Speaker 1  00:00
Alex, welcome to HelixTalk, a podcast presented by the Rosalind Franklin University, College of Pharmacy. We're hoping that our real life clinical pearls and discussions will help you stay up to date and improve your pharmacy knowledge. This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. And now

Narrator - Dr. Abel  00:29
on to the show.

Dr. Sean Kane  00:31
Welcome to Episode 22 of HelixTalk. I'm your co host, Dr. Kane. I'm Dr. Schuman, and I'm Dr. Patel, and I'm proud to announce the first ever critical care topic in the HelixTalk episode, of course, you're happy, Dr. Kane, and today we're going to be talking about sedation minimization. And I don't mean preventing students from falling asleep in class. What I mean is reducing the amount of sedatives that we give our ICU patients who are receiving mechanical ventilation to kind of set the stage for the topic. I wanted to ask both of you to I assume you've never received mechanical ventilation, right?

Unknown Speaker  01:04
At least not in the last week or two.

Speaker 2  01:06
No, I might have, but they gave me a really good sedative, so I forgot.

Dr. Sean Kane  01:10
Okay, so one hot topic in critical care right now is if you were to be mechanically ventilated, which means that they're going to take an endotracheal tube, put it down your trachea, inflate a balloon at the end of it and then deliver air through that endotracheal tube or ET tube. That seems like a fairly painful procedure to have this big tube down your throat. So the question becomes, would you like to be deeply sedated while you're receiving this therapy? Would you rather be alert and aware of your surroundings? Or what would you rather have?

Speaker 2  01:40
I think, personally, I would like to be completely knocked out. Just the thought of having something stuck down my throat sounds really frightening. And there's always

Speaker 3  01:48
those horror stories of somebody who wakes up in the middle of it and realizes all of a sudden they've got a tube shoved down them. So you hear those stories and you think, okay, that may be an issue.

Dr. Sean Kane  01:57
So if we think about people as an example, getting their wisdom teeth taken out and getting general anesthesia for that. If that qualifies as an indication for general anesthesia, the argument is, well, we want our patients basically to not remember anything about their painful ICU stay because of all the things that happen, including mechanical ventilation, but all of the other things like chest tubes and suctioning and turning and things like that. So there's a couple of reasons why we sedate patients. The most obvious one is patients are uncomfortable when they're on mechanical ventilation, and we have drug therapy that makes them more comfortable, and we call those agent sedatives. So it's only the ethical thing to do that would be the argument.

Speaker 3  02:37
Yes, I think I said one other reason, maybe to reduce myocardial oxygen demand. We talk about someone who's starting to get either agitated or they're starting to hyper, hyperventilate, and then get the system revving up, and there's a lot of oxygen, a lot of blood flow that has to go to the tissues.

Speaker 2  02:52
And I think the third one, probably most important one, when you're in ICU, is to prevent any self activation, you know, taking out the lines or catheters or devices patients doing these things on

Speaker 3  03:03
their own, and that's been an issue. I know in some of the patients, when I have worked in inpatient psychiatry, that you've occasionally had some patients will be sent out, and then that becomes the issue if somebody then becomes agitated, and again, then there's concern about, you know, hurting themselves, or again, hurt hurting other individuals.

Dr. Sean Kane  03:20
And then there's another term called ventilator desynchrony, which is a fancy way of saying that the patient doesn't receive or accept a breath from the mechanical ventilator because they're very uncomfortable. So especially in patients who have some kind of lung disease, let's say a really severe pneumonia, where we have to be very aggressive in the volume or the pressure that they receive or the rate at which we make them breathe at that can be very concerning to the patient, where they don't accept the breath that the ventilator is trying to give them. So for those patients, sometimes they do need to be sedated in order to ventilate them appropriately, in this abnormal way that we need to ventilate them with mechanical ventilator.

Speaker 2  03:56
So the big question is, how much is enough? Exactly, in this case here. So talking about the agents themselves, the sedatives, you know, we have a handful of them out in the market that we can utilize, or have been used this far. The first category is benzodiazepine, mainly midazolam, brand name Versed, or lorazepam, brand name Ativan, right?

