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ABCDE Protocol. ICU Delirium and Cognitive Impairment Study Group Why the ABCDE Protocol?. Need for Sedation and Analgesia. Prevent pain and anxiety Decrease oxygen consumption Decrease the stress response Patient-ventilator synchrony

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abcde protocol

ABCDE Protocol

ICU Delirium and Cognitive Impairment Study Group

need for sedation and analgesia
Need for Sedation and Analgesia

Prevent pain and anxiety

Decrease oxygen consumption

Decrease the stress response

Patient-ventilator synchrony

Avoid adverse neurocognitivesequelae

  • Depression, PTSD

Rotondi AJ, et al. Crit Care Med. 2002;30:746-752.

Weinert C. Curr Opin in Crit Care. 2005;11:376-380.

Kress JP, et al. Am J Respir Crit Care Med. 1996;153:1012-1018.

potential drawbacks of sedative and analgesic therapy
Potential Drawbacks of Sedative and Analgesic Therapy


Failure to initiate spontaneous breathing trials (SBT) leads to increased duration of mechanical ventilation (MV)

Longer duration of ICU stay

Impede assessment of neurologic function

Increase risk for delirium

Numerous agent-specific adverse events

Kollef MH, et al. Chest. 1998;114:541-548.

Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.


Patient with Sepsis






Cognitive and Functional Impairment, Institutionalization, Mortality

Vasilevskis et al Chest 2010; 138;1224-1233

we need coordinated care
We Need Coordinated Care
  • Many tasks and demands on critical care staff
  • Great need to align and supporting the people, processes, and technology already existing in ICUs
  • ABCDE protocol is multiple components, interdependent, and designed to:
      • Improve collaboration among clinical team members
      • Standardize care processes
      • Break the cycle of oversedation and prolonged ventilation

Vasilevskis et al Chest 2010; 138;1224-1233

what is the mind usa abcde protocol
What is the MIND-USAABCDE Protocol?

Awakening and Breathing


Delirium Identification and


Early Exercise and Mobility






Awakening and Breathing Coordination

icu sedation it s a balancing act
ICU Sedation: It’s a Balancing Act

Over sedation

Patient Comfort and

Ventilatory Optimization

consequences of suboptimal sedation
Consequences of Suboptimal Sedation

Inadequate sedation/analgesia

Excessive sedation

Prolonged mechanical ventilation, ICU LOS



Additional testing

Added cost

Inability to communicate

Cannot evaluate for delirium

  • Anxiety
  • Pain
  • Patient-ventilator dyssynchrony
  • Agitation
    • Self-removal of tubes/catheters
  • Care provider assault
  • Myocardial ischemia
  • Family dissatisfaction
structured approaches to sedation analgesia in the icu
Structured Approaches to Sedation & Analgesia in the ICU
  • Multidisciplinary development, implementation
  • Establish goals/targets, frequently re-evaluate
  • Measure key components using validated scales
  • Select medications based on characteristics, evidence
  • Incorporate key patient considerations
  • Prevent oversedation, yet control pain and agitation
  • Promote multidisciplinary acceptance and integration into routine care

Sessler & Pedram. Crit Care Clinics 2009; 25:489-513

validated icu sedation scales
Validated ICU Sedation Scales
  • Richmond agitation-sedation scale (RASS)
  • Sedation agitation scale (SAS)
  • Ramsay sedation scale
  • Motor activity assessment scale (MAAS)
  • Vancouver interactive and calmness scale (VICS)
  • Adaptation to intensive care environment (ATICE)
  • Minnesota sedation assessment tool (MSAT)
setting targets
Setting Targets

Provide for agitation/anxiety free, amnesia, comfort

  • Trying to achieve a balance

Adjust target depending on current need

  • Per patient
  • Different over the course of Illness/Treatment
use protocols to achieve goals minimize drug accumulation maximize alertness
Use Protocols to Achieve Goals, Minimize Drug Accumulation, Maximize Alertness
  • Patient-focused drug selection
  • Preference for analgesia > sedation
  • Intermittent therapy via boluses
  • Frequent evaluation of sedation, pain, ICU therapy tolerance
    • Titrate therapy for lowest effective dose
  • Daily interruption of sedation

RCT: 2x2 factorial design

    • Midazolam vs propofol
    • Daily interruption of sedation vs routine
  • Discontinue all sedative and analgesic medications
  • Monitor patient closely until awake or agitated, i.e., can perform at least 3 of 4 on command:
    • Open eyes
    • Squeeze hand
    • Lift head
    • Stick out tongue
  • Restart medications at half dosage (if necessary)

