Coagulopathy and Analgesia

Welcome to the latest episode of Stay Current in Pediatric Surgery. Today's episode is created and edited by Todd Ponsky, Alex Kassar, Ray Hanke, and me, Alexander Gibbons. Today we continue our review of critical care as we delve into the topics of coagulopathy, analgesia, sedation, and delirium in pediatric patients. Confused? Well, we're here to reorient you. So please, join us for another episode, and then help us spread our message that knowledge should be free. Dr. Vogel is a pediatric surgeon at Texas Children's Hospital and an associate professor of surgery and pediatrics at Baylor College of Medicine. He completed fellowships in both pediatric surgery and surgical critical care, and his research interests include viscoelastic monitoring techniques and goal-directed hemostatic resuscitation, and massive transfusion, as well as optimizing anticoagulation and ventilation during extracorporeal life support. Dr. Vogel, thank you for joining us. Great to be here. Thanks for having me. And this podcast is going to continue our series looking specifically at critical care issues. So we'll be kind of jumping in, looking with a topic that Dr. Vogel will be an expert in, coagulopathy. So we're just going to get started with a case scenario here. We have a 12-year-old helmeted male in a high-speed vehicle versus bicycle collision. EMS gave two crystalloid boluses prior to arrival with a transient response. He's taken to the OR for hypotension and a positive fast, and massive transfusion protocol was activated. His bleeding was discovered to be from a liver lab for which he underwent packing. He's brought to the PICU postoperatively and is noted to have an INR of 2.5 on post-op labs. And we'll also eventually discuss whether INR is even the test that we should be using here. But initially, just with this information, how would you manage this patient? Now, I think, you know, I think, first of all, that's a great question. And, you know, we unfortunately see altogether too many of these type of patients in our practices within pediatric trauma. I mean, there's obviously a host of ways of approaching this type of patient. They're incredibly complex. I mean, really, to start with and drill down on the coagulopathy part, you know, we clearly have a patient that was severely injured. We clearly have a patient that was in hemorrhagic shock. And in all likelihood, since the massive transfusion protocol was activated, had likely received substantial blood product transfusion therapy in the emergency department and likely in the operating room, you know, as his resuscitation was ongoing. And so I think the first step when you get back to the PICU, you know, obviously in initially talking, you know, starting to drill down on the coagulopathy aspects is to just take a step back and really see where you are. So over the course of time where that patient's been in the hospital, so what has his trend been as far as his coagulopathy? So in all likelihood, that INR of 2.5 is not the first coagulopathy assessment or measure of assessment that's been done. So the first thing I'd be interested in is how did he present? And through the course of his resuscitation, the OR, what additional lab values had been checked and what those results are? Because my first question is, is that an INR that's going up or is that an INR that's going down? I think when we focus on critical care, you know, one point measure, one moment in time is not nearly as helpful as what those trends are. So the first thing is I'd want to know kind of what has his trajectory been. The second thing that I'd be most interested in is what has he received thus far? So you mentioned that he received two crystalloid boluses en route, but since he's been at the institution in the ER in resuscitation, how much crystalloid has he received? How much blood products have received? And specifically, of the blood products that he may have gotten, what was the ratio in which he received them? That is specifically the ratio of red cells to plasma and platelets. And so just when they get to the ICU, one of the most important things is go back to the records, talk to the anesthesiologists, and get a sense of where he's been. Because if you don't know where he's been, you don't have a sense of that trajectory. It's a little bit hard to know where you want to go. So obviously, the goal of how we manage this coagulopathy is going to be to get him as normal as possible. He is going to be at higher risk of bleeding. The bleeding was so severe from the liver laceration that it was only able to be packed. So we're going to want to get him warm, and we want to start addressing that coagulopathy. So what I'd want to know beyond just the INR, I'd want to know what his PTT was. I'd want to know what his blood counts are, what is his hemoglobin level, what is his platelet count. And honestly, for me, and I recognize this is an interest of mine, but I would want some sort of sense of viscoelastic monitoring, whether it be a Teg or a Rotem, to get a sense of what the functional aspects of his coagulation cascade is doing. And