ICU Liberation Bundle (A-F)

Implement the A-F elements of the ICU Liberation Bundle to improve outcomes while transforming culture.

The Society of Critical Care Medicine's (SCCM) ICU Liberation Bundle (A-F) is unique because it can be applied to every patient, every day, by the full team. Your implementation does not have to be perfect right away. Small changes make a big difference.

By fostering a holistic approach to treating patients and improving ICU team communication, the ICU Liberation Bundle has been proven in multiple studies involving more than 20,000 patients to:

Decrease the likelihood of hospital death within seven days by 68%
Reduce delirium and coma days by 25% to 50%
Reduce physical restraint use by more than 60%
Cut ICU readmissions in half
Reduce discharges to nursing and rehabilitation facilities by 40%

The A-F elements of the ICU Liberation Bundle represent the implementation strategy used to provide each of the recommendations in the pain, agitation/sedation, delirium, immobility, and sleep disruption (PADIS) guidelines to every ICU patient.

The ICU Liberation Bundle consists of the following individual elements

A Element: Assess, Prevent, and Manage Pain
B Element: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)
C Element: Choice of Analgesia and Sedation
D Element: Delirium: Assess, Prevent, and Manage
E Element: Early Mobility and Exercise
F Element: Family Engagement and Empowerment

ICU Liberation Bundle (A-F)

A ElementB ElementC Element D Element E ElementF Element

Introduction

The “A” element of the ICU Liberation Bundle consists of assessing, preventing, and managing pain. Pain is an unpleasant sensory and emotional experience that is best reported by the person who is experiencing it, although self-reporting can be a challenge in the ICU. The inability to communicate verbally does not negate the possibility that a patient is experiencing pain.

Assessment

Pain affects most ICU patients. Patients with diminished communication or cognitive capabilities are at risk of experiencing higher levels of pain. A reliable and valid pain assessment is the foundation for effective pain treatment. Choosing the best intervention to treat pain is challenging.

The ICU Liberation’s implementation tools offer a stepwise approach to pain assessment. Assessment is suggested in this order:

Attempt to obtain a patient’s self-report of pain.
Look for behavioral changes.
Ask the family to help identify pain behaviors.
Assume that pain is present.

Pain and sedation levels should be assessed frequently in the ICU, at least every four hours, and reassessment should be performed within one hour after an intervention is made.

The following tools are available for ICU patients:

Additional pain assessment references:

Bedside calculators:

In pediatric patients, the following tools can be used for pain assessment:

Intervention/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 among the most painful procedures. Preprocedural analgesia and/or nonpharmacologic interventions should be administered and should be considered for other procedures as well. Treat pain first!

Nonpharmacologic Interventions:

Relaxation and or distraction techniques
Information/education
Massage/touch
Music therapy
Pet therapy
Family presence for support and distraction

For pharmacologic treatment of pain, ICU Liberation recommends:

IV opioids should be considered as the first-line drug class for nonneuropathic pain.
IV opioids are especially effective when titrated to similar pain intensity end point.

For further information about pharmacologic treatment options for pain, see “C” – Choice of Analgesia and Sedation.

Resources

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.
Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
Gélinas C, Puntillo KA, Joffe AM, Barr J. A validated approach to evaluating psychometric properties of pain assessment tools for use in nonverbal critically ill adults. Semin Respir Crit Care Med. 2013 Apr;34(2):153-168.
Nordness M, Hayhurst CJ, Pandharipande P. Current perspectives on the assessment and management of pain in the intensive care unit. J Pain Res. 2021 Jun 14;14:1733-1744.

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 preprocedural analgesia and/or nonpharmacologic interventions and consider the same for other procedures. Treat pain first!

Introduction

The “B” element of the ICU Liberation Bundle consists of both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs).

Studies have shown that using SATs and SBTs synergistically helps decrease mechanical ventilation days (3.1-day reduction; 95% CI, 0.7-5.6; P = 0.02), necessity for tracheostomy, and delirium (odds ratio 0.505; 95% CI, 0.299-0.853; P = 0.01).
Reducing the duration of ventilation time is an important goal because prolonged mechanical ventilation can lead to undesirable outcomes, such as longer (approximately 4 days) hospitalizations and ICU stays.

