1. ICU Delirium and Cognitive Impairment Study Group
ABCDE Protocol
ICU Delirium and Cognitive Impairment Study Group

2. Why the ABCDE Protocol?

3. Need for Sedation and Analgesia
Prevent pain and anxiety
Decrease oxygen consumption
Decrease the stress response
Patient-ventilator synchrony
Avoid adverse neurocognitive sequelae
Depression, PTSD
Rotondi AJ, et al. Crit Care Med. 2002;30:
Weinert C. Curr Opin in Crit Care. 2005;11:
Kress JP, et al. Am J Respir Crit Care Med. 1996;153:

4. Potential Drawbacks of Sedative and Analgesic Therapy
Oversedation:
Failure to initiate spontaneous breathing trials (SBT) leads to increased duration of mechanical ventilation (MV)
Longer duration of ICU stay
Impede assessment of neurologic function
Increase risk for delirium
Numerous agent-specific adverse events
Background on purpose and hazzard of potent psychoactive medications
Kollef MH, et al. Chest. 1998;114:
Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.

5. Cognitive and Functional Impairment, Institutionalization, Mortality
Patient with Sepsis
Mechanical
Ventilation
Sedation
Weakness
Delirium
Cognitive and Functional Impairment, Institutionalization, Mortality
Vasilevskis et al Chest 2010; 138;

6. 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
Pull and add pratik’s here.
Vasilevskis et al Chest 2010; 138;

7. What is the MIND-USA ABCDE Protocol?
Awakening and Breathing Coordination Delirium Identification and Management Early Exercise and Mobility D E

8. Awakening and Breathing Coordination
ABC
Awakening and Breathing Coordination

9. ICU Sedation: It’s a Balancing Act
Over sedation
Patient Comfort and
Ventilatory Optimization 9

10. Consequences of Suboptimal Sedation
Inadequate sedation/analgesia
Excessive sedation
Anxiety
Pain
Patient-ventilator dyssynchrony
Agitation
Self-removal of tubes/catheters
Care provider assault
Myocardial ischemia
Family dissatisfaction
Prolonged mechanical ventilation, ICU LOS
Tracheostomy
DVT, VAP
Additional testing
Added cost
Inability to communicate
Cannot evaluate for delirium 10

11. Structured Approaches to Sedation & Analgesia in the ICU
Multidisciplinary development, implementation
Establish goals/targets, frequently re-evaluate
Measure key components using validated scales
Select medications based on characteristics, evidence
Incorporate key patient considerations
Prevent oversedation, yet control pain and agitation
Promote multidisciplinary acceptance and integration into routine care
Sessler & Pedram. Crit Care Clinics 2009; 25:

12. 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)

13. 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
A sedation goal or endpoint should be established and regularly redefined for each patient. Regular assessment and response to therapy should be systematically documented.
Give examples of Insulin, Pressors and how we titrate to endpoint
Grade of recommendation = C
The use of a validated sedation assessment scale is recommended.
Grade of recommendation = B

14. Use Protocols to Achieve Goals, Minimize Drug Accumulation, 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

15. Discontinue all sedative and analgesic medications
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

16. Daily Awakening Trial Results
Shorter duration of mechanical ventilation
Shorter ICU LOS
Fewer tests for altered mental status
Kress et al. N Engl J Med 2000; 342:1471-7

17. Why Is Interruption of Sedation Effective?
Less accumulation of sedative drug and metabolites
Significantly less midazolam and morphine with DIS in midazolam subgroup
But… no difference in amount of propofol and morphine with DIS in propofol subgroup
Opportunity for more effective weaning from mechanical ventilation?
Wake Up and Breathe
Sessler CN. Crit Care Med 2004
Kress et al. NEJM. 2000

18. Multicenter RCT:
168 patients with “spontaneous awakening trial” (SAT)
i.e., daily interruption of sedation (SAT) + spontaneous breathing trial (SBT)
168 patients with standard sedation + SBT

20. “SAT + SBT” Was Superior to Conventional Sedation + SBT
Intervention (SAT) group = Less benzodiazepine
Extubated faster
Discharged from ICU sooner
P = 0.01
P = 0.02
Girard et al. Lancet 2008; 371:126-34

