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Haines KJ, Skinner EH, Pastva A, Berney S, Denehy L. How Can Clinicians Use Outcome Measures in Routine Care? Knowledge Translation Strategies. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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252
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Choong K. Acute Rehabilitation in Critically Ill Children. J Pediatr Intensive Care 2015; 4:171-173. [PMID: 31110869 PMCID: PMC6513168 DOI: 10.1055/s-0035-1563384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Karen Choong
- Division of Pediatric Critical Care, Departments of Pediatrics, Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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253
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Sommers J, Engelbert RHH, Dettling-Ihnenfeldt D, Gosselink R, Spronk PE, Nollet F, van der Schaaf M. Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations. Clin Rehabil 2015; 29:1051-63. [PMID: 25681407 PMCID: PMC4607892 DOI: 10.1177/0269215514567156] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/14/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units. METHODS We used the EBRO method, as recommended by the 'Dutch Evidence Based Guideline Development Platform' to develop an 'evidence statement for physiotherapy in the intensive care unit'. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts. RESULTS Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment. CONCLUSIONS These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.
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Affiliation(s)
- Juultje Sommers
- Department of Rehabilitation, University of Amsterdam, Amsterdam, The Netherlands
| | - Raoul H H Engelbert
- Department of Rehabilitation, University of Amsterdam, Amsterdam, The Netherlands Education of Physiotherapy, University of Applied Sciences, Amsterdam, The Netherlands
| | | | - Rik Gosselink
- Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Peter E Spronk
- Department of Intensive Care, University of Amsterdam, Amsterdam, The Netherlands
| | - Frans Nollet
- Department of Rehabilitation, University of Amsterdam, Amsterdam, The Netherlands
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255
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Geriatric Age Is Not a Barrier to Early Physical Rehabilitation and Walking in the Intensive Care Unit. TOPICS IN GERIATRIC REHABILITATION 2015. [DOI: 10.1097/tgr.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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256
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Connolly B, O'Neill B, Salisbury L, McDowell K, Blackwood B. Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery: an overview of systematic reviews protocol. Syst Rev 2015; 4:130. [PMID: 26419458 PMCID: PMC4588271 DOI: 10.1186/s13643-015-0119-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery. METHODS/DESIGN This protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool. DISCUSSION We anticipate the findings from this novel overview of systematic reviews will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015001068.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK. .,Centre of Human and Aerospace Physiological Sciences, King's College London, London, UK. .,Guy's & St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Biomedical Research Centre, London, UK.
| | - Brenda O'Neill
- School of Health Sciences, Institute of Nursing and Health Research, Ulster University, Ulster, UK.
| | - Lisa Salisbury
- School of Health in Social Science, The University of Edinburgh, Edinburgh, UK.
| | - Kathryn McDowell
- School of Health Sciences, Institute of Nursing and Health Research, Ulster University, Ulster, UK.
| | - Bronagh Blackwood
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
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257
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Ehlenbach WJ, Larson EB, Curtis JR, Hough CL. Physical Function and Disability After Acute Care and Critical Illness Hospitalizations in a Prospective Cohort of Older Adults. J Am Geriatr Soc 2015; 63:2061-9. [PMID: 26415711 DOI: 10.1111/jgs.13663] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate associations between acute care and critical illness hospitalizations and performance on physical functional measures and activities of daily living (ADLs). DESIGN Prospective cohort study. SETTING Large health maintenance organization. PARTICIPANTS Two thousand nine hundred twenty-six participants in Adult Changes in Thought, a study of aging enrolling dementia-free individuals aged 65 and older not living in a nursing home from 1994 to September 30, 2008 (N = 2,926). MEASUREMENTS The exposure of interest was hospitalization during study participation, subdivided by presence of critical illness. Outcomes included gait speed, grip strength, chair stand speed, and difficulty and dependence in performing ADLs measured at biennial visits. RESULTS Median time between hospital discharge and the next study visit was 311 days (interquartile range (IQR) 151-501 days) after acute care hospitalization and 359 days (IQR 181-420 days) after critical illness hospitalization. Gait speed was slower after acute care (-0.05 m/s, 95% confidence interval (CI) = 0.01-0.04 m/s slower, P < .001) and critical illness (-0.16 m/s, 95% CI = -0.22 to -0.10, P < .001). Grip was weaker after acute care hospitalization (-0.8 kg, 95% CI = -1.0 to -0.6, P < .001) but not significantly different after critical illness hospitalization. Chair-stand speed was slower after acute care hospitalization (-0.04 stands/s, 95% CVI = -0.05 to -0.04, P < .001) and critical illness hospitalization (-0.09, 95% CI = -0.15 to -0.03, P = .003). The odds of difficulty with (odds ratio (OR) = 1.4, 95% CI = 1.2-1.6, P < .001) or dependence in (OR = 2.0, 95% CI = 1.2-3.2, P = .006) one or more ADLs was higher after acute care hospitalization, as were the odds of difficulty with (OR = 1.9, 95% CI = 1.1-3.6, P = .03) or dependence in (OR = 7.9, 95% CI = 2.5-25.7, P = .001) one or more ADLs after critical illness. CONCLUSION In older adults, hospitalization, especially for critical illness, was associated with clinically relevant decline in gait and chair stand speed and strongly associated with difficulty with and dependence in ADLs.