Kress et al. N Engl J Med 2000; 342:1471-7

daily awakening trial results
Daily Awakening TrialResults
  • Shorter duration of mechanical ventilation
  • Shorter ICU LOS
  • Fewer tests for altered mental status

Kress et al. N Engl J Med 2000; 342:1471-7

why is interruption of sedation effective
Why Is Interruption of Sedation Effective?
  • Less accumulation of sedative drug and metabolites
    • Significantly less midazolam and morphine with DIS in midazolam subgroup
    • But… no difference in amount of propofol and morphine with DIS in propofol subgroup
  • Opportunity for more effective weaning from mechanical ventilation?

Wake Up and Breathe

  • Sessler CN. Crit Care Med 2004
      • Kress et al. NEJM. 2000

Multicenter RCT:

    • 168 patients with “spontaneous awakening trial” (SAT)
      • i.e., daily interruption of sedation (SAT) + spontaneous breathing trial (SBT)
    • 168 patients with standard sedation + SBT
sat sbt was superior to conventional sedation sbt
Intervention (SAT) group = Less benzodiazepine“SAT + SBT” Was Superior to Conventional Sedation + SBT

Extubated faster

Discharged from ICU sooner

P = 0.01

P = 0.02

Girard et al. Lancet 2008; 371:126-34

sat sbt was superior to conventional sedation sbt1
Intervention (SAT) group = More unplanned extubation, but not more reintubation“SAT + SBT” Was Superior to Conventional Sedation + SBT

Discharged from hospital sooner

Better survival at 1 yr

P = 0.04

P = 0.01

P = 0.01


P = 0.02

Girard et al. Lancet 2008; 371:126-34

a wakening b reathing c oordination
Awakening &BreathingCoordination
  • Synergy of daily awakening – via interruption of sedation – plus spontaneous breathing trial
    • Less medication accumulation, less excessive sedation
    • Opportunity for more effective independent breathing (SBT)
  • Perform safety screens for SAT and for SBT
abc safety screens
ABCSafety Screens

Wake Up Safety Screen

  • No active seizures
  • No active alcohol withdrawal
  • No active agitation
  • No active paralytic use
  • No myocardial ischemia (24h)
  • Normal intracranial pressure

Breathe Safety Screen

  • No active agitation
  • Oxygen saturation >88%
  • FiO2< 50%
  • PEEP < 7.5 cm H2O
  • No active myocardial ischemia (24h)
  • No significant vasopressor use
  • Girard et al. Lancet 2008; 371:126-34.
  • Kress et al. Crit Care Med 2004; 32(6):1272-6
  • Ely et al. NEJM 1996; 335:184-9
abc a wakening b reathing c oordination
ABCAwakening & Breathing Coordination

Eligibility = On the ventilator

  • SAT Safety Screen - pass/fail
  • If pass safety screen, perform SAT

If fail; restart sedatives if necessary (1/2 dose)

If pass; continue to SBT safety screen

  • SBT Safety Screen - pass/fail
  • If pass safety screen, perform SBT

If fail; return to previous ventilatorysupport

If pass; consider extubation



Delirium Monitoring and Management

delirium key features
Delirium: Key Features

Disturbance of consciousnesswith reduced ability to focus, sustain or shift attention

A change in cognitionor the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia

Develops over a short period of time and tends to fluctuate over the course of the day

There is evidencefrom the H&P and/or labs that the disturbance is caused by a medical condition, substance intoxication or medication side effect

delirium subtypes
Delirium Subtypes

Hyperactive Delirium






Alert & Calm




Hypoactive Delirium

icu delirium
ICU Delirium
  • Increased ICU length of stay (8 vs 5 days)
  • Increased hospital length of stay (21 vs 11 days)
  • Increased time on ventilator (9 vs 4 days)
  • Higher ICU costs ($22,000 vs $13,000)
  • Higher ICU mortality (19.7% vs 10.3%)
  • Higher hospital mortality (26.7% vs 21.4%)
  • 3-fold increased risk of death at 6 months

Ely, et al. ICM2001; 27, 1892-1900

Ely, et al, JAMA 2004; 291: 1753-1762

Lin, SM CCM 2004; 32: 2254-2259

Milbrandt E, et al, Crit Care Med 2004; 32:955-962.

