ABCDE Protocol

ICU Delirium and Cognitive Impairment Study Group

www.icudelirium.orgdelirium@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

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.

- Depression, PTSD

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.

SedationMechanical Ventilation

DeliriumWeakness

Patient with Sepsis

Cognitive and Functional Impairment, Institutionalization, MortalityVasilevskis 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-USAABCDE Protocol? Awakening and Breathing Coordination Delirium Identification and Management

Early Exercise and Mobility

ABC

D

E

Awakening and

Breathing Coordination

ABC

Over sedation

Patient Comfort and

Ventilatory

Optimization

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

• 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

Daily Awakening Trial Results

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?

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

Wake Up and Breathe

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

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

P = 0.02

P = 0.01

Extubated faster Discharged from ICU sooner

“SAT + SBT” Was Superior to Conventional Sedation + SBT

Intervention (SAT) group = More unplanned extubation, but not more reintubation

P = 0.02

P = 0.01

Discharged from hospital sooner Better survival at 1 yr

Ali

ve

P = 0.01P = 0.04

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

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):1272-6Ely et al. NEJM 1996; 335:184-9

ABCAwakening & 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 dose)

If pass; continue to SBT safety screen

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 Features1. 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

Alert & Calm

CombativeAgitatedRestless

LethargicSedated

Stupor

Hyperactive Delirium

Hypoactive Delirium

Mixed 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: 1753-1762Lin, SM CCM 2004; 32: 2254-2259Milbrandt 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

statusAnd

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized thinking

Or

Inouye, et. al. Ann Intern Med 1990; 113:941-948.1Ely, et. al. CCM 2001; 29:1370-1379.4Ely, et. al. JAMA 2001; 286:2703-2710.5

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

Eligibility = RASS ≥ -3

Delirium Nonpharmacologic Interventions

+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 openingto physical stimulation

-5 UNAROUSEABLE No response to voice or physical stimulation

Delirium Nonpharmacologic InterventionsPain: • 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)

Early Exercise and Mobility

E

Early Exercise in the ICU

• Early exercise = progressive mobility• Study design: paired SAT/SBT protocol

with PT/OT from earliest days of mechanical ventilation

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

Wake Up, Breathe, and Move

Early Exercise Study Results

OutcomeIntervention

(n=49)Control(n=50) P

Functionally independent at discharge 29 (59%) 19 (35%) 0.02

ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) 0.03

Time in ICU with delirium (%) 33 (0-58) 57 (33-69) 0.02

Hospital delirium (days) 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

Hospital mortality 9 (18%) 14 (25%) 0.53

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 FirstSafety 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

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 & Mobility Levels of Therapy*

Early Exercise and Mobility Protocol Progression

Active ROM (in bed)

Sit/ Dangle

March/ Walk

Transfer

No Exercises, but Passive

Range of Motion allowed

Pro

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RASS ≥ -3RASS -5 / -4

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

Benefits of ABCDE Protocol

Questions?

www.ICUdelirium.org delirium@vanderbilt.ed

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