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Affiliation(s)
- William J Ehlenbach
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Eric B Larson
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.,Group Health Research Institute, Seattle, Washington.,Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - J Randall Curtis
- Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Catherine L Hough
- Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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258
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Wahab R, Yip NH, Chandra S, Nguyen M, Pavlovich KH, Benson T, Vilotijevic D, Rodier DM, Patel KR, Rychcik P, Perez-Mir E, Boyle SM, Berlin D, Needham DM, Brodie D. The implementation of an early rehabilitation program is associated with reduced length of stay: A multi-ICU study. J Intensive Care Soc 2015; 17:2-11. [PMID: 28979452 DOI: 10.1177/1751143715605118] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Survivors of critical illness face many potential long-term sequelae. Prior studies showed that early rehabilitation in the intensive care unit (ICU) reduces physical impairment and decreases ICU and hospital length of stay (LOS). However, these studies are based on a single ICU or were conducted with a small subset of all ICU patients. We examined the effect of an early rehabilitation program concurrently implemented in multiple ICUs on ICU and hospital LOS. METHODS An early rehabilitation program was systematically implemented in five ICUs at the sites of two affiliated academic institutions. We retrospectively compared ICU and hospital LOS in the year before (1/2011-12/2011) and after (1/2012-12/2012) implementation. RESULTS In the pre- and post-implementation periods, respectively, there were a total of 3945 and 4200 ICU admissions among the five ICUs. After implementation, there was a significant increase in the proportion of patients who received more rehabilitation treatments during their ICU stay (p < 0.001). The mean number of rehabilitation treatments per ICU patient-day increased from 0.16 to 0.72 (p < 0.001). In the post-implementation period, four of the five ICUs had a statistically significant decrease in mean ICU LOS among all patients. The overall decrease in mean ICU LOS across all five ICUs was 0.4 days (6.9%) (5.8 versus 5.4 days, p < 0.001). Across all five ICUs, there were 255 (6.5%) more admissions in the post-implementation period. The mean hospital LOS for patients from the five ICUs also decreased by 5.4% (14.7 vs. 13.9 days, p < 0.001). CONCLUSIONS A multi-ICU, coordinated implementation of an early rehabilitation program markedly increased rehabilitation treatments in the ICU and was associated with reduced ICU and hospital LOS as well as increased ICU admissions.
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Affiliation(s)
- Romina Wahab
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Natalie H Yip
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Subani Chandra
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Michael Nguyen
- Department of Quality and Patient Safety Improvement, New York-Presbyterian Hospital, New York, NY, USA
| | | | - Thomas Benson
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Denise Vilotijevic
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Danielle M Rodier
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Komal R Patel
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Patricia Rychcik
- Department of Nursing, New York-Presbyterian Hospital, New York, NY, USA
| | - Ernesto Perez-Mir
- Department of Nursing, New York-Presbyterian Hospital, New York, NY, USA
| | - Suzanne M Boyle
- Department of Nursing, New York-Presbyterian Hospital, New York, NY, USA
| | - David Berlin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA
| | - Dale M Needham
- Outcomes After Critical Illness & Surgery (OACIS) Group, Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
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259
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Choong K, Chacon MDP, Walker RG, Al-Harbi S, Clark H, Al-Mahr G, Timmons BW, Thabane L. In-Bed Mobilization in Critically Ill Children: A Safety and Feasibility Trial. J Pediatr Intensive Care 2015; 4:225-234. [PMID: 31110874 DOI: 10.1055/s-0035-1563545] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 10/23/2022] Open
Abstract
The objective of this study was to evaluate the feasibility and safety of implementing two methods of in-bed mobilization in critically ill children. This prospective cohort trial was conducted at McMaster Children's Hospital, Pediatric Critical Care Unit (PCCU). Hemodynamically stable patients aged 3 to 17 years with a longer than 24-hour PCCU stay were eligible to participate in the study. Children with cardiorespiratory instability, already mobilizing well or at their baseline mobility, anticipated death during this PCCU admission, and those with contraindications to mobilization were excluded. Two methods of mobilization were applied for a maximum of 2 days, respectively, depending on the level of consciousness and cognitive ability of the participant. In-bed cycling was used for passive mobilization and interactive video games (VG) were used for active mobilization. The primary outcomes were safety and feasibility. Secondary outcomes were physical activity during the study period, as reflected by accelerometer measurements. A total of 406 patients were screened over 1 year, 35 of who were eligible and 31 (89%) consented to participate. Median age of participants was 11 years (quartile 1 is 6 years and quartile 3 is 14 years), and 15 (48%) were male. Twenty-five (81%) participants received the study intervention, 22 (88%) of who received the intervention within 24 hours of consent. Twenty-one (84%) participants received in-bed cycling, five (20%) received VG, and only one received both. Fifteen (60%) completed the prescribed 2-day intervention, while in 11 (44%) the intervention was interrupted or not applied, most commonly because the patient was transferred out of the PCCU. Physical activity was greater during the intervention compared with nonintervention times with in-bed cycling, but not with VG. There were no adverse events attributable to the intervention. This pilot reveals that in-bed cycling can enhance physical activity, and appears to be safe and feasible in this group of critically ill children. VG was feasible only in a minority of patients who were cooperative and age appropriate. Further research is necessary to evaluate the efficacy and most appropriate methods of enhancing mobility and rehabilitation in this population.
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Affiliation(s)
- Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Maria D P Chacon
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rachel G Walker
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Samah Al-Harbi
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Heather Clark
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Ghadah Al-Mahr
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Brian W Timmons
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.,Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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260
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Wieczorek B, Burke C, Al-Harbi A, Kudchadkar SR. Early mobilization in the pediatric intensive care unit: a systematic review. J Pediatr Intensive Care 2015; 2015:129-170. [PMID: 26380147 PMCID: PMC4568750 DOI: 10.1055/s-0035-1563386] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 12/08/2014] [Indexed: 12/16/2022] Open
Abstract
Children admitted to the pediatric intensive care unit (PICU) can experience significant morbidity as a consequence of mechanical ventilation and sedative medications. This morbidity could potentially be decreased with the implementation of activities to promote early mobilization during critical illness. The objective of this systematic review is to summarize the current evidence regarding rehabilitation therapies in the PICU and to highlight the knowledge gaps and avenues for future research on early mobilization in the PICU. Using a combination of controlled vocabulary and key word terms PubMed, CINAHL, and EMBASE databases were searched; no limiters were imposed on search strategies. Two reviewers abstracted data and assessed quality independently. From the 1928 articles identified in the search 168 abstracts were identified for full text review. Fifty-nine articles were chosen for data extraction and five were identified for inclusion in review. A sixth article was identified through expert clinician query. The studies were categorized into three groups based on the outcomes discussed: safety and feasibility, functional outcomes, and length of stay. A synthesis of the studies indicates that early rehabilitation in the PICU is safe and feasible with potential short and long-term benefits. Institutional, provider and patient-related barriers to initiation of early rehabilitation in the PICU are identified. Recommendations for future investigation include early rehabilitation protocols for children hospitalized in the PICU and identification of outcome measures.
