Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

effective strategy to improve clinical outcomes in critically ill patients. SCCM recommends implementing the

“ABCDEF” bundle to align and coordinate care using an interprofessional approach (e.g., physician, nursing,

pharmacy, respiratory therapy, physical and occupational therapy). The following practice principles are

applied to the bundle:

A: Assess, prevent, and manage pain

C: Choice of analgesia and sedation

D: Delirium: Assess, prevent, and manage

E: Early mobility and exercise

F: Family engagement and empowerment.

CPOT or BPS if the patient is nonverbal. Preventing pain by recognizing patients with known sources of pain

(i.e., rib fractures) and scheduling analgesics when indicated. Managing pain by ordering the most appropriate

pharmacologic agent on the basis of the source of pain and renal and liver function.

shown to significantly decrease the time on mechanical ventilation and ICU length of stay in randomized

studies. This was reviewed earlier in the chapter in the Agitation section.

input, to choose a sedative according to individual patient needs, hemodynamic stability, and organ function

(e.g., hepatic, renal, cardiac, pulmonary, pancreatic).

using the CAM-ICU or the ICDSC every 8–12 hours. Use delirium preventive measures in all patients when

safe to do so.

Early Mobility (“E” of the bundle): Perform a mobility safety screen, and implement a daily mobility

protocol.

at every step of the patient’s clinical course, and empowering the family to be part of the team to ensure best

care is adhered to diligently will improve many aspects of the patient’s experience.

20-month collection period, performance of the complete ABCDEF bundle was associated with a lower

likelihood of death within 7 days (HR 0.32; CI, 0.17–0.62), next-day mechanical ventilation (OR 0.28; CI,

0.22–0.36), coma (OR 0.35; CI, 0.22–0.56), delirium (OR 0.60; CI, 0.49–0.72), physical restraint use (OR

0.37; CI, 0.30–0.46), ICU readmission (OR 0.54; CI, 0.37–0.79), and discharge to a facility other than home

(OR 0.64; CI, 0.51–0.80). There was a dose response in between higher proportional bundle performance and

improvement in each clinical outcome (p<0.002). Pain was more commonly reported as bundle performance

increased (p=0.0001), probably because more patients were awake.