Adult ICU patient: daily ABCDEF bundle review
Apply each element to every adult ICU patient each day unless the team documents a reason not to. In comfort-focused care, apply only what fits the goals of care.
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Critical CareManagement
ICU Liberation ABCDEF Bundle
ICU Liberation ABCDEF Bundle: Adult ICU patient: daily ABCDEF bundle review → A: Assess, prevent and manage pain → Before an SAT: do not stop sedation i...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action A: Assess, prevent and manage pain
Assess pain routinely with a valid scale. Treat pain before you consider a sedative.
- Able to self-report: 0-10 numeric rating scale (NRS)
- Unable to self-report: Behavioral Pain Scale (BPS or BPS-NI) or CPOT
- Vital signs alone are not valid for pain; use them only as a cue to assess
- Stepwise, protocol-based analgesia; add non-opioid adjuncts (for example paracetamol) to reduce opioid use
- Reassess after each treatment and before procedures
03Warning Before an SAT: do not stop sedation if any of these apply
Screen patients on continuous sedation each day. If any item applies, continue sedation at the current rate and re-screen in 24 h.
- Neuromuscular blocker infusion (risk of awareness while paralysed), or ECMO
- Sedation for active seizures or alcohol withdrawal; RASS above +2 or escalating sedative doses
- Raised ICP: on therapy to control ICP, or ICP above 20 mmHg; or myocardial ischaemia in the past 24 h
04Action B1: SAT screen passed: spontaneous awakening trial (SAT)
Stop sedative infusions and hold sedative boluses. Continue opioid only if needed for active pain.
- Pass: opens eyes to voice with no failure signs, or no failure signs after 4 h off sedation
- Fail: RASS above +2, SpO2 below 88% or RR above 35/min for 5 min or more, new arrhythmia, ICP above 20 mmHg, or 2 or more signs of distress
- Fail: restart sedation at half the previous dose, titrate to the target, and find the cause on rounds
- Ventilated: coordinate with the SBT screen (next step) while the patient is awake
05Action B2: Ventilated and SBT screen passed: spontaneous breathing trial (SBT)
Do an SBT only if the screen passes. If it fails, keep full ventilator support and re-screen in 24 h.
- Screen (all needed): SpO2 88% or more on FiO2 0.5 or less and PEEP 7 cmH2O or less; inspiratory effort; no rising vasopressor dose
- Screen also needs: no myocardial ischaemia in 24 h, no raised ICP or ventilation to control ICP, no chronic ventilator dependence
- Method: low pressure support or T-piece; do not raise FiO2 during the SBT; screen before noon each day
- Fail: RR above 35/min for 5 min or more or below 8/min, SpO2 below 88% for more than 5 min, new arrhythmia, mental status change, or 2 or more signs of distress
- Fail: restore previous ventilator settings; restart sedation at half the previous dose only if needed
- Pass: team assesses for extubation the same day; high risk and ventilated over 24 h: extubate to preventive NIV
- High risk of post-extubation stridor: cuff-leak test; if it fails, give systemic steroids at least 4 h before extubation
06Action C: Choice of analgesia and sedation
Treat pain first. Aim for light sedation, except when deep sedation is needed (neuromuscular blocker, refractory raised ICP, status epilepticus). Benzodiazepines stay first line for alcohol or benzodiazepine withdrawal and for seizures.
- Sedate only for a clear reason; set a sedation target each day and check it with RASS or SAS
- Light sedation: RASS -2 to +1, kept with a daily SAT or nurse-protocolised targeted sedation
- Routine sedation of ventilated adults: propofol or dexmedetomidine rather than a benzodiazepine
- Dexmedetomidine rather than propofol when light sedation or less delirium is the priority; watch for bradycardia and hypotension
- Deep sedation needed: follow the specific protocol and reassess the need each day
07Action D: Delirium: assess, prevent and manage
Screen regularly with a valid tool (CAM-ICU or ICDSC). If positive, look for and treat the causes. No routine antipsychotics. Avoid haloperidol in Parkinson's disease, Lewy body dementia or a prolonged QTc.
