Evidence-based guideline for pain assessment, sedation management, delirium prevention and treatment, early mobility, and sleep promotion in the ICU — the PADIS/ABCDEF bundle approach.
A comprehensive, evidence-based clinical guideline for the assessment and management of pain, agitation, sedation, delirium, immobility, and sleep disruption in critically ill adult patients. This resource synthesizes recommendations from the major international critical care professional societies — including the 2018 clinical practice guidelines for pain, agitation/sedation, delirium, immobility, and sleep (PADIS), the ICU Liberation ABCDEF bundle framework, European intensive care sedation and analgesia recommendations, pain management society guidelines for ICU populations, and delirium assessment and management consensus statements — into a single integrated reference for intensivists, ICU nurses, pharmacists, physical therapists, and respiratory therapists managing critically ill patients.1 2 3 4 5 6 7
Pain is among the most common and distressing experiences reported by ICU survivors, with up to 50% of critically ill patients experiencing moderate-to-severe pain at rest and up to 80% during routine procedures. Inadequately treated pain drives agitation, sympathetic activation, immunosuppression, and long-term psychological sequelae. Conversely, excessive sedation prolongs mechanical ventilation, increases ICU length of stay, and independently predicts mortality. Delirium affects 60–80% of mechanically ventilated patients and is associated with increased mortality (odds ratio 2.0–4.0), prolonged hospitalization, and long-term cognitive impairment persisting in up to 34% of survivors at 12 months. ICU-acquired weakness develops in 25–50% of patients ventilated for more than 7 days. Sleep disruption is nearly universal in the ICU and contributes to delirium, immune dysfunction, and impaired recovery.
The ABCDEF bundle — a coordinated, interprofessional approach to Assess/prevent/manage pain, Both spontaneous awakening and breathing trials, Choice of analgesia and sedation, Delirium assessment/prevention/management, Early mobility and exercise, and Family engagement — has demonstrated dose-dependent reductions in delirium, coma, mechanical ventilation duration, ICU readmissions, and mortality when implemented with high compliance.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | ABCDEF Bundle Overview & Pain Assessment and Management | ABCDEF bundle components and implementation evidence; pain assessment tools (BPS, CPOT, NRS — complete scoring tables); pharmacologic analgesia (opioid dosing tables, non-opioid adjuncts, multimodal protocols); procedural pain management; regional anesthesia in the ICU |
| Part 2 | Agitation and Sedation Assessment and Management | Sedation assessment scales (RASS, SAS — complete scoring tables); light sedation targets and evidence; sedative agents (propofol, dexmedetomidine, midazolam, ketamine — complete dosing); propofol infusion syndrome; daily sedation interruption (SAT) protocols; nurse-driven sedation protocols; neuromuscular blockade considerations |
| Part 3 | Delirium Assessment, Prevention, and Management | Delirium subtypes; assessment tools (CAM-ICU complete flowsheet, ICDSC complete scoring); risk factors (modifiable vs. non-modifiable); non-pharmacologic prevention bundles; pharmacologic management (haloperidol, quetiapine, dexmedetomidine — dosing); benzodiazepine avoidance; special delirium populations |
| Part 4 | Early Mobility and Exercise & Sleep Promotion | Safety screening for mobilization; mobility progression levels; ICU-acquired weakness (risk factors, diagnosis, prevention); barriers and implementation; sleep disruption assessment and causes; non-pharmacologic sleep promotion; pharmacologic sleep considerations; circadian rhythm management |
| Part 5 | Special Populations & Quality Metrics | Post-operative ICU sedation and analgesia; neurological injury; substance withdrawal (alcohol withdrawal/CIWA, opioid withdrawal/COWS); ECMO and continuous renal replacement therapy dosing adjustments; quality metrics; bundle compliance measurement; implementation science |
Devlin JW, Skrobik Y, Gélinas C, et al. “Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.” Crit Care Med. 2018;46(9):e825-e873. DOI: 10.1097/CCM.0000000000003299 ↩︎
Marra A, Ely EW, Pandharipande PP, Patel MB. “The ABCDEF Bundle in Critical Care.” Crit Care Clin. 2017;33(2):225-243. DOI: 10.1016/j.ccc.2016.12.005 ↩︎
Pun BT, Balas MC, Barnes-Daly MA, et al. “Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults.” Crit Care Med. 2019;47(1):3-14. DOI: 10.1097/CCM.0000000000003482 ↩︎
Barr J, Fraser GL, Puntillo K, et al. “Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit.” Crit Care Med. 2013;41(1):263-306. DOI: 10.1097/CCM.0b013e3182783b72 ↩︎
Celis-Rodríguez E, Birchenall C, de la Cal MA, et al. “Clinical Practice Guidelines for Evidence-Based Management of Sedoanalgesia in Critically Ill Adult Patients.” Med Intensiva. 2013;37(8):519-574. DOI: 10.1016/j.medin.2013.04.001 ↩︎
Chanques G, Jaber S, Barbotte E, et al. “Impact of Systematic Evaluation of Pain and Agitation in an Intensive Care Unit.” Crit Care Med. 2006;34(6):1691-1699. DOI: 10.1097/01.CCM.0000218416.62457.56 ↩︎
DAS-Taskforce 2015, Baron R, Binder A, et al. “Evidence and Consensus Based Guideline for the Management of Delirium, Analgesia, and Sedation in Intensive Care Medicine (DAS-Guideline 2015).” Ger Med Sci. 2015;13:Doc19. DOI: 10.3205/000223 ↩︎
PADIS management in special populations including post-operative, neurological injury, substance withdrawal (alcohol/CIWA, opioid/COWS), ECMO and CRRT dosing adjustments, plus quality metrics, bundle compliance measurement, and implementation strategies.
Safety screening criteria for ICU mobilization, progressive mobility levels, ICU-acquired weakness diagnosis and prevention, barriers to early mobility, sleep disruption assessment and causes, non-pharmacologic and pharmacologic sleep interventions, and circadian rhythm management.
Complete delirium assessment tools (CAM-ICU flowsheet, ICDSC scoring), delirium subtypes, modifiable and non-modifiable risk factors, evidence-based non-pharmacologic prevention bundles, and pharmacologic management including haloperidol, quetiapine, and dexmedetomidine dosing.
Comprehensive sedation assessment (RASS, SAS complete scoring tables), light sedation targets, sedative agent pharmacology and dosing (propofol, dexmedetomidine, midazolam, ketamine), propofol infusion syndrome, daily sedation interruption protocols, and nurse-driven sedation algorithms.
The ABCDEF bundle framework for ICU liberation, comprehensive pain assessment tools (BPS, CPOT, NRS) with complete scoring tables, and evidence-based analgesic management including opioid dosing, non-opioid adjuncts, and multimodal protocols.