2. AACN PEARL: Implementing the ABCDE Bundle at the Bedside
An Evidence-Based Approach for Managing the Complex Care of the Critically and Acutely Ill Patient
How to Use This Tool:
This presentation is designed as a tool to educate teams about the ABCDE Bundle. It provides a brief introduction to the evidence-based patient care strategies designed to minimize the unintended consequences associated with acute and critical illness.
While all of this content is applicable to mechanically ventilated adult patients, elements of the ABCDE bundle apply to all patients with acute or critical illness, no matter where their physical location. If you work in a Pediatric Intensive Care Unit, your patients are equally at risk for developing similar unintended consequences as their adult counterparts. Unfortunately, there is little research available on the effectiveness of awakening and breathing trials or mobility protocols in the pediatric population. However, there is an evidence-based, valid and reliable tool to assess for pediatric delirium. Overall the tools, drugs and assessment parameters may differ but the approach is similar across all age groups along the continuum of acute and critical illness. When applying the elements of the ABCDE Bundle to a pediatric or progressive care population, it is important to look at the risk of using a tool or assessment vs. the benefit of implementation to improve patient outcomes.
This presentation may be used in its entirety as-is or supplemented with your organization-specific resources. It can also be broken down into short in-services or used for poster presentations.
The presentation includes:
Introduction to the ABCDE Bundle
Benefits of the ABCDE Bundle
Awakening and Breathing Trial Coordination elements
Delirium Assessment and Management elements
Early Exercise and Progressive Mobility elements
NOTE: Extensive speaker notes are included with this presentation. Click on View > Notes Page

3. Why Another Bundle?
Managing critically ill patients is becoming more complex
Effective care requires alignment of people, processes and technology
A bundle approach provides a guide to coordinating evidence-based care practices at the bedside
Over the past decade, there has been an increased focus on providing evidence-based care to patients across the continuum of care. Heightened attention to quality and patient outcomes has permeated everything we do from oral care to skin care to managing sepsis, and so on. As we become increasingly awareness of the unintended consequences of the critical care we provide, we must continue to diligently seek evidence that supports the interventions designed to return the patients in our care to their normal lives.
Over the past several years, more and more evidence has come to light on how to best manage patients with critical illnesses. So much information is available on this subject that articles about Intensive Care Unit practices can be found in mainstream media such as the Wall Street Journal.
For patients to move safely through our complex systems, there must be a collaboration and alignment of people, processes and technology. The bundle approach provides a guide that assists with aligning all of these factors.

4. ABCDE Bundle Evidence-based organizational approach
Improves collaboration among clinical team members
Standardizes care processes
Breaks the cycle of oversedation and prolonged ventilation in critically ill patients
The ABCDE bundle consists of five interdependent components designed to:
Provide an evidence-based approach
Improve collaboration
Standardize care processes
Address oversedation and prolonged mechanical ventilation

5. ABCDE Bundle Components
Awakening & Breathing Trial Coordination
Delirium Assessment & Management
Early Exercise & Progressive Mobility
ABCDE Bundle Components
The major components of the ABCDE Bundle are:
Awakening and Breathing Trial Coordination: This is a collaborative approach to administering the appropriate type and amount of sedation, safely allowing the patient to wake up daily, and safely evaluating the patient’s ability to breathe independently of the ventilator. The ABC approach requires cooperation between physicians, nurses, respiratory therapists and pharmacists. If your patient is not ventilated but is sedated, elements of this bundle will apply as well.
Delirium Assessment and Management: This bundle element involves daily monitoring for the presence of delirium, as well as addressing the presence of pain and agitation. Valid, reliable and quick assessment tools are necessary. Managing delirium is currently an area of great focus. While no single drug is the “magic bullet” for minimizing the effects of delirium, research continues to identify the most effective management strategies – both pharmacologic and non-pharmacologic. All patients should be assessed for the presence of delirium.
Early Progressive Mobility: This final component of the bundle incorporates everything from passive and active range of motion to ambulation, all dependent upon a variety of safety factors. Whether a patient is in the critical care unit or on a progressive care unit, safely mobilizing patients will improve their outcomes. All patients should be evaluated and assessed for progressive mobility needs.

