#APSA50: Top Educational Content

Hi everyone and welcome to this new episode of the Stay Current podcast titled Top Educational Content. This is Alex Cassar, and today we're doing a throwback to the ABSA 50th anniversary meeting in May. This is part of our collaboration with the Behind the Knife podcast and includes portions of the main stage talks and interviews with some of the most popular speakers at the conference. The tech session started with a review of the 2018 pediatric surgery practice gaps by the ABSA Professional Development Committee. You can find all of them as video reviews on the stay current app, so remember to check them out. Stay Current is a multimedia publication designed to keep healthcare professionals up to date on standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Alex Cassar, Alex Gibbons, and Ray Hankin and is recorded and produced at Cincinnati Children's Hospital in Cincinnati, Ohio. First off, we have Doctor Aaron Jensen, associate trauma Medical Director at UCSF Children's Hospital of Oakland, with a case-based review of cervical spine trauma. Show of hands, who thinks they over-image C-spines and trauma? Most of the room, right? And we're talking to a group of pediatric surgeons. So we are the experts in pediatric trauma, and we self-admittedly over-image. So, The goals of my talk really are to provide you with some tools and some guidelines for how we can decrease imaging for cervical spine injury in kids. Who can we get away with not imaging with good outcomes in the long-term. Talk about some cases to start, so I've changed all the names on these, but Sarah, I'm sure all of you have seen a, a kid like this, high speed motor vehicle crash. She was restrained, wearing her seatbelt, airbag went off. Comes to your trauma bay and, she actually looks pretty good. GCS is normal, she's talking, no loss of consciousness, human dynamics are normal. Her right shoulder hurts and she's got terrible neck pain. Show of hands, who will screen this kid with plain films? OK. Who's gonna go straight to advanced imaging? OK, CT MRI. When I say advanced imaging, CT MRI. OK. So, uh, she comes in and she gets wonderful, beautiful plain films. And this is pretty typical in kids. They've got nice thin necks, not a lot of chronic changes. These are beautiful, you don't quite see down to the top of T1 on the lateral, but you see a nice, beautiful set of C spines. These are normal. The radiologist says they're normal, they're great views. Except she's got this wicked clavicle fracture on the right side, which is leading to her pain. Uh, no neuro, no focal neuro deficits, she just has pain. Who wants to clear her now, clinically? Just take her collar off. Nobody? OK, good. Uh, who wants to go to advanced imaging now if you didn't do so before? So 345. Who wants to just send her home in a collar and re-examine her. So, I'm actually a big fan of sending these kids home in a collar. Uh, unfortunately, the collar sits right on top of that clavicle fracture, and that really hurts. So her compliance with that collar is probably gonna be pretty minimal. She's 14, she can get an MRI without sedation and the scanner was available, so we sent her over for an MRI. Uh, and it shows she does have a ligamentous injury. Her ligamentum flavum is torn at C7 on T1. This is not an unstable injury, does not need surgery, needs a collar for 6 weeks. So we could have sent her out in a collar and probably treated her without the MRI, but this gives you a little bit more information, a little bit more motivation for her to wear her collar that probably hurts over her right shoulder. But I think this is pretty typical of the MRI's that we get in these kids who have normal plane films, that they do have these ligamentous injuries, but none of them are unstable and they almost never need a surgery. Let's talk about another kid, Devon, he's 12. He was in a car similar to that white one, restrained front seat passenger and was hit by a car similar to that black one, a big SUV head-on. And Devin's in pretty rough shape. He's taken to a local receiving center, which is not a pediatric trauma center. He's hypotensive, his GCS is 8, and they intubate him. And as most non-pediatric trauma centers do, they do a pan scan, and it's quite an impressive scan. He's got lots of injuries, including a head injury. He's transferred to our pediatric trauma center for management of all of his injuries, and you can see some of his imaging here. He's got a little epidural, but he, he turns out to have a much more severe TBI as he has some contusions that flower in the next 24 hours and doesn't really wake up all that much. Uh, but he got a real pan scan, top of his head down to the bottom of his feet at the adult center. And he's got some pretty bad, uh, femur fractures that on the first day, uh, because of his head and instability, he just got Xfixes and got his open fracture washed out. And then he has to go back to the OR the next day to get the left side nailed. And then he goes back the next day to get the right side fixed cause we wanted to limit the amount of anesthesia time because of his head injury. So 3 OR trips in 3 days. Anybody seen a patient like this? OK. So, unfortunately, Devin is kind of a big kid, uh, and he was a difficult intubation. Uh, we did extubate him in the ICU and when they had to reintubate him for a second operation, uh, he, he's a little obese, he's immobilized, he's gotten a lot of fluid, and it was a difficult intubation. So they nasotracheal intubate him with a scope. And anesthesia does not want to take that out, they're gonna leave the endotracheal tube in for 3 days, cause he's got all these planned re-operations. He already has a completely normal, high quality, high resolution CT scan. In that 12 hour period that he was extubated, he wasn't following commands, but he has a non-focal exam, he moves all extremities, he withdraws from pain. Who would send this kid for an MRI so they can get the collar off within the 1st 24 to 48 hours? OK, about 68 minutes, 10% of the audience, OK. Who will just leave him in the collar until he's awake and examinable? And clear him when he's clearable, OK? Who wants to just take the collar off based on a normal CT scan? 12, you've been reading the adult data. I like it. We're going to talk about that in a little bit. Alright, cool. So I named this kid Aaron after me because this is something that I probably would do. Um, so a little 5 year old boy was sent to his room for timeout because he wasn't behaving. And, uh, Dad was gonna go to the Warrior game, had to throw something in there about the Warriors. Uh, and he was mad that he didn't get to go, so he climbed out his window, and he fell and hit the roof and then fell onto Dad's car and sort of bounced his way down all the way to the driveway. It was a first floor fall, but he had lots of things on the way down to break his fall. I could totally see myself doing this when I was 5. He comes in, he looks like a million bucks. No loss of consciousness, he cried immediately, he's complaining of terrible arm pain and a little bit of leg pain, but otherwise looks fine. Who wants to screen this kid with plain films? OK, most of the audience, advanced imaging right away. Who wants to get a CT of this kid's C-spine? Nobody, it looks like, maybe one in the back. OK. Well, unfortunately he didn't go to a pediatric trauma center, he went somewhere else where they pan scanned everything, head, neck, chest, abdomen, pelvis, which of course all was negative, and he could have been cleared clinically with clinical prediction models. Uh, and he did have a broken arm that ended up needing to be fixed. I think of all the things I'm. Talking about today, this is the one problem that we as pediatric surgeons need to address. We need to take ownership of this problem, we need to take ownership of the over-imaging, over radiation of trauma patients at non-pediatric centers. I think we in our own centers do a great job of not imaging kids that don't need imaging. But we need to get the word out. So at the end, I'll show you with uh a tool that we can use to get the word out. OK, so we have different mechanisms, different injuries, different ways to image, all these moving parts. So how can we make sense of these things? So the first thing I'll point you to, and I'm not gonna go through all these guidelines, but these are really good guidelines. So these were written in 2013 by the AANS and CNS, uh, evidence-based guidelines. The best evidence in here is level one, which says that if you want to diagnose Atlanto occipital dissociation, you should get a CT scan, I think that's pretty clear. Everything else is grade two and grade 3. The best thing about these is they tell us who doesn't need imaging. Who can we clinically clear without a single X-ray? OK. This is another thing that if, if you can just walk away with the first set of guidelines and know who you can get away with not imaging safely, and share that with your adult centers, that would be huge. So kids you can communicate with, GCS 14 or 15, who are not intoxicated, you can clear clinically. Unless they have a painful, distracting injury. 