21. “SAT + SBT” Was Superior to Conventional Sedation + SBT
Discharged from hospital sooner
Better survival at 1 yr
P = 0.04
P = 0.01
P = 0.01
Alive
P = 0.02
Intervention (SAT) group = More unplanned extubation, but not more reintubation
Girard et al. Lancet 2008; 371:126-34

22. Awakening & Breathing Coordination
Synergy of daily awakening – via interruption of sedation – plus spontaneous breathing trial
Less medication accumulation, less excessive sedation
Opportunity for more effective independent breathing (SBT)
Perform safety screens for SAT and for SBT

23. ABC Safety Screens Wake Up Safety Screen No active seizures
No active alcohol withdrawal
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 vasopressor use
Girard et al. Lancet 2008; 371:
Kress et al. Crit Care Med 2004; 32(6):1272-6
Ely et al. NEJM 1996; 335:184-9

24. ABC Awakening & Breathing Coordination
Eligibility = On the ventilator
SAT Safety Screen - pass/fail
If pass safety screen, perform SAT
If fail; restart sedatives if necessary (1/2 dose)
If pass; continue to SBT safety screen
SBT Safety Screen - pass/fail
If pass safety screen, perform SBT
If fail; return to previous ventilatory support
If pass; consider extubation

25. Delirium Monitoring and Management

26. Delirium: Key Features
Disturbance of consciousness with reduced ability to focus, sustain or shift attention
A change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia
Develops over a short period of time and tends to fluctuate over the course of the day
There is evidence from the H&P and/or labs that the disturbance is caused by a medical condition, substance intoxication or medication side effect

27. Delirium Subtypes Hyperactive Delirium Mixed Delirium
Combative
Agitated
Restless
Mixed
Delirium
Alert & Calm
Lethargic
Sedated
Stupor
Hypoactive Delirium

28. 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
Each additional day spent in delirium was associated with a 20% increased risk of remaining in hospital and a 10% increased risk of death (7).
We are stressing that delirium is not the cause of these, but is one of the biggest predictors.
Ely, et al. ICM2001; 27,
Ely, et al, JAMA 2004; 291:
Lin, SM CCM 2004; 32:
Milbrandt E, et al, Crit Care Med 2004; 32:
Ouimet, et al, ICM 2007: 33:

29. Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or fluctuating course of mental status
And
Feature 2: Inattention
And
Feature 3: Altered level of consciousness
Feature 4: Disorganized thinking Or
Inouye, et. al. Ann Intern Med 1990; 113:
Ely, et. al. CCM 2001; 29:
Ely, et. al. JAMA 2001; 286:

30. Delirium Management 30 1. Identify etiology 2. Identify risk factors
3. Consider pharmacologic treatment
CPG provided this framework.
The best thing is they get us to look at etiology and risk factors before jumping to pharmacologic treatment.
Jacobi J, et al. Crit Care Med 2002;30: 30

31. Consider antipsychotics after evaluating etiology & risk factors
Stop and THINK
Do any meds need to be stopped or 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 Situations
CHF, shock, dehydration
New organ failure (liver/kidney)
Hypoxemia
Infection/sepsis (nosocomial), Immobilization
Nonpharmacologic interventions
Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation
K+ or electrolyte problems
Consider antipsychotics after evaluating etiology & risk factors

32. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients
852 patients ≥70 years old on general medicine service, no delirium at time of admission
Intervention: standardized protocol for management of 6 delirium risk factors (n=426)
Usual care: standard hospital services (n=426)
Primary Outcome: Delirium incidence & prevalence
Inouye, et al. NEJM. 1999;340:

33. Standardized Intervention
Elder Life Program
Targeted Risk Factor
Standardized Intervention
Cognitive impairment
Orientation & therapeutic activity protocol
(discuss current events, word games, reorient, etc)
Sleep deprivation
Sleep enhancement & nonpharm sleep protocol
(noise reduction, back massages, schedule adjustment)
Immobility
Early mobilization protocol
(active ROM, reduce restraint use, ambulation, remove catheters)
Visual impairment
Vision protocol
(glasses, adaptive equipment, reinforce use)
Hearing impairment
Hearing protocol
(amplification devices, hearing aids, earwax disimpaction)
Dehydration
Dehydration protocol
(early recognition of dehydration & volume repletion)
“Targeted risk factors were selected on the basis of evidence of their association with the risk of delirium and because they were amenable to intervention strategies considered feasible in the context of current hospital practice.”
Intervention provided by a trained interdisciplinary team: geriatric nurse specialist, ELP specialists, recreational therapist, PT consultant, geriatrician, trained volunteers.
Inouye, et al. NEJM. 1999;340:

34. Results Improved (p=0.04) orientation score with targeted intervention
Outcome
Intervention
Control
P-value
Incidence of delirium, N (%)
42 (9.9)
64 (15)
0.02
Total days of delirium
105
161
Episodes of delirium 62 90
0.03
Improved (p=0.04) orientation score with targeted intervention
Reduced rate of sedative use for sleep (p=0.001)
87% overall adherence to protocol
Inouye, et al. NEJM. 1999;340:

35. Delirium Nonpharmacologic Interventions
Eligibility = RASS ≥ -3
+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 <10 sec)
-3 MODERATE SEDATION Movement or eye opening to voice (no eye contact)
-4 DEEP SEDATION No response to voice, but movement or eye opening
to physical stimulation
-5 UNAROUSEABLE No response to voice or physical stimulation

36. Delirium Nonpharmacologic 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

37. Nonpharmacologic Interventions
Sensory:
Determine need for hearing aids and/or eye glasses
If needed, request surrogate provide these for patient when appropriate
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)

38. Early Exercise and Mobility

39. Early Exercise in the ICU
Early exercise = progressive mobility
Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation
Wake Up, Breathe, and Move
Schweickert WD, et al. Lancet. 2009;373:

40. Early Exercise Study Results
Outcome
Intervention
(n=49)
Control
(n=50) P
Functionally independent at discharge
29 (59%)
19 (35%)
0.02
ICU delirium (days)
2.0 ( )
4.0 ( )
0.03
Time in ICU with delirium (%)
33 (0-58)
57 (33-69)
Hospital delirium (days)
4.0 ( )
Hospital days with delirium (%)
28 (26)
41 (27)
0.01
Barthel index score at discharge
75 (7.5-95)
55 (0-85)
0.05
ICU-acquired paresis at discharge
15 (31%)
27 (49%)
0.09
Ventilator-free days
23.5 ( )
21.1 ( )
Length of stay in ICU (days)
5.9 ( )
7.9 ( )
0.08
Length of stay in hospital (days)
13.5 ( )
12.9 ( )
0.93
Hospital mortality
9 (18%)
14 (25%)
0.53
24% improvement (1.7-fold better) return to independent functional status at discharge (NNT=4)
Standing
Marching
Walking
Transferring
*P<0.001
Milestones achieved safely ~3 dyas earlier
Schweickert WD, et al. Lancet. 2009;373:

41. Early Exercise and Mobility
Eligibility = All patients are eligible for Early Exercise and Mobility

42. Perform Safety Screen First
Patient responds to verbal stimulation (i.e., RASS > -3)
FIO2 <0.6
PEEP <10 cmH2O
No  dose of any vasopressor infusion for at least 2 hours
No evidence of active myocardial ischemia (24 hrs)
No arrhythmia requiring the administration of new antiarrhythmic agent (24hrs)
If patient passes Exercise/Mobility Safety Screen, move on to Exercise and Mobility Therapy
If patient fails, s/he is too critically ill to tolerate exercise/mobility

43. Early Exercise & Mobility Levels of Therapy*
Active range of motion in bed and sitting position in bed
Dangling
Transfer to chair (active), includes standing without marching in place
Ambulation (marching in place, walking in room or hall)
*All may be done with assistance.
Range of motion in bed includes bed adjustment, passive transfer, or transfer with lift assistance

44. No Exercises, but Passive Range of Motion allowed
Early Exercise and Mobility Protocol Progression
Active ROM (in bed)
Sit/ Dangle
March/ Walk
Transfer
No Exercises, but Passive Range of Motion allowed
Progress as tolerated
ICU Discharge
Exercise screen
RASS ≥ -3
RASS -5 / -4

45. Benefits of ABCDE Protocol
Morandi A et al. Curr Opin Crit Care,2011;17:43-9

46. Questions? www.ICUdelirium.org delirium@vanderbilt.edu
The website is a great resource.