Speaker 3  04:18
I know within that class, and I think Dr. K may be speaking on this a little bit later, but you have kind of distinguishing characteristics, such as, do they have active metabolites? Do they have inactive metabolites? How long do they lean on the body? And that can be something that can be a concern when choosing one of these agents, and the risk benefit

Dr. Sean Kane  04:33
of it. And as we'll talk about, benzodiazepines used to be the workhorse sedative in the ICU, and that practice has actually changed over the past 10 to 15 years, and we'll definitely touch on that kind of the thing that has taken the place of benzodiazepines as the quote, unquote workhorse is probably propofol. So the brand name of propofol is Diprivan. Yes, it is the same medication that Michael Jackson used inappropriately that caused respiratory depression and eventually his death, but we use it very safely and very commonly in the ICU and people who are intubated with mechanical ventilation, where the issues of respiratory depression are not a problem.

Speaker 2  05:16
The third agent, probably a little bit more expensive out of all the agents is dexmedetomidine. Brand name is Precedex, and that one is recently introduced in the market, not too long ago. And like I said, we'll talk about the cost of it, but it is one of the costlier agents.

Speaker 3  05:32
And this one to be interesting when I believe it's an alpha two agonist. So it kind of works on some of these noradrenergic receptors to kind of, again, bring down the system. So just like that fight or flight mechanism we talked about in calming individuals down, reducing myocardial workload, and a different type of receptor to kind of produce some gating or slowing down of some of those impulses.

Dr. Sean Kane  05:52
And I'm sure that we have at least one other alpha two agonist on the market, not for sedation in the ICU, but clonidine is the other agent that pharmacologically, it's very similar to dexmedetomidine or presidex, in the sense that it's an alpha two agonist. It basically decreases the total amount of sympathetic tone you have in certain areas of the brain, and they do get in different places within the brain. But I think that helps understand the pharmacology, right?

Speaker 3  06:15
And just like clonidine, can be used in both hypertension and also has been used off labeling treatment of Attention Deficit Hyperactivity Disorder, so just in the same way, you can then say, okay, then something like dexmedetomidine, by nature of its alpha two eggs and could be used in maybe a place that's not just hyper, you know, not hypertension, but in a more neurologic area.

Dr. Sean Kane  06:35
Kind of. The final agent that we have at our disposal for sedation are actually opioids. This is interesting, because opioids aren't typically thought as a sedative. We think of them more as an analgesic. So the typical opioids that are available to us as a continuous infusion in the ICU are morphine, or, more commonly, fentanyl. Both of these at higher doses, actually do have a sedative quality to them, in addition to their analgesic or pain relief property, and we'll talk more about why that's actually an incredibly attractive option, at least a first line option for ICU sedation.

Speaker 3  07:08
That's what I believe. Going back to the idea about sedation minimization is there's the issue about drugs accumulating over time. Can either of y'all speak to that? Sure.

Speaker 2  07:17
So we know we talked about the opioids being used for sedation, although they're, you know, first line analgesics, morphine is one of them that comes to mind when we talk about, you know, active metabolites. That active metabolite is morphine six glucuronide, which is again, renally eliminated. But if patient's renal function is down, which is very possible in ICU patients, then we are running into prolonged sedation or even other side effects of morphine. Absolutely.

Dr. Sean Kane  07:44
The other big offender in addition to morphine is midazolam. And I actually hate midazolam or versatile as a continuous infusion. It's really a nice drug for quick IV push, because it has one of the quickest onsets of the benzodiazepines that are available to us. But when you hang a midazolam reverse that infusion, it becomes an extremely long acting agent over a one to two day period, as you accumulate two different actin metabolites. So the first active metabolite is produced through the liver with CYP3A4. And as you know, CYP3A4 is the most common CYP enzyme system in terms of drugs that use it for metabolism and also drugs that like to cause drug interactions with that pathway. The second thing that happens once you go through CYP3A4 is you make another active metabolite, which, again, like morphine, is a glucuronide product. So now we have two different active metabolites. We're susceptible to drug interactions, inter patient variability, and issues with renal dysfunction, where you'll start accumulating these less active, but still active metabolites. So with both morphine and midazolam as continuous infusions, we absolutely have to worry about this term called the pharmacology of over sedation, where, because of the pharmacology of the drug, with prolonged use of continuous infusions, patients will start accumulating these drugs and they won't wake up and we turn them off, which is a huge problem.

Speaker 3  09:02
All right, so in that case, then what is the perfect sedative?

Dr. Sean Kane  09:05
So unfortunately, we don't have a perfect

Speaker 2  09:07
sedative, right? Everyone that we talked about has one drawback, and I guess that makes them, you know, not perfect. So let's look at each one individually. We just talked about midazolam, like you said, Dr. Kane, the active metabolites Do you accumulate over the period of time, right?

