Ref Number = ASPR0049
Promoting Value in Critical Care by Practicing ?Less is More?
Antonius H. Pudjiadi
Child Health Department FKUI-RSCM, Jakarta
Over the last 30 years, critical care medicine dramatically decreases mortality of the patients. However, with amazingly large healthcare expenditures, the survivors have a lower quality of life because of their cognitive, emotional and physical sequelae.1-3 
Many studies that have been marked as a ?strong evidence?, and used for developing guidelines, nowadays interpreted differently. Marik and Bellomo argued the sacred Starling?s law, and the shocking River?s Early Goal Directed Therapy, by showing the effect of fluid on extravascular lung water.4,5 Gattinoni and Pasenti came with the baby lung concept that provides a gentle lung treatment to prevent baro- and volutrauma.6 Amato et al. have done a post hoc analysis data from the ARDSNet-trial, and showed that tidal volume target alone can be misleading.7,8 Recently, a large randomized controlled trial by Girard et al. suggest that daily awakening (interruption of sedative) with daily spontaneous breathing trials result in better outcomes for mechanical ventilated patients than current standard approaches.9 

Overused of fluids and drugs, in the ICU, caused an altered consciousness, delirium and prolonged mechanical ventilation. Over the past 20 years, many investigators focus on patient comfort and safety issues in the ICU related to pain, sedation, delirium (PAD), and early mobility, evolving to a bundle of care.10-12 The ABCDEF bundles consist of the awakening and breathing coordination of daily sedation and ventilator removal trials, delirium monitoring and management, and early mobility and assessment, prevent and manage pain, both spontaneous awakening and spontaneous breathing trials, choice of analgesia and sedation, assess, prevent and manage delirium, early mobility and exercise, family engagement bundles are part of the science of the liberation of the intensive care unit.  Implementing the ABCDEF bundle showed a significant improvements in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions and post-ICU discharge disposition (destination other than home among survivors).13,14
1. Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in the epidemiology of pediatric severe sepsis*. Pediatr Crit Care Med 2013;14:686-93.
2. Weiss SL, Fitzgerald JC, Pappachan J, et al. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med 2015;191:1147-57.
3. Ely EW. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit Care Med 2017;45:321-30.
4. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.
5. Marik P, Bellomo R. A rational approach to fluid therapy in sepsis. Br J Anaesth 2016;116:339-49.
6. Gattinoni L, Pesenti A. The concept of "baby lung". Intensive Care Med 2005;31:776-84.
7. Acute Respiratory Distress Syndrome N, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8.
8. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372:747-55.
9. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008;371:126-34.
10. Bassett R, Adams KM, Danesh V, et al. Rethinking critical care: decreasing sedation, increasing delirium monitoring, and increasing patient mobility. Jt Comm J Qual Patient Saf 2015;41:62-74.
11. Vasilevskis EE, Pandharipande PP, Girard TD, Ely EW. A screening, prevention, and restoration model for saving the injured brain in intensive care unit survivors. Crit Care Med 2010;38:S683-91.
12. Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care 2011;17:43-9.
13. Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med 2017;45:171-8.
14. 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;47:3-14.

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