So I'm going to talk a little bit about our ABCDEF bundle, and I'll start with our objective. So we're going to talk about some of the new data-driven mechanisms in the bundle that's been studied in the ICU Liberation Collaborative in more than 15,000 patients, learn some of the strengths and pitfalls of the bundle, and then talk a little bit about delirium and some of the evidence about preventing it. We'll start with a case. 75-year-old male is admitted for acute hypoxic respiratory failure due to pneumonia. In the ER, he is saturating 75% on non-invasive and is subsequently intubated. He has started on broad-spectrum antibiotics and is admitted to your unit. He started on fentanyl and propofol for analgesia and sedation. Next morning, his vent settings are as follows. He's on volume control with a tidal volume of 420. His respiratory rate is 22. PEEP is set to 12, and his FAO2 is 70%. He's currently calm on the ventilator with a RAS minus 1 to 0. Which of the following is the most appropriate next step? Should we stop all sedation, perform a spontaneous breathing trial, and extubate if he passes? Should we stop all sedation, assess him for agitation or any kind of instability? If sedation is still required, resume at half the dose. Should we cut the sedative dose to half the current dose and slowly wake the patient up? And then if he tolerates all this, perform a spontaneous breathing trial? Or should we increase our sedative dose to achieve a RAS of minus 4 to minus 5? So I know you guys don't have the pointer at this point, but in this case, probably the second option is the best. This guy, he's still on pretty high ventilator settings, so probably not the most appropriate patient to extubate at this point. In terms of doing an appropriate spontaneous awakening trial, you assess them for safety, right? You probably don't want to be performing an SAT on a patient who's in status. But then assuming they pass some of your safety screens, then you'll stop all their sedation and then assess them for agitation or instability. So things you might be looking for, RAS persistently above 2 for more than 5 minutes. If he starts desaturating or he becomes tachypneic, he gets any new arrhythmias or his ICP goes up. These are all reasons to resume our sedation, but we would be doing so at about 50%. Our goal is to do so at 50% of the previous dose. And then he's calm on the ventilator already. You don't need to increase his RAS goal. Second case, 83-year-old female with past medical of coronary artery disease, diabetes, and Alzheimer's is admitted to your ICU with septic shock from pyelonephritis. She's growing E. coli in her blood. She's currently on antimicrobials with ceftriaxone. She remains on a little bit of low-dose levophed. Her daughter reports to you she hasn't been sleeping well at night and seems a bit more confused than normal right now. What is the most appropriate next step? Should we start a little low-dose quetiapine, start a presidex infusion? Should we open the blinds during the day, bring in her reading glasses, and encourage family presence and engagement? Or should we close the blinds so that she can catch up on sleep during the day? So C is the answer. Really maximizing or prioritizing some of those non-pharmacologic options is probably the best at managing our delirious patients. I think we all know at this point that closing the blinds during the day is very, very rarely the answer. It's not to say that she won't need a little low-dose Seroquil or some presidex if she gets really agitated, but really kind of maximizing some of those non-pharma options is a really good place to start. All right, so what do we know about ICU survivors? More and more, we're having increased survivorship from the ICU, and so obviously this is very good news, but more and more, with more survivorship, we're getting more and more some of the post-ICU syndrome patients. So they get profound and often persistent physical, mental, and cognitive health impairments after discharge. Collectively, this is known as the post-intensive care syndrome, and so this can be kind of exacerbated by a lot of different factors, but certainly use of mechanical ventilation or long periods of immobility can add to this. And so ICU-acquired pain, anxiety, delirium, weakness, these are all associated with numerous adverse health outcomes, so things like prolonged mechanical ventilation, PTSD, depression, severe neurocognitive dysfunction, and so trying to modify some of these risk factors is where the bundle really comes in. A lot of us know to look for pain, and we know the problems associated with pain, but again, we don't always pay attention to some of those, or don't always recognize the symptoms of some of those other issues, like anxiety, delirium. So out of concerns for some of this came the SCCM PADIS guidelines. PADIS here stands for pain, agitation, sedation, delirium, immobility, and sleep disruption, and there's more evidence that suggests that patient outcomes improve when we utilize an integrated, interprofessional approach to mechanical ventilation, liberation, symptom management, and immobility, and when they're applied early in the course of critical illness, and so one approach that I'm sure many ICUs that you work in are utilizing is the ABCDEF bundle. So the bundle, so here, this aims to help reduce delirium, improve pain management, and reduce some of these long-term consequences that we see for the adult ICU patients, and so A here stands for assess, prevent, and manage pain. B stands for performing both the SAT, or spontaneous awakening