Speaker 3  09:22
And I do remember actually learning, you know, we talked about in school, okay? Or azepam is a nice option, because it's one of those few of the benzos that does not have these active tablets. However, the nature of its formulation that it contains propylene glycol, which can then accumulate over time. It can be problematic

Dr. Sean Kane  09:38
there, yep. And that propylene glycol can cause bad things like lactic acidosis, renal failure and other bad problems. So it has to be monitored, especially in patients who have renal impairment. The next one, and probably one of my favorite drugs, period, is propofol, or Diprivan. I love propofol, if you get a chance, go to Wikipedia. Look at the drug molecule of propofol. It may be the most. Drug structure you've ever seen in your life. It's perfectly symmetrical, very simple, beautiful drug. What are the things with propofol? Well, one thing, if you look at it, it looks like a milkshake. It's actually an a lipid emulsion. So that lipid emulsion that makes it so that the drug is soluble can accumulate and cause hypertriglyceridemia. So we have to look out for that.

Speaker 3  10:18
And when I talk in my nutrition lecture, we actually discuss the fact that if you're looking at a patient, looking at a patient who you have to put on either enter or total parenteral nutrition, you have to factor for these calories in terms of their overall data requirements, so that you don't add calories. And there's also the fact that this can be a nice growth habitat for microbes, since it is fat, rich bacteria love to get in there and hang out a little bit.

Dr. Sean Kane  10:41
And kind of piggybacking off that in the ICU, we actually changed the tubing of propofol every 12 hours because of the risk of bacterial growth in the tubing. Because there is no preservative in the propofol bottle. Once you hang it, it's 12 hours, got to change it. So some of the other downsides to propofol, hypotension, bradycardia, so kind of diminishment of cardiovascular function, and we can also see this really rare thing called PRIS (propofol-related infusion syndrome). So this PRIS, when it does happen, it is best characterized by an elevation in CK (creatine kinase) and also cardiovascular collapse, often leading to mortality. So of the patients that do get it, they typically have very, very high doses. Oftentimes their trauma patients had traumas well described in the literature, so super rare, but something that we at least have to worry about.

Speaker 3  11:29
I do know that with Precedex (dexmedetomidine), there can be an issue, as it works on these alpha-2 receptors and is similar to its cousins, maybe clonidine, the antihypertensive. So we can have an issue of hypotension here, as well as some bradycardia as well, because we're not doing anything for the beta receptors.

Dr. Sean Kane  11:48
and in terms of cost, just obviously the dose and the body weight of the patient matters in terms of dexmedetomidine cost. But a general rule of thumb is somewhere between three and $400 per day, or about 10 to $20 per hour, depending on the body weight and the dose for the patient. And you can compare that to something like propofol or Lorazepam, where we're probably spending about 10 to $20 per day, as opposed to per hour. So it's a huge difference in cost.

Speaker 2  12:15
Yeah, that does sound like a very expensive medication to be on. And then we talked about morphine. So again, the glucuronide metabolite, which is an active metabolite that can accumulate, and again, the side effects of morphine, as we know it, can also cause hypertension, itching, as well as increased constipation with any opioid use here, and we have to be very, very of risk of constipation in patients who are ICU.

Dr. Sean Kane  12:38
I know it sounds stupid to talk about constipation, but bowel regimens and bowel frequency is a huge discussion point on many ICU patients, especially if they've been in the ICU on a mechanical ventilator for a few days, we absolutely follow the number of bowel movements they have, and often initiate prophylactic therapy to prevent some of the constipation associated with things like fentanyl and morphine.

Speaker 3  13:00
So since we talked about morphine, you touched on fentanyl as well. So they can also cause constipation, any other concerns with fentanyl.

Dr. Sean Kane  13:07
So fentanyl is metabolized through three a four, just like midazolam. So there are some drug interactions with the three a four pathway. With that said, though the half life of fentanyl is actually extremely short, so we're looking at a duration of effective anywhere from 30 to 60 Minutes with fentanyl. So even if you have a drug interaction that doubles your half life, it becomes more like a morphine as opposed to a fentanyl. Morphine last in between two and four hours. So there are drug interactions, whether they're clinically relevant or not. In an ICU patient, probably not, but it's something that as pharmacists, we should at least be aware of.

Speaker 3  13:39
I know Dr. King, we're talking a little bit today about the history of pharmacy. So this is it's kind of interesting to look at how mechanical ventilation had in the thoughts on it has changed over the years. I know in the 1960s patients were generally kept fairly, fairly awake on mechanical ventilation. That was just how it was practiced.

