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In this episode, Kali explains how families should understand the ABCDEF bundle as the gold standard of care to prevent delirium and muscular atrophy in the ICU.

Episode Transcription

Alright, now that you have quite the foundation of understanding behind the principles of delirium prevention and mobility- let’s tie it all together into a neat little package that your ICU is most likely to recognize- the ABCDEF bundle.

Dr. Wes Ely from Vanderbuilt and his powerhouse team spent years researching delirium- identified the problem as well as some solutions. They created a protocol to guide ICU teams out of the rut of sedation and immobility that they are in and called in the “ABCDEF Bundle”.

Let’s review it letter by letter.

• Is for Assess, prevent and manage pain
• Both spontaneous awakening and breathing trials
• Choice analgesia
• Delirium- assess, prevent, and manage
• Early mobility and exercise
• Family engagement and empowerment

This is recognized as the gold standard of care, and yet implementation and standardization of it have really struggled. Often because real education behind the reality of sedation and immobility is lacking, so old beliefs and habits have persisted. It is important for you to understand what this protocol is and how it’s supposed to be conducted.

So let’s break it down again-

• Assess, prevent, and manage pain- there can a lot of pain during critical illness- but infections, trauma, surgery, tubes, lines, down to back pain from being stuck in that bed- pain can and should be treated. This has turned into automatically starting high-dose narcotics such as fentanyl along with the sedation right after a breathing tube is placed.

I would suggest that pain cannot be adequately treated if it do not have the opportunity to assess it, and best yet- if patients cannot report it. When we automatically start medically-induced comas, we are guessing at pain.

Furthermore, narcotics are not benign. For every equivalent of 10mg of morphine, there is a 2.4% risk of delirium. That doesn’t sound like very much until you have a fentanyl drip going at 75-250 mcg per hour and now the risk of your loved one developing delirium, or acute brain failure, has increased from 72-108%. So yes, we need to treat pain, but when we automatically deeply sedate patients, we miss the opportunity to do so optimally while preventing harm.

I have found that many patients in the medical-surgical ICU are able to have their pain managed with things besides narcotics and then narcotics can be given at low dose and titrated up- but never to the point of being sedated. Patients can usually tell us what they are experiencing, what they need, and what helps when we allow them to be awake and communicative.

In episode 78 of my other podcast, a delirium survivor talks about being in incredible pain but couldn’t understand where it was coming from because he was lost in terrible delirium and was watching his siblings be pulled apart limb by limb- and the misinterpreted pain was far worse. He said he would have rather have been in the reality of the ICU than where he was in his mind. He would have rather have understood his situation and that the pain was coming from an infection in his arm and not from graphic abuse and violence.

Also, when patients are sedated, delirium or other things can be interpreted as pain. For example, when they start to move around and become agitated and act impulsive, the fear is that they are having pain, so the narcotic dose is increased. That is not assessing pain or treating pain.

A common complication of continuous narcotic infusion and immobility is that the bowels slow down and can stop which causes an ileus. This is very uncomfortable and dangerous. It is better to treat pain with minimal narcotics and to the patient’s needs rather than automatically giving high dose narcotics to everyone on a ventilator.

Being on high doses of narcotics for a prolonged period of time can also cause tolerance, so when the ICU team is ready to wake the patient up, they can’t safely stop the narcotic without the patient going into withdrawal from that medication.

The problem is, a patient may be admitted for pneumonia requiring the breathing tube but was never in pain, but these medications were automatically started without the patient’s ability to tell the team what they were experiencing or needed and now they have delirium, and ileus, bedsore, weakness, and dependency on narcotics. – That is not what the ABCDEF bundle is about. A means- assess and treat it with minimal narcotics and harm rather than follow a cookie-cutter process for every patient.

• Is for both spontaneous awakening and breathing trials

This step somehow came with the assumption that teams are going to habitually sedate patients after intubation.  This “B” part obligates them to give the patient a break from sedation and see what their brain is doing and if they can breath on their own. This requires the nurse to gradually turn down the sedation on the IV pump and allow the patient to wake up and for the respiratory therapist to then change the setting on the ventilator so that ventilator doesn’t give the patient breaths and the patient has to take their own breaths.

Ideally, this should be so that we can see if the patient is delirious, has pain, and to push to treat the delirium by keeping the sedation off, involving family, and getting them up. It is important to recognize that this part can be very difficult and taxing on the nurse.

Understanding that sedation causes delirium, then when we continue this habit of automatically starting sedation, then when we push the nurses to follow this protocol of turning sedation down, then they have to try to keep the breathing tube in a patient that is likely very scared, confused, agitated, thrashing, and trying to pull out their lines and tubes and get out of bed.

