ABCDE Protocol and MIND-USA: Enhancing Critical Care Practices

ABCDE Protocol
ICU Delirium and Cognitive Impairment Study Group
www.icudelirium.org
delirium@vanderbilt.edu
Why the ABCDE Protocol?
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
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
Kollef MH, et al. 
Chest
. 1998;114:541-548.
Pandharipande PP, et al. 
Anesthesiology
. 2006;104:21-26.
Sedation
Mechanical
Ventilation
Delirium
Weakness
Patient with
Sepsis
Cognitive and Functional Impairment, Institutionalization, M
ortality
Vasilevskis et al Chest 2010; 138;1224-1233
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;1224-1233
What is the MIND-USA
ABCDE Protocol?
 Awakening and Breathing
 Coordination
Delirium Identification and
 Management
 Early Exercise and Mobility
ABC
D
E
A
wakening and
B
reathing 
C
oordination
Over sedation
Patient Comfort and
Ventilatory Optimization
 
ICU Sedation: It’s a Balancing
Act
Consequences of Suboptimal
Sedation
Inadequate
sedation/analgesia
Anxiety
Pain
Patient-ventilator
dyssynchrony
Agitation
Self-removal of
tubes/catheters
Care provider assault
Myocardial ischemia
Family dissatisfaction
Excessive sedation
Prolonged mechanical
ventilation, ICU LOS
Tracheostomy
DVT, VAP
Additional testing
Added cost
Inability to
communicate
Cannot evaluate for
delirium
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
Sessler & Pedram. Crit Care Clinics 2009; 25:489-513
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)
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
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
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
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
Daily Awakening 
Trial Results
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?
Sessler CN. Crit Care Med 2004
Kress et al. 
NEJM.
 2000
Wake Up and Breathe
 
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
“SAT + SBT” Was Superior to
Conventional 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
“SAT + SBT” Was Superior to
Conventional Sedation + SBT
Intervention (SAT) group = 
More unplanned
extubation, but not more reintubation
P = 0.02
P = 0.01
Discharged from hospital sooner
Better survival at 1 yr 
Alive
P = 0.01
P = 0.04
Girard et al. Lancet 2008; 371:126-34
A
wakening 
&
 
B
reathing
C
oordination
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
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%
FiO
2
 
<
 50%
PEEP 
<
 7.5 cm H
2
O
No active myocardial
ischemia (24h)
No significant
vasopressor use
Girard et al. Lancet 2008; 371:126-34.
Kress et al. Crit Care Med 2004; 32(6):1272-6
Ely et al. NEJM 1996; 335:184-9
ABC
A
wakening & 
B
reathing 
C
oordination 
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
3.
SBT Safety Screen - pass/fail
4.
If pass safety screen, perform SBT
  
If fail
; return to previous ventilatory support
  
If pass
; consider extubation
D
D
elirium Monitoring and
Management
Delirium: Key Features
1.
Disturbance of 
consciousness
 
with reduced ability to
focus, sustain or shift 
attention
2.
A change in 
cognition
 
or the development of a
perceptual 
disturbance that is not better accounted
for by pre-existing,  established or evolving dementia
3.
Develops over a 
short period 
of time and tends to
fluctuate over the course of the day
4.
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
Delirium Subtypes
 
Alert & Calm
Combative
Agitated
Restless
Lethargic
Sedated
Stupor
 
Hyperactive Delirium
Hypoactive Delirium
Mixed 
Delirium
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, 1892-1900
Ely, et al, JAMA 2004; 291: 1753-1762
Lin, SM CCM 2004; 32: 2254-2259
Milbrandt E, et al, Crit Care Med 2004; 32:955-962.
Ouimet, et al,  ICM 2007: 33: 66-73.
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; 113:941-948.1
Ely, et. al. CCM  2001; 29:1370-1379.4
Ely, et. al. JAMA  2001; 286:2703-2710.5
Delirium Management
1.  Identify etiology
2.  Identify risk factors
3. Consider pharmacologic
treatment
Jacobi J, et al. 
Crit Care Med
 2002;30:119-141
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!
T
oxic Situations
CHF, shock, dehydration
New organ failure (liver/kidney)
H
ypoxemia
I
nfection/sepsis (nosocomial),
I
mmobilization
N
onpharmacologic  interventions
Hearing aids, glasses, reorient,
sleep protocols, music, noise
control, ambulation
K
+ or electrolyte problems
 
