ABCDEF (A2F) Bundle

Background

• Post-Intensive Care Syndrome (PICS): complex constellation of cognitive, physical, and psychological impairments that impact most survivors of critical illness, leading to disability, frailty, and poor quality of life
  • Predicted by (1) duration of immobility and (2) delirium; very common in ICU pts
  • Both are reduced by >80% compliance with ABCDEF (A2F) Bundle concepts
• ABCDEF (A2F) Bundle: Interprofessional, evidence-based safety bundle of care principles to help reduce LOS, mortality, bounce-backs, and the duration of ICU delirium and coma
  • Assess/Prevent/Manage Pain
  • Both SAT/SBT
  • Choice of Analgesia and Sedation
  • Delirium—Assess, Prevent, and Manage
  • Early Mobility and Exercise
  • Family Engagement and Empowerment
• Goal: allow pt to “prove us wrong” about readiness for liberation from devices, sedatives, etc.
• Evidence  Associated with higher likelihood of ICU and hospital discharge and lower likelihood of death, mechanical ventilation, coma, delirium, physical restraint, ICU readmission, discharge to a destination other than home, and lower cost

Assess, prevent, and manage pain

• Tools to assess pain using facial expressions, body movements, muscle tension, compliance with ventilator, or vocalization for extubated pts
  • Behavioral Pain Scale (BPS): scale 0-12, uncontrolled pain ≥ 5
  • Critical Care Pain Observation Tool (CPOT): scale 0-8, uncontrolled pain 3 if non-verbal pt
• Uncontrolled pain increases risk for delirium, limits inspiratory effort and weaning from ventilator, and limits ability to mobilize
• Treatment: multi-modal with parenteral opioids (e.g., fentanyl, dilaudid), neuropathic meds (e.g., gabapentin, ketamine), adjunctive non-opioids analgesics (e.g., acetaminophen, NSAIDs), nonpharmacologic interventions (repositioning, heat/cold)

Both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)

• SATs = daily sedative interruptions
  • RN-driven protocol involving safety checklist: no active seizures, alcohol withdrawal, agitation, paralytics, myocardial infarction, or increased ICP
  • If pass SAT, then proceed to SBT
  • If fail SAT (anxiety, agitation, pain, resp distress)  restart sedation at ½ doses
• SBTs = PS ventilation (Fi02 ≤ 50%, PEEP ≤ 7.5; typically 40% and 5/5) for ≥ 30 minutes
  • RT or physician/APP-driven protocol with safety screen: passed SAT, O2 sat ≥ 88%, inspiratory efforts, no myocardial ischemia, no/low vasopressor support
  • If pass SBT, physician/APP judgment on extubation
  • If fail SBT (RR > 35 or < 8, O2 sat < 88%, resp distress, mental status change)  restart full ventilatory support
• Evidence:
  • Liberated pts from mechanical ventilation 3 days sooner, decreased ICU and hospital length of stay by 4 days, and 14% absolute reduction in mortality at 1 year

Choice of analgesia and sedation

• Richmond Agitation-Sedation Scale (RASS): sedation and level of arousal assessment tool (Figure 1)
  • Target light sedation of RASS -1 to 0 with goal of (1) pt following commands without agitation and (2) limiting immobilization
  • Over-sedation:  hold sedatives till target, then restart at ½ prior dose
• Analgosedation with focus on treating pain first and then adding sedation meds PRN
• Sedatives: dexmedetomidine (dex) or propofol >>> benzodiazepines
  • Benzodiazepines increase risk of delirium in a dose-dependent fashion

Figure 1: Richmond Agitation-Sedation Scale (RASS)

Delirium - assess, prevent, and manage

• Screening for delirium: q4hr using CAM-ICU (Figure 2)
  • Affects 60-80% of ventilated pts and associated with increased morbidity and mortality, longer ICU and hospital length of stay, long-term cognitive dysfunction
• Risk factors and treatment: see Delirium topic under Geriatrics
  • Dr. Dre mnemonic:  Disease remediation (heart failure, COPD, and sepsis), Drug removal (benzos, anticholinergics, steroids) and Environment (hearing aids, eye glasses, mobilize the pt, normalize sleep wake cycle)

Early mobility and Exercise

• Prolonged immobilization during critical illness leads to ICU-acquired weakness, associated with worse outcomes: ↑ mechanical ventilation, increased hospital length of stay, greater mortality, and greater disability
• Consult PT/OT to initiate rehab at the beginning of critical illness
  • Can be done safely in pts receiving advanced support
  • ↓ duration of delirium, ↓ ICU and hospital length of stay, and improved return to independent functional status

Family engagement and empowerment

• Especially important when pts are unable to communicate themselves
• Incorporate family at the bedside and on rounds to learn pt preferences and values, engage in shared-decision making, and address questions and concerns
  • Associated with greater satisfaction with care and increased feelings of inclusion, respect, and understanding of the pt’s care
  • Can facilitate family decision to transition to comfort-focused care

Figure 2: Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)