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The ABCDEF Bundle

Original Editor - Saud Alghamdi Top Contributors - Saud Alghamdi and Vidya Acharya

Introduction

The ABCDEF Bundle was created over 10 years ago by the society of critical care medicine. The ABCDEF bundle (sometimes referred to as the ICU Liberation Bundle (A-F)), provides a novel way for multidisciplinary teams within the ICU to work together. [1]

The ABCDEF Bundle Includes: Assess, Prevent and Manage Pain, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, and Family engagement and empowerment. [2]

A: Assess, Prevent and Manage Pain

Pain is a frequent event in ICU, with an incidence of up to 50% in both surgical and medical patients. [2][3] Assessment of pain is the first step prior to any administration of pain relief.[2] Using a 1–10 numerical rating scale (NRS) for awake and abled patients is considered to be the gold standard. [2]

In the absence of patients' self reports, behavioural and physiological indicators can be utilised to assess pain. [2] The Behavioural Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioural pain assessments for ICU patients who are unable to communicate. [2]

B: Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)

Spontaneous Awakening Trials (SAT):

An estimated 33% of all ICU admissions are admitted for respiratory failure. Subsequently, these patients are intubated and placed on mechanical ventilation. [4] Part of the standard of care for intubation is to sedate patients continuously to: [4]

  • Reduce pain and anxiety.
  • Decrease oxygen consumption.
  • Reduce the body's stress response.
  • Prevent patient-ventilator desynchrony.
  • Reduce adverse neurocognitive events. E.g., depression and post-traumatic stress disorder.
  • Reduce ventilator-associated events. E.g., pneumonia and tracheostomy.
  • Reduce total nursing requirements.

However, continuous and deep sedation is strongly associated with unfavourable outcomes.[2] Sedatives, in the short term, appear to blunt the sympathetic response and may cause cardiovascular dysfunction. [5] In the medium to long term, deep sedation of ICU patients has been associated with:[5] [4]

  • Increased length of ICU stay.
  • Increased risk of Delirium.
  • Post-traumatic stress disorder (PTSD).

Daily SATs are the stopping of narcotics and sedatives every day and only, if needed, restarting either at half the previous dose and titrating the dose as needed. [2] Daily interruption of sedation shortens the duration of mechanical ventilation and the ICU length of stay. The 2018 ICU PADIS Guidelines emphasises the importance of minimising sedation and maintaining a light level of sedation in patients, highlighting that light levels of sedation are associated with improved outcomes and are needed to facilitate other interventions such as spontaneous breathing trials and early mobilisation. [6]

Spontaneous Breathing Trials (SBT):

Approximately 40-50% of the time spent on mechanical ventilation is attributed to the weaning process (The process in which ventilator support is gradually decreased). [7] [8][9]Delayed extubation may provoke adverse events such as: [10]

  • Cardiopulmonary compromise.
  • Increased risk of pulmonary infection.
  • Patient discomfort from the endotracheal tube.
  • Increased ICU length of stay.
  • Increased healthcare cost.

Clinicians, however, need to be very careful to avoid Failed Extubation. Failed Extubation occurs when re-intubation or respiratory assistance is needed within 48 hours of extubation. Failed extubation is associated with poor outcomes such as: [11]

  • Increased morbidity.
  • Increased mortality.
  • Prolonged duration of mechanical ventilation.
  • Increased ICU Length of stay.
  • Increased risk of tracheotomy.
  • Pneumonia.
  • Ventilator-Induced Lung Injury.
  • Increased healthcare costs.


As a result, the ICU Multidisciplinary Team implement Spontaneous Breathing Trials (SBT). SBT is the assessment of a patient's ability to breathe while receiving minimal or no ventilator support. [8]SBTs aid clinicians to minimise the duration of invasive ventilation. [9]

C: Choice of analgesia and sedation

Sedatives and analgesics must be carefully chosen to maximise patients outcomes. Furthermore, medication doses, titration, and discontinuation must also be considered in an effort to maximise patient outcomes. [2]

Deep sedation in critically ill ICU patients is associated with:

  • Prolonged mechanical ventilation. [12][13]
  • Increased hospital length of stay. [13]
  • Higher rates of mortality. [13]

Decreased exposure to sedative (particularly benzodiazepines) has been clearly associated with improved patient outcomes. [13] Furthermore, increasing evidence suggest that targeting sedation to a level that keeps the patients awake and cooperative can result in shorter ventilation time, shorter ICU stays, lower incidence of delirium and decreased ICU mortality. [13]

