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Purpose
Deep sedation, immobility and delirium are linked to longer mechanical ventilation, weakness and poor recovery after critical illness. The ABCDEF bundle groups evidence-based practices to address them: Assess, prevent and manage pain; Both spontaneous awakening and spontaneous breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention and management; Early mobility and exercise; and Family engagement. This synthesis appraises the key trials behind the bundle and the evidence on implementing it as a whole, to inform a DNP project in a medical ICU.
The component evidence
| Study | Design | Key findings |
|---|---|---|
| Kress et al. (2000) | Randomized trial; 128 ventilated adults in a medical ICU | Daily interruption of sedative infusions shortened median mechanical ventilation from 7.3 to 4.9 days and ICU stay from 9.9 to 6.4 days |
| Girard et al. (2008) | Randomized trial; 336 ventilated patients in 4 hospitals | Pairing daily spontaneous awakening trials with spontaneous breathing trials gave more days breathing without assistance (14.7 vs. 11.6) and earlier ICU and hospital discharge; patients were less likely to die during the following year (hazard ratio 0.68), with one life saved for about every seven patients treated |
| Schweickert et al. (2009) | Randomized trial; 104 ventilated adults at 2 hospitals | Early physical and occupational therapy during sedation interruption returned 59% to independent function at discharge vs. 35%; delirium lasted a median of 2.0 vs. 4.0 days |
| Pun et al. (2019) | Prospective cohort in a national quality improvement collaborative; 15,226 adults in 68 ICUs | Complete bundle performance was associated with lower hospital death within 7 days (adjusted hazard ratio 0.32) and less next-day mechanical ventilation, coma, delirium, physical restraint use, ICU readmission and discharge to a facility other than home, with a dose–response relationship |
The 2018 Society of Critical Care Medicine guideline on pain, agitation/sedation, delirium, immobility and sleep disruption (PADIS) supports the same direction, including light rather than deep sedation and propofol or dexmedetomidine rather than benzodiazepines for sedation in ventilated adults (Devlin et al., 2018).
Synthesis
The component trials are randomized and consistent: lighter sedation, coordinated awakening and breathing trials, and early mobility each shorten ventilation and improve recovery. The cohort study adds evidence that the elements work in combination across many kinds of ICUs, and that more complete bundle performance tracks with better outcomes. One unexpected finding was that significant pain was reported more often as bundle performance increased, which may reflect patients being awake enough to report pain, and is a reason to keep pain assessment central.
Strength and limitations of the evidence
The component trials were relatively small and mostly in academic centers, and staff could not be blinded to awakening or mobility interventions. The collaborative study was observational, so sicker patients may have been less likely to receive every element, which could exaggerate the bundle's apparent benefit despite statistical adjustment. Even so, the consistency across designs gives a strong basis for practice change.
Implications for the DNP project
The evidence supports implementing the full bundle rather than single elements, with measures of bundle compliance by element, ventilator days, delirium days, mobility level and ICU length of stay. The project should include an interprofessional team (nursing, respiratory therapy, physical and occupational therapy, pharmacy and physicians) and a daily checklist on rounds, since the bundle depends on coordinated timing.
References
Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., . . . Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825–e873. https://doi.org/10.1097/CCM.0000000000003299
Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W., Schweickert, W. D., Pun, B. T., Taichman, D. B., Dunn, J. G., Pohlman, A. S., Kinniry, P. A., Jackson, J. C., Canonico, A. E., Light, R. W., Shintani, A. K., Thompson, J. L., Gordon, S. M., Hall, J. B., Dittus, R. S., Bernard, G. R., & Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial. The Lancet, 371(9607), 126–134. https://doi.org/10.1016/S0140-6736(08)60105-1
Kress, J. P., Pohlman, A. S., O'Connor, M. F., & Hall, J. B. (2000). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine, 342(20), 1471–1477. https://doi.org/10.1056/NEJM200005183422002
Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., . . . Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU Liberation Collaborative in over 15,000 adults. Critical Care Medicine, 47(1), 3–14. https://doi.org/10.1097/CCM.0000000000003482
Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K. E., Hall, J. B., & Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. The Lancet, 373(9678), 1874–1882. https://doi.org/10.1016/S0140-6736(09)60658-9
