Page 36/55 · Pain, Agitation/Sedation, Delirium, Immobility & Sleep

Data Tables

Pain, Agitation/Sedation, Delirium, Immobility & Sleep

Joanna L. Stollings ~3 min read Module 17 of 20

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

V.ABCDEF BUNDLE

A.Incorporating multiple concomitant patient care interventions into one consolidated bundle may be an

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

2B: Both SATs and SBTs

C: Choice of analgesia and sedation

D: Delirium: Assess, prevent, and manage

E: Early mobility and exercise

F: Family engagement and empowerment.

B.Assess, Prevent, and Manage Pain (“A” of the bundle): Asking the patient to self-report pain or to use the

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.

C.Daily coordination of the SAT with the SBT (“B” of the bundle) versus usual care with the SBT has been

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.

D.Choice of Sedation (“C” of the bundle): Use a multidisciplinary approach, including focused pharmacy

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

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

E.Delirium Assessment, Prevention, and Management (“D” of the bundle): Regularly assess for delirium

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.

G.Family Engagement and Empowerment (“F” of the bundle): Good communication with the family is critical

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.

H.In a prospective, multicenter, cohort study from 68 academic, community, and federal ICUs during a

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.

HD Video Explanation — Synchronized with PDF

Starts at: minute 35 Open on YouTube