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Affiliation(s)
- Beth Wieczorek
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, Maryland, United States
| | - Christopher Burke
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, Maryland, United States
| | - Ahmad Al-Harbi
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, Maryland, United States
| | - Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine and Pediatrics, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, Maryland, United States
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261
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Feasibility and Safety of Early Physical Therapy and Active Mobilization for Patients on Extracorporeal Membrane Oxygenation. ASAIO J 2015; 61:564-8. [DOI: 10.1097/mat.0000000000000239] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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262
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Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior. J Crit Care 2015; 30:1243-50. [PMID: 26365000 DOI: 10.1016/j.jcrc.2015.08.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 07/27/2015] [Accepted: 08/11/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions. MATERIALS AND METHODS A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator. RESULTS Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture. CONCLUSIONS Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions.
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263
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Morrow BM. Chest Physiotherapy in the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2015; 4:174-181. [PMID: 31110870 DOI: 10.1055/s-0035-1563385] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/31/2014] [Indexed: 10/23/2022] Open
Abstract
Despite widespread practice, there is very little, high-level evidence supporting the indications for and effectiveness of cardiopulmonary/chest physiotherapy (CPT) in critically ill infants and children. Conversely, most studies highlight the detrimental effects or lack of effect of different manual modalities. Conventional CPT should not be a routine intervention in the pediatric intensive care unit, but can be considered when obstructive secretions are present which impact on lung mechanics and/or gaseous exchange and/or where there is the potential for long-term complications. Techniques such as positioning, early mobilization, and rehabilitation have been shown to be beneficial in adult intensive care patients; however, little attention has been paid to this important area of practice in pediatric intensive care units. This article presents a narrative review of chest physiotherapy in pediatric critical illness, including effects, indications, precautions, and specific treatment modalities and techniques.
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Affiliation(s)
- Brenda M Morrow
- Department of Pediatrics and Child Health, University of Cape Town, Rondebosch, Cape Town, South Africa
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264
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Piva S, Dora G, Minelli C, Michelini M, Turla F, Mazza S, D'Ottavi P, Moreno-Duarte I, Sottini C, Eikermann M, Latronico N. The Surgical Optimal Mobility Score predicts mortality and length of stay in an Italian population of medical, surgical, and neurologic intensive care unit patients. J Crit Care 2015; 30:1251-7. [PMID: 26315654 DOI: 10.1016/j.jcrc.2015.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/29/2015] [Accepted: 08/02/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE We validated the Italian version of Surgical Optimal Mobility Score (SOMS) and evaluated its ability to predict intensive care unit (ICU) and hospital length of stay (LOS), and hospital mortality in a mixed population of ICU patients. MATERIALS AND METHODS We applied the Italian version of SOMS in a consecutive series of prospectively enrolled, adult ICU patients. Surgical Optimal Mobility Score level was assessed twice a day by ICU nurses and twice a week by an expert mobility team. Zero-truncated Poisson regression was used to identify predictors for ICU and hospital LOS, and logistic regression for hospital mortality. All models were adjusted for potential confounders. RESULTS Of 98 patients recruited, 19 (19.4%) died in hospital, of whom 17 without and 2 with improved mobility level achieved during the ICU stay. SOMS improvement was independently associated with lower hospital mortality (odds ratio, 0.07; 95% confidence interval [CI], 0.01-0.42) but increased hospital LOS (odds ratio, 1.21; 95% CI: 1.10-1.33). A higher first-morning SOMS on ICU admission, indicating better mobility, was associated with lower ICU and hospital LOS (rate ratios, 0.89 [95% CI, 0.80-0.99] and 0.84 [95% CI, 0.79-0.89], respectively). CONCLUSIONS The first-morning SOMS on ICU admission predicted ICU and hospital LOS in a mixed population of ICU patients. SOMS improvement was associated with reduced hospital mortality but increased hospital LOS, suggesting the need of optimizing hospital trajectories after ICU discharge.
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Affiliation(s)
- Simone Piva
- Department of Anesthesia, Critical Care Medicine and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Giancarlo Dora
- Department of Physical Medicine and Rehabilitation, Spedali Civili University Hospital, Brescia, Italy
| | - Cosetta Minelli
- National Heart and Lung Institute, Imperial College London, London, England, UK
| | - Mariachiara Michelini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Fabio Turla
- Department of Anesthesia, Critical Care Medicine and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Stefania Mazza
- Department of Anesthesia, Critical Care Medicine and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Patrizia D'Ottavi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Ingrid Moreno-Duarte
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Caterina Sottini
- Department of Physical Medicine and Rehabilitation, Spedali Civili University Hospital, Brescia, Italy
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Nicola Latronico
- Department of Anesthesia, Critical Care Medicine and Emergency, Spedali Civili University Hospital, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
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265
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Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues. Clin Nutr 2015. [PMID: 26212171 DOI: 10.1016/j.clnu.2015.07.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies.
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266
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Castro-Avila AC, Serón P, Fan E, Gaete M, Mickan S. Effect of Early Rehabilitation during Intensive Care Unit Stay on Functional Status: Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0130722. [PMID: 26132803 PMCID: PMC4488896 DOI: 10.1371/journal.pone.0130722] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 05/24/2015] [Indexed: 12/27/2022] Open
Abstract
Background and Aim Critically ill survivors may have functional impairments even five years after hospital discharge. To date there are four systematic reviews suggesting a beneficial impact for mobilisation in mechanically ventilated and intensive care unit (ICU) patients, however there is limited information about the influence of timing, frequency and duration of sessions. Earlier mobilisation during ICU stay may lead to greater benefits. This study aims to determine the effect of early rehabilitation for functional status in ICU/high-dependency unit (HDU) patients. Design Systematic review and meta-analysis. MEDLINE, EMBASE, CINALH, PEDro, Cochrane Library, AMED, ISI web of science, Scielo, LILACS and several clinical trial registries were searched for randomised and non-randomised clinical trials of rehabilitation compared to usual care in adult patients admitted to an ICU/HDU. Results were screened by two independent reviewers. Primary outcome was functional status. Secondary outcomes were walking ability, muscle strength, quality of life, and healthcare utilisation. Data extraction and methodological quality assessment using the PEDro scale was performed by primary reviewer and checked by two other reviewers. The authors of relevant studies were contacted to obtain missing data. Results 5733 records were screened. Seven articles were included in the narrative synthesis and six in the meta-analysis. Early rehabilitation had no significant effect on functional status, muscle strength, quality of life, or healthcare utilisation. However, early rehabilitation led to significantly more patients walking without assistance at hospital discharge (risk ratio 1.42; 95% CI 1.17-1.72). There was a non-significant effect favouring intervention for walking distance and incidence of ICU-acquired weakness. Conclusions Early rehabilitation during ICU stay was not associated with improvements in functional status, muscle strength, quality of life or healthcare utilisation outcomes, although it seems to improve walking ability compared to usual care. Results from ongoing studies may provide more data on the potential benefits of early rehabilitation in critically ill patients.