then based on those numbers, that's where I would start to titrate my specific coagulopathy therapy. So, for instance, if he's massively volume overloaded, which you might expect anisarcadous, deminous, stiff lungs, and had a massive resuscitation, you'd really want to be goal-directed with your therapy. So if his platelet count was reasonable and the platelets were functional on a Teg, then you may not need to give platelets just to give platelets. If his INR is 2.5 and his PTT is elevated and the viscoelastic monitoring shows a prolonged clotting time, then certainly giving something like fresh frozen plasma would be very appropriate to start that process. I think that the more frequently you assess these patients, not just from a laboratory perspective, but also a clinical perspective, is there ongoing bleeding? Is his blood clotting? You can gain a lot just by being at the bedside and getting those assessments. So that would be my initial approach. But in general, I'd say we want to get him warm, and then we want to see where we've been. We know we want to get his coagulopathy normalized, and I've used an assortment of tests that we would trend over time to do a goal-directed hemostatic therapy approach. I want to kind of go off a little bit more what you were talking about with the viscoelastic monitoring, whether it be the Teg or the Rotem. I know in the adult world, this has kind of taken off quite successfully in the past several years, and I'm familiar with it from my residency program, but I haven't seen it as much in the pediatric world. So can you kind of summarize some of the main aspects of viscoelastic monitoring and how that allows for better goal-directed hemostatic resuscitation? Yeah, and so what the viscoelastic monitoring tests do, and whether it's Teg or Rotem, they really, there are different flavors of testing, but they will provide you with similar information. What they do is allow you to get a global kind of overall assessment of the entire coagulation system, not only how blood clots, so not just the hemostasis part, but also the fibrinolytic portion of coagulopathy and the hemostasis. And so what these tests do is they start with a small amount of blood and some sort of reacting agent. And as the blood clots in the machine, the machine itself transduces the mechanical changes in blood as it clots into an electrical signal, and that's what you're measuring. And the way, in general, there are four major phases that these tests allow you to process. So the first is the time to actual clot formation, so how long it takes the clotting process to actually start. The second is how rapidly that clotting process progresses, so sort of the amplification of the clotting cascade as we tend to think about it. And then the third phase is sort of the, as you get the clot to form, what that clot strength is like. And over time, if you leave a clot in the system, the fibrinolytic cascade will start, that process will start, and you'll start losing clot strength. And so it's able to assess that. So you're able to get four very valuable pieces of information. How long the clot takes to start forming, how rapidly it progresses, what the clot strength is, and a sense of what the fibrinolytic system is doing. And as it turns out, each of those four values allow you to provide goal-directed therapy. So in general, the entire system is interlinked, and it's incredibly complex. I don't think anyone actually totally understands the whole process. But if you try to simplify it as much as possible, that first phase, that time to clot formation, really depends on factor function. In fact, in order to have factors functioning properly, first of all, you have to have the factors there, and they have to be working. And so if that's abnormal, you would treat that abnormality with plasma. The amplification phase, the cross-linking phase, is primarily determined by fibrinogen function. So your fibrinogen has to be there, and it has to be working. And so if you have an abnormality in that phase, which on the Teg and Rotems is that alpha angle, that can be treated with cryoprecipitate or fibrinogen itself. That third component, that clot strength on the Teg is the maximal amplitude. That is a sense of platelet function. And so you can either treat that if it's abnormal, either by administering platelets or, you know, in some patients, like, say, that are end-stage renal disease that have platelet dysfunction from their kidney disease. You can give maybe DDAVP, or those are patients that may need dialysis. And then finally, if their fibrinolytic cascade is hyperactive, then you'll have a very rapid drop-off in that clot strength. That may be an appropriate indication for an antifibrinolytic agent like tranexamic acid or amacar. And tranexamic acid has been widely used in adults for management of hyperfibrinolysis associated with trauma and is being used more and more in children. And so one of the nice things about these viscoelastic monitoring tests is it gives you a really good sense of how the whole system is functioning and how the whole system is interacting with itself. And