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Critically Ill Children and the ICU Liberation Bundle

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Daniel E. Sloniewsky, MD, FCCM

Does use of the ICU Liberation Bundle (A-F) improve outcomes in critically ill children? Explore the first multicenter report on the impact of the entire ICU Liberation Bundle in critically ill children. Previous studies have focused only on individual bundle elements.

The Society of Critical Care Medicine’s (SCCM) ICU Liberation Campaign is a quality improvement project that seeks to limit the harmful effects of pain, agitation/sedation, delirium, immobility, and sleep disruption in critically ill patients through daily interventions consisting of six goals of care called the ICU Liberation Bundle (A-F). The six bundle elements are:
A: Assess, Prevent, and Manage Pain
B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)
C: Choice of Analgesia and Sedation
D: Delirium: Assess, Prevent, and Manage
E: Early Mobility and Exercise
F: Family Engagement and Empowerment
The use of the ICU Liberation Bundle in critically ill adults has been demonstrated to improve multiple clinically relevant outcomes.1 Data in children, however, have been lacking. To assess the effectiveness of the bundle in critically ill children, the PICU Liberation Collaborative, a group of eight quaternary-care children’s hospitals, implemented and studied pediatric versions of the bundle.2 The goal of the PICU Liberation Collaborative was for each center to implement its own bundle element in a decentralized, site-specific fashion based on local resources and limitations. The main hypothesis of the collaborative was that use of the pediatric bundle would result in four clinical outcomes: decreased mechanical ventilation duration, decreased pediatric intensive care unit (PICU) length of stay, decreased delirium, and improved mortality.
The authors first sought to measure overall bundle use and then the subsequent association with the four clinical outcomes. They recruited critically ill children between ages two months and 18 years who were expected to be in the PICU for at least two days and who required either noninvasive or mechanical ventilation. They excluded patients who were previously enrolled in this study during a previous PICU admission, those admitted for less than two days, and those whose data did not reflect a complete 24-hour period.
Overall bundle use was defined using two approaches: subject-specific use, representing the percentage of use for a patient during the entire PICU stay, and day-specific use, representing the percentage of use of all eligible elements for a single patient on a single PICU day. The data were divided into three-month epochs: pre-implementation, intermediate implementation, and final implementation. The authors then collected demographic data clinical outcome data, and Pediatric Index of Mortality (PIM) 2 and Pediatric Risk of Morality (PRISM) III severity scores for enrolled patients.
Of the 622 enrolled patients (comprising 5017 PICU days), 90 (comprising 741 PICU days) were excluded because they lacked PIM and PRISM scores. Data from 552 patients (comprising 4275 PICU days) were used to evaluate bundle use and examine the association between bundle use and clinical outcomes.
Lin et al found that subject-specific bundle use increased over time.2 Median use for elements B, D, E, and F, as well as overall use, increased by 15% to 40%, although the interquartile range was broad for each of these elements. Element A use remained close to 100% and element C use remained around 80% throughout the study period. The authors did not find any correlation between patient-specific or day-specific bundle use and mechanical ventilation duration, PICU length of stay, and delirium incidence, but a decrease in mortality occurred for every 10% rise in bundle use.
This is the first multicenter report of the impact of the ICU Liberation Bundle on clinical outcomes in critically ill children. The lack of correlation between bundle use and the three studied clinical outcomes raises questions about the validity of the observed decreased mortality with increased bundle use. The authors suggest that potential bias may have played a role since the instability of patients early in their course may not have allowed for the initiation of bundle elements such as early mobilization or mechanical ventilation weaning. The authors discuss the limitations of allowing individual centers to implement their own bundle elements in their own unique ways. However, the decrease in mortality remains a significant finding and should be the impetus for more studies using these clinical tools.


  1. 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 Jan;47(1):3-14.
  2. Lin JC, Srivastava A, Malone S, et al; Society of Critical Care Medicine’s Pediatric ICU Liberation Campaign Collaborative. Caring for critically ill children with the ICU Liberation Bundle (ABCDEF): results of the pediatric collaborative. Pediatr Crit Care Med. 2023 Aug 1;24(8):636-651.


Daniel E. Sloniewsky, MD, FCCM
Daniel E. Sloniewsky, MD, FCCM
Daniel E. Sloniewsky, MD, FCCM, is an associate professor in the Division of Pediatric Critical Care Medicine in the Department of Pediatrics at Stony Brook Long Island Children’s Hospital. Dr. Sloniewsky is an editor of Concise Critical Appraisal.

Posted: 10/16/2023 | 0 comments

Knowledge Area: Quality and Patient Safety Pediatrics 

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