3 and under is an interesting population, because they don't communicate all that well. But most of the time you can clear them, but the data suggests that if they have a high risk mechanism of injury, particularly child abuse, where C-spine injury rates are very high, if they have one of these high risk mechanisms, even if they seem totally fine, you should screen them radiographically. OK. Clinical clearance involves no neurologic deficits, so you actually have to do a neuro exam. No midline cervical tenderness, no painful distracting injury, and no unexplained hypotension, and then they have to be able to move their head in all distractions, in all directions without distraction, without any um limitation. Clinical clearance works in a defined population of kids. And I think if we stick to this guideline, we can really cut down on the amount of imaging. The problem with this is it doesn't, the guidelines don't really tell us what to do when the neck hurts. What do you do with that kid who you can't clear them? Uh, the evidence for this is quite frankly terrible. I can't tell you what to do with these kids, but there are many options, and the evidence is emerging as to what we can do with these kids, to again decrease the risk of radiation. So we talked about this kid earlier. Normal plain films, but still has neck pain. So do all these kids really need to go get an MRI in the ED? Or do they need to be admitted overnight so they can get an MRI with sedation the next day? You're gonna give a kid general anesthesia to get an MRI? Or can they be sent home with cervical collar from the ED with follow-up in 1 to 2 weeks, with a re-attempt. To clear them clinically. I think the biggest concern here is, are we sending potentially unstable injuries out of the ED? And what if that kid takes their collar off and there's a lapse, and they have a neurologic deficit because we sent them home in a collar and we don't know that compliance is gonna be 100%. So there's a great paper out of Boston, a few years old now. They looked at 300 kids, 300 kids who had no fractures on their imaging in the ED. And they followed them up, they actually had 94% follow-up, that's pretty good. Only 2% of these kids had a ligamentous injury on their MRI. And none of them required surgery. None of them were unstable. So it actually is safe to send kids out from the ED in a collar. 84% of the kids that were sent out in a collar, had it clinically cleared at their first clinic visit 1 to 2 weeks later. 84%, that's a lot of MRI's we can cut down on. That's a lot of CT scans we can cut down on. 10% required persistent use of the collar beyond the first visit, referral to neurosurgery, sub-specialty follow-up and MRI. But again, very few of those patients who had normal initial imaging had an injury that required surgery. They only lost 18 kids to follow up. I think this is what we all worry about. You send a kid out in a collar, are they gonna come back? And this is gonna vary by center. I would hope that those kids would have come back if they developed neck pain or symptoms, uh, but that is always the biggest concern of sending kids home in a collar. What about the kid who's abunded in the ICU? Do we just clear him? Do we get an MRI? Do we wait? What do we do? Well, the thing we worry about are pressure ulcers. Anybody seen a pressure ulcer from a collar? Yeah, I saw 3 of them last year, and they can be pretty terrible. We all know who the patients are that get these. They occur 6 to 38%, they occur on the clavicles, back of the head, base of the neck. And these can be pretty bad. They occur in kids in the ICU. They occur in kids who get a lot of fluid, they occur in kids who have ICP monitors who are on the ventilator. We, we know who these kids are. One of the biggest independent risk factors is whether or not you had to get an MRI to clear their C-spine. If they had to wait for their MRI, they were more likely to get an ulcer. But the real question is, do they really need an MRI? And I think this is probably the, the biggest controversy right now, is whether or not these kids need an MRI. This is the adult data that I think some people have uh alluded to. This is a meta-analysis of 5 studies that looked at 1000 patients that have normal, completely stone cold normal CTs of their C-spine. No osteophytes, no degenerative disease, stone cold normal CTs. Again, these are adult patients. They found on follow-up that 9% who ended up eventually getting an MRI. Had stable injuries that required no treatment. 91% had no injuries on either MRI or clinical follow-up. The most important part is that no single patient in these 1000 that had a stone cold normal CT scan. Required surgery to fix an injury, so these were all stable injuries. So the recommendation in adults now is to take the collar off, with a normal CT scan, and don't send these patients to MRI. I don't think this is applicable to kids. We know that kids have greater um frequency of ligamentous injury, unstable ligamentous injury, but we are now going to start getting pressure. To clear collars based on CTs. I think we as a community need to come together and reproduce this study in kids. We could come up with 1000 patients easily amongst our centers. Let's try to define that subset of, of kids that this actually applies to. I actually think this would apply to kids who are in the sort of preteen to teenage years. But the 5 year old, probably not. I think this needs more definition. But I do think we need to figure out how to get these collars off quicker, and sending a poly trauma patient to the MR scanner is not without risk. Finally, what about The kid like me who fell out of the roof and got pan scanned, uh, what do we do about this problem? I think this is a rampant problem, we get lots of transfers from non-pediatric trauma centers that have been pan scanned without a real indication for that other than mechanism. Um, I would like everybody to know about this new resource from the American College of Surgeons TQuip program. This is a free download, you can all download it today. This is written by adult trauma surgeons and it includes standardized evidence-based guidelines for imaging and trauma patients. We had a seat at the table. So there were 5 of us. Doctor Gaines, Doctor Bird, Doctor Malik, Doctor Falcone and myself spent hours upon hours on conference calls discussing these things, and we made sure that there are pediatric specific sections. For CT of the head, C-spine, whole body CT, chest imaging, so forth and so on. There are evidence-based guidelines in here that you can share with adult trauma centers, with non-trauma centers, so that they can follow these for their imaging of pediatric trauma patients. I, I would ask that you download this, familiarize yourself with this, and use this in your outreach efforts to your referral centers that are sending you these patients. In summary, we have a huge opportunity to decrease radiation sedation resource utilization in these patients. Uh, I think that there are reasonable guidelines that exist, but we really need to improve these, and the only way to improve these is for us to be at the table, generating data, strengthening these guidelines, and really reaching out to the adult centers so that we can provide our expertise for them. I hope you all got the memo that we are currently overutilizing imaging and underutilizing clinical clearance for pediatric trauma patients. For more on the issue, our partners from behind the knife led a