so, you know, a patient may be coagulopathic, and if you do a viscoelastic monitoring test and you find that it's a problem with fibrinogen and they're massively volume overloaded, you don't have to necessarily give them a bunch of plasma. You may not have to give them a bunch of cryoprecipitate. You might be able to give them an infusion of fibrinogen and address the coagulopathy without contributing more to their volume overload. So that's just one example in a way that these tests can really help you drill down on what the problem is contributing to coagulopathy and allows you to start tackling that in a systematic fashion. You can also trend these values over time and really, you know, get a really good sense of what the trajectory is and how patients are reacting to your therapy. Another benefit of viscoelastic monitoring, as I understand it, is that you are measuring this in real time. So you have three of those four components within five minutes of starting the monitoring. That's very true. And a lot of that depends on a little bit of how the coagulation lab, what the logistics are at the specific institution where you're practicing. At the higher volume, you know, state-of-the-art, predominantly adult trauma facilities, the viscoelastic monitoring tests are practically performed real time where exactly, as you mentioned, within the first five to 15 minutes, you have a sense of what the factors are doing, what fibrinogen is doing, and what the platelet are doing. And then the fibrinolytic part comes just a little bit further down the line. Depending upon the sophistication of the hospital system, as the data comes back from the lab, they can be displayed real time within the trauma bay, and it's widely available for the trauma surgeons and the trauma team to be able to incorporate into their ongoing resuscitation. One of the nice features of this testing is that there's also the ability to see these values remotely on different computers. There are web-based interfaces. So if it's not directly integrated into coming up on the display where the vitals are, it can be fairly easy to log into the system and see these numbers being run and get the data as quickly as possible. In general, I think for each institution, it just depends on what the setup is and what the relationship is between the emergency department, the trauma base, the OR, and the lab, and how they want to run things. But the true benefit of this type of testing is that the quicker you get the results, the easier it is to incorporate that into your resuscitation. And again, you're getting those results within the 5 to 15 minutes where typically the conventional coagulation tests like the PT, INR, PTT typically take between 30 and 45 minutes even when they're tagged stat to get those results. So you're already 45 minutes down the line in your resuscitation. And that, depending upon how sick the patient is, their coagulopathy profile and their clinical status could change a lot in that 45 minutes. So it allows you to get data quicker. So these tests, just to sort of summarize, you can get these very important data as it relates to the function of coagulation cascade very quickly, and it allows them to be incorporated into practice. Awesome. There's a great resource that I've used for studying these tests in residency. It's an article in Life in the Fast Lane that we will link in the summary below that just gives a great breakdown of tag and rotem and has a nice mnemonic for kind of quickly reading these and helping you understand which components are missing. That's awesome. Could you speak a little bit to management of fibrinolysis in this patient population? The management of fibrinolysis, I think, has something that's become more and more prominent in the adult world and has also been translating down to pediatrics in the sense that we know that severely injured children, there are two phenotypes. There's the hyperfibrinolysis, there's the hyperfibrinolytic phenotype where there's rapid fibrinolysis that contributes to the coagulopathy, but there's also a fibrinolytic shutdown phenotype, which is a smaller percentage of children. And one, you know, clearly the anti-fibrinolytic, the TXA administration can be very helpful in the hyperfibrinolytic patient population, but it may potentially be detrimental in the fibrinolysis shutdown patient population. And so this is a real opportunity where these viscoelastic monitoring tests that give you a sense of fibrinolysis can help you manage those patients because if you're in fibrinolysis shutdown where it may actually make the patient hypercoagulable in certain elements, you wouldn't want to give those children TXA because that could potentially attribute to more complications. So knowing the fibrinolytic status of these critically ill patients, I think is really important and is going to get more and more of an emphasis over the next few years. So talking about kind of balanced resuscitation for a bleeding patient, what exactly does that mean and how do you go about achieving a balanced resuscitation? That's a really good question. And what we've learned, just