ICU Liberation Bundle (A-F)

The A Element of the ICU Liberation Bundle (A-F) 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.

• 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 PADIS Guidelines, including Quality of Evidence and Strength of Recommendations.

Assessment 

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. 

Bedside Calculators
 

• Behavioral Pain Scale (BPS) for Pain Assessment in Intubated Patients
• Critical Care Pain Observation Tool (CPOT)

Calculators provided by MDCalc

 Tools for Pain Assessment 
 

• Numerical Rating Scale (NRS) 
• Behavioral Pain Scale (BPS) 
• Behavioral Pain Scale Training Poster 
• Critical-Care Pain Observation Tool (CPOT) 
• Critical-Care Pain Observation Tool: How to Use it in Your ICU 

Treatment

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 
 

• Primary Pain Management: Opioids 
• Nonopioid Medication Options 
• Non-neuropathic pain: IV opioids with or without nonopioid analgesics 
• Neuropathic pain: gabapentin or carbamazepine plus IV opioids 
• After abdominal aortic aneurysm repair and rib fractures: thoracic epidural agent 

Nonpharmacologic Interventions 
 

• Relaxation and/or distraction techniques 
• Information/education 
• Massage/touch 
  • Healing Touch International 
• Music therapy 
  • American Music Therapy Association 
• Pet therapy 
  • Project Dispatch: Impact of Pet Music Therapy 

Prevention

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!

Within the ICU Liberation Bundle (A-F), the B Element refers to Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT). The B Element focuses on setting a time(s) each day to stop sedative medications, orient the patient to time and day, and conduct an SBT in an effort to liberate the patient from the ventilator.

Reducing the duration of ventilation time is an important goal because prolonged mechanical ventilation can lead to undesirable outcomes. ICU sedation can help reduce anxiety and agitation for patients, facilitate mechanical ventilation, and decrease traumatic memories. But deep sedation has been found to reduce six-month survival and increase hospital mortality, ICU lengths of stay, ventilator duration and physiologic stress.

Studies have shown that using SAT and SBT synergistically helps decrease mechanical ventilation days, hospital lengths of stay and delirium.
 

Assessment 

Both SATs and SBTs are incorporated into the Wake Up and Breathe Protocol, a two-step process that focuses on creating a synergy between SAT and SBT protocols. These protocols typically incorporate safety screens and failure criteria. 
 
The SAT safety screen includes the absences of seizures, alcohol withdrawal, paralysis and increased intracranial pressure. SAT failure criteria focus attention on the signs of pain, agitation and delirium (PAD), along with signs common to respiratory distress in aroused patients. 
 
The SBT safety screen includes evaluation of the need for ventilator support; this helps facilitate ventilation weaning and decreases reintubation rates. 
 
To enable successful implementation of SATs and SBTs, it is important to create an interprofessonal team. The  
 
ABCDEF bundle is most effective when implemented by a team that includes a physician, a nurse, a respiratory therapist, and a physical therapist at all levels of care. 
 
Wake Up and Breath Protocol
  

Treatment

The PAD guidelines recommend that:
 

• Depth and quality of sedation should be routinely assessed in all ICU patients. 
• The Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale (SAS) are the most valid and reliable scales for assessing quality and depth of sedation in ICU patients. 
• Objective measures of brain function should be used adjunctively to monitor sedation in patients receiving neuromuscular blocking agents. 
• EEG monitoring should be used to either monitor nonconvulsive seizure activity in ICU patients at risk for seizures or titrate electrosuppressive medication to achieve burst suppression in ICU patients with elevated intracranial pressure.

Within the ICU Liberation Bundle (A-F), the C Element refers to Choice of Analgesia and Sedation. The C Element focuses on constructing a safe and effective medication regimen for the management of pain and agitation in critically ill adults, consistent with ICU pain, agitation and delirium (PAD) Guidelines recommendations.
  