6. ABCDE Bundle Benefits Decreased ventilator time
Decreased ICU length of stay
Improved return to normal brain function
Increased independent functional status
Improved patient and family satisfaction
Increased survival
Patient outcomes are enhanced by implementation of the ABCDE Bundle in its entirety. Each component of the bundle contributes to an improved outcome for the patient that, when combined, have a synergistic effect.

7. Multi-Professional Collaboration
Patient & Family
Nurses
Physicians
Respiratory Care
Pharmacist
Physical Therapist
Dietician
Admin. Support
As previously noted, collaboration is a key component of the bundle. All members of the multi-professional team must effectively communicate and coordinate care in order to meet the outcomes referenced in this bundle. The use of daily rounds and daily goals sheets can facilitate this process.

8. Awakening and Breathing Trial Coordination
The ABC component of the bundle addresses both sedation and breathing trials. The goal is to minimize patient sedation as much as possible to facilitate efforts to wean them from ventilator support.

9. The Problem Negative outcomes of prolonged ventilation VAP Immobility
Delirium
Sedation used to relieve anxiety and agitation
Oversedation
Undersedation
Harmful outcomes
Evidence demonstrates that prolonged ventilation has a variety of negative outcomes. We are all familiar with ventilator-associated pneumonia (VAP), as well as the muscle-wasting resulting from prolonged immobility. As we’ll learn later, delirium is underdiagnosed but has dire consequences.
Sedation is used to manage anxiety and agitation. However, the medications themselves have consequences when used for prolonged periods of time. Oversedation is as common in the mechanically ventilated patient as is undersedation. Achieving the right balance for each individual patient can be a challenge. The harmful outcomes associated with inappropriate management of anxiety and agitation are well known.

10. Evidence-Based Management
Targeted Sedation Protocols
Effective in achieving sedation goals
Minimize drug accumulation
Maximize alertness
Spontaneous Awakening Trials (SAT)
Decrease ventilator time
Decrease complications without increased psychological discomfort
Spontaneous Breathing Trial (SBT)
Objective screening
Decreases time on ventilator
Decreases complications
The ABCDE Bundle specifically addresses the components of the spontaneous awakening trials and spontaneous breathing trials. Having a targeted sedation protocol to achieve the best balance for the patient lies at the heart of all of these strategies.
Patient safety serves as the core of both the SAT and SBT.

11. ABC Protocol Synergy of SAT & SBT Decreased medication accumulation
Decreased oversedation
Increased opportunity for effective independent breathing
“Wake Up and Breathe” Protocol
Combines SAT and SBT
Two step process
Safety screen
Trial period
Using the SAT and SBT together achieves better patient outcomes. Each protocol is a two-step process that includes a safety screening followed by a trial period. If the patient fails the safety screening, the trial is not initiated that day.

12. Wake Up and Breathe Protocol
The Wake Up and Breathe Protocol was developed by experts at Vanderbilt University. This chart illustrates one example of a spontaneous awakening trial and spontaneous breathing trial. Others are available but most incorporate the same elements. As you can see, the protocol is performed every 24 hours. If at any time the patient fails the screening or the trial, they are returned to the targeted sedation protocol and/or ventilator support.
© 2008 Vanderbilt University. All rights reserved.

13. Coordination and Collaboration
Collaborate
Spontaneous
Awakening
Trial
Breathing
RN, RT and physician communicate patient’s status
Consideration of new therapy goals
SAT Safety Screen
Sedation off or decreased
SBT Safety Screen
Begin SBT
RT and RN monitoring patient
Communicate with RT regarding patient’s tolerance of SAT
The SAT and SBT cannot be done without true collaboration between the nurse and respiratory therapist. The SAT screen is completed first and if the patient passes the screening, they move on to the trial phase. Sedatives are decreased until the patient is awake and responsive. Once the SAT is passed, the SBT safety screen is completed. Upon passing the screen, the SBT trial is performed. If the patient passes the trial, extubation should be considered.

