Early mobilization in the critical care unit: A review of adult and pediatric literature

Early Mobilization after Pediatric Liver Transplantation

Objective  This study aims to evaluate the impact of early mobilization (EM) after pediatric liver transplantation in the pediatric intensive care unit (PICU). Design  A 14-month prospective before and after study. Setting  Multivalent PICU with 20 beds at a tertiary children's hospital. Patients  A total of 57 patients aged younger than 16 years who received liver transplantation and were admitted to the PICU after surgery. Interventions  EM project, a multifaceted framework for successful EM practice in the PICU focusing on a multidisciplinary team approach. Measurements and Main Results  Compared with the period before the implementation of the EM project, there was a significant increase in the proportion of patients who received physical therapy in the PICU (43 vs. 97%, p  < 0.001). Also, there were greater median numbers of physical therapy per eligible patient (0 vs. 3, p  < 0.001). Moreover, patients achieved higher functional mobility level within a shorter time. Length of intubation, PICU stay, and hospital stay were not significantly different. There were no adverse events or deaths. Conclusion  Using an EM project process, the proportion of patients who received physical therapy after liver transplantation increased. However, there was no difference in the length of PICU or hospital stay. Our findings indicated that EM for pediatric patients who received liver transplantation was well tolerated and safe.

Early Mobilization of Mechanically Ventilated Patients

Critically ill patients requiring mechanical ventilation are least likely to be mobilized and, as a result, are at-risk for prolonged complications from weakness. The use of bed rest and sedation when caring for mechanically ventilated patients is likely shaped by historical practice; however, this review demonstrates early mobilization, with little to no sedation, is possible and safe. Assessing readiness for mobilization in context of progressing patients from passive to active activities can lead to long-term benefits and has been achievable with resource-efficient implementations and team work.

Prolonged Intermittent Renal Replacement Therapy

Prolonged intermittent renal replacement therapy (PIRRT) is becoming an increasingly popular alternative to continuous renal replacement therapy in critically ill patients with acute kidney injury. There are significant practice variations in the provision of PIRRT across institutions, with respect to prescription, technology, and delivery of therapy. Clinical trials have generally demonstrated that PIRRT is non-inferior to continuous renal replacement therapy regarding patient outcomes. PIRRT offers cost-effective renal replacement therapy along with other advantages such as early patient mobilization and decreased nursing time. However, due to lack of standardization of the procedure, PIRRT still poses significant challenges, especially pertaining to appropriate drug dosing. Future guidelines and clinical trials should work toward developing consensus definitions for PIRRT and ensure optimal delivery of therapy.

A Practical Approach to Managing Transcatheter Aortic Valve Replacement With Sedation

Transcatheter aortic valve replacement is increasingly performed as a minimally invasive treatment option for aortic valve disease. The typical anesthetic management for this procedure was traditionally similar to surgical aortic valve replacement and involved general anesthesia and transesophageal echocardiography. In this review, we discuss the technological advances in transcatheter valve systems that have improved outcomes and allow for use of sedation instead of general anesthesia. We describe an anesthetic protocol that avoids general anesthesia and utilizes transthoracic echocardiography for procedural guidance.

Automated Management of Exercise Intervention at the Point of Care: Application of a Web-Based Leg Training System

Background

Recent advances in information and communication technology have prompted development of Web-based health tools to promote physical activity, the key component of cardiac rehabilitation and chronic disease management. Mobile apps can facilitate behavioral changes and help in exercise monitoring, although actual training usually takes place away from the point of care in specialized gyms or outdoors. Daily participation in conventional physical activities is expensive, time consuming, and mostly relies on self-management abilities of patients who are typically aged, overweight, and unfit. Facilitation of sustained exercise training at the point of care might improve patient engagement in cardiac rehabilitation.

Objective

In this study we aimed to test the feasibility of execution and automatic monitoring of several exercise regimens on-site using a Web-enabled leg training system.

Methods

The MedExercise leg rehabilitation machine was equipped with wireless temperature sensors in order to monitor its usage by the rise of temperature in the resistance unit (Δt°). Personal electronic devices such as laptop computers were fitted with wireless gateways and relevant software was installed to monitor the usage of training machines. Cloud-based software allowed monitoring of participant training over the Internet. Seven healthy participants applied the system at various locations with training protocols typically used in cardiac rehabilitation. The heart rates were measured by fingertip pulse oximeters.

Results

Exercising in home chairs, in bed, and under an office desk was made feasible and resulted in an intensity-dependent increase of participants’ heart rates and Δt° in training machine temperatures. Participants self-controlled their activities on smart devices, while a supervisor monitored them over the Internet. Individual Δt° reached during 30 minutes of moderate-intensity continuous training averaged 7.8°C (SD 1.6). These Δt° were used as personalized daily doses of exercise with automatic email alerts sent upon achieving them. During 1-week training at home, automatic notifications were received on 4.4 days (SD 1.8). Although the high intensity interval training regimen was feasible on-site, it was difficult for self- and remote management. Opportunistic leg exercise under the desk, while working with a computer, and training in bed while viewing television were less intensive than dosed exercise bouts, but allowed prolonged leg mobilization of 73.7 minutes/day (SD 29.7).

Conclusions

This study demonstrated the feasibility of self-control exercise training on-site, which was accompanied by online monitoring, electronic recording, personalization of exercise doses, and automatic reporting of adherence. The results suggest that this technology and its applications are useful for the delivery of Web-based exercise rehabilitation and cardiac training programs at the point of care.