Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

Abstract

Background and SignificanceAdvances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children.Material and MethodsA narrative review of existing literature was used.ResultsOne obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics.ConclusionIn addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.

Risk factors of delirium in a paediatric intensive care unit: A prospective case series study

“…In our study, we also tried to reduce the use of sedative medications or physical restraints, but the implementation rate was low because nurses were concerned about the occurrence of adverse events such as unplanned extubation or falling down the bed. According to Engel et al, 32 the use of ABCDEF bundles can reduce the impact of mechanical ventilation on delirium in critically ill children. Family education and empowerment represent a key element, and we can try to invite parents to participate in the care and treatment of children in the future, which may help to reduce the use of sedative drugs and physical restraints.…”

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

“…Although the implementation of an algorithm for the management of pain, sedation, delirium, and IWS is an important first step for critically ill children, a cultural shift that includes the ABCDEF bundles is important (97,118), along with engaging patients and families through family-centered care (119,120).…”

Pediatric Delirium Educational Tool Development With Intensive Care Unit Clinicians and Caregivers in Canada: Focus Group Study

“…Family-based identification can be comparable to clinical identification [ 14 ] and is essential in pediatrics, given that only 2% to 7% of PICU patients are routinely screened for delirium [ 4 ]. Thus, empowering caregivers to increase their understanding and involvement in preventing, detecting, and managing delirium has been suggested [ 9 , 12 - 14 , 20 , 21 ]. Despite these recommendations and the clinical relevancy of delirium, family caregiver education remains rare [ 10 ], representing an opportunity to implement practical educational tools in the PICU.…”