The PAD guidelines recommend the use of the: [2]

D: Delirium: Assess, Prevent, and Manage

Delirium is a an acute change in attention and awareness that develops over a relatively short time interval and is associated with additional cognitive deficits such as memory deficit, disorientation, or perceptual disturbances. [14]Delirium is a common phenomenon occurring in 20 to 70% of hospitalised patients, with the majority of cases occurring in the ICU setting. [1] [14]ICU Delirium (previously known as ICU psychosis), has been found to occur in up to 80% of mechanically ventilated patients. [14]

In 2018, clinical practice guidelines for Pain, Agitation, Delirium, Immobility, and Sleep Disruption (PADIS) recommended that all adult ICU patients be regularly assessed for delirium using either: [15][16]

E: Early Mobility

Early Mobility is an integral part of ABCDEF bundle. On average, ICU patients can lose almost 2% of skeletal muscle per day during their first week of admission. [17]Early mobilisation decreases the incidence of ICU Acquired Weakness (ICUAW), increases the number of ventilator-free days and increases the walking distance at hospital discharge. [18]

Early mobilisation also seem to have favourable effects on delirium. Early ICU mobilisation seem to prevent and shorten the duration of delirium in critically ill patients. [19] [20]Although the evidence is limited, early ICU mobilisation presents as one of the only interventions that has shown promising results for the management ICUAW and delirium. [2]

Despite promising evidence of efficacy, patients and healthcare providers seem to fear early mobilisation. For patients, some studies have reported that patients feel great fears and anxiety when initiating their early mobilisation. [21] However, Despite their initial fears, early ICU mobilisation seemed to have a hugely positive effect, with several patients reporting feeling more alive which eased their pain and shortness of breath following their engagement in early ICU mobility. [21]

Healthcare providers face many barriers to implementing early ICU mobilisation for the critically ill. From inadequate staffing and time constraints, to low confidence and lack of training. [22] [23] [24] Furthermore, In a survey that investigated physiotherapists' attitudes towards early ICU mobilisation, 71% reported low confidence in managing ICU cases while 42% reported inadequate training. [25] Luckily, regular training for healthcare providers seems to significantly reduce fear and lack of confidence. [24]

F: Family Engagement

The ABCDEF bundle, previously known as the ABCDE bundle has evolved to include family engagement. [2]There is increasing recognition of the importance of patient and family engagement in ICU. With some evidence suggesting that family engagement in ICU is associated with a decreased ICU length of stay. [26]As a result, there is a trend of ICU societies recommending engaging with patients' families routinely as part of the care plan for the critically ill. [27]