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Affiliation(s)
- Ana Cristina Castro-Avila
- Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
- * E-mail:
| | - Pamela Serón
- Internal Medicine Department, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Mónica Gaete
- Internal Medicine Department, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Sharon Mickan
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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267
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Elkins M, Dentice R. Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unit: a systematic review. J Physiother 2015; 61:125-34. [PMID: 26092389 DOI: 10.1016/j.jphys.2015.05.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 11/29/2022] Open
Abstract
QUESTION Does inspiratory muscle training improve inspiratory muscle strength in adults receiving mechanical ventilation? Does it improve the duration or success of weaning? Does it affect length of stay, reintubation, tracheostomy, survival, or the need for post-extubation non-invasive ventilation? Is it tolerable and does it cause adverse events? DESIGN Systematic review of randomised trials. PARTICIPANTS Adults receiving mechanical ventilation. INTERVENTION Inspiratory muscle training versus sham or no inspiratory muscle training. OUTCOME MEASURES Data were extracted regarding: inspiratory muscle strength and endurance; the rapid shallow breathing index; weaning success and duration; duration of mechanical ventilation; reintubation; tracheostomy; length of stay; use of non-invasive ventilation after extubation; survival; readmission; tolerability and adverse events. RESULTS Ten studies involving 394 participants were included. Heterogeneity within some meta-analyses was high. Random-effects meta-analyses showed that the training significantly improved maximal inspiratory pressure (MD 7 cmH2O, 95% CI 5 to 9), the rapid shallow breathing index (MD 15 breaths/min/l, 95% CI 8 to 23) and weaning success (RR 1.34, 95% CI 1.02 to 1.76). Although only assessed in individual studies, significant benefits were also reported for the time spent on non-invasive ventilation after weaning (MD 16 hours, 95% CI 13 to 18), length of stay in the intensive care unit (MD 4.5 days, 95% CI 3.6 to 5.4) and length of stay in hospital (MD 4.4 days, 95% CI 3.4 to 5.5). Weaning duration decreased in the subgroup of patients with known weaning difficulty. The other outcomes weren't significantly affected or weren't measured. CONCLUSION Inspiratory muscle training for selected patients in the intensive care unit facilitates weaning, with potential reductions in length of stay and the duration of non-invasive ventilatory support after extubation. The heterogeneity among the results suggests that the effects of inspiratory muscle training may vary; this perhaps depends on factors such as the components of usual care or the patient's characteristics.
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Affiliation(s)
| | - Ruth Dentice
- Physiotherapy Department, Royal Prince Alfred Hospital, Sydney, Australia
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268
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A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury. Ann Am Thorac Soc 2015; 11:1230-8. [PMID: 25167767 DOI: 10.1513/annalsats.201406-231oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice. OBJECTIVES To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI). METHODS This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU. MEASUREMENTS AND MAIN RESULTS The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]). CONCLUSIONS In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.
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269
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Connolly B, Salisbury L, O'Neill B, Geneen LJ, Douiri A, Grocott MPW, Hart N, Walsh TS, Blackwood B. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness. Cochrane Database Syst Rev 2015; 2015:CD008632. [PMID: 26098746 PMCID: PMC6517154 DOI: 10.1002/14651858.cd008632.pub2] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Skeletal muscle wasting and weakness are significant complications of critical illness, associated with degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and can markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients after critical illness. Exercise-based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However, its effectiveness when initiated after ICU discharge has yet to be established. OBJECTIVES To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, for functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated longer than 24 hours. SEARCH METHODS We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid SP MEDLINE, Ovid SP EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host to 15 May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015 and will deal with the three studies of interest when we update the review. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs and controlled clinical trials (CCTs) that compared an exercise intervention initiated after ICU discharge versus any other intervention or a control or 'usual care' programme in adult (≥ 18 years) survivors of critical illness. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by the Cochrane Collaboration. MAIN RESULTS We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both on the ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to length of hospital stay following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. For other domains, at least half of the studies were at low risk of bias. One study was at high risk of selection bias, attrition bias and other sources of bias. Risk of bias was unclear for the remaining studies across domains. We decided not to undertake a meta-analysis because of variation in study design, types of interventions and outcome measurements. We present a narrative description of individual studies for each outcome.All six studies assessed functional exercise capacity, although we noted wide variability in the nature of interventions, outcome measures and associated metrics and data reporting. Overall quality of the evidence was very low. Individually, three studies reported positive results in favour of the intervention. One study found a small short-term benefit in anaerobic threshold (mean difference (MD) 1.8 mL O2/kg/min, 95% confidence interval (CI) 0.4 to 3.2; P value = 0.02). In a second study, both incremental (MD 4.7, 95% CI 1.69 to 7.75 watts; P value = 0.003) and endurance (MD 4.12, 95% CI 0.68 to 7.56 minutes; P value = 0.021) exercise testing results were improved with intervention. Finally self reported physical function increased significantly following use of a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability was evident with regard to findings for the primary outcome of health-related quality of life. Only two studies evaluated this outcome. Individually, neither study reported differences between intervention and control groups for health-related quality of life due to the intervention. Overall quality of the evidence was very low.Four studies reported rates of withdrawal, which ranged from 0% to 26.5% in control groups, and from 8.2% to 27.6% in intervention groups. The quality of evidence for the effect of the intervention on withdrawal was low. Very low-quality evidence showed rates of adherence with the intervention. Mortality ranging from 0% to 18.8% was reported by all studies. The quality of evidence for the effect of the intervention on mortality was low. Loss to follow-up, as reported in all studies, ranged from 0% to 14% in control groups, and from 0% to 12.5% in intervention groups, with low quality of evidence. Only one non-mortality adverse event was reported across all participants in all studies (a minor musculoskeletal injury), and the quality of the evidence was low. AUTHORS' CONCLUSIONS At this time, we are unable to determine an overall effect on functional exercise capacity, or on health-related quality of life, of an exercise-based intervention initiated after ICU discharge for survivors of critical illness. Meta-analysis of findings was not appropriate because the number of studies and the quantity of data were insufficient. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others did not. No effect on health-related quality of life was reported. Methodological rigour was lacking across several domains, influencing the quality of the evidence. Wide variability was noted in the characteristics of interventions, outcome measures and associated metrics and data reporting.If further trials are identified, we may be able to determine the effects of exercise-based intervention following ICU discharge on functional exercise capacity and health-related quality of life among survivors of critical illness.