Consider antipsychotics after evaluating etiology & risk factors
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;340:669-676.
Elder Life Program
Inouye, et al. 
NEJM
. 1999;340:669-676.
Results
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;340:669-676.
Eligibility = RASS ≥ -3
D
elirium
Nonpharmacologic Interventions
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D
elirium
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
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)
E
arly 
E
xercise and Mobility
E
Early Exercise in the ICU
Early exercise = progressive mobility
Study design: paired SAT/SBT protocol
with PT/OT from earliest days of
mechanical ventilation
Schweickert WD, et al. 
Lancet.
 2009;373:1874-1882.
Wake Up, Breathe, and Move
Early Exercise Study Results
Schweickert WD, et al. 
Lancet.
 2009;373:1874-1882.
E
arly 
E
xercise and Mobility
Eligibility = All patients are
eligible for Early Exercise and
Mobility
Perform Safety Screen First
Safety Screen
Patient responds to verbal stimulation (i.e., RASS 
>
 -3)
FIO
2  
<
0.6
PEEP  
<
10 cmH
2
O
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
1.
Active range of motion in bed and sitting
position in bed
2.
Dangling
3.
Transfer to chair (active), includes standing
without marching in place
4.
Ambulation (marching in place, walking in
room or hall)
*All may be done with assistance.
E
arly 
E
xercise & Mobility
Levels of Therapy*
E
arly 
E
xercise and Mobility Protocol
Progression
Morandi A et al. Curr Opin Crit Care,2011;17:43-9
Benefits of ABCDE Protocol
Questions?
www.ICUdelirium.org
delirium@vanderbilt.edu
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Explore the importance of the ABCDE Protocol in managing ICU patients, focusing on sedation, analgesia, and the prevention of delirium. Learn about the potential drawbacks of sedative therapies and the need for coordinated care in critical care settings. Discover the MIND-USA ABCDE Protocol, emphasizing awakening, breathing coordination, delirium identification, and early exercise and mobility.

  • ABCDE Protocol
  • MIND-USA
  • Critical Care
  • Sedation
  • Delirium

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  1. ABCDE Protocol ICU Delirium and Cognitive Impairment Study Group www.icudelirium.org delirium@vanderbilt.edu

  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;30:746-752. 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.

  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 Kollef MH, et al. Chest. 1998;114:541-548. Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.

  5. Patient with Sepsis Mechanical Ventilation Sedation Weakness Delirium Cognitive and Functional Impairment, Institutionalization, Mortality Vasilevskis et al Chest 2010; 138;1224-1233

  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 Vasilevskis et al Chest 2010; 138;1224-1233

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

  8. ABC Awakening and Breathing Coordination

  9. ICU Sedation: Its a Balancing Act

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

  11. 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 Sessler & Pedram. Crit Care Clinics 2009; 25:489-513

  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

  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. 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

  19. 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

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

  21. 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

  22. 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; 371:126-34. Kress et al. Crit Care Med 2004; 32(6):1272-6 Ely et al. NEJM 1996; 335:184-9

  23. ABC Awakening & 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 3. SBT Safety Screen - pass/fail 4. If pass safety screen, perform SBT If fail; return to previous ventilatory support If pass; consider extubation

  24. D Delirium Monitoring and Management

  25. Delirium: Key Features 1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention 2. A change in cognition or the development of a perceptual disturbance that is not better accounted for by pre-existing, established or evolving dementia 3. Develops over a short period of time and tends to fluctuate over the course of the day 4. 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

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

  27. 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, 1892-1900 Ely, et al, JAMA 2004; 291: 1753-1762 Lin, SM CCM 2004; 32: 2254-2259 Milbrandt E, et al, Crit Care Med 2004; 32:955-962. Ouimet, et al, ICM 2007: 33: 66-73.

  28. 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; 113:941-948.1 Ely, et. al. CCM 2001; 29:1370-1379.4 Ely, et. al. JAMA 2001; 286:2703-2710.5

  29. Delirium Management 1. Identify etiology 2. Identify risk factors 3. Consider pharmacologic treatment Jacobi J, et al. Crit Care Med 2002;30:119-141

  30. Stop and THINK Do any meds need to be stopped or lowered? 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 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! Consider antipsychotics after evaluating etiology & risk factors

  31. Delirium Nonpharmacologic Interventions Eligibility = RASS -3 +4 +3 +2 +1 0 -1 COMBATIVE VERY AGITATED AGITATED RESTLESS ALERT & CALM DROWSY Combative, violent, immediate danger to staff Pulls to remove tubes or catheters; aggressive Frequent non-purposeful movement, fights ventilator Anxious, apprehensive, movements not aggressive Spontaneously pays attention to caregiver 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

  32. 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

  33. 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)

  34. E Early Exercise and Mobility

  35. 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;373:1874-1882.

  36. Early Exercise Study Results Intervention (n=49) Control (n=50) Outcome P Functionally independent at discharge 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 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 (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) 0.93 Hospital mortality 9 (18%) 14 (25%) 0.53 Schweickert WD, et al. Lancet. 2009;373:1874-1882.

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

  38. Perform Safety Screen First Safety Screen 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

  39. Early Exercise & Mobility Levels of Therapy* 1. Active range of motion in bed and sitting position in bed 2. Dangling 3. Transfer to chair (active), includes standing without marching in place 4. Ambulation (marching in place, walking in room or hall) *All may be done with assistance.

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

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

  42. Questions? www.ICUdelirium.org delirium@vanderbilt.edu

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