like everything else that I think within the trauma world, started with adults but then gets translated down to kids. It's not just resuscitating patients from a volume perspective. That's important. It really matters what you give them. And so there's a litany of evidence in adults and now there's actually some decent evidence in children that administering blood products in what's called a balanced resuscitation or that one-to-one-to-one ratio of red cells to plasma to platelets is incredibly beneficial. In adults, we know that there's actually some really good prospective observational and even randomized studies that a balanced resuscitation improves mortality. Not just does it improve mortality from that level of outcomes but improves almost every outcome that you can have within the ICU environment. So complications like kidney injury, length of time on the ventilator, length of time of the ICU infections are all improved with that balanced resuscitation. And not only does it improve mortality, it doesn't improve morbidity, but the evidence has shown that by resuscitating in that manner, you actually have a more efficient resuscitation. So even though it sounds like you're giving more blood, more plasma, more platelets, because it's more effective, you actually get control of the coagulopathy with less overall volume. So if you tackle this approach or if you resuscitate patients in this manner, you wind up improving almost every outcome more efficiently and using less blood products overall, which all of our transfusion medicine and blood bank colleagues tend to get very excited about. And although we don't have the same level of evidence in children, there are some really good retrospective studies using the National Trauma Databank and TQIP showing that that one-to-one ratio, at least particularly for red cells and plasma, provides improved outcomes. And there's a really nice study that the Atomic Group recently published in their severely injured trauma patients. I think they had over 100 or so where they looked at patients that were massively transfused, and they had the best outcomes and the best survival. Again, these are all pediatric patients that were closer to that one-to-one balanced resuscitation. So I think standard of care for chemostatic resuscitation in 2019 is balanced resuscitation with red cells, plasma, and platelets in that one-to-one-to-one ratio. And can these one-to-one-to-one transfusion ratios be built into massive transfusion protocols to make it even easier for providers to achieve that ratio? Absolutely. That is absolutely, I think, the standard of care that we have today. And that is something that the American College of Surgeons, the Committee on Trauma, that's one of the things that they look at when they verify trauma centers. So that, the massive transfusion protocols include, deliver your products in that one-to-one-to-one ratio. So for the next case, then, we have a two-year-old male who's discovered to have neuroblastoma and undergoes a laparotomy for resection. Post-operatively, he is having poor pain control. How would you go about helping treat his pain? So I think the first thing to recognize is that there are going to be multiple causes of pain and distress in this type of child in this kind of situation. I mean, the first and most obvious aspect is the pain from a really large incision, the incisional pain and the post-surgical pain. And I think more and more we have a really good understanding that a multimodal approach to post-operative analgesia really has a ton of benefits. So thankfully, and I think a lot of our children's hospitals, we have our anesthesia colleagues that have pain service teams that are an incredible resource for us in helping to manage this type of post-operative pain. And I think partnering with anesthesiologists and pharmacists can really be very helpful in tackling what can sometimes be a really challenging problem in these patients. So, you know, just taking a step back when I think about the incisional pain and things along those lines, there's likely going to be a component of narcotics that we're going to treat this patient with. And so, you know, I think that that has been a standard of care for years and years and years. And narcotic analgesia is certainly going to play a role in these type of patients and many, many others moving forward. We have learned and has really come to light, especially within the past couple of years, that, you know, when you factor in the use of narcotics and the opioid epidemic and all those things that are out there in 2019, 2020, there are so many ways of really tackling the approach from multiple options to try to decrease narcotic and opioid use. And so certainly using non-narcotic medications, non-steroidal medications, intravenous medications like Toradol or oral NSAIDs will certainly play a role in these patients and allow us to minimize narcotic use, which can help decrease other post-operative related complications like ileus and things along those lines. In patients that have certainly large incisions, even smaller incisions, I think regional