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Affiliation(s)
- Bronwen Connolly
- Guy's and St Thomas' NHS Foundation TrustLane Fox Clinical Respiratory Physiology Research UnitLondonUK
- King’s College LondonDivision of Asthma, Allergy and Lung BiologyLondonUK
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, National Institute of Health Research Biomedical Research CentreLondonUK
| | - Lisa Salisbury
- University of EdinburghEdinburgh Critical Care Research Group MRC Centre for Inflammation ResearchEdinburghUK
| | - Brenda O'Neill
- Ulster UniversityCentre for Health and Rehabilitation Technologies (CHaRT), Institute of Nursing and Health ResearchNewtownabbeyNorthern IrelandUK
| | | | - Abdel Douiri
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, National Institute of Health Research Biomedical Research CentreLondonUK
- King's College LondonDepartment of Public Health Sciences, Division of Health and Social Care Research42 Weston StreetLondonUKSE1 3QD
| | - Michael PW Grocott
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUK
- Southampton NIHR Respiratory Biomedical Research UnitCritical Care Research AreaSouthamptonUK
- University Hospital Southampton NHS Foundation TrustAnaesthesia and Critical Care Research UnitSouthamptonUK
| | - Nicholas Hart
- Guy's and St Thomas' NHS Foundation TrustLane Fox Clinical Respiratory Physiology Research UnitLondonUK
- King’s College LondonDivision of Asthma, Allergy and Lung BiologyLondonUK
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, National Institute of Health Research Biomedical Research CentreLondonUK
| | - Timothy S Walsh
- Edinburgh Royal InfirmaryLittle France CrescentEdinburghUKEH16 2SA
| | - Bronagh Blackwood
- Queen’s University BelfastHealth Sciences, School of Medicine, Dentistry and Biomedical Sciences, Centre for Infection and ImmunityBelfastUK
| | - for the ERACIP Group
- The Intensive Care FoundationThe Intensive Care Society, Churchill House35 Red Lion SquareLondonUKWC1R 4SG
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270
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Marik PE. Feeding critically ill patients the right 'whey': thinking outside of the box. A personal view. Ann Intensive Care 2015; 5:51. [PMID: 26055186 PMCID: PMC4460184 DOI: 10.1186/s13613-015-0051-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/15/2015] [Indexed: 01/02/2023] Open
Abstract
Atrophy of skeletal muscle mass is an almost universal problem in survivors of critical illness and is associated with significant short- and long-term morbidity. Contrary to common practice, the provision of protein/amino acids as a continuous infusion significantly limits protein synthesis whereas intermittent feeding maximally stimulates skeletal muscle synthesis. Furthermore, whey-based protein (high in leucine) increases muscle synthesis compared to soy or casein-based protein. In addition to its adverse effects on skeletal muscle synthesis, continuous feeding is unphysiological and has adverse effects on glucose and lipid metabolism and gastrointestinal function. I propose that critically ill patients' be fed intermittently with a whey-based formula and that such an approach is likely to be associated with better glycemic control, less hepatic steatosis and greater preservation of muscle mass. This paper provides the scientific basis for my approach to intermittent feeding of critically ill patients.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA,
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271
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Thomas K, Wright SE, Watson G, Baker C, Stafford V, Wade C, Chadwick TJ, Mansfield L, Wilkinson J, Shen J, Deverill M, Bonner S, Hugill K, Howard P, Henderson A, Roy A, Furneval J, Baudouin SV. Extra Physiotherapy in Critical Care (EPICC) Trial Protocol: a randomised controlled trial of intensive versus standard physical rehabilitation therapy in the critically ill. BMJ Open 2015; 5:e008035. [PMID: 26009576 PMCID: PMC4452749 DOI: 10.1136/bmjopen-2015-008035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/25/2015] [Accepted: 04/28/2015] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Patients discharged from Critical Care suffer from excessive longer term morbidity and mortality. Physical and mental health measures of quality of life show a marked and immediate fall after admission to Critical Care with some recovery over time. However, physical function is still significantly reduced at 6 months. The National Institute for Health and Care Excellence clinical guideline on rehabilitation after critical illness, identified the need for high-quality randomised controlled trials to determine the most effective rehabilitation strategy for critically ill patients at risk of critical illness-associated physical morbidity. In response to this, we will conduct a randomised controlled trial, comparing physiotherapy aimed at early and intensive patient mobilisation with routine care. We hypothesise that this intervention will improve physical outcomes and the mental health and functional well-being of survivors of critical illness. METHODS AND ANALYSIS 308 adult patients who have received more than 48 h of non-invasive or invasive ventilation in Critical Care will be recruited to a patient-randomised, parallel group, controlled trial, comparing two intensities of physiotherapy. Participants will be randomised to receive either standard or intensive physiotherapy for the duration of their Critical Care admission. Outcomes will be recorded on Critical Care discharge, at 3 and 6 months following initial recruitment to the study. The primary outcome measure is physical health at 6 months, as measured by the SF-36 Physical Component Summary. Secondary outcomes include assessment of mental health, activities of daily living, delirium and ventilator-free days. We will also include a health economic analysis. ETHICS AND DISSEMINATION The trial has ethical approval from Newcastle and North Tyneside 2 Research Ethics Committee (11/NE/0206). There is a Trial Oversight Committee including an independent chair. The results of the study will be submitted for publication in peer-reviewed journals and presented at national and international scientific meetings. TRIAL REGISTRATION NUMBER ISRCTN20436833.
