The A2F ICU Liberation Bundle in Neurocritical Care

Purpose of reviewThe A2F intensive care unit (ICU) liberation bundle is a multi-component management strategy that has been shown to improve hospital survival and reduce rates of delirium and ICU readmission. In this review, we aim to highlight the potential role of the A2F bundle in neurocritical care settings while further delineating its individual components.Recent findingsThe A2F bundle and its components are supported by a robust evidence base that continues to develop regarding the management of critically ill patients. Recent additions include the DEXACET trial, which found that scheduled intravenous acetaminophen reduced delirium, breakthrough analgesia, and ICU length of stay for post-operative patients. Meanwhile, although previous trials indicated that dexmedetomidine for light sedation reduces delirium when compared with benzodiazepine sedation, the MENDS2 and SPICE-III trials did not find that dexmedetomidine as a first-line sedative for mechanically ventilated ICU patients improved outcomes compared with propofol. Trials of family engagement support more frequent goals of care discussions and improvements in quality of communication and patient-centered care. However, evidence specific to neurocritically ill patients remains limited. A small trial found utility for goals of care decision aids to support shared decision-making in patients with severe acute brain injury. Recent studies have also suggested that delirium may have a unique impact on outcomes in neurocritically ill patients, and new tools may have utility in delirium identification in patients with acute neurological injury. Finally, there is accumulating evidence to suggest that early mobilization is safe and feasible in neurocritically ill patients, even those with external ventricular drains, and that it may improve outcomes.SummaryAlthough the A2F bundle in its entirety has not been specifically studied in neurocritically ill patients, many of its goals overlap with contemporary neurocritical care practices. Future studies are needed to determine optimal ICU liberation strategies that can be safely and effectively implemented in patients with acute neurological injury.