question and answer session with Doctor Jensen. Here's what he had to say. Uh, we wanted to quickly run you through a couple of scenarios. Tell us what imaging you think is needed or not, uh, for these scenarios related to the cervical spine. Uh, and initial evaluation and assessment of the trauma patient. So let's say you have a child, GCS 15, no distracting injuries, no neurologic deficits. Their only complaint is neck pain. Would you start with an X-ray? Would you go straight to advanced imaging? What do you do for these patients currently? Well, I think the definition of child is, you know, are we talking about a 2 year old child, a seventeen-year-old child? And, and also, I think you have to think about the mechanism of injury. But in most cases, uh, plain film screening, uh, is adequate. Great. So again, plain film screening, as long as that's negative, they're still complaining of neck pain, would you not get a CT or MRI at that point? Again, I think it depends on the mechanism of injury, the, um, where the patient lives, how reliable they're gonna be for follow-up. There's good data that suggests that if you have normal, and you need to have high-quality radiographs with, you know, a complete series of images. Less than 9, you don't need the odontoid view. Above 9, you do, at least that's what the guidelines suggests. But if you can get adequate imaging of the complete C spine, With plain radiography, a reasonable option is to send these kids home in a rigid collar for a week or two and reassess them clinically. You just have to ask yourself, is this patient gonna come back? Are they gonna be lost to follow-up? Are they gonna wear the collar? Uh, but I think that that's a reasonable alternative for a patient who has no other distracting injuries, neurologically intact, uh, and, you know, has no other reason to be in the hospital. Great. And so let's say you have the same child, 12 years old, um, intubated now for a GCS of 8. prior to intubation, this child was seen moving all extremities. Uh, they were PAT scanned, CT PET scan, uh, at the outside facility prior to transfer, and that showed no C-spine injury. Do you need an MRI before you clear the spine? So I think this is a highly controversial topic right now. Uh, and, and this gets back to your first question of, you know, what's a kid? Is a 12-year-old a kid? Is a 12-year-old an adult? They're, Almost skeletally mature. Uh, the adult data suggests that you can just take that collar off with a CT of the C-spine. I'm not sure that that data actually applies to kids. It's not been studied in a 12-year-old. Ligamentous injury is much, much more common in kids. And I think we need more data here. So I think we're not quite ready to say that the standard of care would be to take the collar off without an MRI. And this is really the data that we need in the next 3 to 5 years going forward to better, uh, protocolize care for these kids. Great. So when we're talking about infants, uh, if you clinically don't suspect a C-spine injury, um, what in the history triggers you to, uh, go further as far as imaging? So infants are, are a special population. I think you always have to worry about child abuse. Uh, child abuse is the one diagnosis the family does not want you to figure out. They're not gonna give you historical cues to help you figure that out, and they may in fact give you a history that, uh, is not true at all, uh, so that you don't figure out that it's child abuse. So, when we're talking about infants, uh, clinical clearance. You have to be really sure that you're not dealing with a high-risk mechanism. You have to be really sure you're not dealing with child abuse. You have to look at associated injuries. If they're in a high-speed motor vehicle crash, if they're in a fall greater than 10 ft, if you have any of these high-risk factors, you have to be really, really cognizant that you may be missing an injury because clinical clearance has not been validated with high mechanism in these young kids. Great. So, at this point, would you say there are still gaps in knowledge? And if so, uh, where are those gaps when it comes to C-spine imaging? I would say the biggest gap is, is, you know, Can we clear a collar? Based on normal cervical spine films. And, and I think the answer to that is no, but there may be populations of kids that we can, and that you don't need to expose them to the risks of sedation for the MRI, the healthcare costs associated with the MRI. Uh, we really need to define what is the best imaging approach. I think we, we've got good data that suggests, you know, or that guides us as to what kids don't need to be imaged. But once you have that kid who's got persistent neck pain, Or perhaps they're obtunded. We don't really have good data to guide how those patients should be imaged and how soon they should be imaged. I think in the obtunded patient, we really wanna get the cervical collar off because the incidence of pressure ulcers is quite high. Uh, so if we can get the collars off, that would be ideal. Sending a poly trauma patient to the MR is not an ideal place to be cause you have to switch out all of their devices and monitors to MRI compatible equipment, and you have to go on a road trip and they're in the magnet for half an hour. So MRI is not a benign test in an unstable patient, but a cervical collar is also not a benign device. So I think we need to figure this out, especially in these sick poly trauma patients. Great. And our last question is, uh, when we are talking about reducing the amount of, uh, radiation exposure and imaging to these patients, a lot of times these trauma patients go to either adult trauma centers or non-trauma centers, and they end up getting pan scanned. Um, so how can we work to reduce that as our pediatric surgical community? So that's a very complicated question to answer. I wish I could answer that in 10 seconds. Uh, this gets into the whole realm of implementation science, right? We have data, we have data that suggests you don't need to do this yet. It's still being done. Um, I think it's multi-factorial. I think there is a knowledge gap in, in many of these providers who are used to taking care of adults. Uh, a knowledge gap, not only in the clinical decision rules that would allow you to not image kids, but also You know, their routine is to just pan scan and send home from the ED. Uh, so, more data may be the answer. I suspect that that's not the entirety of the answer. I think that there are two other real components that we probably can't answer with data. The first is that of reimbursement. Uh, Hospitals get reimbursed for doing CT scans, MRI's, and they make money, um. If you order lots of fancy tests, your medical decision making is, you know, easier to document at a higher level. I think that there is a reimbursement bias towards ordering more tests and doing more rather than just slapping a collar on and saying, come back and see me in 2 weeks. Uh, so there are financial incentives to doing imaging. Uh, and I think there's also disincentive from a legal standpoint. Uh, I think. If you miss a cervical spine injury and a kid has neurologic, you know, devastating neurologic injury that you miss, there is a huge legal liability there. Um, I think we all come to work every day trying to do the best thing for our patients and we're trying to do the best thing for our patients. But when it comes to certain injuries, people often practice defensive medicine and they order more studies that are indicated. So we need to come up with legal protections for following protocols and guidelines. If the data suggests that you don't need to order an expensive test. And you miss an injury, you, you should somehow be protected, uh, because you did follow the standard of care, even though you may have missed one of these very rare injuries. So I think that, yes, we need more data. We also need to work on the reimbursement structure and we also need to look at, you know, the legal implications of missed injuries. Our second speaker was Dr. Sean Ron Hell, senior surgical advisor and chair for the Advancement in Quality and safety at Boston Children's Hospital. His talk covered some of the bases for antibiotic stewardship and pediatric surgery. Why now should we care about this as pediatric surgeons? You know this is something that's not