analgesia can play a huge role. So, again, reviewing with the anesthesiologist, you know, even before the surgery itself, this is someone that would be a great candidate for something like an epidural catheter for managing the pain intraoperatively, minimizing opioid use intraoperatively, and certainly helping with patients' pain control in the post-operative period. Certainly other types of regional techniques, ultrasound-guided nerve blocks, things along those lines, can be really helpful in managing incisional pain and post-operative pain. And then, you know, one other option that I know has come up recently and become more prominent is the use of indwelling analgesic catheters that allow for a slow release and delivery of local anesthetics into the wound. I know have also been shown to be very helpful, particularly in large incisions. And so when you take all those things into effect, so use of narcotics, use of non-narcotics, use of regional analgesic, use of other non-narcotic medications like the gabapentinoids, pregabalin and gabapentin, things along those lines, can all allow for a really nice multimodal approach for pain management. You know, the other aspect that I think we don't focus on as much, especially in younger children, but certainly can happen with older children, is the anxiety component and just the pure stress of having a big surgical procedure. These children are scared. They're in an unfriendly environment. So there are a host of environmental and non-pharmacologic therapies that can be really helpful in managing pain, and not just pain, distress in these patients. So creating a child-friendly environment, supporting the family, things like pet therapy, whether it be dogs or whatnot, visiting with these kids can be hugely helpful in decreasing stress levels. And we know that when children are less stressed, their pain tends to be more manageable. And so we know there are multiple techniques. And I know that it's not as relevant necessarily for this type of patient, but for patients that require, say, multiple complex dressing changes, burn patients, things like that, there are augmented virtual reality devices that can be used to create an entire different environment distracting for patients that can markedly improve how patients go through those type of stressful, painful situations. So we really have, you know, in current era, lots of different ways of managing postoperative pain. And I think, like everything else, you take a look at your patient, you take a look at what operation they had, what environment they're in, and you do your best to tailor the specific analgesic therapies, whether it be narcotic, non-narcotic, environmental, whatnot, to that specific patient. Excellent. Let's just kind of summarize that then. There's multimodal analgesia at this point, and surgeons should really be utilizing all of them and not just relying on the traditional Tylenol and narcotics. Absolutely. So using narcotics, using non-narcotic agents, utilizing the regional analgesic therapies, really that multimodal approach can have an incredible impact on postoperative pain and really improve outcomes, whether it's on the floor or in the ICU. So for this patient that we talked about, he's discovered to have bleeding postoperatively and is taken back to the OR to achieve hemostasis. He remains intubated postoperatively. What sedation options are available for him? And so in general, I'd say most intubated postoperative patients are on a combination of sedative therapies to really help facilitate their interaction with the ventilator and keep them comfortable. You know, the mainstay pharmacologic agent that we have are the benzodiazepines, the most commonly used infusions probably midazolam or adivan, things along those lines. That's usually combined with a low-dose narcotic infusion, whether it be something like fentanyl, morphine, or delazol along those lines. A medication that's been used more and more frequently started really in the congenital heart cardiac population is dexmetomidine. So Presidex can be very helpful for really decreasing the anxiety associated with being intubated and having an endotracheal tube. You know, we know that as a general rule, you really want to have that multimodal approach to sedation in the ICU environment. As a general rule, I think you want to minimize the amount of the amounts and volumes of these drugs that you're administering to your patients. And really to that extent, when you think about, you know, postoperative pain, postoperative sedation, postoperative anxiety, all those things with being in the ICU environment, the most important thing is to recognize that each of those elements are distinct, but also related to each other. So when we think about postoperative pain that we touched on earlier, making sure that we're having daily frequent assessments of pain, you know, through validated pain scores, which there are validated pain scores across all ages. So we really have that information. Can you provide some of the examples that you've used for these validated pain score systems? Some of the most common ones, there's