Ouimet, et al, ICM 2007: 33: 66-73.

confusion assessment method for the icu cam icu
Confusion Assessment Method for the ICU (CAM-ICU)

Feature 1: Acute change or fluctuating course of mental status


Feature 2: Inattention


Feature 3: Altered level of consciousness

Feature 4: Disorganized thinking


Inouye, et. al. Ann Intern Med 1990; 113:941-948.1

Ely, et. al. CCM 2001; 29:1370-1379.4

Ely, et. al. JAMA 2001; 286:2703-2710.5

delirium management
Delirium Management

1. Identify etiology

2. Identify risk factors

3. Consider pharmacologic treatment

Jacobi J, et al. Crit Care Med 2002;30:119-141

stop and think
Stop and THINK
  • Toxic Situations
    • CHF, shock, dehydration
    • New organ failure (liver/kidney)
  • Hypoxemia
  • Infection/sepsis (nosocomial), Immobilization
  • Nonpharmacologic interventions
    • Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
  • K+ or electrolyte problems

Consider antipsychotics after evaluating etiology & risk factors

Do any meds need to be stoppedor lowered?

  • Especially consider sedatives
  • Is patient on minimal amount necessary?
    • Daily sedation cessation
    • Targeted sedation plan
    • Assess target daily
  • Do sedatives need to be changed?
  • Remember to assess for pain!
d elirium nonpharmacologic interventions
Delirium Nonpharmacologic Interventions

Eligibility = RASS ≥ -3

+4 COMBATIVE Combative, violent, immediate danger to staff

+3 VERY AGITATED Pulls to remove tubes or catheters; aggressive

+2 AGITATED Frequent non-purposeful movement, fights ventilator

+1 RESTLESS Anxious, apprehensive, movements not aggressive

0 ALERT & CALM Spontaneously pays attention to caregiver

-1 DROWSY Not fully alert, but has sustained awakening to voice

(eye opening & contact >10 sec)

-2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec)

-3 MODERATE SEDATION Movement or eye opening to voice (no eye contact)

-4 DEEP SEDATION No response to voice, but movement or eye opening

to physical stimulation

-5UNAROUSEABLE No response to voice or physical stimulation

d elirium nonpharmacologic interventions1
Delirium Nonpharmacologic Interventions


Monitor and manage pain using an objective scale (e.g., FACES, BPS, VAS, CPOT, etc.)


Convey the day, date, place, and reason for hospitalization

Update the whiteboards with caregiver names

Request placement of a clock and calendar in room

Discuss current events

nonpharmacologic interventions


Determine need for hearing aids and/or eye glasses

If needed, request surrogate provide these for patient when appropriate


Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs)

Normal day-night variation in illumination

Use “time out” strategy to minimize interruptions in sleep

Maintain ventilator synchrony

Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, and daytime bath, massage)



Early Exercise and Mobility

early exercise in the icu
Early Exercise in the ICU
  • Early exercise = progressive mobility
  • Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation

Wake Up, Breathe, and Move

Schweickert WD, et al. Lancet. 2009;373:1874-1882.

early exercise study results
Early Exercise Study Results

Schweickert WD, et al. Lancet. 2009;373:1874-1882.

e arly e xercise and mobility
Early Exercise and Mobility

Eligibility = All patients are eligible for Early Exercise and Mobility

perform safety screen first
Perform Safety Screen First

Safety Screen

  • Patient responds to verbal stimulation (i.e., RASS > -3)
  • FIO2 <0.6
  • PEEP <10 cmH2O
  • No  dose of any vasopressor infusion for at least 2 hours
  • No evidence of active myocardial ischemia (24 hrs)
  • No arrhythmia requiring the administration of new antiarrhythmic agent (24hrs)

If patient passes Exercise/Mobility Safety Screen, move on to Exercise and Mobility Therapy

If patient fails, s/he is too critically ill to tolerate exercise/mobility

e arly e xercise mobility levels of therapy
Early Exercise & Mobility Levels of Therapy*
  • Active range of motion in bed and sitting position in bed
  • Dangling
  • Transfer to chair (active), includes standing without marching in place
  • Ambulation (marching in place, walking in room or hall)

*All may be done with assistance.


Early Exercise and Mobility Protocol Progression

RASS -5 / -4

RASS ≥ -3

Active ROM (in bed)

No Exercises, but Passive Range of Motion allowed

Sit/ Dangle

Exercise screen

Progress as tolerated

ICU Discharge


March/ Walk

benefits of abcde protocol
Benefits of ABCDE Protocol

Morandi A et al. Curr Opin Crit Care,2011;17:43-9