The A component of the ABCDEF Bundle refers to assessing, preventing and managing pain.

Pain is an unpleasant sensory and emotional experience. It is best reported by the person who is experiencing it, although self-reporting can be a challenge in the ICU. However, the inability to communicate verbally does not negate the possibility that a patient is experiencing pain.

Implementing the A component of the ABCDEF bundle

  • Compare valid and reliable pain assessment tools.
  • Identify special challenges to effective pain assessment, prevention, and management.
  • Integrate effective strategies to prevent and manage pain into everyday clinical practice.
  • Incorporate evidence from the Pain, Agitation, and Delirium (PAD) Guidelines, including Quality of Evidence and Strength of Recommendations.

Search A Element Resources

We know that pain affects the majority of ICU patients. Patients with diminished communication or cognitive capabilities are at risk of experiencing higher levels of pain. Reliable and valid pain assessment is the foundation for effective pain treatment, although choosing the best intervention to treat pain is challenging. 

The ICU Liberation’s implementation tools offer a stepwise approach to pain assessment, suggesting assessment in this order: 
  • Attempt to obtain the patient’s self-report of pain. 
  • Look for behavioral changes. 
  • Ask the family to help identify pain behaviors. 
  • Assume that pain is present. 
 Tools for Pain Assessment 
ICU Liberation recommends that, for treating pain: 
  • IV opioids should be considered as the first-line drug class of choice for non-neuropathic pain. 
  • All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective. 
Pharmacologic Treatment  Nonpharmacologic Interventions 
The most important step for clinicians seeking to prevent pain is to recognize the painfulness of common ICU procedures. Turning, wound drain removal, wound care, chest tube removal and arterial line insertion are rated among the most painful procedures. Administer pre-procedural analgesia and/or nonpharmacologic interventions and consider the same for other procedures. Treat pain first!
The measurement of pain in intensive care unit
Citation: Pain. 2010 Dec;151(3):711-21
Population: Adult
Bundle: A Element
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Implementation of the critical-care pain observation tool on pain assessment/management nursing practices in an intensive care unit with nonverbal critically ill adults: a before and after study
Citation: Int J Nurs Stud. 2011 Dec;48(12):1495-504
Population: Adult
Bundle: A Element
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Validation of the critical-care pain observation tool in adult patients
Citation: Am J Crit Care. 2006 Jul;15(4):420-7
Population: Adult
Bundle: A Element
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Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study
Citation: Anesthesiology. 2009 Dec;111(6):1308-16
Population: Adult
Bundle: A Element
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Patients' perceptions and responses to procedural pain: results from Thunder Project II
Citation: Am J Crit Care. 2001 Jul;10(4):238-51
Population: Adult
Bundle: A Element
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Determinants of procedural pain intensity in the intensive care unit. The Europain study.
Citation: Am J Respir Crit Care Med. 2014 Jan 1;189(1):39-47
Population: Adult
Bundle: A Element
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Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help
Citation: Crit Care Med. 2012 Oct;40(10):2760-7
Population: Adult
Bundle: A Element
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Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different?
Citation: J Crit Care. 2009 Dec;24(4):628.e7-17.
Population: Adult
Bundle: A Element
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Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults
Citation: J Adv Nurs. 2009 Jan;65(1):203-16.
Population: Adult
Bundle: A Element
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Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery
Citation: J Pain Symptom Manage. 2009 Jan;37(1):58-67
Population: Adult
Bundle: A Element
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Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators
Citation: Clin J Pain. 2007 Jul-Aug;23(6):497-505
Population: Adult
Bundle: A Element
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A validated approach to evaluating psychometric properties of pain assessment tools for use in nonverbal critically ill adults
Citation: Semin Respir Crit Care Med. 2013 Apr;34(2):153-68
Population: Adult
Bundle: A Element
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Nurses' evaluations of the feasibility and the clinical utility of the Critical-Care Pain Observation Tool
Citation: Pain Manag Nurs. 2010 Jun;11(2):115-25
Population: Adult
Bundle: A Element
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Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool
Citation: Pain Manag Nurs. 2013 Dec;14(4):259-267
Population: Adult
Bundle: A Element
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Reevaluation of the critical-care pain observation tool in intubated adults after cardiac surgery
Citation: Am J Crit Care. 2013 Nov;22(6):491-7
Population: Adult
Bundle: A Element
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Pain assessment tool in the critically ill post-open heart surgery patient population
Citation: Pain Manag Nurs. 2010 Sep;11(3):134-40
Population: Adult
Bundle: A Element
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A preliminary validation of the Swedish version of the Critical-Care Pain Observation Tool in adults
Citation: Acta Anaesthesiol Scand. 2011 Apr;55(4):379-86
Population: Adult
Bundle: A Element
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Comparison of two pain assessment tools in nonverbal critical care patients
Citation: Pain Manag Nurs. 2011 Dec;12(4):218-24
Population: Adult
Bundle: A Element
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Behavioral pain assessment tool for critically ill adults unable to self-report pain
Citation: Am J Crit Care. 2013 May;22(3):246-55
Population: Adult
Bundle: A Element
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Pain assessment in turning procedures for patients with invasive mechanical ventilation
Citation: Nurs Crit Care. 2011 Jul-Aug;16(4):178-85
Population: Adult
Bundle: A Element
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Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines
Citation: Send to Crit Care Med. 2013 Sep;41(9 Suppl 1):S116-27
Population: Pediatrics
Bundle: A Element
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Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals
Citation: Intensive Care Med. 2016 Jun;42(6):972-86
Population: Pediatrics
Bundle: A Element
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Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle
Citation: Crit Care Med. 2014 May;42(5):1024-36
Population: Pediatrics
Bundle: A Element
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