Assessment

PAD Delirium Assessment Recommendations
Routinely monitor for delirium in all adult ICU patients. Use either:
 

• Confusion Assessment Method for the ICU (CAM-ICU)
• Intensive Care Delirium Screening Checklist (ICDSC)

Bedside Calculator
 

• Confusion Assessment Method for the ICU (CAM-ICU) Calculators provided by MDCalc

Tools for Delirium Assessment
The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools for adult ICU patients.
 

• CAM-ICU Assessment Tool
• CAM-ICU Flowsheet
• CAM-ICU Training Manual
• Intensive Care Delirium Screening Checklist (ICDSC)

 

Treatment

Pain

Nonpharmacologic strategies play an important role in managing pain and agitation. IV opioids should be considered first-line analgesics for the treatment of non-neuropathic pain. Nonopioid analgesics should be considered to decrease the amount of opioids administered and thereby to decrease opioid-induced adverse effects.

Optimize opioid regimens by assessing the following considerations:

• Is pain acute, persistent, or both?
• Route of administration
• Hemodynamic instability

Agitation

When treating agitation, it is important to titrate sedative medications to maintain lighter levels of sedation; deep sedation or coma should be avoided.

Delirium

The PAD Guidelines suggest that, in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidine (rather than benzodiazepine infusions) be administered for sedation to reduce the duration of delirium. Also, atypical antipsychotics may reduce the duration of delirium in adult ICU patients. Treatment with rivastigmine or haloperidol does not reduce the duration of delirium.

Prevention 

Nonpharmacologic strategies play an important role when preventing and managing delirium. Before administering a medication to either prevent or treat delirium in the ICU:
 

• Consider nonmedication-related, reversible factors for delirium (e.g., hypoxemia, infection, electrolyte abnormalities).
• If possible, stop (or decrease the dose of) any medication that may increase delirium risk.
• Mobilize patients when possible.
• Optimize nonpharmacologic interventions that may reduce delirium incidence and/or burden (e.g., hearing aids, eyeglasses, reorientation, sleep protocols, music, noise control, family interaction).

The D Element of the ICU Liberation Bundle (A-F) refers to assessing, preventing and managing delirium.

Delirium is experienced by 50%–80% of mechanically ventilated patients and 20%–50% of patients with illness of lower severity, resulting in prolonged hospitalization, increased mortality and increased cost. Long-term effects on the patient include increased risk of mortality and long-term cognitive impairment.

Assessment

Routinely monitor for delirium in all adult ICU patients. Use either:
 

• Confusion Assessment Method for the ICU (CAM-ICU)
• Intensive Care Delirium Screening Checklist (ICDSC)

Bedside Calculator
 

• Confusion Assessment Method for the ICU (CAM-ICU) Calculators provided by MDCal

Tools for Delirium Assessment
The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools for adult ICU patients.

• ​Intensive Care Delirium Screening Checklist (ICDSC)
• CAM-ICU Training Manual
• CAM-ICU Flowsheet
• CAM-ICU Assessment Tool

Within the ICU Liberation Bundle (A-F), the E element refers to Early Mobility and Exercise. The E Element focuses on understanding the physical deficits that ICU survivors face, and identifying strategies for successful implementation of early mobilization programs.
 

The key question to ask during rounds is: Did the patient achieve maximum mobility or exercise today? If early mobilization is falling short, it is important to determine the reasons. Some factors to consider are:

• Was the patient walking before admission?
• Is the patient hemodynamically stable?
• Is the patient awake?

Also take into account the following aspects before mobilizing a patient in the ICU:

• Neurologic (level of alertness)
• Cardiac (hemodynamic stability and vasoactive medications)
• Pulmonary (ventilation/oxygenation needs)
• Risk versus benefit
• Guidelines versus protocols (fewer absolute contraindications, importance of interdisciplinary collaboration)

Assessment

Step 1: Patient Selection Process
Do any of the following exclusion criteria apply?
 