Dr. Sean Kane  13:56
And then when the 1970s came around, we started having basically continuous infusion, benzodiazepines. And we thought, hey, this is great. We can really make our patients super comfortable. They'll look like they're sleeping. They won't remember any aspect of their painful ICU stay and their horrible acute illness that they had, and whenever they're better, we'll just wake them up and no harm, no foul, right?

Speaker 2  14:18
And this was called, basically snowing your patient Absolutely.

Dr. Sean Kane  14:22
And the problem with that, as we'll discuss, is at some point, if the patient gets better, we want to wake them up and get them off mechanical ventilation. So if we overdo it, we think that there are bad things that can happen if we know the patient with too much sedation.

Speaker 3  14:36
Sure, I think again, it parallels, well, with what we were doing from the in general psychiatric medicine at that time, going from the idea about just keeping somebody, not, you know, completely snowed under, versus, you know, trying to, you know, get somebody better, get them out, get them, you know, either treated or off the med in this, in this kind of case,

Speaker 2  14:54
yeah, and the problem with snowing again, like you mentioned, Dr. Kane, is longer duration of ventilation. It can't. Ventilation, and then longer duration of the stay, that equates to a lot of money, costing to the patient, as well as to the institution, absolutely.
Dr. Sean Kane  15:08
And one of the philosophies of why snowing is a bad thing, is, if you think about it, if you were a patient on mechanical ventilation, and you wake up, let's say, three times a day, for 10 minutes, and then you fall back asleep because of the sedation regimen that you're on, you'll have no idea what day it is, you'll have no idea where you're at, why you're there. You will have no idea who's in the room. You'll be out of it. And because of that disorientation to your environment, disorientation to time and place, we think that that snowing philosophy of making patients look extremely comfortable is detrimental to their mental health because of that dissociation from reality, because of over sedation. So I

Speaker 3  15:46
believe that, and that was something that started in the late 1990s and the game changer, or in terms of practice, was an article that came out with the lead author of cress, that came out in the year 2000

Dr. Sean Kane  15:57
This was actually a University of Chicago study that looked at what they termed daily interruption to sedation. What that meant was that they randomized patients who were on mechanical ventilators, and they either gave them daily interruption to sedation, where they turned everything off, waited for either the patient to get really agitated, or waited for the patient to follow simple commands, like sticking their tongue out, tracking the provider with their eyes, things like that, or they just did standard of care, which meant that whenever they thought the patient was ready to get off mechanical ventilation, they turned off their sedatives and analgesics and then waited for them to wake up and then extubated them. And what the thought process here was that we know things like midazolam and morphine are the biggest offenders for accumulation because of active metabolites. If we turn off our sedatives and our analgesics, wait for all of those active metabolites to go away and then restart again, maybe we can prevent this pharmacology of an over sedation issue, right?

Speaker 2  16:53
So then, what did this study show, as far as the outcomes go, that's

Speaker 3  16:57
what I think. It was fairly interesting, I believe, is that the daily interruption. So what from doing that daily interruption, they decrease the duration of the ventilation by two and a half days, or 33% overall. And then ICU length of stay was a similar 33% reduction here, 3.5 days. And just

Dr. Sean Kane  17:12
think about that from a cost perspective. So we're doing something that costs no money, if anything, it saves money by using less drug and we get the patient out of the ICU and off mechanical ventilation 33% faster. That's a huge deal in terms of money. Mechanical ventilators and ICU rooms cost a lot of money to the patient and to the institution, so this is a low or really no cost intervention that can save a ton of money, right?

Speaker 2  17:37
And probably this study did not look at these other outcomes. But if you can equate that, or kind of theoretically say that less time on mechanical ventilation, that's complications such as infections and other issues,

Speaker 3  17:50
and that's all well and good, though, but what about any any concerns about, you know, patients getting agitated, and what happens then, if somebody get starts to get a ladder? Doesn't that contribute to maybe

Dr. Sean Kane  17:59
some bad outcomes, though? Sure. So the study certainly because of the way that our practices were, we were worried about things like self extubation, removal of central lines, removal of other catheters. And what they found was there was no difference in removing any of these devices or lines, self removal of these devices or lines. And of the events that did happen, they did not occur during the daily interruption period. From a safety perspective, it was incredibly safe. One of my favorite things of the trial was they also looked at the need for CT MRI or lumbar puncture to assess why a patient wasn't waking up. So if you think of it this way, let's say you turn off your midazolam and your morphine, and you wait 12 hours and the patient is still deeply sedated. At this point, you have to wonder, did they have a stroke? Do they have meningitis that we didn't know about? Did something else happen from CNS standpoint? So then you take them, send them to a CT scan, or do a lumbar puncture, an MRI, they actually found a significant decrease in these three diagnostic tests for the purpose of assessing mental status. So again, a huge cost savings, right?