14. Delirium Assessment and Management
Acutely and critically ill patients are at risk for developing delirium. Delirium frequently goes undiagnosed. Because patients with delirium are at higher risk for poor outcomes, it is crucial that we learn to apply evidence-based practices to prevent, identify and manage delirium.

15. The Problem Affects up to 60-80% of mechanically ventilated patients
Generates $4-16 billion annually in associated costs in the U.S.
Associated with increased:
Length of stay
Ventilator time
Mortality
Long-term neuropsychological deficits
Undetected and untreated in many patients
Delirium impacts between 60 and 80 percent of mechanically ventilated patients in the U.S. This results in anywhere from $4-16 billion dollars in associated costs annually.
Efforts aimed at prevention, early detection and management of delirium patients often results in decreased ventilator times, decreased length of stays, decreased mortality rates and a decrease in longterm neuropsychological deficits.
Delirium also occurs in patients who are not mechanically ventilated, so don’t assume non-ventilated patients are not at risk.

16. Delirium Defined
Acute change in consciousness accompanied by inattention and either a change in cognition or perceptual disturbance
Three subtypes:
Hyperactive: Agitation, restlessness, attempts to remove catheters, emotionally labile
Hypoactive: Flat affect, withdrawal, apathy, lethargy, decreased responsiveness
Mixed: Combination of hypoactive and hyperactive
There are three subtypes of delirium:
Hyperactive delirium is characterized by restlessness, agitation and emotional lability.
Hypoactive delirium is found in 34 percent of patients experiencing any delirium. It is associated with the worst prognosis and is characterized by psychomotor slowing demonstrated by a calm appearance, inattention and decreased mobility.
Mixed delirium is characterized by periods of hypoactivity fluctuating with periods of hyperactivity.

17. Evidence-Based Management
Assess for presence of delirium
Baseline risk factors to identify susceptibility
Pre-existing dementia
History of baseline hypertension
Alcoholism
Admission severity of illness
Standardized assessment tool to detect delirium that would otherwise go undetected
Two valid and reliable tools
Confusion Assessment Method for the ICU (CAM-ICU)
Intensive Care Delirium Screening Checklist (ICDSC)
Identifying patients at risk for developing delirium is the first step in preventing delirium from developing.
Mechanically ventilated patients should be assessed for the presence of delirium every 24 hours using a standardized, valid and reliable tool.
For critically ill adults, two assessment tools are available:
CAM-ICU
ICDSC
In the progressive care population: the CAM-ICU has not been validated for this patient population in this specific location however, it has been validated in both ventilated and non-ventilated patients. Validation studies for the CAM-ICU have also included progressive care non-ventilated patients.
For pediatric patients, use of the pCAM –ICU tool has been validated in patients ranging in age from five to 17 years old. An alternative slide depicting pCAM-ICU tool is included at the end of this presentation.

18. CAM-ICU Assessing for delirium is a two-step process.
Step One: Assess level of consciousness.
Utilize a standard sedation/arousal scales such as RASS or Ramsey
If the patient is at a deep level of consciousness, such as “coma” or “stupor,” the assessment is stopped. It is not possible to assess for the presence of delirium at that level.
Step Two: Evaluate for signs of delirium.
Four features of CAM-ICU – Mental status, inattention, level of consciousness and disorganized thinking.
Once you are familiar with the CAM-ICU tool, it takes about two minutes to complete.
NOTE: An alternative slide illustrating pediatric delirium assessment (pCAM-ICU) is included at the end of this presentation.
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

19. Stop, Think and (Perhaps) Medicate
Do any medications (especially benzo-diazepines) need to be stopped or lowered?
Is the patient on the minimal amount of sedation necessary? Do any titration strategies need to be used, such as a targeted sedation plan or daily sedation cessation?
Do the sedative drugs need to be changed?
A helpful way to think about preventing and managing delirium is to stop, think and, if needed, medicate.
The questions on this slide are useful to consider when assessing the patient or discussing the patient on rounds.
Benzodiazepines are an independent risk factor for the transition to delirium.
In studies comparing dexmedetomidine with benzodiazepines, patients receiving dexmedetomidine demonstrated a reduction in the duration of delirium. It is important to consider all drugs that the patient is on – no matter where they are physically located – and determine the risk to the patient for developing delirium.

