ABCDE Protocol
ICU Delirium and Cognitive Impairment Study Group
www.icudelirium.org
delirium@vanderbilt.edu
Why the ABCDE Protocol?
Need for Sedation and Analgesia
• Prevent pain and anxiety
• Decrease oxygen consumption
• Decrease the stress response
• Patient-ventilator synchrony
• Avoid adverse neurocognitive sequelae
- 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
• Oversedation:
• 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
Mechanical
Ventilation
Weakness
Sedation
Delirium
Cognitive and Functional Impairment, Institutionalization, Mortality
Vasilevskis et al Chest 2010; 138;1224-1233
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?
ABC
D
E
Awakening and Breathing
Coordination
Delirium Identification and
Management
Early Exercise and Mobility
ABC
Awakening and
Breathing Coordination
ICU Sedation: It’s a Balancing
Act
Consequences of Suboptimal
Sedation
Inadequate
sedation/analgesia
• Anxiety
• Pain
• Patient-ventilator
dyssynchrony
• Agitation
– Self-removal of
tubes/catheters
• Care provider assault
• Myocardial ischemia
• Family dissatisfaction
Excessive sedation
• Prolonged mechanical
ventilation, ICU LOS
– Tracheostomy
– DVT, VAP
• Additional testing
• Added cost
• Inability to
communicate
• Cannot evaluate for
delirium
Structured Approaches to
Sedation & Analgesia in the ICU
1. Multidisciplinary development, implementation
2. Establish goals/targets, frequently re-evaluate
3. Measure key components using validated scales
4. Select medications based on characteristics, evidence
5. Incorporate key patient considerations
6. Prevent oversedation, yet control pain and agitation
7. Promote multidisciplinary acceptance and integration
into routine care
Sessler & Pedram. Crit Care Clinics 2009; 25:489-513
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
Provide for agitation/anxiety free,
amnesia, comfort
• Trying to achieve a balance
• TIGHT TITRATION
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
• 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
• 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?
• 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
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 + SBT
Discharged from hospital sooner
Better survival at 1 yr
P = 0.04
Alive
P = 0.01
P = 0.01
P = 0.02
Intervention (SAT) group = More unplanned
extubation, but not more reintubation
Girard et al. Lancet 2008; 371:126-34
Awakening & Breathing
Coordination
• 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
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
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
•
•
•
•
•
•
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
ABC
Awakening & Breathing Coordination
Eligibility = On the ventilator
1. SAT Safety Screen - pass/fail
2. If pass safety screen, perform SAT
If fail ; restart sedatives if necessary (1/2
If pass ; continue to SBT safety screen
dose)
3. SBT Safety Screen - pass/fail
4. If pass safety screen, perform SBT
If fail ; return to previous ventilatory support
If pass ; consider extubation
D
Delirium Monitoring and
Management
Delirium: Key Features
1.
Disturbance of consciousness with reduced ability to
focus, sustain or shift attention
2.
A change in cognition or the development of a
perceptual disturbance that is not better accounted
for by pre-existing, established or evolving dementia
3.
Develops over a short period of time and tends to
fluctuate over the course of the day
4.
There is evidence from the H&P and/or labs that the
disturbance is caused by a medical condition,
substance intoxication or medication side effect
Delirium Subtypes
Combative
Agitated
Restless
Hyperactive Delirium
Mixed
Delirium
Alert & Calm
Lethargic
Sedated
Stupor
Hypoactive 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)
Feature 1: Acute change or
fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
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
Or
Feature 4: Disorganized
thinking
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
Do any meds need to be
stopped or 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!
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
Delirium
Nonpharmacologic Interventions
Eligibility = RASS ≥ -3
+4
+3
+2
+1
0
-1
COMBATIVE
VERY AGITATED
AGITATED
RESTLESS
ALERT & CALM
DROWSY
Combative, violent, immediate danger to staff
Pulls to remove tubes or catheters; aggressive
Frequent non-purposeful movement, fights ventilator
Anxious, apprehensive, movements not aggressive
Spontaneously pays attention to caregiver
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
-5
UNAROUSEABLE
No response to voice or physical stimulation
Delirium
Nonpharmacologic Interventions
Pain:
• Monitor and manage pain using an objective
scale (e.g., FACES, BPS, VAS, CPOT, etc.)
Orientation:
• 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
Sensory:
• Determine need for hearing aids and/or eye glasses
• If needed, request surrogate provide these for patient
when appropriate
Sleep:
• 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)
E
Early Exercise and Mobility
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
Outcome
Intervention
(n=49)
Control
(n=50)
P
Functionally independent at discharge
29 (59%)
19 (35%)
0.02
2.0 (0.0-6.0)
4.0 (2.0-7.0)
0.03
33 (0-58)
57 (33-69)
0.02
2.0 (0.0-6.0)
4.0 (2.0-8.0)
0.02
Hospital days with delirium (%)
28 (26)
41 (27)
0.01
Barthel index score at discharge
75 (7.5-95)
55 (0-85)
0.05
ICU-acquired paresis at discharge
15 (31%)
27 (49%)
0.09
Ventilator-free days
23.5 (7.4-25.6)
21.1 (0.0-23.8)
0.05
Length of stay in ICU (days)
5.9 (4.5-13.2)
7.9 (6.1-12.9)
0.08
Length of stay in hospital (days)
13.5 (8.0-23.1)
12.9 (8.9-19.8)
0.93
9 (18%)
14 (25%)
0.53
ICU delirium (days)
Time in ICU with delirium (%)
Hospital delirium (days)
Hospital mortality
Schweickert WD, et al. Lancet. 2009;373:1874-1882.
Early Exercise and Mobility
Eligibility = All patients are
eligible for Early Exercise and
Mobility
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
Early Exercise & Mobility
Levels of Therapy*
1. Active range of motion in bed and sitting
position in bed
2. Dangling
3. Transfer to chair (active), includes standing
without marching in place
4. Ambulation (marching in place, walking in
room or hall)
*All may be done with assistance.
Early Exercise and Mobility Protocol
Progression
No Exercises,
but Passive
Range of Motion
allowed
Active ROM (in bed)
Sit/ Dangle
Transfer
March/ Walk
ICU Discharge
RASS ≥ -3
Progress as tolerated
Exercise screen
RASS -5 / -4
Benefits of ABCDE Protocol
Morandi A et al. Curr Opin Crit Care,2011;17:43-9
Questions?
www.ICUdelirium.org
delirium@vanderbilt.edu