No one likes this. This is partially why the ABCDEF bundle has been a struggle to implement with this approach- it is hard on nurses. So, when this is their experience and all they see from decreasing sedation is an absolute nightmare… they’re more likely to skip this step or will turn down the sedation just enough to see them move all of their extremities and know they don’t have obvious signs of a stroke and then hurry and turn the sedation back on. Again, this is not malicious of the nurses. It is because they do not understand the reason patients are thrashing. They think it is all because of the tube and they believe that they help them by turning sedation back on and turning their movements off.

What is your role in this? Ask for a sedation vacation. Hold them to the ABCDEF bundle. Be present during the vacation- when your loved one emerges from sedation, hold their hands, talk to them, re-orient them. Ask for physical and occupational therapy to be present during the vacations so that they can help get your loved one up to truly address the agitation.

Mobility will help them wake up better, release their stress, connect with their environment, get worn out, and be at lower risk of having sedation turned back on. Help keep your loved one safe by keeping them restrained if they are in a wild crisis, keep their breathing tube and lines safe, help the staff feel your support. Help them understand your concern about sending your loved one back into the depths of delirium and risking death, PTSD, and post-ICU dementia. They will be less likely to run back to the sedation.

Some ICU teams have specific parameters for when sedation vacations can be performed. In the early stages of the ABCDEF bundle, there were lower ventilator settings that had to be achieved before it was felt safe to allow patients to be awake. That practice did not have reason or evidence behind it and is now considered outdated.

Despite the lack of evidence, some teams do not do sedation vacations until lungs are healed and ventilator settings are very minimal and they want to see if they can take out the breathing tube. When we wait that long to take off sedation and mobilize patients, too much damage is likely done and they are going to have many complications such as needing a tracheostomy and having more time on the ventilator.

Unless there are exceptions such as continuous seizures, open abdomen, brain bleed, chemical paralysis, and so forth- nearly every patient receiving sedation should have sedation vacations as the standard of care. Ideally, sedation will not even be started. Yet, if it is, help your team understand that you expect the ABCDEF bundle to be practiced and that you want to be present during the sedation vacation for the awakening trial.

Culturally, if a patient becomes agitated during a sedation vacation/ awakening trial, it can be considered a “failed trial”. Please keep in mind the root of the agitation is likely delirium and that sedation will only mask, prolong, and exacerbate it. That is highly misunderstood in the ICU world. If your loved one is showing signs of delirium, it should be an emergency to help them get out of it and sedation is not the long-term answer.

You can ask questions like, “Does my loved one have delirium? How can we treat it? If they’re sedated, they can’t get sleep, family, and mobility, so how is this helping acute brain failure?” – again, use those tools of communication to navigate this appropriately. The ICU team does not need to be under attack- they need to be supported.

Depending on how long your loved one has been sedated and with which medications, a sedation vacation may reveal hypoactive delirium and your loved one won’t wake up for a few hours to days or more. Then it is all the more important to not give the very sedation that caused it.

In the “Awake and Walking ICU”, COVID caused the team to learn sedation vacations. Remember, they don’t start sedation on patients, so there was no need for breaks or awakening trials. Yet, when patients cannot oxygenate with movement and need to be on their stomachs and paralyzed, then it is time for deep sedation and paralysis.

Yet they keep them walking up until that point and are desperate have them down for as little time as possible. So, how can they know if they’re ready to be off of sedation and can oxygenate with movement? They take off the paralytic, then wean off the sedation and see how they oxygenate as they start to move.

Once they see they can be on their backs and maintain oxygen saturations with movement- that sedation is long gone and they have them sitting, standing, and working on walking again. THAT is what an awakening trial is for. IF sedation is necessary- we have to make sure we are assessing for the need for it throughout the day every day. Otherwise we get comfortable with having a flaccid patient we just have to turn every 2 hours and we stop questioning why they’re that way.

So, ultimately, this is how to help teams get your loved one awake on the ventilator. You advocate for an awakening trial, you help everyone stay calm and work through the delirium with the help of physical and occupational therapy. You advocate to keep sedation off.

• C is for choice of analgesia and sedation

If a patient does need to be sedated, then it is important to choose the medications wisely. Each sedative works in different ways and carries different risks of delirium. You can help by asking about what kind of sedation they are on and if there are any options that have a lower risk of delirium. Things like precedex can be a great light sedative that carry a low risk of delirium. Midazolam has made a reappearance during COVID and has a very high risk of delirium and death. The ABCDEF bundle means that the safest sedative with the least harm is chosen.

