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The ICU Liberation Bundle: An Emphasis on Nonpharmacologic Intervention

Devin N. Holden, BCPS, PharmD and Julia Retelski, MSN, RN, CCNS
The ICU Liberation bundle represents the blueprint for implementing the ICU liberation initiative within intensive care units (ICUs) around the world. The aim of this initiative is to liberate patients from iatrogenic harm due to the effects of various intensive care interventions. The ICU Liberation Bundle (formerly the ABCDEF Bundle) is made up of ABCDEF elements that address:

  • Assessing, preventing and managing pain
  • Both SATs and SBTs
  • Choice of analgesia and sedation
  • Delirium
  • Early mobility and exercise
  • Family engagement and empowerment
The aim of intensive care has shifted from keeping patients alive at all costs to doing everything possible to ensure a productive and fulfilling life for patients after they leave the ICU. The ICU Liberation Bundle is best thought of as a dynamic framework on which to adopt and implement emerging data and practices. Thus, myriad interventions can be encapsulated within the bundle, many of which are nonpharmacologic. Indeed, the bundle stipulates that a strong focus should be put on the judicious use of pharmacologic interventions, especially for treating pain, anxiety, delirium, and sleep disturbances. Often, when attempting to fully implement the concepts of ICU Liberation, the most salient intervention is to stop or significantly reduce the use of many medications. With this background in mind, this article emphasizes the use of nonpharmacologic interventions within the context of the ICU Liberation initiative.
Pain, Agitation, and Sedation: Nonpharmacologic Options
In general, pain and anxiety are ubiquitous for patients in the ICU and a significant focus of patients, caregivers, and clinicians. There is no question that the proper utilization of analgesic and anxiolytic medications is important for critically ill patients. The recently released ICU Liberation Guidelines for pain, agitation/sedation, delirium, immobility, and sleep disruption (formerly the PADIS Guidelines) contain a number of recommendations to guide clinicians.1 It is important to remember that pain and anxiety are subjective and personal experiences and can vary significantly from patient to patient. In addition, within the realm of patient experience, dissecting the differential contribution of pain and anxiety to a patient’s discomfort and agitation can be very challenging. In light of these challenges, a number of nonpharmacologic interventions are likely to benefit patients, depending on their personality, personal preferences, and specific circumstances.
Massage therapy has been investigated in a number of studies in ICU patients, with promising results.2-5 Resource utilization in providing massage therapy for patients is likely to be a concern, but brief training provided to nurses may be sufficient to empower them to provide it to patients who are willing to accept it. Music therapy has been investigated in a number of studies for procedural and nonprocedural pain management.3,6-10 The majority of these studies showed a reduction in reported pain but the magnitude is of uncertain clinical relevance. Given the lack of risk of music therapy, it is a reasonable intervention to offer to patients and is likely to benefit certain patients. In addition to resource utilization concerns, storage of headsets and hygiene concerns related to headset use must be addressed before implementation. A promising intervention for procedural pain reduction is cold therapy. This modality was investigated in in two controlled trials for chest tube removal and showed a nonsignificant but potentially clinically meaningful reduction in pain.11,12 Given the potential adverse effects of traditional medications used before procedures (eg, bleeding and renal effects from nonsteroidal antiinflammatory drugs and oversedation and bowel dysmotility with opiates) and the likely lack of adverse effects of cold therapy, it would be reasonable to offer it to patients. Resource utilization concerns would have to be addressed in terms of cold pack storage and a written protocol for nurses would be needed but in motivated ICUs this intervention is promising for reducing the use of potentially unneeded analgesic medications.
Various types of relaxation and meditative techniques have become popular in modern culture and the lay press. Promising data on the effects of these interventions on well-being and emotional health have been published, and long-term changes in brain structures and function have been documented.13 Breathing and relaxation techniques have been tested in a limited fashion in ICU patients before  painful procedures and have shown promise in reducing pain intensity.14,15 Given the limited resource utilization needed to offer these techniques to patients and the potential benefit, it is reasonable to implement them where feasible. In addition, written material could be disseminated to patients and families about the usefulness of breathing and relaxation techniques. Beyond the possible effects on procedural pain, breathing and relaxation techniques would likely help improve anxiety in patients who are able to cooperate, but this intervention needs further study to confirm possible benefits.
Numerous nonpharmacologic interventions that are low cost and low risk are available to clinicians to improve pain control and anxiety in ICU patients. Given the lack of potential harm from these interventions, they are reasonable alternatives to offer to patients. Efforts toward incorporating these interventions into ICU workflow and protocols may be challenging but are likely worth the effort for improvements in patient comfort and experience in the ICU.
Delirium Prevention and Treatment: Nonpharmacologic Options
Delirium is an extremely complex neuropsychiatric syndrome that has been associated with prolonged ICU and hospital stays, increased mortality, and ICU cognitive impairment.1 Delirium in the ICU is often multifactorial, and determining its cause can be complicated.16 Multiple pharmacologic interventions have been explored but no single one has been shown to improve delirium and none are approved by the U.S. Food and Drug Administration for the treatment of delirium. Therefore, the keys to lowering delirium risk are prevention and early recognition.17 Multiple nonpharmacologic options have been explored, with varying success. A useful mnemonic for the quick differential evaluation of the cause of delirium is THINK (Figure 1). The mnemonic is well encapsulated in this statement: A simple framework to guide the management of a delirious patient is “Stop, THINK, and lastly medicate.16 This framework directs our focus and attention to identifying etiology first, before moving toward pharmacologic strategies.

