7/27/2019 ABCDE Education Slides
1/43
7/27/2019 ABCDE Education Slides
2/43
7/27/2019 ABCDE Education Slides
3/43
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
7/27/2019 ABCDE Education Slides
4/43
Potential Drawbacks of Sedativeand Analgesic Therapy
Oversedation:
Failure to initiate spontaneous breathing trials (SBT) leads to increased duration ofmechanical 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.
7/27/2019 ABCDE Education Slides
5/43
SedationMechanicalVentilation
DeliriumWeakness
Patient withSepsis
Cognitive and Functional Impairment, Institutionalization,MortalityVasilevskis et al Chest 2010; 138;1224-
7/27/2019 ABCDE Education Slides
6/43
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-
7/27/2019 ABCDE Education Slides
7/43
What is the MIND-USAABCDE Protocol?
Awakening and Breathing
Coordination
Delirium Identification and
Management
Early Exercise and Mobility
ABC
D
E
7/27/2019 ABCDE Education Slides
8/43
Awakening and Breathing
Coordination
ABC
7/27/2019 ABCDE Education Slides
9/43
Oversedatio
n
PatientComfortand
Ventilatory
Optimization
ICU Sedation: Its a Balancing Act
7/27/2019 ABCDE Education Slides
10/43
Consequences of SuboptimalSedation
Inadequatesedation/analgesia
Anxiety
Pain
Patient-ventilatordyssynchrony
Agitation
Self-removal oftubes/catheters
Care provider assault
Myocardial ischemia
Family dissatisfaction
Excessive sedation
Prolonged mechanicalventilation, ICU LOS
Tracheostomy DVT, VAP
Additional testing
Added cost
Inability to communicate
Cannot evaluate fordelirium
7/27/2019 ABCDE Education Slides
11/43
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
ler & Pedram. Crit Care Clinics 2009; 25:489-513
7/27/2019 ABCDE Education Slides
12/43
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)
7/27/2019 ABCDE Education Slides
13/43
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
7/27/2019 ABCDE Education Slides
14/43
Use Protocols to Achieve Goals, Minimize DrugAccumulation, 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
7/27/2019 ABCDE Education Slides
15/43
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
7/27/2019 ABCDE Education Slides
16/43
Shorter durationof mechanical
ventilation Shorter ICU LOS
Fewer tests foraltered mentalstatus
Kress et al. N Engl J Med 2000; 342:1471-7
Daily Awakening Trial Results
7/27/2019 ABCDE Education Slides
17/43
Why Is Interruption of SedationEffective?
Less accumulation of sedative drug andmetabolites
Significantly less midazolam and morphine with DIS
in midazolam subgroup
But no difference in amount of propofol andmorphine with DIS in propofol subgroup
Opportunity for more effective weaning from
mechanical ventilation?
Sessler CN. Crit Care Med 2004 Kress et al. NEJM. 2000
Wake Up andBreathe
7/27/2019 ABCDE Education Slides
18/43
Multicenter RCT:
168 patients with spontaneousawakening trial (SAT)
i.e., daily interruption of sedation (SAT)+ spontaneous breathing trial (SBT)
168 patients with standard sedation +
SBT
Click to edit Master text styles
7/27/2019 ABCDE Education Slides
19/43
Click to edit Master text stylesSecond level
Third levelFourth level
Fifth level
7/27/2019 ABCDE Education Slides
20/43
SAT + SBT Was Superior toConventional 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
7/27/2019 ABCDE Education Slides
21/43
SAT + SBT Was Superior toConventional Sedation + SBT
Intervention (SAT) group = More unplannedextubation, but not more reintubation
P = 0.02
P = 0.01
Discharged from hospitalsooner
Better survival at 1 yr
Aliv
eP = 0.01
P = 0.04
ard et al. Lancet 2008; 371:126-34
7/27/2019 ABCDE Education Slides
22/43
Awakening & BreathingCoordination
Synergy of daily awakening viainterruption of sedation plusspontaneous breathing trial
Less medication accumulation, lessexcessive sedation
Opportunity for more effective
independent breathing (SBT) Perform safety screens for SAT and
for SBT
7/27/2019 ABCDE Education Slides
23/43
ABC Safety Screens
Wake Up Safety Screen
No active seizures
No active alcoholwithdrawal
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 vasopressoruse
Girard et al. Lancet 2008; 371:126-34.