new. We've all seen these news reports of the superbugs, right, that these are bugs that are resistant to just about every single antibiotic that we throw at them, but this is not new, and we can even say that some of these, you know, reports are a bit stale, and they really don't raise eyebrows anymore. But what you may not know or really appreciate is the scope and the magnitude and the trajectory of this problem, much of which has not been well characterized or even appreciated until just the past couple of months. Now how bad is it and does it impact the patients, the pediatric patients that we care about? Well, there was a recent CDC study that just came out last month, and they estimate that over 2 million patients a year suffer from infections with resistant organisms in the hospital, and this comes at an annual cost of roughly $20 billion per year, and this is largely due to the prolonged hospitalization that's required to treat these infections. Now that's staggering when you think about the fiscal imperative of this, but think about 23, I'm sorry, 23,000 Americans die every year from these infections. Now that's staggering. And then when you back up and think, well, who are the segments of society that are impacted most by these trends, it's the elderly and it's the extremely young. With the largest impact seen in children under one year of age, right, so this is a very real problem and it definitely impacts the patient populations that we care about. There was a recent study of free standing children's hospitals. And it showed that over 40% of all patients undergoing clean surgical procedures without foreign body implantation receive unindicated antibiotic prophylaxis, right? That's fairly alarming, and that's just the tip of the iceberg. If we look at patients who get antibiotics appropriately in terms of indication, over 50% of those patients will get their antibiotic prophylaxis extended well past the incision closure. For cases such as colorectal procedures, the average duration is 2.5 days of prophylaxis, and remember that these are elective procedures, right? These are non-emergent procedures. When we think about antibiotic spectrum, almost 30% of patients will receive an agent which is well broader than the recommended guidelines. Double coverage is common, right? Flagyl and Zosyn, anyone heard of those two, right? That's only quite frequently. Antibiotic utilization. Right, so anaerobic coverage for proximal GI cases, the stomach, the small bowel, that's very common as well. So it appears to be a lot of opportunity that we can focus on and improve upon as us as pediatric surgeons. Well, these are the top 3 situations, topics, events in pediatric surgery, which is responsible for about 85% of the inappropriate use of what we do in this room. The runaway winner is giving prophylaxis for clean cases without foreign body implantation, about 50%. Prophylaxis after incision closure is #2, and then finally giving again anaerobic coverage for proximal stomach and small bowel procedures. These are the top 3, again, 80 to 85% of all the inappropriate utilization. So what I challenge everyone today to do is pick one of these, go back to your department in a faculty meeting, begin the discussions, dialogue, right? What do we do? How do we practice within our department? How does it align with these guidelines and can we begin to think about perhaps becoming a little bit more compliant with these guidelines? What do we need to do to accomplish that? How much has your practice changed since you first heard this talk? Are you still working on the homework he left us and his take home messages? The Behind the Knife team met with him after the session to discuss the issue further. Here's how it went. Uh, you gave an awesome talk, TED style talk today, where you outlined three tangible, achievable goals for surgeons to be better stewards of antibiotic use. What were those three things, and if there's one thing you would emphasize above the others, what was that one? Yeah, so the, the three areas in pediatric surgery where we tend not to be good stewards in antibiotic stewardship based on current guidelines are really given antibiotics when they're not indicated for clean surgical procedures, and those are procedures without foreign bodies. Uh, we typically give prophylaxis when there are foreign bodies to protect from infections, so things like central lines or. If we're talking about orthopedic procedures, this, this would be hardware, right? So those types of procedures are associated with higher risk of infections and also greater morbidity if you have to remove those foreign bodies. But when those foreign bodies aren't present, uh, there's very good data that you do not need to get prophylactic antibiotics for those cases. So in pediatric surgery, when we look at all the areas where we're not compliant with prophylaxis, that single area of prophylaxis is about 50% of where we can improve upon. Now, the other 50% is broken down into continuing those antibiotics for too long, right? So current guidelines would tell you that for any case when there's prophylaxis, you should not continue it past the incision closure. Anything longer than that would be inappropriate. And about 30% of all procedures in pediatric surgery receive antibiotics longer. Then are past the, the point of the incision closure, so that would be inappropriate. And then the other chunk of that last 50% are given antibiotics, which are indicated but too broad of a spectrum. And in pediatric surgery, the vast majority of those cases are giving antibiotics that cover anaerobes, but where there's no anaerobes in surgical site infection data. And these are proximal GI operations, so things like stomach procedures, um, so gastric procedures, small bowel procedures. Whenever there's a procedure involving the gut where you know there's not gonna be a colorectal procedure, you should not be given antibiotic coverage. So those are really the top three. If we're gonna target any of those, and this is what I mentioned in the talk, it should be not giving antibiotics for clean cases. And that's because again, it's the largest chunk of where we can improve upon where it's needed within our field and probably the easiest to get people to change their practice. Um, I had a couple of questions for you on those, uh, if you don't mind. One, would you consider like insertion of a broviac or ports to require antibiotics? I mean, they're technically foreign bodies that are inserted, um. Second, in terms of continuing your antibiotics past the 24 hours, I know that a lot of, you know, colorectal, you'll do for like 24 hours or, you know, small intestine might do for 24 hours. Is that OK? Cause it's past the point of closure. And would you then consider that not prophylaxis then? Um, and then finally, what do you think about fungal, um, coverage for, say, stomach or esophageal because it's a proximal gut. Yeah, so those are, so those are all great, great questions. So the first question regarding central lines or ports, so that's a good one because if you look across what we do at Freest-standing Children's Hospital, about 40% of CVLs, so tunneled CVLs in ports receive prophylaxis. So it's about a 50/50 more or less. And that's because some people believe that, well, if it is, even if there is a foreign body. If it's not a central nervous system, if you're not operating on the spine or the brain, and that this isn't something like central nervous system associated hardware, that you don't need prophylaxis. Um, now, that's a bit challenging because these are different patient populations as well. If you look at the data, and there have been a few Cochrane reviews looking at, uh, the likelihood of infections for central access procedures based on whether or not you give antibiotics, it's, it's very disparate, right? So there's no strong conclusion, but there seems to be a trend toward reduced infection rates in the oncology population, right? So if you look at why we give central, why we place central lines in young patients. It's oncology, it's metabolic disorders, and it's shortcut kids, right? So the patients who are the oncology patients, oftentimes, once you place these lines, they get, they go into induction chemotherapy where all of a sudden they do become at higher risk for SSIs almost