20. Stop, Think and (Perhaps) Medicate
Toxic situations
CHF, shock, dehydration
Deliriogenic medications
New organ failure
Hypoxemia
Infection or sepsis
Immobilization
Non-pharmacologic interventions employed?
Glasses, hearing aids, reorientation, sleep protocols, noise control
K+ or electrolyte problems
THINK – Are there any potential causes of delirium present? T-H-I-N-K provides a mnemonic to help us remember some of those causes.

21. Stop, Think and (Perhaps) Medicate
No FDA-approved drug to treat delirium
Haloperidol (Haldol) and atypical antipsychotics (ziprasidone [Geodon], quetiapine [Seroquel])
Traditionally recommended medication class to treat delirium
Little evidence to support treatment
All patients receiving antipsychotics should be routinely monitored for side effects, especially QT prolongation
Currently no drug is approved by the FDA to treat delirium. In fact, many drugs we routinely use to manage delirium have little evidence to support their use.

22. Patient and Family Education
Involving family and friends in early identification of behaviors associated with delirium (e.g. when the patient is not “acting normal”) may be an early warning. Education can be helpful in allaying fears and fostering an understanding of delirium.
Click to download sample brochure

23. Early Exercise and Progressive Mobility
Prolonged bedrest can cause muscle atrophy and wasting no matter where the patient is physically located. Implementing an early exercise and progressive mobility protocol will help reduce this unintended consequence of acute illness.

24. The Problem
ICU-acquired weakness – Acute onset of neuromuscular/functional impairment without plausible etiology
Impairs ventilator weaning and functional mobility
Patients with ICU-acquired weakness require approximately 20 additional ventilator days
Increased mortality
Effects persist well after discharge
As with the other elements of the ABCDE Bundle, persistent weakness in the acutely ill has a negative impact on patient outcomes.

25. Evidence-Based Management
Early mobility protocols (early exercise, progressive mobility)
Progress from passive to active range of motion (early PT)
Sitting position in bed
Dangle
Stand & Transfer
Ambulation
Screen for participation
Two-step process
Safety screen
Mobility protocol
Implementation of an early mobility protocol can improve patient outcomes. As with the other components of the bundle, a safety screening is performed first, even for patients who were active and mobile prior to hospital admission.

26. Sample Progressive Mobility Protocol
Passive ROM TID
Turn Q 2 hrs.
Active resistance PT
Sitting position 20 mins. TID
Sitting on edge of bed
Active transfer to chair 20 mins./day
Ambulation (marching in place, walking in halls)
Safety Screening (Patient must meet all criteria)
M – Myocardial stability
No evidence of active myocardial ischemia x 24 hrs.
No dysrhythmia requiring new antidysrhythmic agent x 24 hrs.
O – Oxygenation adequate on:
FiO2 < 0.6
PEEP < 10 cm H2O
V - Vasopressor(s) minimal
No increase of any vasopressor x 2 hrs.
E – Engages to voice
Patient responds to verbal stimulation
Level 4
Level 3
Level 2
Level 1
In this sample protocol, there are two steps:
Step 1: The patient must pass all elements of the safety screen. If the patient is unable to pass the safety screen, the patient remains on bedrest with regular repositioning and passive range of motion as tolerated.
Step 2: Once the patient has passed the safety screening protocol, therapy can be performed. Therapy starts at level one and progresses as the patient tolerates.
Able to move leg against gravity
Able to move arm against gravity

27. ABCDE Bundle Improved Patient Outcomes
Awakening & Breathing Trial Coordination
Choice of Sedation
Daily Delirium Monitoring
Early Exercise & Mobility
Implementing the ABCDE Bundle will help complex, acutely and critically ill patients move through the unit in a safer manner with better outcomes. Collaboration and coordination with all members of the multi-professional team is vital to the success of all the components of the bundle. Implementation of the ABCDE Bundle can seem overwhelming at first and should be approached one step at a time.