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 to liberate the patient from the ventilator.

Light-to-moderate ICU sedation can help reduce anxiety and agitation for patients, facilitate mechanical ventilation, and decrease traumatic memories.
Deep sedation has been found to reduce six-month survival and increase hospital mortality, ICU length of stay, ventilator duration, and physiologic stress.

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, along with signs common to respiratory distress in aroused patients, such as tachypnea and use of accessory muscles.
The SBT safety screen evaluates the need for ventilator support, which helps facilitate ventilation weaning and decreases reintubation rates. The SBT safety screen includes the absence of hypoxia, apnea, agitation, significant doses of vasopressors, and increased intracranial pressure. SBT failure criteria include tachypnea, hypoxemia, acute change in mental status, acute cardiac arrhythmia, and signs of respiratory distress.
To enable successful implementation of SATs and SBTs, it is important to create an interprofessional team. At all levels of care, the ICU Liberation Bundle is most effective when implemented by a team that includes a physician or advanced practice provider, a nurse, a respiratory therapist, and a physical therapist.

For pediatric patients:

Data are growing regarding the safety and efficacy of both SATs and SBTs in children.
Each institution should base its conduction of SBTs and SATs in children on the institution’s own experience.

Intervention

The pain, agitation/sedation, delirium, immobility, and sleep disruption (PADIS) guidelines recommend:

Depth and quality of sedation should be routinely assessed in all ICU patients daily, even when SATs and SBTs are contraindicated.
The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliable scales for assessing quality and depth of sedation in adult ICU patients.
For pediatric patients, the RASS and State Behavioral Scale (SBS) are validated sedation scales.
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.

Additional tools:

Wake Up and Breathe Protocol

Resources

Girard TD, Kress JP, Fuchs BD, et al. 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. Lancet. 2008 Jan 12;371(9607):126-134.
Khan BA, Fadel WF, Tricker JL, et al. Effectiveness of implementing a wake up and breathe program on sedation and delirium in the ICU. Crit Care Med. 2014 Dec;42(12):e791-e795.
Curley MA, Harris SK, Fraser KA, Johnson RA, Arnold JH. State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatr Crit Care Med. 2006 Mar;7(2):107-114.

Drug	Metabolic/drug interaction considerations	Usual starting dose	Drug-specific adverse effects	Drug accumulation factors
Fentanyl	3A4 major substrate	CI: 12.5-25 µg/hr OR CI: 0.35-0.5 µg/kg	Muscle rigidity	Hepatic failure, high volume of distribution, high lipophilicity, unpredictable clearance (long context-sensitive half-time) with prolonged infusion
Morphine	Glucuronidation	CI: 1-2 mg/hr	Hypotension, bradycardia from histamine release	Hepatic failure, active metabolite (3-morphine glucuronide) accumulation in renal failure
Hydromorphone	Glucuronidation	CI: 0.25-0.5 mg/hr	Overdose effects from dosing errors of high-potency opioids	Hepatic failure
Methadone	3A4 and 2B6 major substates	N/A	QTc prolongation, serotonin syndrome	Long half-life, delayed clearance with hepatic and renal failure
Remifentanil	Blood and tissue esterases	LD: 1.5 µg/kg	CI: 0.5-15 µg/kg/hr	Chest wall rigidity, rebound pain on discontinuation

Analgesic	Recommendation
Acetaminophen	Use as an adjunct to opioid therapy to decrease pain intensity and opioid consumption.
Ketamine	Use low-dose ketamine (1-2 µg/kg/hr) as an adjunct to opioid therapy to reduce opioid use in post-surgical adults.
Gabapentin and pregabalin	Use neuropathic pain medications with opioids for neuropathic pain management. Use with opioids after cardiovascular surgery.
Lidocaine	Do not routinely use IV lidocaine as an adjunct to opioid therapy.
COX-1 selective NSAIDs	Do not routinely use a COX-1 selective NSAID as an adjunct to opioid therapy.
Cybertherapy and hypnosis	Do not offer cybertherapy (virtual reality) or hypnosis.
Massage therapy	Offer 10- to 30-minute massages once or twice daily for 1 to 7 days.
Music therapy	Use music therapy for procedural and nonprocedural pain.
Cold therapy	Offer cold therapy for procedural pain.

