of development on what’s going on. It’s important in all kinds of different ways. For example, a 25-year-old with severe cerebral palsy, developmental delay, and 20 kilograms, that patient may just be better cared for on a lot of occasions in a pediatric intensive care unit than an adult intensive care unit, just because we’re comfortable and we’re used to dealing with this now young adult but with severe comorbid conditions that may require a different way of monitoring and dealing with than you would have in an adult intensive care unit.

Everything in the pediatric ICU is milligrams per kilogram. We don’t have any just usual doses for a usual condition. Everything is weight-based and developmentally based. Some children can understand this, that you have to use a different approach. Some patients are still in a concrete phase of their development. A three-year-old who’s on mechanical ventilation, who is going berserk, it’s not necessarily that he is in pain, it’s not that he is even agitated or inadequately sedated, he is acting like a normal three-year-old. He just doesn’t want to be there and have us taking care of him. You just have to acknowledge that and it’s part of the job.

Dr. Lin: I have so many questions for you. The first one I’m going to ask as a follow-up is, I am really interested to hear about how you and your teams deal with delirium. I know that I think of delirium as sort of like a complication of being unable to process information logically and to be able to form conclusions, disorientation, and I’m just thinking that, in the younger kids who don’t even necessarily understand why they’re there, it’s just going to make that problem even worse. Do you have an easy-to-understand way to help the rest of us think about how you and your colleagues approach this problem in the pediatric setting?

Dr. Zimmerman: I think this is not unique to pediatrics, what I’m going to say. This is a key aspect of ICU Liberation, PICU Liberation; the best way to treat delirium is to prevent it. There are key risk factors; being on the ventilator with a plastic tube placed in your trachea, gagging you, actually being sedated seems humane. But when patients, when you can do it, can be more awake and be more interactive, they’ll have less of a chance of delirium. There are specific drugs that are risk factors for delirium. These are the anticholinergics like diphenhydramine and benzos. They’re clear risk factors for delirium in adults and children experiencing a critical illness.

A huge one is sleep quality. If you have anyone, it doesn’t make any difference whether it’s a child or an adult who’s critically ill, who feels lousy and hasn’t had good sleep for days, you can imagine yourself, you would probably be delirious too. Anything, in my opinion, and this goes along with ICU Liberation, that you can utilize to keep the patient comfortable that is nonpharmacologic, the better. The pain is critically important, and inadequate pain control leads to delirium. Sedation, sometimes you just need it to make the patient safe, but it’s clear that the less you use, the better, because it’s a clear risk factor for delirium and a number of other things as well. Especially if you can get the family at the bedside, massage, reading, playing games, conversation, an ICU diary, pet therapy, music therapy, all of these things that aren’t drugs, but people interacting with each other, that’s the way you prevent delirium. The best way to treat delirium is not more drugs, it’s actually trying to look at the patient, what they’re receiving, and try to cut down on the amount of sedative drugs that you’re administering.

Dr. Lin: This sounds exactly like the adult world, so that’s very reassuring. Is there a certain age or developmental stage where you’re junior to that, it’s just not possible to minimize the sedatives as much as you would like?

Dr. Zimmerman: Absolutely. As I said, the three-year-old male is exploring his environment. He or she will do whatever they want. I think typically there is some amount of sedation that, universally, kids, all the way up to their teenage years, need in order to conduct mechanical ventilation safely, to keep the endotrachial tube in place so that you don’t lose it. I think what we’ve learned over the last 10 years is, if you can do that with dexmedetomidine or maybe propofol for a while instead of benzos, that’s a good thing. If you could use intermittent doses rather than a continuous infusion, that’s a good thing and, if you actively, proactively, look for ways to turn down that infusion, if the RASS score, the sedation score, whatever you’re using, is where you want it and it’s been there for a while, that infusion should really be turned down. That’s one of the tenets of ICU Liberation. So yes, critical care benefits from sedative medicines, but it also has a number of adverse effects so it is important to be realistic. Of course, you need sedative medications to practice critical care medicine, particularly in kids.

A lot of times we talk about our practice as being veterinary medicine because sometimes you just have to do what you think is safe for the patient. But sedative medications, which actually do decrease the stress response, make the patient safer in terms of synchrony with the ventilator and decreasing airway injury. These are all key variables, of course. But at the same time, sedative medications are associated with risk for delirium. They’re associated with prolonged mechanical ventilation. They’re actually associated with posttraumatic stress disorder, not only the patient, but the family as well.

The prudent thing to do, and ICU Liberation is all about this, is to set a target sedation level, agitation level, and there are validated scores to do that. The team should set that every morning. The nurse at the bedside, who is the one really monitoring this most closely, if you’re there at the target and you haven’t given a number of bolus doses of that sedative, then it’s really important to begin to turn down that infusion as you can, a little bit at a time. That will decrease the overall exposure to that medication. Then, the other part of it is, we now know that dexmedetomidine or propofol are probably better as sedative agents than diphenhydramine and benzos, and if you can use intermittent doses rather than a continuous infusion, again, to lower the total dose, that’s also good.