The ICU Liberation Guidelines’ recommendations for delirium management include a light target level of sedation, analgesia-first sedation in mechanically ventilated patients, sleep promotion by optimizing strategies such as light and noise control, clustering patient activities, and decreasing stimuli at night to protect patients’ sleep cycles. In addition, the guidelines recommend the use of an interdisciplinary ICU team approach that includes provider education, preprinted and/or computerized protocols and order forms, and quality ICU rounds checklists to facilitate the use of pain, agitation, and delirium management guidelines or protocols in adult ICUs.1 Key components of delirium prevention protocols include establishing a daytime routine and a nighttime routine, providing patients with contact lenses or eyeglasses and hearing aids, reorienting patients to time and location, encouraging visitors, turning the television and lights off at night, exposing patients to natural light during the day, and early mobilization. To promote sleep at night, bathing, laboratory draws, and radiographic testing should be completed during daytime hours.
Simple strategies that may prevent delirium are earplugs and eye masks for nonagitated patients, moving patients to a room with natural sunlight, and encouraging family involvement in routine patient care activities. Families can participate in delirium prevention activities by turning lights on and off, closing blinds, reorienting the patient, asking the patient cognitive-stimulating questions, playing music, and bringing eyeglasses and hearing aids from home. The PADIS guidelines do not recommend alternative methods of reducing delirium, such as aromatherapy, acupuncture, or music at night, due to lack of evidence.1
With implementation of the ICU Liberation Bundle comes the recommendation to focus on decreasing pharmacologic interventions. Numerous nonpharmacologic approaches discussed in the literature aim to manage pain and sedation and decrease the incidence of delirium. The interventions discussed may seem simple but can be complicated to standardize due to complex work environments, unit culture, variable support from interdisciplinary team members, and lack of substantial supporting evidence. Nonpharmacologic interventions are often more cost effective than pharmacologic interventions but can be considered more difficult to implement because they are resource intensive and possibly require more education of the family to ensure the family’s awareness of patient goals and definitions of terms. In order to improve patient outcomes by decreasing length of stay and cognitive impairment, nonpharmacologic interventions must be incorporated into ICU patients’ day-to-day care.


  1. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018 Sep;46(9):e825-e873. 
  2. Boitor M, Martorella G, Arbour C, Michaud C, Gélinas C. Evaluation of the preliminary effectiveness of hand massage therapy on postoperative pain of adults in the intensive care unit after cardiac surgery: a pilot randomized controlled trial. Pain Manag Nurs. 2015 Jun;16(3):354-366. 
  3. Kshettry VR, Carole LF, Henly SJ, Sendelbach S, Kummer B. Complementary alternative medical therapies for heart surgery patients: feasibility, safety, and impact. Ann Thorac Surg. 2006 Jan;81(1):201-205. 
  4. Piotrowski MM, Paterson C, Mitchinson A, Kim HM, Kirsh M, Hinshaw DB. Massage as adjuvant therapy in the management of acute postoperative pain: a preliminary study in men. J Am Coll Surg. 2003 Dec;197(6):1037-1046. 
  5. Mitchinson AR, Kim HM, Rosenberg JM, et al. Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial. Arch Surg. 2007 Dec;142:1158-1167; discussion 1167. 
  6. Broscious SK. Music: an intervention for pain during chest tube removal after open heart surgery. Am J Crit Care. 1999 Nov;8(6):410-415. 
  7. Chan MF. Effects of music on patients undergoing a C-clamp procedure after percutaneous coronary interventions: a randomized controlled trial. Heart Lung. 2007 Nov-Dec;36(6):431-439. 
  8. Cooke M, Chaboyer W, Schluter P, Foster M, Harris D, Teakle R. The effect of music on discomfort experienced by intensive care unit patients during turning: a randomized cross-over study. Int J Nurs Pract. 2010 Apr;16(2):125-131. 
  9. Chiasson AM, Linda Baldwin A, McLaughlin C, Cook P, Sethi G. The effect of live spontaneous harp music on patients in the intensive care unit. Evid Based Complement Alternat Med. 2013;2013:428731. 
  10. Jaber S, Bahloul H, Guétin S, Chanques G, Sebbane M, Eledjam JJ. Effects of music therapy in intensive care unit without sedation in weaning patients versus non-ventilated patients [in French]. Ann Fr Anesth Reanim. 2007 Jan;26(1):30-38. 
  11. Gorji HM, Nesami BM, Ayyasi M, Ghafari R, Yazdani J. Comparison of ice packs application and relaxation therapy in pain reduction during chest tube removal following cardiac surgery. N Am J Med Sci. 2014 Jan;6(1):19-24. 
  12. Sauls J. The use of ice for pain associated with chest tube removal. Pain Manag Nurs. 2002 Jun;3(2):44-52. 
  13. Tang YY, Hölzel BK, Posner MI. The neuroscience of mindfulness meditation. Nat Rev Neurosci. 2015 Apr;16(4):213-225. 
  14. Houston S, Jesurum J. The quick relaxation technique: effect on pain associated with chest tube removal. Appl Nurs Res. 1999 Nov;12(4):196-205. 
  15. Friesner SA, Curry DM, Moddeman GR. Comparison of two pain-management strategies during chest tube removal: relaxation exercise with opioids and opioids alone. Heart Lung. 2006 Jul-Aug;35(4):269-276. 
  16. Stollings JL, Devlin JW, Pun BT, et al. Implementing the ABCDEF bundle: top 8 questions asked during the ICU Liberation ABCDEF Bundle Improvement Collaborative. Crit Care Nurse. 2019 Feb;39(1):36-45. 
  17. Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2015 Mar;44(2):196-204.