immediately. And so I think if you distill down the data, even though there's no hard and fast data from the Cochrane reviews to tell you what you should and shouldn't do. What I try to do is use a little judgment and say that, well, the trends in the oncology population seems to suggest the infection risk is higher. So if I expect that the kids' counts would decrease after I placed that line, I would give prophylactic antibiotics, and that's just the way I approach it. Uh, another question is, uh, the duration of, um, uh, proof of quote prophylaxis for colorectal procedures. So many of my partners do the same thing, and they tell me, well, unless you show me data in kids, I'm not going to change my practice, right? Kids are not small adults. They love to say that. Um, but the adult literature is fairly compelling and colorectal cases, if you give antibiotics past the, the, the time of incision closure, there's no benefit at all, and that's pretty good data. So then you have to ask yourself, well, are kids at higher risk? Is that a biological plausibility? And I would say absolutely not. If you look at the NSquip data, SSI rates in kids, the NSquip data for adults. The SSI rates are much higher when adjusting for procedure for CPT code, the type of procedure, and also the RVUs, right? So the intensity of the operative episode, much, much lower in kids, and that's not surprising, right? Because kids are not morbidly obese. They don't have diabetes. Well, you know, we're talking about adults versus kids. They're not tobacco users and so the risk factors in kids tend to be a lot less. So why would we think that we need to be more intensive with our antibiotic utilization? So that, that's, that's my non-evidence based, you know, perspective on that question. And then, um, the third one was the fungal thing. So that. Um, so I don't think there's been any good data and definitely the consensus guidelines would not suggest fungal coverage even for proximal GI procedures because the SSI data just does not support that, right? So, the Bratzler guidelines, and Bratzler is the consensus guidelines from the Infectious Disease Society of America, Surgical Infection Society, American Society of Hospital Pharmacists, right? So these are the big three. All of them agree that routine fungal coverage is not necessary because the SSI data, which those recommendations are based on, are just, we just don't see fungal infections. Now, if it's a kid who is in the ICU and is immunosuppressed or has been on, say, um, you know, reflux prophylaxis for weeks and weeks and weeks where you know, there might be a different kind of bile, you know, you know, different set of organisms in the stomach. And it's already a kid who's immunosuppressed, then yeah, then perhaps prophylactic fungal coverage might be a consideration, but I don't think there's any good evidence to push for it either way. So. So that was great. Doctor Mel, it was fantastic to sit down with you and get a little bit more of a nuanced take on your points. But again, to emphasize those top 3 things we can do as uh pediatric surgeons and and surgical colleagues are number 1, no prophylaxis for clean cases without foreign bodies. Number 2, no further prophylaxis after incision closure for any procedure, and number 3, no anaerobic coverage for cases not involving the colon or rectum. Uh, so to close things out, Dr. Rangel, you know, these are 3 tangible, achievable goals, but beyond that, if you had a pipe dream, what would be the next thing you want to take on in terms of reducing the variability of antibiotic use? So, the pipe dream is actually having probably evidence-based guidelines, right? So right now, everything that we do is based on adult data mostly, right? And so, although, uh, as I mentioned before, I think it's a biologic plausibility that we can apply the adult data to what we should do in kids. I don't think that ultimately at the end of the day, everyone's gonna buy that argument, and we do need good data in kids. And so during the talk, I did mention that uh we have this very large Nesquip collaborative of 84 hospitals. That data that's being collected is not only gonna be used to provide institutions with kind of a pathway where they should focus their efforts to improve stewardship, but also remember in NSCOP, we also collect gold standard surgical site infection data. We also collect data on C. difficile, right, using CDC criteria. So, the, one of the byproducts of this collaborative is for the first time ever after one year of data collection. We're gonna have. Data relating prophylaxis and surgical site infections on about 85,000 kids spanning all the major things we do in pediatric surgery and so you can imagine for the first time ever and probably more rigorous than anything that's been done in adults, we will have data to look at, well, we have this variation in practice and we're now gonna be able to apply. You know, very rigorous methods to say this works, this doesn't with prophylaxis, and then provide best practice guidelines on real actionable data. That's gonna be fantastic. Um, just one quick question after that is, uh, once we have addressed how we as our group of pediatric surgeons are, uh, being stewards of antibiotics, the next complicating factor is that we are consultants and we often see patients who come from other hospitals have already been on certain antibiotics or in the ER they're given antibiotics right away thinking, oh, Appendicitis, let's give some antibiotics. It may not be the appropriate one. How do we moving forward kind of address that issue? Is it by creating the standardized guidelines within ourselves first and then providing those protocols to our colleagues, or how would you say that that issue can be addressed moving forward? Yeah, so that, that's a great question. We're probably gonna take a page from the playbook of, uh, of, uh, diagnosing appendicitis, right? And so one of the first collaboratives that was launched in Nesquip, and this wasn't a formal collaborative, this was just a grassroots one which was not supported by the ACS at this time, but there was about 30 hospitals who wanted to decrease their CT utilization rates. And uh there was a very effective collaborative in terms of uh of reducing that those CTs and increasing the rate of ultrasound and the quality of ultrasound. But what we realized is that if you really wanna make an impact, it's, it's actually gonna be those hospitals that transfer patients because the rate of CT scans outside Nesquit hospitals was about 75% where within Nesquit hospitals, it was 25%. And so overall we reduced 25% down to about 15% within ESCO hospitals but didn't do anything in terms of the 50% of patients who come in. And so what we learned from that collaborative is you really have to develop those best practices about how to say, improve your ultrasound availability and quality, particularly if you have an adults, you know, adult sonographers who are doing the studies, right, and they're not really used to kids. And so there's a number of things we learned about what we had to do first within the, the, the NSC apostles before reaching out into the community and that's, that's really been the next step over the past year. You can apply the same approach to stewardship, right? I will tell you that the vast majority of kids who are referred into our, um, ER after being diagnosed in the outpatient setting in another hospital receive Zosin no matter what. And one of the other stewardship principles that we really push is that for kids where we don't think they have perforated appendicitis, don't start with an anti-pseudomonal, right? Start with either cefoxitin or ceftriaxone and Flagyl. And, uh, and that's a huge push as well. We didn't talk about that today because it's outside prophylaxis, it's treatment, but if you look in terms of the entire spectrum of what we do in pediatric surgery, that's probably the single most important thing we can do, and it has nothing to do with prophylaxis really, right? And so it really has to do with the, it's really kind of fixing what's broken within our network and then reaching out systematically to the community and, uh, and best practices are gonna be an important part of that, so. Last but not least, we had Doctor Samir Gapalli, director of pediatric surgical critical care at Mott Children's Hospital, crushing it with his talk about sepsis as a surgical problem. You be the judges. Sepsis is a surgical problem. Yeah, I said it. Sepsis is a surgical problem. There are 70,000 children that are hospitalized every year in the United States. 