Speaker 2  19:02
Which further can bring more cost savings to us. And then good thing about, you know, after this trial kind of published, we've had many more other trials that shown the similar approach, and has shown that sedation minimization has been helping patients improve, improve on the length of stay in the hospital as well, as, you know, length of duration and mechanical ventilation, again, that equates to saving more money as well.

Speaker 3  19:28
And then I know in practice, you know, articles can be, can be well and good, but a lot of times what we go by and we live and die by, or what do the guidelines say?

Dr. Sean Kane  19:36
Unfortunately, SCCM, the Society of Critical Care Medicine, recently updated their sedation practice guidelines. They're called the PAD guidelines, pain, agitation, delirium guidelines, and they've really incorporated a lot of these newer strategies that came about as a result of the crest trial and many other trials that came out after that, where they analyzed ways that we can where we can minimize sedation for our ICU patients to. Improve outcomes.

Speaker 2  20:01
So what's the first step that they recommend in these particular patient population?

Dr. Sean Kane  20:06
So the first step is called the a one strategy. It's not the steak sauce, but it's analgesia first strategy. What that means is using analgesics because we know our patients have pain. When we do surveys after patients are out of the ICU, very frequently they say that they had unmet pain needs, meaning that they had pain and we didn't treat it very well. So because of that, it makes sense that we can be proactive, whether we see that the patient truly has pain or not, but we can be proactive in providing analgesia through something like a fentanyl infusion to be able to make the patients have analgesia. But also, as we said earlier, that analgesia strategy provides some sedative quality, especially at higher doses, and

Speaker 3  20:45
that's been seen specifically with the opioids. And the nice thing they do is you're not going to have that amnestic property or lower overall awareness that you may be seen with something like a benzodiazepine.

Speaker 2  20:56
Exactly. Yeah. So actually, the guideline is saying to avoid benzodiazepine because that it is related to something called ICU delirium, and basically it defines as acute change in mental status, basically inattention, inability to follow the commands, and disorganized thinking, or even altered level of consciousness.

Speaker 3  21:16
And this fits in a lot of what we're learning from other populations, such as in geriatrics, that the idea about we almost create a type of disinhibition by overuse of some of these benzodiazepines, and not only have the cognitive problems, but again, sometimes actually, almost counterintuitively, at least based on our current understanding that allow for certain behaviors to then come through.

Dr. Sean Kane  21:35
So of the data that we do have, we believe that the use of benzodiazepines versus another sedation strategy increases your risk of ICU delirium by about 20 to 30% and the incidence rate is somewhere between 60 and 80% so if that gives you some idea, you can decrease a patient's risk of ICU delirium to around the 50 to 60% range, as opposed to being up in the 80% range. So it does have a pretty good impact on reducing ICU delirium, right?

Speaker 2  22:03
And the reason we want to reduce ICU delirium because it is associated with mortality. So again, benzos are not shown to increase mortality or cause mortality. However, if we put patients on benzos and cause ICU delirium, it has shown to increase mortality. So we want to avoid any of those issues too.

Dr. Sean Kane  22:21
It's the whole A equals B, B equals C, therefore a equals C. Problem we we associate benzos with delirium. We associate delirium with bad things. But we haven't directly shown the use of benzodiazepines causes some of these bad things, aside from length of mechanical ventilation. We do know that using benzos instead of propofol or dexmedetomidine, will increase your length of mechanical ventilation.

Speaker 2  22:45
So I guess we're boiling down to last two agents, propofol and dexmedetomidine, absolutely.

Dr. Sean Kane  22:50
And that's what the recommendation is. Once you've achieved your a one strategy with something like a fentanyl trip, if you do need a sedative, you should be looking at propofol or dexmedetomidine.

Speaker 3  23:00
And so then we'll be looking at, I believe, so it's a two day decrease on average, in the duration medical mechanical ventilation, although I do believe that there what appears that there is no difference in the ICU length of stay, unfortunately.