the FLAC, F-L-A-C-C, which stands for Faces, Legs, Activity, Cry, and Consolability Score, which is typically used in preverbal children. It's been validated in children with pain from surgery, trauma, cancer, and other disease processes. There's also the Faces Pain Scale Revive Score. There are also the Visual Analog Score, VAS, as well as the Color Analog Score, which is known as CAS. In general, the Visual Analog Score and the Color Analog Score tend to be a little bit better received than the Faces Pain Scale. And there is also, for children that don't communicate, there is the Non-Communicating Children's Pain Checklist. There is a postoperative version that is available that's also been validated. So there are a host of these scores that can be applied. I think most institutions, most hospitals already have some sort of validated pain assessment tool built into their protocols and nursing assessments, things along those lines. Like anything else, typically they're just one number, one point in time. I think that trends are a lot more valuable. But at the end of the day, these scores can be incredibly helpful in allowing you to assess what a child's postoperative pain is and be able to adjust your therapy accordingly so that we can be titrating whatever pain protocol or whatever pain medicines we're using to get the patient in an appropriate analgesic state without giving more medication that we need. And the same thing goes for sedation. In general, you want patients to be comfortable but not in a coma and not overly agitated so that they are at risk to themselves or others. So that really starts with how we assess these children. In adults, the most commonly employed technique is, I think, something called RAS, the Richmond Agitation Station Score. In children, there are other types of scores, but the SBS or the State Behavioral Score is a score that's commonly used. And so in most ICU environments, the physicians and the nurses are constantly assessing the level of sedation in patients and titrating the sedative infusions so that it's a goal-directed therapy because we want patients to be able to wake up and interact and be assessed. We don't typically want them comatose. So there are certainly situations where that's more appropriate, and we don't want them overly agitated or engaged. When we think about that, so then using the narcotic infusions, the benzodiazepine infusions, and things like Presidex, we can usually achieve an appropriate sedative plane, if you will, where patients are interacting with the ventilator. They're safer themselves, but we're also not over-medicating them because we know that that can have a negative impact in their outcomes. How do you manage sedation holidays for these patients? Is it you have a standardized protocol where everybody has a certain amount of time where they're kind of being weaned down a little bit, or what's your strategy? I guess the best way of framing it is just to take a step back. When we think about management of these patients in the ICU, there's actually an incredible resource that's out there from the Society of Critical Care Medicine. It's an evidence-based bundled approach. It's called ABCDEF. It's the ABCDEF bundle really for management of these type of issues within critical care. It's been extensively studied in adults, and really probably over the past five years or so, that information has really trickled down and becoming really used in pediatric ICU environments. The A part of that is really assessing pain and managing pain, which we touched upon earlier, knowing what's causing the pain, treating the pain, and not over-treating the pain. The second part to that, the B part, is what you were alluding to, which is that spontaneous awakening trials and coupled with spontaneous breathing trials. And so what we've learned in adults, and that's been replicated in children, is that in the appropriate patient, having a sedation holiday, so stopping those infusions, allowing the patients to wake up, getting a full assessment of where they are, decreases the amount of time that they're on some of the medications, decreases the amount of time they're in the ICU, decreases the amount of time they're on the ventilator. And the same thing goes for spontaneous breathing trials. So waking patients up, getting their assessment, allowing them to breathe on their own, or really allowing the ICU team to see what they're doing, doing those trials every day decreases duration of mechanical ventilation, duration of intubation, duration of time in the ICU, and really overall improves outcomes. So having patients in the right sedation plane really allows you to do that. The third component of that bundle is the choice of analgesia and sedation, and that also kind of gets to what you're alluding to in the sense that most ICUs have escalation and de-escalation protocols that have been developed along with hospital pharmacists that are often unique to the ages and the patient populations that those hospitals will see in their ICU environments. So when we think about choosing analgesia and sedation, giving the patients just