Devlin John W, O'Neal Hollis R, Thomas Christopher, Barnes Daly Mary Ann, Stollings Joanna L, Janz David R, Ely E Wesley, Lin John C
School of Pharmacy, Northeastern University, Boston, MA.
Division of Pulmonary and Critical Care, Louisiana State University Health Sciences Center, Baton Rouge, LA.
Crit Care Explor. 2020 Jun 12;2(6):e0139. doi: 10.1097/CCE.0000000000000139. eCollection 2020 Jun.
The severe acute respiratory syndrome coronavirus 2 pandemic has stretched ICU resources in an unprecedented fashion and outstripped personal protective equipment supplies. The combination of a novel disease, resource limitations, and risks to medical personnel health have created new barriers to implementing the ICU Liberation ("A" for Assessment, Prevention, and Manage pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; and "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, a proven ICU care approach that reduces delirium, shortens mechanical ventilation duration, prevents post-ICU syndrome, and reduces healthcare costs. This narrative review acknowledges barriers and offers strategies to optimize Bundle performance in coronavirus disease 2019 patients requiring mechanical ventilation.
The most relevant literature, media reports, and author experiences were assessed for inclusion in this narrative review including PubMed, national newspapers, and critical care/pharmacology textbooks.
Uncertainty regarding coronavirus disease 2019 clinical course, shifts in attitude, and changes in routine behavior have hindered Bundle use. A domino effect results from: 1) changes to critical care hierarchy, priorities, and ICU team composition; 2) significant personal protective equipment shortages cause; 3) reduced/restricted physical bedside presence favoring; 4) increased depth of sedation and use of neuromuscular blockade; 5) which exacerbate drug shortages; and 6) which require prolonged use of limited ventilator resources. Other identified barriers include manageable knowledge deficits among non-ICU clinicians unfamiliar with the Bundle or among PICU specialists deploying pediatric-based Bundle approaches who are unfamiliar with adult medicine. Both groups have been enlisted to augment the adult ICU work force to meet demand. Strategies were identified to facilitate Bundle performance to liberate patients from the ICU.
We acknowledge current challenges that interfere with comprehensive management of critically ill patients during the coronavirus disease 2019 pandemic. Rapid response to new circumstances precisely requires established safety mechanisms and protocols like the ABCDEF Bundle to increase ICU and ventilator capacity and help survivors maximize recovery from coronavirus disease 2019 as early as possible.
严重急性呼吸综合征冠状病毒2大流行以前所未有的方式耗尽了重症监护病房（ICU）的资源，使个人防护装备供应捉襟见肘。新型疾病、资源限制以及医务人员健康风险的综合因素，给实施ICU解放集束化治疗方案（“A”代表评估、预防和管理疼痛；“B”代表自主唤醒试验和自主呼吸试验；“C”代表镇痛和镇静的选择；“D”代表谵妄评估、预防和管理；“E”代表早期活动和锻炼；“F”代表患者家属参与和赋能[ABCDEF]）带来了新的障碍，该方案是一种经证实的ICU护理方法，可减少谵妄、缩短机械通气时间、预防ICU后综合征并降低医疗成本。这篇叙述性综述认识到了障碍，并提供了在需要机械通气的2019冠状病毒病患者中优化集束化治疗方案实施效果的策略。
数据来源、研究选择和数据提取：评估了最相关的文献、媒体报道和作者经验，以纳入本叙述性综述，包括PubMed、全国性报纸以及重症监护/药理学教科书。
关于2019冠状病毒病临床病程的不确定性、态度转变和日常行为变化阻碍了集束化治疗方案的使用。多米诺效应源于：1）重症监护等级、优先级和ICU团队组成的变化；2）个人防护装备严重短缺；3）床边实际接触减少/受限；4）镇静深度增加和神经肌肉阻滞剂的使用；5）这加剧了药物短缺；6）这需要长期使用有限的呼吸机资源。其他已确定的障碍包括不熟悉该集束化治疗方案的非ICU临床医生或采用基于儿科的集束化治疗方案但不熟悉成人医学的儿科重症监护专家存在可解决的知识缺陷。这两组人员都已被招募来扩充成人ICU的劳动力以满足需求。已确定了促进集束化治疗方案实施以将患者从ICU解放出来的策略。
我们认识到在2019冠状病毒病大流行期间干扰重症患者综合管理的当前挑战。对新情况的快速应对恰恰需要像ABCDEF集束化治疗方案这样既定的安全机制和规程，以提高ICU和呼吸机容量，并帮助幸存者尽早从2019冠状病毒病中最大程度地康复。