Dr. Sean Kane  23:12
And that's kind of a an interesting finding that compared to benzodiazepines, using either of these agents, gets people off the vent two days quicker, but they stay in the ICU the same amount of time. One of the issues is length of stay in general, is a very tricky thing to look at, because the variation is so wide. Some people will be in the ICU a very short amount of time. Some others will be in a very long amount of time. So you really need a large patient population to show a difference between these two findings that could have a very large range associated with them.

Speaker 2  23:42
So if you're saying the outcomes with propofol and dexmedetomidine are equal, then in your practice, Dr. Kane, have you seen that hospitals will choose one agent over the other? Since we already talked about how dexmedetomidine is a little bit more expensive compared to

Dr. Sean Kane  23:58
propofol, so some of the first dexmedetomidine data that came out were dexmedetomidine versus benzodiazepines, and they did show an improvement in mechanical ventilation versus midazolam or Lorazepam. So at one point, it was thought that using dexmedetomidine made sense, because we could improve mechanical ventilation. After that, though, they did a dexmedetomidine versus propofol study, which was a study that many people really wanted to have happen. And that study was called the prodex trial. There was no difference in many of the clinical endpoints, including ICU length of stay and duration mechanical ventilation. So the short story is, at one time it looked like pressed x had an edge, but after the prodex trial, they lost the edge against propofol.

Speaker 3  24:40
So I guess it comes down to a matter of you know which one which one of these agents are we can to kind of choose, and does anyone have any preferences? Dr. King,

Dr. Sean Kane  24:47
I love propofol. Propofol is my favorite drug, and it's cheaper. It has a similar adverse effect profile in terms of hypotension, bradycardia. The only caveat to it is that triglyceride issue with it because of its lipid emulsion. With that, said, many patients actually don't even need propofol or dexmedetomidine. Oftentimes, we can control patients on mechanical ventilation with either PRN benzodiazepines or just a fentanyl drip alone, not reaching for our sedative. And that's really exciting, given that we know the more awake a patient is, the easier they are to get off mechanical ventilation, the more they can participate in their own care, the more they can do range of motion and things like that, to become less deconditioned. So it's exciting to think that not every patient needs high dose propofol infusion to basically knock them out until they're over their acute illness. So then to kind of readdress the original question, many patients, or many practitioners probably still feel like, Oh, I totally want to be knocked out if I'm on mechanical ventilation. But the problem is that that philosophy means that you'll be on mechanical ventilation at least two days longer, with a snowing strategy where you get high doses of sedatives that accumulate and cause issues, even with propofol. We still think that minimizing the use of any sedative is probably a good idea in terms of cognitive delay that can last up to six months after your ICU stay. So the more involved with your patient care you are, the better off you're going to be. So I

Speaker 3  26:10
believe there's still, we would agree, there's room then for some inner patient variability. Because again, if you have somebody who does have a profound fear of waking up amongst it, we probably have to take those into account, but again, doing it in a way that we're going to provide a sufficient level of sedation, but not cause some of these outcomes, such as, you know, communicate with them. You know about the risk of increased length of stay, and thus to avoid situation will lead to more complications down the road, and

Dr. Sean Kane  26:36
all the more reason to monitor. So we have standardized monitoring scales that are recommended by the guidelines in terms of what is an appropriate amount of sedation. So generally, we want our patients to be able to open their eyes to follow commands and things like that. At worst, we want them to have their eyes closed but be able to open on command. We don't want patients where you actually have to touch them in order for them to wake up. They're too deeply sedated, unless they're receiving deep sedation for something else, like they're on a paralytic, as an example. So that sedation assessment is just as important as the selection of our agent, and is just as important as minimizing sedation when we can Well, wonderful.

Speaker 2  27:13
I think I'm going to change my answer from beginning. I'm going to say I'm going to use the daily interruption strategy and get out of the ICU couple days faster.

Unknown Speaker  27:22
Yeah, I think I'll take my milkshake, but I think I'll

Dr. Sean Kane  27:23
hold the propofol on this one. Sounds like a plan. So for the HelixTalk audience, if you haven't done so already, we really love reading those positive reviews in the iTunes store. You can also find us at HelixTalk.com which also has a link to the iTunes Store to give those positive reviews. So with that, I'll go ahead and sign off. I'm Dr. King, I'm Dr

Speaker 2  27:43
Schuman, and I'm Dr. Patel, and as always, study hard.

Narrator - Dr. Abel  27:47
Thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science. For more information about the show, please visit us at HelixTalk.com. You.