Situation	Preferred intervention
Acute pain	Fentanyl IV push until pain resolves
Acute pain that persists or recurs	Fentanyl infusion plus fentanyl IV push for breakthrough pain
Acute pain in chronic opioid user	Account for prior opioid use when dosing IV opioid (consider ketamine)
Planned transition out of ICU and patient on IV opioid infusion	Start scheduled oral or enteral opioid (e.g., oxycodone) therapy plus intermittent IV opioid (e.g., IV push or patient-controlled analgesia)

Drug	Onset and duration	Precautions for use	CYP substrate (major)	Usual dose	Significant adverse effects
Propofol	Onset: 1 min Duration: Short term: 0.5-1 hr Long term > 7 days: variable, 25-50 hr has been observed (depends on depth and time on sedation	Hypotension, bradycardia, hepatic/renal failure, pancreatitis	2B6	5-50 µg/kg/min, 0.3-3 mg/kg/hr	Hypotension, respiratory depression, bradycardia, propofol infusion syndrome
Dexmedetomidine	Onset: 5-10 min with LD, 1-2 hr without LD Duration: 1-2 hr	Hepatic failure, symptomatic bradycardia	2A6	LD: 0.5-1 µg/kg (optional) MD: 0.2-0.7 µg/kg/hr	Hypo- or hypertension, bradycardia
Lorazepam	Onset: 5-20 min Duration: 4-8 hr, prolonged with CI	Delirium, renal failure	N/A	Intermittent: 1-4 mg IV every 4-6 hr	Oversedation, propylene glycol toxicity
Midazolam	Onset: 3-5 min Duration: 2-6 hr, prolonged with CI	Hepatic failure, end-stage renal failure, dialysis, delirium	3A4 (active metabolite)	0.02-0.1 mg/kg/hr	Oversedation

Situation	Preferred intervention
Agitation and pain	Fentanyl until agitation resolves
Acute agitation in a patient who requires deep sedation	Opioid continuance with the addition of propofol infusion
Acute agitation in a nonintubated patient	Low-dose intermittent IV opioid, haloperidol, or dexmedetomidine infusion

Opioid	Usual dose
Fentanyl	0.5-5 µg/kg/hr
Remifentanyl	0.1-0.5 µg/kg/min
Morphine	0.025-0.1 mg/kg/hr
Hydromorphone	0.01-0.015 mg/kg/hr
Methadone	0.05-0.1 mg/kg every 6-12 hours

Drug	Onset and duration	Usual dosage	Precautions
Dexmedetomidine	Onset: 5-10 minutes Duration: 1-2 hours	0.2-2.0 µg/kg/hr	Bradycardia, hypo- or hypertension
Propofol	Onset: 1 minute Duration: Short term: 0.5-1 hour Long term: (> 7 days): variable, depends on depth and time of sedation	25-300 µg/kg/min	Hypotension, propofol infusion syndrome, respiratory depression
Midazolam	Onset: 3-5 minutes Duration: 2-6 hours	0.05-0.15 mg/kg/hr	Hypotension

Introduction

The “D” element of the ICU Liberation Bundle consists of assessing, preventing, and managing delirium.

Delirium is experienced by 50% to 80% of mechanically ventilated patients and 20% to 50% of patients with lower-severity illness, resulting in prolonged hospitalization and duration of mechanical ventilation and increased costs. Long-term effects include increased risk of mortality and long-term cognitive impairment. The etiology of delirium is often multifactorial. There is limited evidence to support pharmacologic interventions. Thus, our most powerful interprofessional tools are daily prevention using nonpharmacologic interventions and early recognition using valid and reliable screening tools.