Dr. Lin: This sounds really, really similar to the adult ICU Liberation goals, which I think makes it, like you said, a lot more calming for the rest of us. Your team sounds so incredible. I have so much respect for the great work that they must do at the bedside every day. My curiosity is about the impact of EHR on the workflow. Has that in a way made things perhaps easier for them or has it made it more difficult? Do you have any comments about that?

Dr. Zimmerman: The EHR is not what healthcare professionals expected. It’s still not there yet, and we have to look for ways to continue to be able to automate this. Now we’re collecting all this information that is hugely valuable in comparative descriptive research studies, so we need to figure out how to do this right, and there are a number of things about the electronic health record. It’s crazy that every hospital who gets a new EHR has to reinvent the wheel. Part of that is that what happens is, each hospital has their own idiosyncrasies about how they’re collecting the data, what data are being collected. The Society of Critical Care Medicine has put a lot of work into what are the critical variables that need to be included, for example, in research studies involving critically ill people.

We need to figure out how to do that in the same way so that each hospital doesn’t have their own database. Ideally, if we had a federated EHR database in the United States, that would be huge. The impact it could have on discovering and identifying best practice would be huge. I think China could maybe do this, they could identify a good system and just say, all right, this is what we’re going to use, folks, and if they do that, they’re going to be hugely powerful in terms of identifying best practice and promoting research in critical care. I think it’s something that’s hugely important in our whole data science thing, is how can we figure out how different hospitals can talk to each other in the same language, and also have that data available for research to identify best practice because it’s rich and it’s hugely important.

Dr. Lin: Sure. I always think about something more granular for these different age groups, and different developmental stages make it easier for the bedside person. Usually, it’s the PICU nurse to do, for example, the daily CAM assessment and things like that.

Dr. Zimmerman: Yes. I think, downloading data from the EHR, looking at what vital signs are being recorded, looking at the patient. Does this look right? Are there outliers there that don’t reflect what’s been going on? But if a patient looks like this at the moment, click the button and that all goes into the record appropriately. Then the bedside nurse has the time to actually interact with the patient. Those are the best monitoring tools, where there is interaction between the nurse and the patient to assess, for example, the presence of delirium. So yes, the nurses, physicians as well, should be freed up from this just data collection stuff to actually be able to concentrate their workday on the patient and the family.

Dr. Lin: Hear, hear. Speaking of the family, you were talking about the impact on the family of a pediatric patient’s ICU stay. I wanted to ask you about your experience and perhaps goals you have for assessing children with post-critical care syndrome. What are your feelings about this?

Dr. Zimmerman: I think in pediatrics we are farther behind than the adult world. There are a few, I would say not a lot, of pediatric hospitals that do have clinics for post-intensive care syndrome, and they’ve been described here in the United States as well as Canada. I think it’s a great idea, and I think one of the things that a post-intensive care syndrome clinic could do for ICU providers, especially nurses who are just under constant stress all the time, is take them out of that for one or two hours a week in this clinic and see these patients who are now out of the ICU in the community, maybe still struggling, but looking a lot better. I think it would be good for patients and families on the one hand, and I think it would be good for ICU staff in terms of decreasing the risk for burnout.

The other way of approaching this, which I think has great potential, is with the critical care personnel having a closer relationship with the community, the family physician, the general pediatrician that that child goes to. You know what discharge summaries from hospitals look like, sometimes they have every detail and nobody reads that stuff, and the referring physician doesn’t even want to see this. But what if the discharge summary said, “The patient was critically ill in the intensive care unit. He was very unstable on the ventilator and required neuromuscular blockade for a week and sedation to go with that. His mobility was delayed because of this neuromuscular blockade. We had trouble feeding him for whatever reason and, because of this, these are the problems that we would expect that he’s going to encounter because of these adverse events of providing critical care when he was critically ill in the intensive care unit.”

This discharge summary would actually alert the primary care physician what to expect and what to watch out for, and then use local resources to help with that as well. This is really important where I come from in Washington where our patients may live a thousand miles away, and that’s true for lots of places. If you live in New York City, it’s much easier to do this clinic because most of your patients come right from that area and it’s not hard for them to travel. But if a big chunk of your patients live in a rural setting far from the referral center, that’s a big ask for them to come back. The second thing too is, who is going to pay for that clinic to actually make it happen? Another unresolved question.

Dr. Lin: Yes, yes. I totally agree with that part. This seems like such a necessary essential thing, but where’s the money? But I love it that you’re advocating for this concept in that it serves the patients and their families. It serves the well-being of the healthcare providers, and it facilitates communication. So. I think it’s a win-win-win. I wanted to ask you about your experience in introducing ICU Liberation strategies to the pediatric world and what the biggest problem spots have been and how you went about trying to get people through those problem spots.

Dr. Zimmerman: I would preface this with, it’s easy to talk about this and a lot harder to actually do it, and take that times 10 to sustain it. But where my view of ICU Liberation is about being proactive with this concept of continuous advancement of care, I think that’s what ICU Liberation is really about. If you attend the PICU Liberation session here at Congress on Monday, you’ll hear me talk about this concept that waiting is the biggest waste in medicine. Waiting for the Christmas holiday to be over with, waiting for the consultation, waiting for this lab result to come back, and the care is stuttered because we’re waiting instead of being continuously advancing. I think the engine of ICU Liberation in adult and children is reducing this waste of waiting by weaning and being proactive about it.