28. References Awakening and Breathing Trial Coordination
Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995; 332:
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Girard 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 randomized controlled trial. Lancet 2008; 371:126-34
Jackson, JC, et al. Long-term Cognitive and Psychological Outcomes in the Awakening and Breathing Controlled Trial. Am. J. Respir. Crit. Care Med. 2010; 182:183–191.
Patel, R, et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med Mar; 37(3):
Mehta S, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med Feb;34(2):

29. References Delirium Assessment and Management
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely EW (2006) Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 54:479–484
Pisani MA, Murphy TE, Van Ness PH, Araujo KL, Inouye SK. Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med. 2007;167(15):1629–1634.
Pandharipande P, Cotton BA, Shintani A, et al. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma. 2008;65(1):34–41.
Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM- ICU). Crit Care Med. 2001;29(7):1370–1379.
McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc. 2003;51(5):591–598.
Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med. 2004;32(4):955–962.
Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAVA. 2004;291(14):1753–1762
Ely EW, Gautam S, Margolin R, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001;27(12):1892–1900.
Jackson JC, Hart RP, Gordon SM, et al. Six-month neuropsychological outcome of medical intensive care unit patients. Crit Care Med. 2003;31(4):1226–1234.

30. References Delirium Assessment and Management, cont.
Hopkins RO, Jackson JC. Assessing neurocognitive outcomes after critical illness: are delirium and long-term cognitive impairments related? Curr Opin Crit Care. 2006;12:388–394.
Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513–1520.
Fong TG, Jones RN, Shi P, et al. Delirium accelerates cognitive decline in Alzheimer disease. Neurology. 2009; 72(18):1570–1575.
Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective non- cardiac surgery. JAMA. 1994;271(2):134–139.
Pun, BT et al. Large-scale implementation of sedation and delirium monitoring in the intensive care unit: A report from two medical centers. Crit Care Med 2005; 33:1199 –1205.
Devlin JW, Fong JJ, Schumaker G, O’Connor H, Ruthazer R, Garpestad E. Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients. Crit Care Med. 2007;35(12):2721–2724.
Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann Emerg Med. 2002;39:338–341.
Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39(3):248–253.
Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009;35(7):1276–1280.
Van Eijk MM, van Marum RJ, Klijn IA, de WN, Kesecioglu J, Slooter AJ. Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med. 2009;37(6): 1881–1885.

31. References Delirium Assessment and Management, cont.
Pisani MA, Murphy TE, Van Ness PH, Araujo KL, Inouye SK. Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med 2007 August 13;167(15):
Pisani MA, Murphy TE, Araujo KL, Slattum P, Van Ness PH, Inouye SK. Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 2009;37(1):
Pandharipande P, Shintani A, Peterson J et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006 January;104(1):21-6.
Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007 January;33(1):66-73.
Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L. Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 2009 May 20;13(3):R77.
Dubois MJ, Bergeron N, Dumont M, Dial S, Skrobik Y. Delirium in an intensive care unit: a study of risk factors. Intensive Care Med 2001 August;27(8):
Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009 July;35(7):
Van Eijk MM, van Marum RJ, Klijn IA, de WN, Kesecioglu J, Slooter AJ. Comparison of delirium assessment tools in a mixed intensive care unit. Crit Care Med 2009 June;37(6):
Jacobi J, Fraser GL, Coursin DB et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002 January;30(1):
Borthwick M, Bourne R, Craig M, Egan A, Oxley J, for the United Kingdom Clinical Pharmacy Association. Detection, prevention and treatment of delirium in critically ill patients. United Kingdom Clinical Pharmacy Association 2006;1.2. Available at URL: Accessed January 25, 2010.