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Affiliation(s)
- Kirsty Thomas
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen E Wright
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gillian Watson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Baker
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Victoria Stafford
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Clare Wade
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Thomas J Chadwick
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Leigh Mansfield
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jennifer Wilkinson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jing Shen
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Deverill
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Bonner
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Keith Hugill
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Philip Howard
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | | | - Alistair Roy
- City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Julie Furneval
- City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Simon V Baudouin
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Abstract
PURPOSE OF REVIEW Survivors of a critical illness may experience poor physical function and quality of life as a result of reduced skeletal muscle mass and strength during their acute illness. Patients diagnosed with sepsis are particularly at risk, and mechanical ventilation may result in diaphragm dysfunction. Interest in the interaction of these conditions is both growing and important to understand for individualized patient care. RECENT FINDINGS This review describes developments in the presentation of both diaphragm and limb myopathy in critical illness, as measured from muscle biopsy and at the bedside with various imaging and strength-testing modalities. The influence of unloading of the diaphragm with mechanical ventilation and peripheral muscles with immobilization in septic patients has been recently questioned. Systemic inflammation appears to primarily accelerate and accentuate dysfunction, which may be remedied by early mobilization and augmented with developing muscle and/or nerve stimulation techniques. SUMMARY Many acute muscle changes in septic patients are likely to stem from pre-existing impairments, which should provide context for clinical evaluations of strength. During illness, sarcolemmal injury promotes a cascade of intra-cellular abnormalities. As unique characteristics of ICU-acquired weakness and differential effects on muscle groups are understood, early diagnosis and management should be facilitated.
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Affiliation(s)
- Claire E Baldwin
- aInternational Centre for Allied Health Evidence and School of Health Sciences, University of South Australia, Adelaide bPhysiotherapy Department, Flinders Medical Centre, Bedford Park cDepartment of Critical Care Medicine, School of Medicine, Faculty of Health Sciences, Flinders University, Bedford Park dIntensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
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273
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Mechanical bridge to long-term device implant: the necessary step for better outcomes. ASAIO J 2015; 61:225-6. [PMID: 25914949 DOI: 10.1097/mat.0000000000000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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274
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Jacobs FM. Early mobilization on continuous renal replacement therapy is safe and may improve filter life. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:205. [PMID: 25927350 PMCID: PMC4411787 DOI: 10.1186/s13054-015-0781-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Frederic M Jacobs
- Service de Réanimation Polyvalente, Hopital Antoine Béclère AP-HP, 157 rue de la Porte de Trivaux, Clamart, 92140, France.
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275
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Lee H, Ko YJ, Suh GY, Yang JH, Park CM, Jeon K, Park YH, Chung CR. Safety profile and feasibility of early physical therapy and mobility for critically ill patients in the medical intensive care unit: Beginning experiences in Korea. J Crit Care 2015; 30:673-7. [PMID: 25957499 DOI: 10.1016/j.jcrc.2015.04.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 04/16/2015] [Accepted: 04/18/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate risk factors for potential safety events during mobility physical therapy sessions in the medical intensive care unit. METHODS The safety profiles and potential risk factors of 99 patients who were admitted to the medical intensive care unit of a single teaching hospital in Korea between May 1 and December 31, 2013, were retrospectively evaluated. RESULTS A total of 26 potential safety events (5.0%; 95% confidence interval [CI], 3.4%-7.3%) during 520 mobilization sessions were observed in 17 (17.2%; 95% CI, 10.6%-26.4%) of 99 patients. The common potential safety events were as follows in order of frequency: 11 events of tachypnea or bradypnea (2.1%; 95% CI, 1.1%-3.9%), 6 events of desaturation (1.2 %; 95% CI, 0.5%-2.6%), 4 events of tachypnea or bradycardia (0.8%; 95% CI, 0.3%-2.1%), 4 events of patients' intolerance (0.8%; 95% CI, 0.3%-2.1%), and 1 event of tracheostomy tube removal (0.2%; 95% CI, 0%-1.2%). In multivariate analysis, the use of extracorporeal membrane oxygenation was associated with potential adverse events with an adjusted odds ratio of 5.8 (95% CI, 2.2-15.6), respectively. CONCLUSION Early mobility physical therapy performed by a newly established group was feasible for critically ill patients in Korea. However, potential safety events need to be monitored carefully for patients with extracorporeal membrane oxygenation support.
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Affiliation(s)
- Hyun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Jun Ko
- Department of Rehabilitation and Physical Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yun Hee Park
- Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Chi Ryang Chung
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Kayambu G, Boots R, Paratz J. Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomised controlled trial. Intensive Care Med 2015; 41:865-74. [DOI: 10.1007/s00134-015-3763-8] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 03/18/2015] [Indexed: 01/19/2023]
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277
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Skinner E, Warrillow S, Denehy L. Organisation and resource management in the intensive care unit: A critical review. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2015. [DOI: 10.12968/ijtr.2015.22.4.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Linda Denehy
- Professor in physiotherapy, The University of Melbourne, Australia
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278
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Eakin MN, Ugbah L, Arnautovic T, Parker AM, Needham DM. Implementing and sustaining an early rehabilitation program in a medical intensive care unit: A qualitative analysis. J Crit Care 2015; 30:698-704. [PMID: 25837800 DOI: 10.1016/j.jcrc.2015.03.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/10/2015] [Accepted: 03/15/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Early rehabilitation programs in a medical intensive care unit can improve patient outcomes, but clinicians face barriers in implementing and sustaining such programs. We sought to describe a multidisciplinary team perspective regarding how to implement and sustain a successful early rehabilitation program. METHODS Semistructured interviews were conducted with 20 staff and faculty who were involved in the early rehabilitation program at the Johns Hopkins Hospital Medical Intensive Care Unit. Transcripts were evaluated using the Consolidated Framework of Implementation Research Theory. RESULTS Four major constructs emerged as important, as follows: (1) necessary components, (2) implementation strategies, (3) perceived barriers, and (4) positive outcomes. All participants reported that staff buy-in was necessary, whereas having a multidisciplinary team with good communication among team members was reported as helpful by 90% of participants. The most common barrier reported was increased staff workload (80%). All participants (100%) noted improved patient outcomes as an important benefit, and 95% reported improved job satisfaction. CONCLUSIONS This qualitative study of a successful early rehabilitation program highlights the importance of assessing and engaging a multidisciplinary team before implementation and the positive outcomes of early rehabilitation on staff by improving job satisfaction and changing the culture of a hospital unit.