The dose and depth of sedation can also really vary between teams and clinicians. The ABCDEF bundle means that the lowest dose of sedation for the most awake and level of calm possible is chosen.

You have a right to understand the choice of sedation for your loved one and to advocate for the least harm IF sedation is necessary.

• Delirium- assess, prevent, treat, manage

By now you understand how important this step is. It is important to note that it is impossible to assess delirium if a patient is deeply seated. It is especially impossible to treat delirium when you are giving something that causes it. Sedation is rarely appropriate management for delirium.

Delirium is assessed with a tool called the CAM score. It is a test that evaluates how awake a patient Is or how quickly they respond to voice or stimulation. Then their mental status and orientation is assessed, and then they are given the task of squeezing a clinicians hand upon hearing the letter A during the spelling of the phrase “Saveahaart”. That tests how well they pay attention, understand and following commands and more complex tasks.

If they do not pass this test, they are considered “CAM +” , meaning, they have delirium. Sedation should only be considered if a patient is climbing on the walls and a huge risk to themselves or others. Then it goes back to C- choice of analgesia. This will be demonstrated in a case study next episode.

• Early mobility- After last episode, you understand how important this is. Be aware, that “early mobility” is very subjective and means different things depending on the ICU team.

“Early” can mean anywhere between hours after admission to the ICU or right before they leave the ICU.

“Mobility” can mean moving their flaccid limbs while they’re sedated, or it can mean walking, doing arm and leg bikes, step boxes on the ventilator.

Coming from an “Awake and walking ICU”, the standard of early mobility is doing their baseline, which is usually walking, hours to 24 hours after having the breathing tube placed. It maintains their baseline physical function from the very beginning. This is the goal and they are usually successful. If a patient walks into the hospital, they should be able to walk out days to weeks later. This level of early mobility has led that ICU to have only a few tracheostomies in their COVID survivors and almost all of them have been able to walk out the door and discharge home.

• There was a large ABCDEF bundle study done a few years ago with 15,000 patients. It had impressive findings such as

Decrease in:

• Death
• Coma
• Delirium
• Physical restrain
• Mechanical ventilation
• ICU readmission by 46%
• Discharge to destination other than home, by 36%

Yet one of the most important things to note about these findings is that it was “dose dependent”. Clearly across 15,000 patients in many different hospitals with different teams, not everyone implemented this protocol the same or to the full extent. For example, among those 15,000 patients, only 7% took steps on the ventilator by their bed, and only 5% took steps in the halls. That means out of 15,000 patients, only 12% were actually standing, bearing weight, trying to walk. Yet those that adhered more closely to this protocol, had the best outcomes. The more you avoid sedation, the sooner and more aggressively you mobilize most patients, – the more likely they are to survive and thrive.

• Is for family engagement and empowerment

This means that family are involved in the patient’s journey in the ICU. This is a vital piece of the puzzle that was removed during COVID. Families are being allowed back into the ICU in varying degrees, but it is important to recognize that part of practicing evidence-based medicine is having families involved.

If you have not been invited to rounds, ask if you can join. Have confidence as an important part of the ICU team. Listen to rounds and be prepared to ask questions when you have a family meeting with the providers.

I am not sure how limited visiting hours are validated by facilities that profess to practice the ABCDEF bundle. For years, research and the ICU community was moving to open visitation without restrictions. Yet, During COVID, the risk of infection closed the doors to families for far too long. Especially for overwhelmed hospitals with understaffed teams, it makes sense to me to allow families to be more present and more helpful in patient care. If we really care about patient safety and outcomes, then increasing family presence should be a top priority in critical care medicine. In the “Awake and Walking ICU” during Pre-COVID days, rarely did a family not have the opportunity to stay with a patient 24/7. If the family was a huge hindrance to care to be asked to leave for the night. Other than that, they were totally open to being as present and involved as they wanted to be. We recognized they were an important tool to keeping patients safe, happy, survival, delirium prevention, maximum mobility, and  humanity in patient care.

Just know, that the research is behind you. Get in there, be a team player, be involved, advocate, support your team members, be there for your loved one. You are part of best practices in medicine.

Check the blog for citations. Keep up the good work. Advocate on.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351776/

Westphal GA, Moerschberger MS, Vollmann DD, et al. (2018). Effect of a 24-h extended visiting policy on delirium in critically ill patients. Intensive Care Medicine, 44(968-70). https://pubmed.ncbi.nlm.nih.gov/29605880/

Rosa, et al. (2017). Effectiveness and safety of an extended icu visitation model for delirium prevention: a before and after study. Critical Care Medicine, 45(10).

 

 

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