Kress et al. Crit Care Med 2004; 32(6):1272-6
-
7/27/2019 ABCDE Education Slides
24/43
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
5. SBT Safety Screen - pass/fail
6. If pass safety screen, perform SBT
If fail; return to previous ventilatory support
If pass; consider extubation
7/27/2019 ABCDE Education Slides
25/43
D
Delirium Monitoring and
Management
7/27/2019 ABCDE Education Slides
26/43
Delirium: Key Features
1. Disturbance ofconsciousness with reduced ability tofocus, sustain or shift attention
2. A change in cognition or the development of aperceptual disturbance that is not better accounted for
by pre-existing, established or evolving dementia
3. Develops over a short period of time and tends tofluctuate over the course of the day
4.There is evidence from the H&P and/or labs that thedisturbance is caused by a medical condition, substanceintoxication or medication side effect
7/27/2019 ABCDE Education Slides
27/43
Delirium Subtypes
Alert &Calm
CombativeAgitatedRestless
LethargicSedatedStupor
Hyperactive Delirium
Hypoactive Delirium
MixedDelirium
7/27/2019 ABCDE Education Slides
28/43
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, 1892-1900Ely, et al, JAMA 2004; 291: 1753-1762Lin, SM CCM 2004; 32: 2254-2259
Milbrandt E, et al, Crit Care Med 2004; 32:955-962.
-
7/27/2019 ABCDE Education Slides
29/43
Confusion Assessment Method forthe ICU (CAM-ICU)
Feature 1: Acute changeor fluctuating course of
mental status
And
Feature 2:Inattention
And
Feature 3: Alteredlevel of consciousness
Feature 4:Disorganized thinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-
948.1Ely, et. al. CCM 2001; 29:1370-1379.4
7/27/2019 ABCDE Education Slides
30/43
Delirium Management
1. Identify etiology
2. Identify risk factors
3. Consider pharmacologictreatment
Jacobi J, et al. Crit Care Med 2002;30:119-141
7/27/2019 ABCDE Education Slides
31/43
Stop and THINK
Do any meds need to be stoppedor 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 SituationsCHF, shock, dehydrationNew organ failure
(liver/kidney)
Hypoxemia Infection/sepsis
(nosocomial),
Immobilization
Nonpharmacologicinterventions
Hearing aids, glasses,reorient,sleep protocols, music, noise
control, ambulation
Consider antipsychotics after evaluating etiology &
risk factors
7/27/2019 ABCDE Education Slides
32/43
Eligibility = RASS -3
DeliriumNonpharmacologic 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
7/27/2019 ABCDE Education Slides
33/43
DeliriumNonpharmacologic Interventions
Pain:
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
7/27/2019 ABCDE Education Slides
34/43
Nonpharmacologic Interventions
Sensory: Determine need for hearing aids and/or eye glasses
If needed, request surrogate provide these for patient whenappropriate
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)
7/27/2019 ABCDE Education Slides
35/43
Early Exercise and
Mobility
E
7/27/2019 ABCDE Education Slides
36/43
Early Exercise in the ICU
Early exercise = progressive mobility
Study design: paired SAT/SBT protocolwith PT/OT from earliest days of
mechanical ventilation
eickert WD, et al. Lancet. 2009;373:1874-1882.
Wake Up, Breathe, andMove
7/27/2019 ABCDE Education Slides
37/43
Early Exercise Study Results
OutcomeIntervention
(n=49)Control(n=50) P
Functionally independent atdischarge
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 atdischarge
75 (7.5-95) 55 (0-85) 0.05
ICU-acquired paresis atdischarge
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) 0.93eickert WD, et al. Lancet. 2009;373:1874-1882.
7/27/2019 ABCDE Education Slides
38/43
Early Exercise and Mobility
Eligibility = All patients are
eligible for Early Exercise andMobility
7/27/2019 ABCDE Education Slides
39/43
Perform Safety Screen First
Safety Screen
Patient responds to verbal stimulation (i.e., RASS > -3)
FIO2
7/27/2019 ABCDE Education Slides
40/43
1. Active range of motion in bed and sittingposition in bed
2. Dangling
3. Transfer to chair (active), includes standingwithout marching in place
4. Ambulation (marching in place, walking inroom or hall)
*All may be done with assistance.
Early Exercise & MobilityLevels of Therapy*
E l E i d M bili
7/27/2019 ABCDE Education Slides
41/43
Early Exercise and MobilityProtocol Progression
Active ROM (in bed)
Sit/ Dangle
March/ Walk
Transfer
No Exercises,but Passive
Range ofMotion allowed
Progre
ss
as
tolerated
I
CUD
ischarge
Ex
ercise
screen
RASS -3RASS -5 / -4
Benefits of ABCDE Protocol
7/27/2019 ABCDE Education Slides
42/43
Morandi A et al. Curr Opin Crit Care,2011;17:43-9
Benefits of ABCDE Protocol
7/27/2019 ABCDE Education Slides
43/43
Questions?
Top Related