enough to keep them right where you want them to be and not over-medicating is really important. Minimizing benzodiazepine use, because we know that benzodiazepine use contributes to patients developing delirium, is very important. Using benzospearing agents like Presidex can be very important to that. The fourth component is delirium. The assessment, prevention, and management, which is something I think we can talk about a little bit more. Then there's early mobility and exercise, getting these patients up, moving around, physical therapy, and then finally engaging the family, engaging the caregivers, and really allowing the patients and their families to play a role in their care has been shown to improve outcomes down the line. So there's this really nice bundle, and through the Society of Healthcare Medicine, there's opportunity to see all of the evidence behind each of these protocols and why they work. And all of these protocols and guidelines are really being deployed and implemented, I think, in ICUs across the country. So it's a really great evidence-based tool and approach to sedation, vent weaning, things along those lines within the ICU environment. And we can link to the Society of Critical Care and those bundles in the information below as well. And then to just kind of summarize some of the main points here then for sedation in the ICU, kind of treat it similar to analgesia in that it should be a multimodal approach, and there's specific protocols in place that allow us to kind of empirically manage sedation across different patient populations. All right, moving on with this same patient. So over the next day, he's able to be weaned from the ventilator, but after extubation, he's confused and at times combative. Delirium is suspected after other potential causes for his altered mental status have been evaluated and ruled out. How should his delirium be managed? Yeah, and so delirium is something that we've become really prominent and really been recognizing more and more in our pediatric population. We know that it increases in incidence the longer children in the ICU. A number that I commonly see is commonly thrown around is about 40-ish percent of patients in an ICU will have delirium at some point during their ICU stay. And delirium is a waxing and waning change in mental status. We know that there certainly are risk factors for delirium in the pediatric population. Younger children, so children, I think the number is typically less than two, can be a risk factor. Children that are intubated in mechanical ventilation is a risk factor. Not surprisingly, benzodiazepine use, narcotic use is a risk factor. Children that are physically restrained is a risk factor for delirium, which kind of makes sense when you think about it. If you're a kid that's used to moving around and all of a sudden you can't because you're restrained, that can certainly increase the stress and contribute to delirium. So there are well-known risk factors that exist out there for delirium, and it is pretty frequent. And just like everything else, as we talked about with pain and sedation, it really starts with making an assessment. And one of the nice things that's out there is that there are several tools, delirium assessment tools, that are widely available that we can use for this that have been validated across all ages and are incredibly helpful. So the two that I think of most commonly in the older population is something that was developed out of Vanderbilt. It's called the CAM-ICU, which is the Confusion Assessment Method for the ICU Environment. This was developed for adults, but they've subsequently translated their experience into both a pediatric and a preschool confusion assessment method. The other common method out there is called the CAP-D, which is the Cornell Assessment of Pediatric Delirium. And at least at our institution, that's what we use. And to use all of these delirium assessment tools, you actually, before you even get to that delirium assessment, you have to assess where the patients are from a sedation perspective because if a patient is comatose, then you're not even able to start the delirium assessment process. So they have to be in a position where you can reliably assess whether or not they have delirium using these screening tools. In general, these tools, they're pretty straightforward, easy to follow. When we think about children, things like, you know, are they making appropriate eye contact? Are their actions purposeful? Do the children appear aware of their surroundings? Are they able to interact with their family, their caregivers? Are they able to communicate? Those type of components, you know, each of those components have a score. They get added up. And whether you're above a score puts you at risk for delirium. At the end of the day, these are screening tools. And if someone screens positive, if you will, for delirium, that doesn't necessarily mean they're delirious. They may be uncomfortable and in distress because they're having – because their pain is not under good control. Or they may be uncomfortable and stressed because they're