Elsevier

Critical Care Clinics

Volume 33, Issue 2, April 2017, Pages 225-243
Critical Care Clinics

The ABCDEF Bundle in Critical Care

https://doi.org/10.1016/j.ccc.2016.12.005Get rights and content

Section snippets

Key points

  • The ABCDEF bundle is an evidence-based guide for clinicians to coordinate multidisciplinary patient care in the intensive care unit (ICU).

  • Assessment of pain is the first step before administering pain relief. The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for ICU patients unable to communicate.

  • Coordination of spontaneous awakening trials (SAT) with spontaneous breathing trials (SBT) is associated with

Assess, prevent, and manage pain

ICU patients commonly experience pain, with an incidence of up to 50% in surgical and medical patients. It is a major clinical symptom that requires systematic diagnosis and treatment.7, 8

In a prospective, cross-sectional, multicenter, multinational study of pain intensity associated with 12 procedures, the Europain study, Puntillo and colleagues9 showed that common ICU procedures induced a significant increase in pain, although no procedure caused severe pain. For the three most painful

Both spontaneous awakening trials and spontaneous breathing trials

Daily SATs are the stopping of narcotics (as long as pain is controlled) and sedatives every day and, if needed, restarting either narcotics or sedatives at half the previous dose and titrating as need. Daily interruption of sedation shortens the duration of mechanical ventilation and the ICU length of stay. The 2013 ICU PAD Guidelines emphasize the importance of minimizing sedative use and maintaining a light level of sedation in patients, using either a daily sedative interruption strategy

Choice of analgesia and sedation

The 2013 PAD guidelines emphasize the need for goal-directed delivery of psychoactive medications to avoid oversedation, to promote earlier extubation, and to help the medical team agree on a target sedation level by using sedation scales. Of the available reliable and valid sedation scales, the PAD guidelines recommend the use of the RASS and the Riker Sedation-Agitation Scale (SAS). Table 2 shows the psychometric properties of the RASS and SAS. The SAS has seven individual tiers ranging from

Delirium—assess, prevent, and manage

An important third element in the PAD guidelines is monitoring and management of delirium. Delirium is a disturbance in attention and awareness that develops over a short period of time, hours to days, and fluctuates over time.33 More than 80% of patients developed delirium during their hospital stay, with most cases occurring in the ICU with an average time of onset between the second and the third day.

Several methods have been developed and validated to diagnose delirium in ICU patients but

Early mobility

Early mobility is an integral part of the ABCDEF bundle and has been the only intervention resulting in a decrease in days of delirium.54 During ICU stay critically ill patients can lose up to 25% peripheral muscle weakness within 4 days when mechanically ventilated and 18% in body weight by the time of discharge and this process is higher in the first 2 to 3 weeks of immobilization.55 The consequence of physical dysfunction in critically ill patients is profound and long-term with significant

Family engagement

The ABCDE bundle has evolved to include family engagement, because no ICU treatment plan is complete without incorporation of the family’s wishes, concerns, questions, and participation. Family members and surrogate decision makers must become active partners in multiprofessional decision-making and treatment planning. Through this partnership, patients’ preferences are identified, the anxiety of families is lessened, and physicians can have appropriate input into decisions.67

Family presence on

Summary

The core evidence and features behind the ABCDEF bundle have been reviewed, which was created to combat the adverse effects of critical illness related to acute and chronic brain dysfunction. The ABCDEF bundle represents one method of approaching the organizational changes that create a culture shift in treatment of ICU patients. The multifold potential benefits of these recommended strategies outweigh minimal risks of costs and coordination. Ultimately, the ABCDEF bundle is one path to

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    Disclosures and Funding Sources: E.W. Ely, P.P. Pandharipande, and M.B. Patel are supported by National Institutes of Health HL111111 and GM120484 (Bethesda, MD). E.W. Ely is supported by the Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (Nashville, TN). E.W. Ely and P.P. Pandharipande are supported by the VA Clinical Science Research and Development Service (Washington, DC) and the National Institutes of Health AG027472 and AG035117 (Bethesda, MD). M.B. Patel is supported by the Vanderbilt Faculty Research Scholars Program. This project was supported by REDCap, a secure online database, supported in part by the National Institutes of Health TR000445. E.W. Ely has received honoraria from Abbott Laboratories, Hospira, Inc, and Orion Corporation, and research grants from Abbott Laboratories. P.P. Pandharipande and E.W. Ely have received research grants from Hospira, Inc. A. NIHMS: 834685. The authors have no other disclosures relevant to this article.

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