Assessment

Delirium should be routinely monitored in all ICU patients using validated and reliable delirium screening tools. It is recommended that screening be performed at least once a shift and more frequently for any changes in mental status.

In adults, use either:

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

In children, use either:

Intervention and Prevention

Strategies for delirium treatment include all the nonpharmacologic interventions that have been outlined for prevention. When a patient has delirium, the first step is to identify the potential etiology.

A useful mnemonic for the quick differential evaluation of the cause of delirium is THINK: “Stop, THINK, and lastly medicate.” This framework directs our focus and attention to identifying etiology first, before moving toward pharmacologic strategies. If all potential risk factors have been addressed and/or removed and all etiologies have been considered and treated, the team may consider initiation of pharmacologic therapies.

Consider using dexmedetomidine for delirium in mechanically ventilated adults when agitation is precluding weaning or extubation.

Reduce deliriogenic drugs and provide daily sedation breaks
Improve wakefulness (reduce sedation)

Prevention of delirium focuses on implementation of nonpharmacologic strategies to minimize delirium risk factors with integration of all elements of the ICU Liberation Bundle. Additionally, daily ICU care should focus on optimizing comfort and mobility, promoting sleep, and maintaining day-night cycles and patients’ normal routines as much as possible. There are no data to support the routine use of antipsychotics for the prevention of ICU delirium in adults.

Key strategies for delirium prevention include:

Nonpharmacologic: Employ a multicomponent strategy, including:

Daily and regular orientation to the environment
Engaging patients with familiar items from home and family interaction
Removing urinary catheters and invasive devices as early as possible
Reducing visual or hearing impairment by providing hearing aids and glasses as needed
Early involvement of rehabilitation team and daily mobility goals
Optimizing nutrition and hydration
Promoting sleep at night and clustering patient care activities during the daytime
Exposure to sunlight during the daytime and dimming lights and minimizing noise at night
ICU diaries

Pharmacologic:

Reviewing drugs daily to avoid deliriogenic drugs, including benzodiazepines and anticholinergics
Optimizing pain control (See “A” – Assess, Prevent, and Manage Pain)
Goal-directed and minimal sedation (See “C” – Choice of Sedation)

Resources

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.
Holden DN, Retelski J. The ICU Liberation Bundle: an emphasis on nonpharmacologic intervention. Crit Connections. 2019 Aug. Accessed January 17, 2023. https://www.sccm.org/Communications/Critical-Connections/Archives/2019/The-ICU-Liberation-Bundle-An-Emphasis-on-Nonpharm

Introduction

The “E” element of the ICU Liberation Bundle consists of early mobility and exercise. Early mobilization of critically ill patients has been shown to be safe and feasible in both adult and pediatric populations. In adults, studies have shown that ICU-based early mobilization decreases delirium, improves functional outcomes, and is cost effective.

Assessment

Mobilization of ICU patients can vary based on the strength of activity, from passive stretching to active walking. It is important to set a daily activity goal for each patient based on the patient’s clinical status and resources available for support.

Consider the following aspects before deciding on an ICU patient’s activity goal:

Neurologic (level of alertness, weakness of an extremity, deconditioning)
Cardiac (hemodynamic stability and vasoactive medications)
Pulmonary (ventilation and oxygenation needs)
Lines and drains (stability of lines, location, comfort if mobilized)
Support staff available (physical and occupational therapy, nursing staff, family presence)

If activity goals are not being met, consider these questions:

Is the patient awake enough to participate?
Does sedation need to be optimized?
Is pain adequately controlled to allow for comfortable activity?
What was the patient’s activity level prior to admission?
Is there enough support staff available to assist with mobilization?
What other barriers exist?