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Affiliation(s)
- Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Linda Ugbah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Tamara Arnautovic
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ann M Parker
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA
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Mehrholz J, Pohl M, Kugler J, Burridge J, Mückel S, Elsner B. Physical rehabilitation for critical illness myopathy and neuropathy. Cochrane Database Syst Rev 2015; 2015:CD010942. [PMID: 25737049 PMCID: PMC11026869 DOI: 10.1002/14651858.cd010942.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Intensive care unit (ICU) acquired or generalised weakness due to critical illness myopathy (CIM) and polyneuropathy (CIP) are major causes of chronically impaired motor function that can affect activities of daily living and quality of life. Physical rehabilitation of those affected might help to improve activities of daily living. OBJECTIVES Our primary objective was to assess the effects of physical rehabilitation therapies and interventions for people with CIP and CIM in improving activities of daily living such as walking, bathing, dressing and eating. Secondary objectives were to assess effects on muscle strength and quality of life, and to assess adverse effects of physical rehabilitation. SEARCH METHODS On 16 July 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register and on 14 July 2014 we searched CENTRAL, MEDLINE, EMBASE and CINAHL Plus. In July 2014, we searched the Physiotherapy Evidence Database (PEDro, http://www.pedro.org.au/) and three trials registries for ongoing trials and further data about included studies. There were no language restrictions. We also handsearched relevant conference proceedings and screened reference lists to identify further trials. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs), quasi-RCTs and randomised controlled cross-over trials of any rehabilitation intervention in people with acquired weakness syndrome due to CIP/CIM. DATA COLLECTION AND ANALYSIS We would have extracted data, assessed the risk of bias and classified the quality of evidence for outcomes in duplicate, according to the standard procedures of The Cochrane Collaboration. Outcome data collection would have been for activities of daily living (for example, mobility, walking, transfers and self care). Secondary outcomes included muscle strength, quality of life and adverse events. MAIN RESULTS The search strategy retrieved 3587 references. After examination of titles and abstracts, we retrieved the full text of 24 potentially relevant studies. None of these studies met the inclusion criteria of our review. No data were suitable to be included in a meta-analysis. AUTHORS' CONCLUSIONS There are no published RCTs or quasi-RCTs that examine whether physical rehabilitation interventions improve activities of daily living for people with CIP and CIM. Large RCTs, which are feasible, need to be conducted to explore the role of physical rehabilitation interventions for people with CIP and CIM.
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Affiliation(s)
- Jan Mehrholz
- Private Europäische Medizinische Akademie der Klinik Bavaria in Kreischa GmbHWissenschaftliches InstitutAn der Wolfsschlucht 1‐2KreischaGermany01731
- Technical University DresdenDepartment of Public Health, Dresden Medical SchoolDresdenGermany
| | - Marcus Pohl
- Klinik Bavaria KreischaAbteilung Neurologie und Fachübergreifende RehabilitationAn der Wolfsschlucht 1‐2KreischaGermany01731
| | - Joachim Kugler
- Technical University DresdenDepartment of Public Health, Dresden Medical SchoolDresdenGermany
| | - Jane Burridge
- University of SouthamptonResearch Group, Faculty of Health SciencesBuilding 45, University of SouthamptonSouthamptonUKSO17 1BJ
| | - Simone Mückel
- Private Europäische Medizinische Akademie der Klinik Bavaria in Kreischa GmbHWissenschaftliches InstitutAn der Wolfsschlucht 1‐2KreischaGermany01731
| | - Bernhard Elsner
- Technical University DresdenDepartment of Public Health, Dresden Medical SchoolDresdenGermany
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Hodgson C, Bellomo R, Berney S, Bailey M, Buhr H, Denehy L, Harrold M, Higgins A, Presneill J, Saxena M, Skinner E, Young P, Webb S. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:81. [PMID: 25715872 PMCID: PMC4342087 DOI: 10.1186/s13054-015-0765-4] [Citation(s) in RCA: 205] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/22/2015] [Indexed: 11/18/2022]
Abstract
Introduction The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients. Method This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work. Results We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18). In 94 of the 156 ICU survivors, strength was assessed at ICU discharge and 48 (52%) had ICU-acquired weakness (Medical Research Council Manual Muscle Test Sum Score (MRC-SS) score <48/60). The MRC-SS score was higher in those patients who mobilized while mechanically ventilated (50.0 ± 11.2 versus 42.0 ± 10.8, P = 0.003). Patients who survived to ICU discharge but who had died by day 90 had a mean MRC score of 28.9 ± 13.2 compared with 44.9 ± 11.4 for day-90 survivors (P <0.0001). Conclusions Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90. Clinical trial registration ClinicalTrials.gov NCT01674608. Registered 14 August 2012.
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Connolly B, Thompson A, Douiri A, Moxham J, Hart N. Exercise-based rehabilitation after hospital discharge for survivors of critical illness with intensive care unit-acquired weakness: A pilot feasibility trial. J Crit Care 2015; 30:589-98. [PMID: 25703957 PMCID: PMC4416081 DOI: 10.1016/j.jcrc.2015.02.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 01/05/2015] [Accepted: 02/04/2015] [Indexed: 02/07/2023]
Abstract
Purpose The aim of this study was to investigate feasibility of exercise-based rehabilitation delivered after hospital discharge in patients with intensive care unit–acquired weakness (ICU-AW). Materials and methods Twenty adult patients, mechanically ventilated for more than 48 hours, with ICU-AW diagnosis at ICU discharge were included in a pilot feasibility randomized controlled trial receiving a 16-session exercise-based rehabilitation program. Twenty-one patients without ICU-AW participated in a nested observational cohort study. Feasibility, clinical, and patient-centered outcomes were measured at hospital discharge and at 3 months. Results Intervention feasibility was demonstrated by high adherence and patient acceptability, and absence of adverse events, but this must be offset by the low proportion of enrolment for those screened. The study was underpowered to detect effectiveness of the intervention. The use of manual muscle testing for the diagnosis of ICU-AW lacked robustness as an eligibility criterion and lacked discrimination for identifying rehabilitation requirements. Process evaluation of the trial identified methodological factors, categorized by “population,” “intervention,” “control group,” and “outcome.” Conclusions Important data detailing the design, conduct, and implementation of a multicenter randomized controlled trial of exercise-based rehabilitation for survivors of critical illness after hospital discharge have been reported. Registration Clinical Trials Identifier NCT00976807
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Affiliation(s)
- Bronwen Connolly
- Department of Asthma, Allergy & Respiratory Science, Division of Asthma, Allergy and Lung Biology, King's College London, London, UK; Guy's & St Thomas' NHS Foundation Trust and King's College London, National Institutes of Health Research Biomedical Research Centre, London, UK; Lane Fox Clinical Respiratory Physiology Research Unit, St. Thomas' Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK.
