Standing Shoulder to Shoulder with our Intensivist Colleagues: How Critical Care Psychiatrists can Enhance the Application of the A-F Bundle

Background: The A-F bundle represents the gold standard of Critical Care delivery. This evidence-based application of the Pain, Agitation, Delirium, Immobility and Sleep Disruption (PADIS) guidelines from the Society of Critical Care Medicine has been associated with clinically meaningful improvements in multiple outcomes including survival, mechanical ventilation use, delirium, ICU readmissions and post-ICU discharge disposition. Compliance with the bundle remains sub-optimal, however by utilizing their experience with delirium, pharmacotherapy, and skill in interviewing and engaging with patients, C-L psychiatrists can help improve overall bundle compliance and the positive outcomes associated with it.

Overview – Dr. Rosen will discuss the evidence behind the A-F Bundle, as well as recent expansions in its implementation. In this context, he will review how the C-L Psychiatrist’s unique skillset can augment ICU Liberation, highlighting examples of how elements of the A-F Bundle align with the C-L Psychiatrist’s knowledge of pharmacotherapeutics, application of behavioral therapies, and integration within an interdisciplinary team.

B (Both SAT and SBT)– Dr. Sher will discuss the Psychiatrist’s role in managing anxiety, dyspnea, and agitation to facilitate ventilation liberation during the peri-extubation window. She will give an overview of ventilation settings and necessary parameters to achieve before extubation. She will discuss how anxiety and dyspnea can interfere with this process and how CL psychiatrists can help with both medications and behavioral interventions to decrease anxiety/dyspnea and to aid extubation or weaning processes.

C (Choice of Sedation) and D (Delirium) – Dr. Maldonado will focus on the SCCM's PADIS guidelines as they apply to titrating analgesic and sedative agents (and understanding their role in delirium causation and agitation management), the role for antipsychotic agents in delirium prevention and management (the good, the bad and the ugly), and the appropriate use of psychopharmacological agents (including novel agents such as alpha-2 agonists and anticonvulsant agents) to optimize ICU care, minimize side effects, maximize positive outcomes, and eventually how to taper off psychotropic agents.

F (Family) – Dr. Bui will provide an overview of the multifaceted value of Family presence in the ICU, with benefits ranging from immediate reduction in delirium incidence and severity, to long term reduction in Post-ICU Syndrome (PICS). She will identify applied principles for integrating Family involvement into other A-F Bundle components, particularly B, D and E.

Breakout Groups: The final portion of this Preconference Course will be spent in an interactive small- and large-group discussion format to facilitate learning and application, which will center around a challenging patient case. Participants will first break into small groups which will be moderated by course leaders to facilitate a deeper understanding of the A-F Bundle in clinical practice. Groups will then reconvene for a larger discussion of the case and the appropriate application of the A-F Bundle as it relates to Critical Care Psychiatry. The discussion will utilize a take-home packet which participants can retain for future use, and which contains the essential tools for any Critical Care Psychiatrist.

References:

Pun, https://doi.org/10.1097/CCM.0000000000003482

Maldonado, https://doi.org/10.1016/j.ccc.2017.03.013

Maldonado, https://doi.org/10.1002/gps.4823