Resources

References

  1. ↑ 1.0 1.1 Grieshop S. ABCDEF Bundle. American Journal of Critical Care [Internet]. 2023 Mar 1;32(2):100.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF bundle in critical care. Critical Care Clinics [Internet]. 2017 Mar 8;33(2):225–43.
  3. ↑ Pota V, Coppolino F, Barbarisi A, Passavanti MB, Aurilio C, Sansone P, et al. Pain in intensive Care: a narrative review. Pain and Therapy [Internet]. 2022 Feb 27;11(2):359–67.
  4. ↑ 4.0 4.1 4.2 Sharma S, Hashmi MF, Valentino DJ III. Sedation vacation in the ICU [Internet]. StatPearls - NCBI Bookshelf. 2024.
  5. ↑ 5.0 5.1 Ceric A, Holgersson J, May TL, Skrifvars MB, Hästbacka J, Saxena M, et al. Effect of level of sedation on outcomes in critically ill adult patients: a systematic review of clinical trials with meta-analysis and trial sequential analysis. EClinicalMedicine [Internet]. 2024 Mar 28;71:102569.
  6. ↑ Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, Agitation/Sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine [Internet]. 2018 Aug 16;46(9):e825–73.
  7. ↑ Boles J m., Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. European Respiratory Journal [Internet]. 2007 Apr 30;29(5):1033–56.
  8. ↑ 8.0 8.1 Ventilator weaning and spontaneous breathing trials; an educational review [Internet]. PubMed.
  9. ↑ 9.0 9.1 Burns KEA, Khan J, Phoophiboon V, Trivedi V, Gomez-Builes JC, Giammarioli B, et al. Spontaneous breathing trial techniques for extubating adults and children who are critically ill. JAMA Network Open [Internet]. 2024 Feb 23;7(2):e2356794.
  10. ↑ Maisat W, Siriratwarangkul S, Charoensri A, Wongkornrat W, Lapmahapaisan S. Perioperative risk factors for delayed extubation after acute type A aortic dissection surgery. Journal of Thoracic Disease [Internet]. 2020 Sep 1;12(9):4796–804.
  11. ↑ Silva-Cruz AL, Velarde-Jacay K, Carreazo NY, Escalante-Kanashiro R. Risk factors for extubation failure in the intensive care unit. Revista Brasileira De Terapia Intensiva [Internet]. 2018 Jan 1;30(3).
  12. ↑ Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous IV sedation is associated with prolongation of mechanical ventilation. CHEST Journal [Internet]. 1998 Aug 1;114(2):541–8.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Balzer F, Weiß B, Kumpf O, Treskatsch S, Spies C, Wernecke KD, et al. Early deep sedation is associated with decreased in-hospital and two-year follow-up survival. Critical Care [Internet]. 2015 Apr 24;19(1).
  14. ↑ 14.0 14.1 14.2 Ali M, Cascella M. ICU delirium [Internet]. StatPearls - NCBI Bookshelf. 2024.
  15. ↑ Critical Illness, Brain Dysfunction, And Survivorship Center. Monitoring delirium in the ICU [Internet]. ICUDelirium.org.
  16. ↑ Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, Agitation/Sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine [Internet]. 2018 Aug 16;46(9):e825–73.
  17. ↑ Fazzini B, Märkl T, Costas C, Blobner M, Schaller SJ, Prowle J, et al. The rate and assessment of muscle wasting during critical illness: a systematic review and meta-analysis. Critical Care [Internet]. 2023 Jan 3;27(1).
  18. ↑ Zhang L, Hu W, Cai Z, Liu J, Wu J, Deng Y, et al. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS ONE [Internet]. 2019 Oct 3;14(10):e0223185.
  19. ↑ Nydahl P, Jeitziner MM, Vater V, Sivarajah S, Howroyd F, McWilliams D, et al. Early mobilisation for prevention and treatment of delirium in critically ill patients: Systematic review and meta-analysis. Intensive and Critical Care Nursing [Internet]. 2022 Oct 27;74:103334.
  20. ↑ McWilliams DJ, King EB, Nydahl P, Darbyshire JL, Gallie L, Barghouthy D, et al. Mobilisation in the EveNing to prevent and TreAt deLirium (MENTAL): a mixed-methods, randomised controlled feasibility trial. EClinicalMedicine [Internet]. 2023 Jul 19;62:102101.
  21. ↑ 21.0 21.1 Söderberg A, Karlsson V, Ahlberg BM, Johansson A, Thelandersson A. From fear to fight: Patients experiences of early mobilization in intensive care. A qualitative interview study. Physiotherapy Theory and Practice [Internet]. 2020 Aug 12;38(6):750–8.
  22. ↑ Capell EL, Tipping CJ, Hodgson CL. Barriers to implementing expert safety recommendations for early mobilisation in intensive care unit during mechanical ventilation: A prospective observational study. Australian Critical Care [Internet]. 2018 Jul 10;32(3):185–90.
  23. ↑ Johnson K, Petti J, Olson A, Custer T. Identifying barriers to early mobilisation among mechanically ventilated patients in a trauma intensive care unit. Intensive and Critical Care Nursing [Internet]. 2017 Jul 23;42:51–4.
  24. ↑ 24.0 24.1 Hunter OO, George EL, Ren D, Morgan D, Rosenzweig M, Tuite PK. Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project. Intensive and Critical Care Nursing [Internet]. 2017 Feb 10;40:44–50.
  25. ↑ Alqahtani M, Kashoo F, Alzhrani M, Ahmad F, Seyam MK, Ahmad M, et al. Current physical therapy practice in the intensive care unit in Saudi Arabia: a Multicentre Cross-Sectional survey. Critical Care Research and Practice [Internet]. 2020 Dec 29;2020:1–7.
  26. ↑ Goldfarb MJ, Bibas L, Bartlett V, Jones H, Khan N. Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis. Critical Care Medicine [Internet]. 2017 Jul 26;45(10):1751–61.
  27. ↑ Goldfarb M, Debigaré S, Foster N, Soboleva N, Desrochers F, Craigie L, et al. Development of a family engagement measure for the intensive care unit. CJC Open [Internet]. 2022 Aug 5;4(11):1006–11.
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