WesElyMD Profile picture
14 Mar, 8 tweets, 6 min read
1/ Do data support pt trial off sedation for “SAT” when pt is comfortable on current dose? Yes
Shared w permission:
“Dr. Ely, yesterday our ICU #nurses went over #A2Fbundle in Epic for implementation. Do you recommend SAT at RASS Goal of RASS -1 to +1?
#medtwitter #criticalcare
2/ Excellent #Nurse added:

“We are currently not doing SAT (Spontaneous Awakening Trial) but keeping pt’s RASS -1 to +1.  Just want to make sure we are interpreting #A2Fbundle correctly.”
#medstudenttwitter #COVID19 #pandemic
3/ my Answers:

Great questions. I don’t think +1 (anxiety) is ever a good goal but 0 to -1 is a 👍 default target RASS if we acknowledge there are times when sedation target should acceptably be set as deep as -3/-4 in bad #ARDS or -5 transiently when pt requires paralytics.
4/ Some HCPs use philosophy that if pt is already “at goal” why shut drugs off? 

Well...what if target is wrong? Also, if a drug isn’t needed, it may be hurting a person & costing $$ unnecessarily. Bottom line: you won’t know if it’s needed until you stop it EVERY DAY w SAT.
5/ Data say stop sedation once a day even if at target. Restart as needed at half previous dose. That’s how we designed our Girard T 2008 ABC study in @TheLancet, which showed BIG survival advantage to SATs.
6/…it’s a gamble with someone else’s #recovery & #life not to do the SAT. What happened yesterday for your pt is NOT proof of how she/he will react today. When the sun comes up it’s a new opportunity to liberate this person! We act in anticipation of progress in #healing.
Committing pts to more drug doesn’t make sense data-wise or to me as a doc since I can safely test need via an SAT. Assuming pts need more sedation is a sentence in favor of more immobilization, #delirium, ultimately more #dementia & #death.
#A2Fbundle = #humanization
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More from @WesElyMD

11 Mar
1/ Home w my 84 y/o Mom for 1st time since 2019 because of #COVID19…She raised 3 of us alone on $17k/yr as a lit teacher after dad left. A few things she’s said that are hilarious... Image
2/ Today we saw an classmate from my grade school & Mom didn’t remember her.

Me: “Mom, she’s really smart, wise, kind, & gentle of heart.”

Mom: “So I guess that’s why you didn’t hang out with her much.”

😳 Zing!
3/ Mom thinking 🤔 ...“Wes, remember when I got us a tent to take you kids camping? I had you set it up in the backyard to make sure we knew how. Then I thought, ‘Hmm, this is good...why don’t you 3 just live out here from now on!’”
Read 6 tweets
24 Feb
1/ Scientific Discovery: time & patience
Be patient in science. 25 yrs ago, I & others felt we were harming ICU patients by deep sedation & immobility. Our goal: PROVE IT & change culture in #criticalcare.
How did we start?

#medtwitter #A2Fbundle #nursetwitter
2/ Scientific Discovery: takes time

There weren’t tools 😤Reluctantly, I had to go “backwards” to validate CAM-ICU & RASS (@JAMA_current X3). A DECADE later we produced studies lightening sedation (MENDS/ABC trials JAMA/@TheLancet). Be patient!

#academictwitter #ScienceTwitter
3/ Scientific Discovery: patience
Give yourself space to be creative! Science takes time & Data must lead you. All our 1st grants & papers were rejected for 5 YEARS. NIH said: #Delirium in ICU is not a viable topic or a “thing.” Go away. Persistence paid off for patient safety.
Read 5 tweets
16 Feb
1/ Tinkling of Ice: #Alcohol & Me
Personal Share: As a 1st year #MedStudent 35 years ago (#MardiGras 1986), I was a cyclic, binge-drinker. It threatened my future as a physician & my personal safety. I draw on these experiences with pts.
#medtwitter #tipsfornewdocs #nurses
2/ For me, #recovery meant detaching from harmful zones of behavior. Years of ups & downs. I often share my story w patients when it comes up. I find this builds a powerful connection between us and helps us both. #healing
#medstudenttwitter #academictwitter #nursetwitter
3/ I needed to give up, fess up, make amends, and keep up. I stumbled along the way & am thankful to those who supported me & did not judge me.
#HOPE = Hang On, Peace Exists
#healing #workinprogress #addiction @ASAMorg @AlAnon_WSO @RyanForRecovery
Read 7 tweets
28 Dec 20
Green Urine: #NEJM
....will be seen in #COVID – Why? Massive use of Propofol. While Green Urine is Benign, effects of prolonged over-sedation & immobilization ++ #DELIRIUM are not 😤 Wake them up & get out of bed. Start w/SAT…#A2Fbundle & #PICS

#medtwitter #nursetwitter
1/ re: SATs to avoid over-sedation in #COVID19 pts, Thx @phanton_icu for Protocol Blindness caution & @Nitkjain reminder “Easier said than done.” I’ve been pondering your comments all day & think them ripe for further conversation on #A2Fbundle

#medtwitter #pulmcc #nursetwitter
2/ Remember, protocols like #A2Fbundle are guides & not “1-shoe-fits-all pts.” Correct, we must deviate when needed. However, these 6 principles (ABCDEF) are derived from 35 NEJM, JAMA, Lancet papers +400 others & now >25,000 pts of data. Not chump change.
Read 10 tweets
20 Nov 20
Trigger alert 🚨: Hard to stomach but this hits so hard I want to face it. Segregation of Blood🩸by color of skin went on until 1972 & the “1-drop rule” persisted until 1983 in my home state of LA. 😩 👀 labels.
I pledge to fight #racism & lift each person.

#medtwitter #MedEd
1/ Dr. Charles Drew, an African-American surgeon & father of blood banking, perfected techniques that saved countless lives. Yet he was prohibited from donating blood himself over “fear” of his black blood. Read #2 w/ ✍🏻
#MedTwitter #MedStudentTwitter
2/ Dr. Drew ✍🏻 this letter of protest because he wasn’t being allowed to🩸: “I think the Army made a grievous mistake, a stupid error in first issuing an order to the effect that blood for the Army should not be received from Negroes. My 3 reasons are...”
Read 7 tweets
8 Oct 20
1/ ICU #diaries for Good #Death:
Especially at EOL, ICU #Diary is part of #A2Fbundle. My pt w/ home-hospice told me details recorded in #ICU by #nurse allowed her to decipher cryptic #delirium memories she was struggling with.


#medtwitter #meded
2/ Then she told me of hours spent reading big-hearted comments others had written in her ICU diary, making her realize how much her life meant to others. It was a priceless gift to her at a critical juncture in what had a time of deep poverty in her life. #PalliativeCare
3/ ICU Diaries give family members at bedside a practical way of helping w/ loved one’s care & can help channel their worries in a focused way.
#criticalcare #pulmcc
Read 7 tweets

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