7000 of them die from sepsis. That's three times more than pediatric cancers. About 20 a day. So in this last hour when you heard these TED Talks, a child died of sepsis. #facts, you can tweet that. I'm Samir Gattapali. I'm a pediatric surgeon and a surgical intensivist at the University of Michigan. So I round on our ICU patients, I write notes and orders. I intubate, I Uh, manage ventilators. Actually, I don't write notes and orders. I have fellows for that, but pretty much everything else. And so what I hope to do in this talk is to prepare and energize everybody in the audience out here to go out there and save some children's lives from sepsis. So, I'm gonna give you, there's been some changes to the surviving sepsis guidelines, so I'm going to give you the lowdown on what you really need to know. And it's a very practical talk, and so just pay attention. And uh surgeons can really impact lives by following some key principles. And so, uh, you know, I'm a surgeon. I like simple algorithms, so I made one up, save, S A V E. Source control Antibiotics Vascular access, monitoring and support. And equilibrium. Not too much fluid, not too little, maybe a little bit of emo. I am from Michigan after all. So before we go through these real quick, I'm going to talk about some definitions. So there's no such thing as severe sepsis anymore. It's just sepsis. And The way sepsis is defined is that it's a life threatening organ dysfunction. Caused by a district disregulated host response to an infection. So look for an infection, labs, cultures, and look for organ dysfunction. So how do we define organ dysfunction? So a real easy way to do that is using what's called a quick sofa, not the one you sit on at home, but it's a sequential organ failure assessment. And it's made up of three things. So it's mental status changes, elevated respiratory rate, 22 in adults, and a low blood pressure, so less than 100 systolic blood pressure in adults. In kids, you have to use age-appropriate criteria, and the heart rate may be a better marker than blood pressure. So quick sofa, good way to look at organ dysfunction, mental status, respiratory rate, heart rate slash blood pressure. Sepsis has a 10% mortality rate. So that's 1 in 10. So it's really important to keep that in mind. Septic shock. Now septic shock, that's a 40% mortality rate. So that's more than 1 in 3 for those who don't know math. This is where we got to really take some action. So shock is where your tissues are not getting enough oxygen, so they shift to anaerobic metabolism. That's right, first year med school. And you get a bunch of lactate. So guess what your goal is going to be? Get oxygen to tissues, so they don't make lactate. Real simple, right? That's what we got to do. The problem though is that we've done this goal-directed resuscitation, and there's been 3 studies that have been done. In the UK, the United States, and the Australian New Zealand group, the process trial, the Promise trial, and the ANZAC trial, and all three showed no difference with goal-directed resuscitation or protocol-based resuscitation. However, there's some key principles that are going to be important. Here they are. So, let's talk about each of these in some more detail. Source control. So, this is also a simple one to remember, 4 D's, OK? Drainage, debridement, device removal, and definitive measures. OK. So, drainage is gonna be IND evacuate that abscess, put a drain in, get rid of the fluid collection. Debridement, get rid of devitalized tissue. So, necrotizing fasciitis, you remove soft tissue, decortication for uh pleural-based diseases. Device removal is removal of Foley catheters, central lines, and infected mesh. And finally, definitive measures. Definitive measures are uh resection of bowel for necrotizing enterocolitis, for example. Antibiotics. So start appropriate antibiotics early. For each hour delay in your antibiotics, there's an increase in mortality. So the duration of time between The time you diagnose till when the antibiotics are given increases your mortality. Kumaral, critical care medicine, 2006. So you've got to give your antibiotics appropriately. So start broad and then de-escalate based on the cultures from your drainage. And make sure you de-escalate and reduce the amount of time that you're on antibiotics. A few things to follow with that will be a procalcitonin measure. So what is procalcitonin? It's a biomarker that's really specific for bacterial infections. So, when you, you, a trend is more important than a value. So trend your procalcitonin when it reaches normal levels, you can stop your antibiotics. Otherwise, Sean Rangel is gonna come after your ass. Um. The other thing to remember with your antibiotics are, you know, you, like stopping antibiotics is just as important with starting antibiotics. Otherwise, you breed antibiotic resistance, and he's right, like this is really important. So in sepsis, we got to start our antibiotics early, but we also got to stop our antibiotics on time. So there's a stop it trial that looked at abdominal sepsis, and it says, in 4 days, you've achieved adequate control that you stop your antibiotics. Randomized multi-center trial, so 4 days for abdominal sepsis. Next, in terms of the clock starting, right? So this is really important in terms of starting early. It's from the time your blood pressure is checked and it's low to when the antibiotics are actually hung. So sometimes that means you've got to get that IV in, in that first hour. So that's the next step, right? Vascular access. That's where we come in as surgeons again. And so vascular access doesn't just mean two large 4 IVs and sepsis. Vascular access means that you might need continuous infusions. So you got to get a central line in and an arterial line in for monitoring ASAP. I tend to use ultrasound because I don't like to randomly poke at vessels, but you got to get your lines in. And then, um, you're monitoring, uh, I use a lot of ultrasound and echo to help guide my resuscitation. And it's a change from CBP and swan numbers, but um it's a useful measure because it's dynamic and it's, you can continue to follow it over time. It's at the bedside, it doesn't involve moving anything and it's a little bit non-invasive in kids who don't need the infusions. In terms of goals for like what you're trying to achieve, um, in terms of lactate, I know I mentioned it earlier, but there was an Andromeda shock study just came out, uh, 2019, Hernandez et al. and JAMA, and it looked at using capillary refill versus lactate as a measure. And what it found was cap refill was just as good as, if not better than And this is in pediatrics, just as good as, if not better than using lactate levels. And that's really important. It had low, uh, the same amount of 28 day mortality, ventilator-free days, renal replacement-free days, and in fact, there was an almost statistic, statistically significant difference in mortality where cap refill had a 35% rate and The lactate level group had a 43% rate. And with a P of like 0.06. So, you're like, wow, how, how is that possible? And it's because the lactate group got a ton more fluid. It was actually over resuscitation trying to correct that lactate, and over resuscitation is bad. So it brings me to my next principle, equilibrium. So we know that fluid overload is associated with mortality, and 30 mL per kilo is a good number to use for your sepsis for volume. Isotonic fluid, 30 mL per kilo. So they come in, they're hypotensive, you give them some volume. The Feast trial, which looked at bolus in children, African children with severe infections, identified that over resuscitation increased their mortality rate and sepsis in children. And so what you have to do is you have to constantly ask yourself, is this shock really still hypovolemic? Because remember, shock can be 4 different things. It can be hypovolemic, it can be cardiogenic, it can be neurogenic, or it can be obstructive. So once you give your 30 mL per kilo, start considering other things. One, albumin. So the Albio's trial looked at ALBIOS trial, looked at use of albumin in sepsis, and was, uh, showed that you need to decrease the amount of fluid to achieve your goals. 