[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Critical care](https://durgical.com/en/nursing/areas/critical-care/) › The ABCDEF (ICU liberation) bundle and early mobility # The ABCDEF (ICU liberation) bundle and early mobility - Safe practice The ABCDEF bundle joins pain, awakening and breathing trials, sedation choice, delirium, early mobility and family into one daily routine. Updated Nov 13, 2026 ## Key points - A: assess, prevent and manage pain. B: both spontaneous awakening and breathing trials. C: choice of analgesia and sedation. - D: delirium, assess, prevent and manage. E: early mobility and exercise. F: family engagement and empowerment. - A, C, D and E apply every ICU day; B applies if the patient is sedated or ventilated; F when family is present. - Full bundle performance was associated with lower mortality and less ventilation, coma, delirium and restraint the next day. - Early mobility is feasible and safe in selected ventilated patients, with very few complications. ## What it is The ABCDEF bundle, also called the ICU liberation bundle, puts six evidence-based practices together so that they are done every day for every eligible patient. Each element supports the others: controlled pain allows lighter sedation, lighter sedation allows awakening and breathing trials and mobility, and fewer sedatives mean less delirium. In a collaborative of more than 15,000 adults, doing all eligible elements on a day was associated with lower mortality and less next-day ventilation, coma, delirium and physical restraint. The nurse is central to almost every element, from pain and sedation scores to mobility and inviting the family. ## What it requires - The bundle is a daily checklist, not a sequence: every eligible element is done each day. - Weakness acquired in the ICU is common; muscle strength falls within days of ventilation and loss can last for years. - Physical therapy has been done safely even in patients on continuous renal replacement or extracorporeal support. - Families on rounds feel more included, and their presence does not disturb teaching or communication. ## Components - A: pain scale and analgesia plan (see the analgesia and pain scale pages). - B: the safety screens and the protocol for the awakening and breathing trials. - C: the sedation target and the choice of drugs (lighter, non-benzodiazepine options often preferred). - D: the delirium tool each shift and the non-drug prevention measures. - E: a mobility plan built with physiotherapy (from sitting in bed to walking). - F: flexible family presence, information and participation in care and decisions. ## How it is applied (and why) - Go through the six elements each shift and mark which apply today: an element that is not checked is easily skipped. - Score pain and treat it per order before procedures and mobility: pain stops patients from moving. - Run the awakening trial with the team and then the breathing trial: done together they lower sedative use and shorten ventilation. - Keep sedation at the ordered target, lightest possible: a patient who is awake can take part in mobility. - Screen for delirium each shift and report a positive result: it changes the plan of the day. - Mobilise with physiotherapy at the level the patient tolerates, with lines and tube secured: movement is the measure most linked to fewer delirium days. - Invite the family to rounds and to simple care, and give them information: family participation is linked to less delirium, and families feel more included. - Avoid restraints when possible and reassess them each shift: full bundle performance was associated with less restraint use. ## In nursing practice - If an element is not done, record why (for example a failed safety screen): it is part of the bundle's audit. - Mobility is stopped if the patient becomes unstable, following the unit's criteria; it is tried again later. - More pain is often found as the bundle improves: that reflects better detection, not worse care. - Rehabilitation continues after the ICU; tell the next team what level of mobility the patient reached. ## Common mistakes - Treating the bundle as a paper exercise: the elements only help if they are actually done at the bedside. - Raising sedation for agitation without first checking pain and delirium. - Waiting for the patient to be «stable enough» for days before any mobility, without asking the team. - Keeping the family away from care and information when they could take part. ## Test yourself Think of the answer, then tap the question to see it. ## What do the letters of the ABCDEF bundle stand for? Pain; both awakening and breathing trials; choice of analgesia and sedation; delirium; early mobility and exercise; family engagement and empowerment. ## Which elements apply to every ICU patient every day? A, C, D and E. B applies if the patient is sedated or ventilated, and F when family or another caregiver is present. ## What was full bundle performance associated with in the ICU Liberation Collaborative? Lower mortality and less next-day mechanical ventilation, coma, delirium and physical restraint. ## Why are awakening and breathing trials paired? Together they reduce sedative use and delirium and shorten ventilation and ICU stay. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/the-abcdef-bundle-and-early-mobility/) ## Connections ## Related 6 - [Analgesia first, then light sedation: RASS and SAS, sedation goals and the daily awakening](https://durgical.com/en/nursing/analgesia-first-then-light-sedation-rass-and-sas-sedation-goals-and-the-daily-aw/) - [ICU delirium: CAM-ICU and ICDSC screening, types, risk factors and prevention](https://durgical.com/en/nursing/icu-delirium-cam-icu-and-icdsc-screening-types-risk-factors-and-prevention/) - [Weaning from the ventilator: readiness, the spontaneous breathing trial, extubation and the hours after](https://durgical.com/en/nursing/weaning-from-the-ventilator-readiness-the-spontaneous-breathing-trial-extubation/) - [The family in the ICU: needs, flexible visiting, information, family conferences and presence during resuscitation](https://durgical.com/en/nursing/the-family-in-the-icu-needs-flexible-visiting-information-family-conferences-and/) - [Complications of immobility and how to prevent them](https://durgical.com/en/nursing/complications-of-immobility-and-how-to-prevent-them/) - [Pain assessment scales: numeric, visual analogue, faces, behavioural (FLACC) and in dementia](https://durgical.com/en/nursing/pain-assessment-scales-numeric-visual-analogue-faces-behavioural-and-in-dementia/) [← All of nursing](https://durgical.com/en/nursing/) Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order. Sources: [Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults (Pun BT et al.)](https://pmc.ncbi.nlm.nih.gov/articles/PMC6298815/) (Critical Care Medicine, author manuscript in PubMed Central, 2019); [The ABCDEF Bundle in Critical Care (Marra A, Ely EW, Pandharipande PP, Patel MB)](https://pmc.ncbi.nlm.nih.gov/articles/PMC5351776/) (Critical Care Clinics, author manuscript in PubMed Central, 2017); [A systematic meta-review of interventions to prevent and manage delirium in the Intensive Care Unit: Part 2, non-pharmacological and multicomponent interventions (Kundakci B et al.)](https://pmc.ncbi.nlm.nih.gov/articles/PMC12639998/) (Critical Care, PubMed Central, 2025). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/nursing/the-abcdef-bundle-and-early-mobility/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/the-abcdef-bundle-and-early-mobility/