- Positive: check for causes such as hypoxia, sepsis, pain, drugs, withdrawal and metabolic upset
- For all patients: reorientation, sleep, mobility, glasses and hearing aids
- Promote sleep: reduce noise and light at night; melatonin is suggested (PADIS 2025)
- Review and reduce deliriogenic drugs, especially benzodiazepines
- Do not give antipsychotics, dexmedetomidine, statins or ketamine only to prevent delirium (this does not change the sedative choice in step C)
- Treatment: no routine antipsychotics (PADIS 2025 makes no recommendation for or against)
- Significant distress, or danger to self or others: short-term haloperidol or an atypical antipsychotic may help; stop when symptoms resolve; IV haloperidol needs continuous ECG monitoring
- Ventilated, and agitation from delirium stops weaning: consider dexmedetomidine
08Action E: Early mobility and exercise
Mobilise each day when cardiovascular, respiratory and neurological status are stable. Vasopressors or ventilation alone do not prevent it. Defer if unstable.
- Defer if: vasopressor dose rising in the past 2 h, FiO2 above 0.6 or PEEP above 10 cmH2O, RASS below -3, active myocardial ischaemia, new antiarrhythmic, unstable fracture, or therapy that restricts mobility (for example ECMO, open abdomen)
- Progress as tolerated: in-bed exercise, sit on bed edge, stand, chair, walk
- Stop for new instability: SpO2 below 88%, HR below 50 or above 130/min, RR below 5 or above 40/min, SBP above 180 mmHg or symptomatic MAP drop, new arrhythmia
- Also stop for marked ventilator dyssynchrony, distress, a fall, or airway or device problems
- Enhanced mobilisation and rehabilitation rather than usual care (PADIS 2025); involve physiotherapy and occupational therapy
09Action F: Family engagement and empowerment
Include the family in care and decisions.
- Offer flexible family presence at the bedside
- Invite the family to ward rounds and give regular updates
- Hold structured family meetings on goals of care
- Support family well-being; offer social work or pastoral care
10Decision Each element done today, or documented as not indicated?
Check A to F before the end of the day.
- If Yes
11Action Yes: document bundle completion
Record each element as done, or not done with the reason.
- Track delirium days, ventilator days and mobility level
- Use the data for audit and quality improvement
12Outcome Repeat the bundle every day until ICU discharge
Reassess each element as the patient changes.
If No13Action No: find the barrier and complete the element today if safe
Do not let a missed element wait until tomorrow without a reason.
- Clinical reason: document it and re-screen tomorrow
- Staff or equipment gap: escalate to the nurse in charge
- Knowledge gap: give education; system issue: fix the process
- Path rejoins step 12Shared downstream outcome
Guideline Source
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS 2018), with the 2025 Focused Update
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Safety screens and pass/fail criteria follow published bundle protocols (ABC trial; Balas 2014). Use your unit protocol where it differs.
- Adults only. In comfort-focused or end-of-life care, apply only the elements that fit the goals of care.
- Gives no drug doses; use unit protocols and product information.
- Needs multidisciplinary team coordination and institutional protocols.
- Family presence may be limited by infection control or isolation.
Contraindicated Populations
pediatric
Applicable Regions
AUUSEUGlobal
AU: Propofol, dexmedetomidine and melatonin are available in Australia; follow local ICU sedation and SAT/SBT protocols.
Global: SCCM ICU Liberation Bundle (A-F), based on PADIS 2018 and the 2025 Focused Update
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the ICU Liberation ABCDEF Bundle?
The ICU Liberation ABCDEF Bundle is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS 2018), with the 2025 Focused Update.
What guideline is the ICU Liberation ABCDEF Bundle based on?
This algorithm is based on Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS 2018), with the 2025 Focused Update (DOI: 10.1097/CCM.0000000000003299).
What are the limitations of the ICU Liberation ABCDEF Bundle?
Known limitations include: Safety screens and pass/fail criteria follow published bundle protocols (ABC trial; Balas 2014). Use your unit protocol where it differs.; Adults only. In comfort-focused or end-of-life care, apply only the elements that fit the goals of care.; Gives no drug doses; use unit protocols and product information.; Needs multidisciplinary team coordination and institutional protocols.; Family presence may be limited by infection control or isolation.. Individual patient factors may require deviation from these recommendations.
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