getting sicker or they're getting septic. Or their pulmonary status has changed and their ventilator is not interacting with them as well as they were doing before. So the screening tools serve a purpose to kind of keep it on your radar, but at the end of the day, you have to go in and do a detailed assessment of what's going on with the kid. And if they're found to be delirious, then there are – then you then move from sort of the – from the assessment phase to how you would tackle them from a treating phase. So assuming that, you know, for this child, they've screened positive for delirium, you've gone in to see them, they're not getting septic, all their – the rest of their physiology is appropriate. Then you really start diving into, okay, well, how can we treat delirium? And like everything else that we've talked about in the ICU, it's a multimodal approach. So the easiest thing to do is really to start with non-pharmacologic therapy. So, you know, I think about that in terms of really the environment. So we think about, you know, sleep-wake cycles, things along those lines. You take children that are used to, you know, their normal day-to-day activities. You give them a big operation. You put them in an unfriendly, stressful environment with a bunch of people they don't know. How do we make that more comfortable for them, right? So, you know, having the family, interacting with – having child life available. Even things like pet therapy can be very important. We completely mess with their sleep-wake cycles in the ICU environment. We're constantly waking them up, moving around, you know, checking them, doing things like that. So sort of the lights-on, lights-off model. So lights on during the day, lights off at night. Trying to keep those sleep-wake cycles as regular and as routine as possible can be very helpful. You can then transition then into potential pharmacologic therapy for things like that. So if patients are having difficulty with sleeping, melatonin can be something that's very effective in helping manage that. Other aspects that can be important for pharmacologic therapy for delirium are the atypical psychotic. So things like risperidone is at least the most common one that we employ at our institution. But starting those at a low dose and titrating them up can be very helpful in managing delirium. But like everything else, it's taking a step back, trying to get a sense of what may be causing this acute change and making sure that you are addressing each of those components. So if the pain is not being well controlled, get better control of the pain. If sedation is not appropriate, adjust that accordingly. If they're on high-dose benzodiazepines, consider dropping that down and adding potentially an alpha-2 agonist like Presidex or Comedine to minimize the negative effects that benzodiazepines have on delirium. And so just taking a fresh perspective each time there's a change in clinical status as it relates to delirium I think is very important. What are some of the best ways that you've found to help prevent it in the first place? I think the first part is making sure the medical needs of the patient are being taken care of. So whatever the underlying pathophysiology is, making sure that's being addressed. So if it's infection, making sure infections are being taken care of. If you're worried that a new infection is arising, early culture, early starting of antibiotics. If you know that the children are in a new environment, getting the family involved, trying to keep the sleep-wake cycles as much of the normal routine as possible can be very helpful. So to summarize, then management of delirium, make sure that underlying causes have been addressed and treated. And then delirium can persist even despite that just because of the environment. So do everything you can to kind of help control the environment, make it as normal as possible, which is difficult obviously in an ICU setting. And then similar to the other things that we've talked about, the multibundal approach, not just jumping straight to pharmacologic treatment for the delirium. Absolutely. Well, Dr. Vogel, thank you very much for a very informative podcast. It was great to hear about two of these obviously big components of surgical ICU care, which I think all of us have experienced in caring for these patients. So very helpful discussion. And thank you again for talking with us. No, my pleasure. Thank you for having me. Thank you. This is Alexander Gibbons from Akron Children's Hospital, the contributing editor for this episode of State Current Pediatric Surgery. We hope you enjoyed Dr. Vogel's discussion on coagulopathy as he put a lot of blood, sweat, and tears into it. And we hope that his talk on analgesia and sedation helped relieve your own anxiety. Let us know your thoughts on our State Current Pediatric Surgery app. We'd also love to hear your ideas for what we should do for future podcasts. Our next episode will continue the critical care theme, looking at traumatic brain injury and burns. Thanks again for listening. And remember, until next time, knowledge should be free. Thank you.