2, think about blood. So the TRISH trial, T R I S S, looked at transfusions in septic shock and identified that a hemoglobin of 7 would be a good adequate number to shoot for. And then 3rd, consider your pressors. So what pressor do you use? So that's where echo is really helpful. Is my SVR low and what's my heart function like? So those are my two questions, right? So, have I given enough volume? Is my heart pumping enough and is my SVR what I need to address? So typically in kids, I start with dopamine in the babies and norepinephrine for the older children. Most of them have pretty good heart function. And that usually changes if I have somebody with renal failure. So there's a Vanish trial, V A N I S H, that looked at vasopressin versus norerepinephrine, and vasopressin was a good adjunct to use in those with septic shock and renal failure. So renal failure, think about vasopressin, otherwise norepinephrine, and then dopamine for your first lines. And then in terms of your shock, if you find that you have warm shock, you have adequate blood pressure but inadequate perfusion, so good blood pressure, bad perfusion, use melranone. Meranone is a really good adjunct to get blood flowing with your heart. It's a good otropic support. So, really simple, dopamine or norepi, basal renal failure, melanoma if you need heart support. So those are good adjuncts to start with. Then, as I'm starting my second presser, if they're not improving, that's when I consider steroids. So there's no data to support using, uh, doing a stem test in this setting. As you start your second presser, start your steroids, typically I use hydrocortisone at 1.5 to 2 per kilo every 6 hours. So steroids, 2nd line at the time of my 2nd presser. And then, so let's walk through this for a second here. So if I have a patient who comes in, say, per appendicitis, looks sick, looks septic, get your drain catheter in, put some IVs in, get a central line in, arterial line, admitted to the ICU setting, give them your isotonic fluid boluss, 30 mL per kilo, check their albumin, check their cultures, procalcitonin, antibiotics. We're good so far, right? So patient's still getting worse, not improving, now on two pressors on hydrocortisone. Think about ECMO So That final consideration of ECMO is key to remember because ECMO helps with oxygenation and cardiac output, but it has a really difficult time with SVR. So if your systemic vascular resistant SVR is really low, you may still need pressors even on VA ECMO. So if somebody is in severe septic shock, like it's really bad, even on ECMO, on VA ECMO, you might need to use some pressors, and it's because it gives you oxygenation. It gives you Oxygen delivery with cardiac output, but you need something to get your vessels to be tighter. So the other thing with ECMO is don't just crank up the dial to get more flow. So either, so place the largest size cannula you can get, add an additional drainage cannula if you need to. And then consider a central cannulation if you need adequate flows. McLorin et al. from Australia. If your SVO2 is 70%, you have plenty of flow. At that point, you should start thinking about going back, do I have adequate source control? Uh, I have, am I on appropriate antibiotics? Is my vascular monitoring appropriate? Am I missing something else? Remember, your key is equilibrium. Your final E can also be ECMO, which is in this case, So keep these four concepts in mind to save some lives source control, antibiotics, vascular access monitoring support, and equilibrium. Remember, sepsis is a surgical problem. For a brief review of the session, check out our tutorial from the conference by following the link in the comments. To finish off the episode, our partners from Behind the knife had the opportunity to meet with Doctor Gattapoli and get more tips and tricks for the management of sepsis and for captivating audiences with their talks. Here it goes. You gave a fantastic talk on sepsis and you really outlined a very simple concept of save. Uh, can you review for us that? And then there are, there were a couple of other key points that we want our listeners. To make sure to, to remember. So first, let's start with save. Yeah, I mean, I kind of had to make up this mnemonic because I wanted something simple that people were going to be able to take away and remember and be able to use at home. So, uh, save basically stands for source control, antibiotics, vascular access monitoring and support, and equilibrium. And I guess you can also say that E could stand for ECMO because that would be the final line. Um, and it was just a, a way for me to, uh, quickly send out the message so that people can know what they should do when they went home. Great. And as part of this, we wanted to ask you, so let's say you have a patient who, according to QSOFA, um, they clearly have sepsis, they have, uh, metabolic derangements suggestive of septic shock. Um, as well as hemodynamic changes, and you've started to initiate, you know, source control, antibiotics, you've gotten vascular access. Um, how do you in your practice incorporate ultrasound, echo? Do you still use a CVP? What, what are your thoughts on those sorts of things? Yeah, that's a great question. And uh, we do trend the CVP when you have the ability to. Uh, you have to imagine that on certain children it's hard to get like triple lumen central lines in, so you may only have like one or two lumen lines in there. I would say typically double lumens are probably the most common lines we place. And so, if one of them has like sedative drips like, you know, morphine or Versed or so forth, and then the other line might have like, uh, you know, say TPN if they're on like, uh, or they're using it as a medline for antibiotics or it's just, you run out of lumens to track. So intermittently, they may put on the CVP check the level, and then take it off. So it's not like a real-time continuous thing. The second thing is like decision points, right? Like, I'm not gonna check an ultrasound every 5, 10 minutes. Like it's usually uh I'm either progressing or I'm not, right? So it's like either that child is getting better or they're not. So I kind of go, all right, if they're not getting better, then echo ultrasound helps me reevaluate and it's really a bedside echo. It's not like I need formal evaluation of the valves. I don't need to check if they have a, you know, I don't, I don't need anything fancy, you know, like it's nice if the cardiologist does it because they're really good at it, but for the most part, it's our intensivists that are doing this. So, you know, we show up at the bedside, use an ultrasound, check the IVC, is it look like. It has respiratory variation. Does it completely collapse when there's lack of fluid? You check the right atrium, see what that looks like. Is it super dilated? Is there a pulmonary hypertension that you're actually seeing here? Um, then look to see what the heart, uh, function is like, just dynamic or not. Like you would expect in sepsis, that heart should be pumping away. Like if it's doing its job, then that gives you an idea. Plus, like you'll see what your, uh, diastolic blood pressures are. Typically in sepsis, you'll see that their diastolic blood pressure just tanked. It's, you know, 70/30 or, you know, 80/20. And you're like, what just happened to that diastolic? And it's cause they have no systemic vascular resistance. And so, uh, if that's the case, then like, you know, I'm not gonna be using inotropes. The heart's already hyperdynamic. I checked my volume status, like the IVC looks full. The Uh, heart looks full and like we know that fluid overload is associated with issues. I didn't go into this in my talk, but like there's a ton you could say about fluid overload and acute kidney injury. And so it's really important to be conservative about the amount of fluid. Like when I was taught, they were like, oh yeah, 10 L, go for it. And it's like, not everybody needs 10 L. Like, you know, be conservative, get the 30 mL per kilo, and then kind of go and see if you've made any room. If they came in super dehydrated, yeah, maybe they. You do need 10 L, but like, I'd say, most kids don't need 10 L. And so, the