Worldwide Survey of the “Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment” (ABCDEF) Bundle

Abstract

Objective To assess the knowledge and use of the ABCDEF bundle to implement the Pain, Agitation, Delirium (PAD) guidelines. Design Worldwide On-line Survey. Setting Intensive care. Intervention A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle (Assessment, prevention and management of pain; spontaneous awakening and Breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise and Family engagement and empowerment.) Measurement and Main Results There were 1521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. SATs and SBTs are performed in 66% and 67% of the responder ICUs respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was “prescribed” by most but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU acquired weakness. Family members were actively involved in 67% of ICUs, however only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hours/day for family visits. Conclusions The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift towards patient- and family-centered ICU care in accordance with the PAD guidelines.

ICU delirium ― a diagnostic and therapeutic challenge in the intensive care unit

“…ICU delirium is monitored only in 12% of ICUs; sedation > 24 h is predominantly induced with benzodiazepines which are also often used to treat delirium [4]. The study by Morandi et al [5] evaluating the same aspect of management worldwide has demonstrated that monitoring of delirium was implemented in 70% of ICUs while a proven diagnostic tool was used only in 42% of them.…”

Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness

“…For more than 40 years, intravenous antipsychotic medications have been used to treat delirium in hospitalized patients. 16,[35][36][37][38][39] In an international survey of 1521 intensivists, 65% reported that they treat delirium in the ICU with haloperidol and 53% reported that they treat delirium with atypical antipsychotic medications. 16 In this double-blind, randomized, placebo-controlled trial of intravenous antipsychotic medications for the treatment of delirium in the ICU, there was no evidence that either haloperidol or ziprasidone led to a shorter duration of delirium and coma.…”

“…Hyperactive delirium can lead to unplanned removal of devices, 12 whereas hypoactive delirium prevents participation in nursing interventions, physical therapy, and occupational therapy. 13 Haloperidol, a typical antipsychotic medication, is often used to treat hyperactive delirium in the ICU, and surveys suggest that the drug is also used to treat hypoactive delirium [14][15][16][17] despite two small randomized trials that showed no evidence that haloperidol results in a shorter duration of delirium in the ICU than placebo. 18,19 Atypical antipsychotic medications, such as olanzapine, quetiapine, risperidone, and ziprasidone, are also used for this purpose, and one placebocontrolled trial has suggested a benefit, 20 whereas another 18 showed no evidence of benefit.…”

Delirium Management, Treatment and Prevention Solid Organ Transplantation

“…Of note, neither antipsychotics nor dexmedetomidine have FDA approval for the treatment of delirium. In an international survey of 1521 intensivists, 65% reported that they treat delirium in the intensive care unit with haloperidol and 53% reported that they treat delirium with atypical antipsychotic medications [65], but there is no evidence-based literature showing efficacy of these medications for delirium treatment and symptom resolution. Despite current practice patterns, there are few data to support their definitive use in treating delirium.…”