• Patient has immediate plans to transfer to outside hospital
• Patient requires significant doses of vasopressors for hemodynamic stability (maintain mean arterial pressure > 60 mm Hg)
• Patient is mechanically ventilated and requires Fio₂ > 0.8 and/or positive end-expiratory pressure > 12 mm Hg, or has acutely worsening respiratory failure
• Patient is maintained on neuromuscular paralytic agents
• Patient has an acute neurologic event (e.g., cerebrovascular accident, subarachnoid hemorrhage, or intracranial hemorrhage) with reassessment for mobility every 24 hours
• Patient is unresponsive to verbal stimuli
• Patient has an unstable spine or extremity fracture
• Patient has a grave prognosis and is transferring to comfort care
• Patient has an open abdomen with a risk for dehiscence

These are guidelines, not precautions. In the presence of any exclusion criterion, consult with patient’s providers to determine if participation in physical activity or exercise is safe.

Step 2: Assess Patient’s Activity History
What was the patient’s level of activity in the past two hours, two days, two weeks, two months, and two years?

Step 3: Grossly Assess Patient’s Strength
How easily can the patient lift legs off the bed? How well does the patient bear weight on the legs?

Step 4: Assess Patient’s Ability to Engage
How well does the patient follow commands and engage in activity?

 

Treatment 

While encouraging and physically supporting patients in their efforts to achieve their individual goals, staff must watch the patient, watch the monitors, and watch the lines while gradually increasing the activity level.

Mobility therapy steps
 

• Step 1: Untangle and create slack on the lines. Secure the lines. Connect the portable monitor.
• Step 2: Initiate bed exercise. Watch the patient, watch the monitor, and watch the lines. 
• Step 3: Sit the patient on the edge of the bed. Assess for pain and orthostatic blood pressure.
• Step 4: Assist seated patient in standing.
• Step 5: Initiate walking. Keep a chair close to the patient. Utilize aides, volunteers and students to push chair and intravenous poles.
• Step 6: Seat and rest the patient as needed.

Consider the following factors with each physical rehabilitation or ICU mobility session: 
 

• Determine whether the level of activity is therapeutic. 
• Identify the available equipment. 
• Schedule a time to work on physical activity with the patient, family, nurse and respiratory therapist. Ascertain whether sedation should be suspended. 
• Assess and manage the patient’s pain before, during and after mobility activity. 
• Optimize the work of breathing and patient level of alertness to make treatment beneficial.
• Create activities that are goal-oriented for the patient.
• Do not delay or defer physical activity and rehabilitation even if the patient is to be extubated that day.
• Do not delay or defer physical activity because of agitation if it can be safely managed by the nurse and therapist. For patients who are agitated or experiencing disorganized thinking and delirium, a focused task provides an opportunity for reorienting conversation.

Stop and rest the patient if the patient:
 

• Is unresponsive
• Is fatigued or appears pale
• Has a respiratory rate consistently > 10 beats/min above baseline
• Has decreased muscle recruitment
• Loses balance
• Has decreased weight-bearing ability
• Has diaphoresis

Within the ICU Liberation Bundle (A-F), the F element refers to Family Engagement and Empowerment.  The F Element focuses on examining the concept of family presence in the ICU and identifying strategies to create family engagement and empowerment.

Patient-centered care is defined as providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. Empowering family members with shared decision-making, safety and future care expectations engages them in the patient’s care.

Family and patient-centered care focuses on the following characteristics:

• Keeping patients and families informed
• Actively involving patients and families in decision-making
• Actively involving patients and families in self-management
• Providing both physical comfort and emotional support to patient and families
• Maintaining a clear understanding of patients’ concepts of illness and cultural beliefs

Social isolation separates patients from their families. Flexible visitation, including an open ICU, daily meetings with the family, and redesign efforts that target family comfort can all positively impact family presence.

Patient benefits of family presence and flexible visitation (Bell L. American Association of Critical-Care Nurses Practice Alert) include:

• Decreased anxiety, confusion, and agitation
• Reduction in cardiovascular complications
• Decreased ICU lengths of stay
• Providing feelings of security
• Increase in patient satisfaction
• Increase in quality and safety

For additional resources for Patient, Families and Healthcare providers related to Post-Intensive Care Syndromes (PICS) and quality of life after the ICU, visit MyICUCare.org