ultrasound and echo are real-time, help guide management on a, you know, hour to hour basis. And you can just have it at the bedside, pull it over, see where you're at. And then typically with each of your interventions, you should be able to reassess and see if that intervention made a difference. So I started my presser, wait like, you know, uh, 20 minutes and see if it's made a difference. I gave some blood. Wait a little bit, see if that made a difference. So each of your interventions should have a reassessment. And typically for me, use of ultrasound or echo is a good way to do that. So along those same lines with that resuscitation, you brought up something that I hadn't heard before and I think it's great to know is that cap refill is the equivalent or even maybe better than using lactate, and we're always drawing lactate levels to guide our resuscitation. So can you talk a little bit more about that? Yeah, I mean I still lactate levels. Follow them, but I don't think I would say, so say for example, if I give you somebody who has a good blood pressure, their lactate, let's say it's mildly elevated to 2.5, OK? But it sits there, it hasn't changed. They're making good urine, their kidney function's improving, maybe even their respiratory drive and mental status, everything seem OK. No reason to chase that lactate down to normal levels at this point. So I think that's kind of the key is that once you're providing adequate profusion, like just kind of see what they look like. And that's a relatively new study. It just came out a few months ago, uh, and it's a multi-center study. I mean, obviously, it generates a lot of controversy and so it'll need to be reevaluated, but Um, I mean, it was an Andromeda shock study like at multiple institutions, it's pretty big data. As far as other, uh, modalities of therapy go, you mentioned also that after you start antibiotics broadly and you're tailoring according to cultures that come back, uh, what are you using to drive your decision of when to stop antibiotic use? Yeah, so typically I use procalcitonin. If I find that the child is improving, getting better, and my procalcitonin levels trended back down to normal, um, and it, and it, it's a second line test. So I'm already thinking, wow, this child is getting better. And so that adds a point for me to like say, yeah, you know what, even the procal is normal, we should stop. Um, I think the The thing is we're really good and we've really emphasized starting antibiotic early, making sure we're broad spectrum, covering a lot of stuff. But I think we have to be just as aggressive about that. We have to de-escalate the antibiotics. We have to stop the antibiotics. So, procal, if you're finding that your, your patient that you're caring for is improving, and procalcitonin may serve as a measure for you to say, you know what, this also adds to the fact that we don't need any more. Cause what you, what ends up happening is that they'll go, oh, maybe a couple more days, maybe another day, and it's like, that's not a good way to do that. Just pick a time. and then follow your trend. And then if you find that your numbers are normalized and you can stop them earlier, great, stop them earlier. And it also allows you if there's a change to reculture them because what you might find is that the antibiotics you're using are already developing some resistance, like the bacteria are developing resistance. So, if you found that the child is sicker again, you can restart your antibiotics with a more tailored effort now that you're off antibiotics when you get the cultures. So shifting gears a little away from the science, um, your talk was a very new format, uh, especially for this audience at APSA, and, um, it was, these were meant to be TED style talks and you did a lot of research, so I wanted to hear from you about your, uh, the learning points and, and kind of what makes an effective talk, especially in this new age of varying presentation styles, visual abstracts being a lot more visual in our presentations. Yeah, I had never done a talk of this kind of this style at all. I'd never done a TED Talk. I'd never done it this magnitude. Uh, the whole concept of doing it this way stems from leadership at ABSA. So, you know, Ron Herschel being the president, Dave Powell being one of the people who kind of proposed this as an alternate format to help our audience kind of really have take home messages. Marge Arka, who was education director who's kind of come up with this concept of doing it as a tech talk, so all of these people had already kind of thought, hey, this may be an alternate format we may want to use. Um, and then when they had decided on sepsis as a topic of need for the pediatric surgery audience, they approached me and they said, would you be willing to give a talk like this to the group? And I said, Yeah, I know that topic very well. Like, when do you want me to give it? I can give it like tomorrow. The problem is that I, I don't really like public speaking and so when they were like, you got to give this talk, I said, OK, I want to do a good job. I want to learn how to do it. So they sent me some videos to watch and there are some really key concepts that I thought were helpful for me. One was, you, these are ideas that you're kind of giving somebody else. So you don't want to give like 10 ideas that they need to take home. You want to pick one. They said if you can pick one simple idea that people walk. Away with that's a good talk. And so for me, I had to decide what is the idea that I was going to give. And so my idea was that sepsis is a surgical problem. My audience is a primary group of pediatric surgeons who may or may not have invested efforts in learning about sepsis. And so that's a concept that I really wanted to convey to people and help them understand that yes, all of the things I talked about are things that surgeons typically do vascular. Access, source control like this is in the purview of surgeons, and I think that people kind of forget that and somehow got lost over time. And so as somebody who's trained in University of Michigan under Bob Bartlett and Lino Napolitano and Sanalla, like we're very big in surgical intensivists and so it, it translated down to me, you know, through Ron Herschel, who also is a big advocate for surgeons in the ICU. Um, so then I was like, OK, how would I, OK, so I have my idea, how would I then deliver that idea in a way that people can remember? So I had to simplify the topic that I was going to talk about. And as I went through, I just kind of noticed the pattern. Almost by accident and I said, wow, save, that's a good way to remember this because I wanted to memorize the talk so I can actually deliver the talk rather than use notes and as I was trying to memorize it, I just found that it was a mnemonic that I could use to remember it. And then, um, then in terms of like conveying it in a style, so the content that you give, so Simon Sinek is a person who was on YouTube and he discusses the power of why, like you start with the why and then you go to the what. So I wanted to make sure I hit the why right away and so in my talk, I was like, OK, get my concept idea out, then talk about the why and then talk about who I am and why people should listen to me. And then concept concept idea in terms of takeaway with simple concepts that people can then remember when they leave and then I went through each of the details. The details, they said this talk would be videotaped, so I figured that could be my advantage where there's a lot of studies on sepsis where I can. Quote the literature up top so that people if they wanted to reference the article, read more about it, look at the methods, they can then go back to the video, watch that segment, pull out the article, and then can get more detail on it. And so I didn't put them on the slides, they said 3 slides, 15 minutes, don't spend more than 5 minutes on, you know, like on each slide, like you should really focus on you as the speaker, not on the slides. So that's kind of how I designed it. I don't know. I hope people got a lot out of it. I tried to make it as inspirational as I could make it. We hope you enjoyed this episode of Stay Current. You can listen, watch, or read our content at any time by downloading the Stay Current app. See you next time.