Intervention

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 steps:

Untangle and create slack on the lines. Secure the lines. Connect the portable monitor.
Initiate bed exercise. Watch the patient, watch the monitor, and watch the lines.
Sit the patient on the edge of the bed. Assess for pain and orthostatic blood pressure.
Assist seated patient in standing.
Initiate walking. Keep a chair close to the patient. Have aides, volunteers, and students push chair and IV poles.
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.
Institute 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 higher than 10 beats/min above baseline
has decreased muscle recruitment
loses balance
has decreased weight-bearing ability
has diaphoresis

Special considerations in pediatric patients:

The highest level of mobility must be tailored to the patient’s age and developmental status. For example, in infants, parents holding the patient out of bed is the highest level of mobility. Stroller and wagon rides can also be added to out-of-bed mobilization activities for nonmobile patients.
Family presence for mobilization events is key in minimizing anxiety and fear among pediatric patients.

Resources

Cameron S, Ball I, Cepinskas G, et al. Early mobilization in the critical care unit: a review of adult and pediatric literature. J Crit Care. 2015 Aug;30(4):664-672.
Dubb R, Nydahl P, Hermes C, et al. Barriers and strategies for early mobilization of patients in intensive care units. Ann Am Thorac Soc. 2016 May;13(5):724-730.
Wieczorek B, Ascenzi J, Kim Y, et al. PICU Up! Impact of a quality improvement intervention to promote early mobilization in critically ill children. Pediatr Crit Care Med. 2016 Dec;17(12):e559-e566.

Introduction

The “F” element of the ICU Liberation Bundle consists of family engagement and empowerment. The “F” element focuses on promoting family presence in the ICU and identifying strategies to engage and empower families. Engaging families in the care of their loved one during critical illness has positive impact on quality and safety and can decrease anxiety, confusion, and agitation.

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

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

Assessment

Assessment of the “F” element of the ICU Liberation Bundle consists of assessing the family unit and engaging them to provide a holistic assessment of the patient.

Assess for key family members, which may include individuals who are not formally related.
Identify key decision-makers.
Assess family support needs.
In addition to social and medical history, involve the family in goal setting, identifying personal and cultural beliefs and providing other key information to support the ICU team in best understanding the patient.
If the patient is unable to speak for him-/herself, engage the family in identifying patient preferences and routines such as music or TV programs and typical sleep/wake cycles.

Intervention

Interventions to promote family engagement include:

Flexible visitation, including an open ICU and virtual capability when in-person visitation is not feasible
Daily meetings with family
Involvement of family in interdisciplinary rounds
Patient and family diaries
Variety of available options for ways family can participate in care that can be tailored to the patient’s needs and family’s level of involvement.
Resources to help family navigate ICU terminology and common interventions
Resources to support identified family needs

Resources

Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. 2017 Jan;45(1):103-128.
Society of Critical Care Medicine. Gap Analysis Tool - Identification of Your ICU’s Practice Differences.
Family-Centered Care Guidelines Supplement: Work Tools for Guideline Implementation.
SCCM Patient Communicator App
SCCM Pod-343 - Patient Diaries in the ICU.
Barreto BB, Luz M, Rios MNO, Lopes AA, Gusmao-Flores D. The impact of intensive care unit diaries on patients’ and relatives’ outcomes: a systematic review and meta-analysis. Crit Care. 2019 Dec 16;23(1):411.
Society of Critical Care Medicine - MyICUCare.

ICU Liberation Implementation Toolkit

The ICU Liberation Implementation Toolkit provides adult and pediatric critical care teams with a variety of resources to champion and sustain bundle implementation. The toolkit contains:

An ICU Liberation Implementation Framework Booklet, with individual guidance for each bundle element
Data metrics and compliance definitions
A spreadsheet for data collection
Dashboard compliance and performance reports

Get the Toolkit

Using these Resources
Use of SCCM's ICU Liberation material is approved for free staff training in hospitals and, in most circumstances, for use in scientific presentations. If the use falls into this category, please ensure that appropriate acknowledgment is given to ICU Liberation. Some content on the website may require permissions from other creators that preceded the SCCM ICU Liberation program.

For medical education programs with associated registration fees or for use in commercial settings, requests for use of SCCM materials should be made in advance by contacting iculiberation@sccm.org.The Society does not endorse any specific product, platform, or other information that may be mentioned.

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ICU Liberation Bedside Calculators

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ICU Liberation Bundle Video Overview

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