Again, mechanical ventilation, sedation, they’re key tools in our armamentarium for delivering critical care. They are lifesaving, but they also have very serious adverse events. If you can wean the sedation, do it. If you can wean the ventilator, do it. In the ICU for kids, if you’re off the ventilator, you’re out of the ICU the next day, statistically speaking. Just shortening the duration of sedation will help shorten the duration of mechanical ventilation, adjusted for initial illness severity. Those are two really key concepts and being proactive about it rather than, “Eh, it’s rounds now. Yeah, let’s turn things down or whatever.”

I think you can develop systems. This has been shown unequivocally, the evidence in adult medicine, the two big trials, tens of thousands of patients. When you do this, you reduce the duration of mechanical ventilation, you reduce the amount of sedation, and this is associated with all kinds of patient-centered, clinically meaningful outcomes, including a reduction in mortality. It turns out we have similar data in terms of reduction of mortality for PICU Liberation as well in our first study, but the connection of that outcome with other measures of performance of the elements doesn’t fit together as well as it did for the adult studies. We need more work there.

Dr. Lin: That’s really good to learn about, and I really like this concept of thinking about the opportunity wastes, that we need to be proactive to try to really minimize those opportunity wastes. Are there any things that you know are wasteful or not constructive toward a patient’s improvement course but you let it go sometimes because it’s a necessary evil?

Dr. Zimmerman: Well, I wouldn’t know that I would call it a necessary evil so much. But again, it’s easy for me to talk because I’ve been doing medicine for a long time and you make mistakes and that’s called experience. It’s hugely important as you go along. But I think we all know in medicine that we use more laboratory and imaging tests, for example, than we really need. If a patient comes into the hospital and they’ve had this whole set of laboratory studies and they are admitted to the ICU two hours later and the admission order says the same thing, then that’s just completely wasteful. If a chest x-ray was obtained in the ER and everything looks good in terms of safety, is it really necessary to get another one a couple hours later? These are wastes that are, I think, often associated, especially in teaching hospitals, with inexperienced people thinking they need more information rather than less in terms of making their decisions. Sometimes it’s helpful. I think a lot of the times, a lot of extra information isn’t helpful.

I think there needs to be this constant effort at being comfortable with uncertainty. I think people who eventually become good in critical care are not ordering laboratory tests all the time, they’re not getting a thousand consultations. They’re sitting, they’re watching the patient at the bedside, not in a room looking at a bunch of computers, but they’re waitfully watching and seeing what the trajectory is. In critical care, we titrate things and sometimes it works and sometimes it doesn’t. That’s what our practice is based on.

I think one way of reducing waste besides practicing ICU Liberation is careful monitoring of the patient with your experience. There are a lot of people watching this patient and, if your decision about what to do next doesn’t work, then you turn the knob back counterclockwise and you resume where you were. Critical care people rush to the code blue; you can always identify somebody who’s going to be a good intensivist because they don’t walk away from the code blue, they run toward it.

At the same time, once they get that patient stabilized, critical care practitioners are reluctant to rock the boat. They’re reluctant to change that status quo. Critical care is lifesaving, but also you want to get your patient out of that intensive care unit as expeditiously, safely, as you can. That’s where ICU Liberation comes into play because it promotes this continuous advancement of care when it’s safe to do so. It treats the patient, not just concentrating on organ system dysfunction resolution, but the patient as a whole. It’s good for the patient and it’s clear that it works.

Dr. Lin: I love it. For me, I think my takeaway points are: rock the boat, ask lots of questions, basically be a really good intern and just be on it. I have so many more questions for you. I know that our audience would love to hear you talk a lot about a lot more of this but, for the sake of time, we will conclude. I’d like to thank you again for spending time with us, Dr. Zimmerman.

Dr. Zimmerman: Thank you for inviting me.

Dr. Lin: This will conclude another edition of the Society of Critical Care Medicines Podcast series. For SCCM, I am Dr. Ludwig Lin.

This podcast is sponsored by Etiometry, where we believe high-acuity care teams deserve access to clinical intelligence to aid in care coordination. Developed within an ICU to meet clinicians’ most pressing needs, the platform’s customized visualization of hospital-specific protocols supports reducing length of stay and readmissions. See why some of the world’s top medical centers rely on Etiometry. Visit etiometry.com.

Ludwig H. Lin, MD, is an intensivist and anesthesiologist at Sutter Hospitals in Northern California and is a consulting professor at Stanford University School of Medicine, where he teaches a seminar on the psychosocial and economic ramifications of critical illness.

This podcast was recorded during the Society of Critical Care medicine’s 2023 Critical Care Congress. Access essential education online through Congress Digital. More than 120 sessions are available on an easy-to-use platform. Continuing education credit is also available. Some SCCM members receive complimentary access to Congress Digital. To learn more, visit sccm.org/congressdigital.

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