ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries

Erwin Ista*, Juliana Redivo, PARK-PICU Investigators, Paurav Kananur, Karen Choong, Jose Colleti, Dale M. Needham, Ronke Awojoodu, Sapna R. Kudchadkar

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

21 Citations (Scopus)


OBJECTIVES: To evaluate current international practice in PICUs regarding components of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/ Mobility, and Family Engagement/Empowerment"(ABCDEF) bundle. DESIGN: Online surveys conducted between 2017 and 2019. SETTING: One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children's hospitals. Median size was 16 beds (interquartile range, 10-24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions. CONCLUSIONS: ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.

Original languageEnglish
Pages (from-to)114-125
Number of pages12
JournalCritical Care Medicine
Issue number1
Publication statusPublished - 1 Jan 2022

Bibliographical note

Funding Information:
We would like to thank Ms. Claire Levine, MS, for her editorial assistance with this article. We would like to thank the International Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU) Investigators, Pediatric Acute Lung Injury and Sepsis Investigators Network, European Society of Pediatric and Neonatal Intensive Care, and the Canadian Critical Care Trials Group and Associação de Medicina Intensiva Brasileira (Brazilian Critical Care Society) for their support.

Publisher Copyright:
Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.


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