trial, and the SBT, or spontaneous breathing trial, daily to assess for ventilation liberation. C stands for choice of analgesia and sedation. D for delirium, again, assessing, preventing, managing. E, early mobility and exercise, and F for family engagement and empowerment. So where did this kind of come from? So initially, there was a single-center study in 2013 that implemented aspects of the bundle, and it found an improved incidence of delirium, and then also fewer ventilator days, and so this later was expanded to a single-system, but multi-center trial, and so here, seven-some community hospitals within the Sutter Health System were included, and just over 6,000 patients were included here. About a quarter of these patients were mechanically ventilated. The study also kind of maximized interprofessional team training to teach about the bundle, but to make sure that all members of the team, not just the physicians, but also all the ancillary staff, was aware of the various bundle components. And so what did they find? So these are some of the most pertinent results, but you can see that in these graphs, both survival and delirium and coma-free days improved with utilizing the bundle, and so pretty dramatic difference by utilizing those components of that bundle. And so this kind of led to the ICU Liberation Collaborative, and so this was run from 2015 to 2017 at ICUs across the country, looking at patients in all kinds of ICUs, medical, surgical, cardiac, neurology ICUs, and they looked here at the bundle implementation, and the goal here was to encourage the adoption of the PATIS guidelines through using the bundle. And so things that they did when specifically looking at the bundle, so for A, for the assessing, managing, and preventing pain. So each patient received more than six pain assessments per day using one of these instruments below. These are reliable instruments. We use the CPOT, but I'm sure you guys have seen some of these other instruments as well. It also looked at an analogous sedation approach, so that means treating pain first before kind of moving towards sedating the patient. The B, again, stands for performing both the daily SAT and SBT. Again, you want to perform your safety screens before moving forward with this, so for the SAT, again. We don't want to be performing an SAT on the young 20-year-old patient who's here for overdose and who's very, very agitated. If they're still kind of in the throes of their overdose or their withdrawal, whatever, that person may still need some sedation. The patient who's in status, probably also not an appropriate person to perform an SAT on, but some of the safety screens are kind of dictated. They're institution-specific. But then to be eligible for an SAT, a patient needs to be receiving a continuous infusion of sedation or regularly scheduled sedatives, so for instance, fentanyl around the clock every two hours. And so for the SAT, the sedation needs to be stopped entirely. We assess for some of those signs that we talked about, so they're persistently agitated with a RAS over two, they start desaturating, new arrhythmias, increased ICP, that kind of thing, and assuming that they still need mechanical ventilation, that they still meet criteria for being sedated, you would resume their sedative at half the current dose. All right. For C, that stands for choice of analgesia and sedation, and so in the bundle, we're looking at six assessments per day for their level of arousal, and again, using a reliable instrument, so something like the RAS, the sedation agitation scale, and really, our goal is to target as light a level of sedation as possible, right? So for someone who's fairly compliant on the ventilator and they're okay being a little bit awake, maybe that minus one to zero goal is okay. For the patient who's extremely agitated, dyssynchronous with the vent, you may wanna target a higher RAS goal. And then D for delirium, so again, over two delirium, or more than two delirium assessments per day using something like the CAM-ICU, I think a lot of us are familiar with that, and really kind of hammering in on those non-pharmacologic interventions. So again, making sure family's there, having the blinds open during the day, trying to get them to sleep at night, and bringing in reading glasses, dentures, that kind of thing, things to make them feel a little bit more comfortable in the space. E stands for mobility, early mobility, and exercise, and so things that are a little bit beyond just the passive range of motion, so things like dangling their legs at the edge of the bed, standing, having them walk to the chair, marching in place, that kind of thing, and so really maximizing some of that. And then finally, F is making sure that families are engaged, and if they can be, present for rounds, and at least updating them on the plan of care every day. And so what did the ICU liberation outcome, what did this study find? Essentially, there were increased, or better outcomes for every single measure that they were looking at. So we see, for people that were getting complete bundle performance, so again, patients that were receiving all aspects of the bundle every single day, we saw a 17% increase in ICU discharge, 19% increase in hospital discharge, and also a marked reduction in death when they had complete performance. So for that reason, more and more institutions, we have some version of the bundle, or if not the bundle, the ABCDEF bundle itself. And that's all I have.

ICU Liberation Collaborative

ABCDEF bundle

sedation management

delirium reduction

post-ICU care