32. References Delirium Assessment and Management, cont.
Young J, Anderson D, Gager M et al. Delirium: diagnosis, prevention and management. National Institute for Health and Clinical Excellence 2010; Available at: URL: Accessed January 19, 2010.
Martin J, Heymann A, Basell K et al. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care - short version. Ger Med Sci 2010;8:Doc02.
Ely EW, Margolin R, Francis J et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001 July;29(7):
Ely EW, Inouye SK, Bernard GR et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001 December 5;286(21):
Lin SM, Liu CY, Wang CH et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 2004 November;32(11):
Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001 May;27(5):
Roberts B, Rickard CM, Rajbhandari D et al. Multicentre study of delirium in ICU patients using a simple screening tool. Aust Crit Care 2005 February;18(1):6, 8-4
Pandharipande PP, Pun BT, Herr DL et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007 December 12;298(22):
Riker RR, Shehabi Y, Bokesch PM et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009 February 4;301(5):

33. References Delirium Assessment and Management, cont.
Pandharipande PP, Sanders RD, Girard TD et al. Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS randomized controlled trial. Crit Care 2010 March 16;14(2):R38.
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Atypical antipsychotics in the elderly. The Medical Letter 2005;47(1214):61-2.
Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005 October 19;294(15):
Wang PS, Schneeweiss S, Avorn J et al. Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med 2005 December 1;353(22):
Girard TD, Pandharipande PP, Carson SS et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med 2010 February;38(2):
Devlin JW, Roberts RJ, Fong JJ et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med 2010 February;38(2):
Van Eijk MM, Roes KC, Honing ML et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet 2010 November 4.
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):

34. References Delirium Assessment and Management, cont.
Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91(4):
Soja SL, et al. Intensive Care Med 2008 July;34(7):1263-8

35. References Early Exercise and Progressive Mobility
Stevens RD, Marshall SA, Cornblath DR, et al. A framework for diagnosing and classifying intensive care unit-acquired weakness. Crit Care Med. 2009;37(10)(suppl):S299-S308.
Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ. Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiatry. 1984; 47(11):
Berek K, Margreiter J, Willeit J, Berek A, Schmutzhard E, Mutz NJ. Polyneuropathies in critically ill patients: a prospective evaluation. Intensive Care Med. 1996;22(9):
De Jonghe B, Cook D, Sharshar T, Lefaucheur JP, Carlet J, Outin H. Acquired neuromuscular disorders in critically ill patients: a systematic review. Groupe de Reflexion et d’Etude sur les Neuromyopathies En Reanimation. Intensive Care Med. 1998;24(12):
de Letter MA, Schmitz PIM, Visser LH, et al. Risk factors for the development of polyneuropathy and myopathy in criti- cally ill patients. Crit Care Med. 2001;29(12):
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345(19):
Bercker S, Weber-Carstens S, Deja M, et al. Critical illness polyneuropathy and myopathy in patients with acute respiratory distress syndrome. Crit Care Med. 2005;33(4):
Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91(4):
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):

36. References Early Exercise and Progressive Mobility, cont.
Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):
Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010;38(11):2089–2094.
Ross AG, Morris PE. Safety and barriers to care. Crit Care Nurse. 2010;30(2):S11–S13.

37. pCAM-ICU Note: Pediatric alternative to CAM-ICU slide.
Assessing for delirium is a two-step process:
Step One: Assess level of consciousness.
Utilize a standard sedation/arousal scales such as RASS or MMAAS or SBS.
If the patient is at a deep level of consciousness, such as “coma” or “stupor,” the assessment is stopped. It is not possible to assess for the presence of delirium at that level.
Step Two: Evaluate for signs of delirium.
Four features of CAM-ICU – Mental status, inattention, level of consciousness and disorganized thinking.
Once you are familiar with the pCAM-ICU tool, it takes about two minutes to complete.