| | - April Thompson
- Lane Fox Clinical Respiratory Physiology Research Unit, St. Thomas' Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Abdel Douiri
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King's College London, London, UK
| | - John Moxham
- Department of Asthma, Allergy & Respiratory Science, Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Nicholas Hart
- Department of Asthma, Allergy & Respiratory Science, Division of Asthma, Allergy and Lung Biology, King's College London, London, UK; Guy's & St Thomas' NHS Foundation Trust and King's College London, National Institutes of Health Research Biomedical Research Centre, London, UK; Lane Fox Clinical Respiratory Physiology Research Unit, St. Thomas' Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK
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Collings N, Cusack R. A repeated measures, randomised cross-over trial, comparing the acute exercise response between passive and active sitting in critically ill patients. BMC Anesthesiol 2015; 15:1. [PMID: 25670916 PMCID: PMC4322801 DOI: 10.1186/1471-2253-15-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 01/02/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early mobilisation of critically ill patients is safe and beneficial, but the metabolic cost of exercise remains unquantified. This study compared the acute exercise response in critically ill participants during passive and active sitting. METHOD We conducted a prospective, randomised, cross-over study, in ventilated patients receiving rehabilitative physiotherapy. Ten participants completed a passive chair transfer, or a sit on the edge of the bed, followed by the alternate exercise activity on the consecutive day. The primary outcome measure was oxygen consumption. RESULTS In comparison to resting supine, a passive chair transfer elicited no change in oxygen consumption, carbon dioxide production or minute ventilation; but mean arterial pressure (91.86 mmHg (95% CI 84.61 to 99.10) to 101.23 mmHg (95% CI 93.35 to 109.11) (p = 0.002)) and heart rate (89.13 bpm (95% CI 77.14 to 101.13) to 97.21 bpm (95% CI 81.22 to 113.20) (p = 0.008)) increased. Sitting on the edge of the bed resulted in significant increases in oxygen consumption (262.33 ml/min (95% CI 201.97 to 322.70) to 353.02 ml/min (95% CI 303.50 to 402.55), p = 0.002), carbon dioxide production (171.93 ml/min (95% CI 131.87 to 211.98) to 206.23 ml/min (95% CI 151.03 to 261.43), p = 0.026), minute ventilation (9.97 l/min (95% CI 7.30 to 12.65) to 12.82 l/min (95% CI 10.29 to 15.36), p < 0.001), mean arterial pressure (86.81 mmHg (95% CI 77.48 to 96.14) to 95.59 mmHg (95% CI 88.62 to 102.56), p = 0.034) and heart rate (87.60 bpm (95% CI 73.64 to 101.56) to 94.91 bpm (95% CI 79.57 to 110.25), p = 0.007). When comparing the 2 activities, sitting on the edge of the bed elicited a significantly larger increase in oxygen consumption (90.69 ml/min (95% CI 44.04 to 137.34) vs 14.43 ml/min (95% CI -27.28 to 56.14), p = 0.007) and minute ventilation (2.85 l/min (95% CI 1.70 to 3.99) vs 0.74 l/min (95% CI -0.92 to 1.56), p = 0.012). CONCLUSION Sitting on the edge of the bed is a more metabolically demanding activity than a passive chair transfer in critically ill patients.
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Affiliation(s)
- Nikki Collings
- Department of Physiotherapy, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 6YD Southampton, UK ; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 6YD Southampton, UK ; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, University Hospital Southampton, Tremona Road, SO16 6YD Southampton, UK
| | - Rebecca Cusack
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 6YD Southampton, UK ; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, University Hospital Southampton, Tremona Road, SO16 6YD Southampton, UK ; Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Tremona Road, SO16 6YD Southampton, UK
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Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. EXTREME PHYSIOLOGY & MEDICINE 2015; 4:16. [PMID: 26457181 PMCID: PMC4600281 DOI: 10.1186/s13728-015-0036-7] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/30/2015] [Indexed: 04/14/2023]
Abstract
Prolonged immobility is harmful with rapid reductions in muscle mass, bone mineral density and impairment in other body systems evident within the first week of bed rest which is further exacerbated in individuals with critical illness. Our understanding of the aetiology and secondary consequences of prolonged immobilization in the critically ill is improving with recent and ongoing research to establish the cause, effect, and best treatment options. This review aims to describe the current literature on bed rest models for examining immobilization-induced changes in the musculoskeletal system and pathophysiology of immobilisation in critical illness including examination of intracellular signalling processes involved. Finally, the review examines the current barriers to early activity and mobilization and potential rehabilitation strategies, which are being, investigated which may reverse the effects of prolonged bed rest. Addressing the deleterious effects of immobilization is a major step in treatment and prevention of the public health issue, that is, critical illness survivorship.
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Affiliation(s)
- Selina M. Parry
- />Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Level 7 Alan Gilbert Building, Parkville, Melbourne, VIC 3010 Australia
| | - Zudin A. Puthucheary
- />Division of Respiratory and Critical Care Medicine, National University Health System, Singapore, Singapore
- />Institute of Health and Human Performance, University College London, London, UK
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Skinner EH, Haines KJ, Hayes K, Seller D, Toohey JC, Reeve JC, Holdsworth C, Haines TP. Future of specialised roles in allied health practice: who is responsible? AUST HEALTH REV 2015; 39:255-259. [DOI: 10.1071/ah14213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/13/2015] [Indexed: 11/23/2022]
Abstract
Allied health professions have developed specialised advanced and extended scope roles over the past decade, for the benefit of patient outcomes, allied health professionals’ satisfaction and to meet labour and workforce demands. There is an essential need for formalised, widely recognised training to support these roles, and significant challenges to the delivery of such training exist. Many of these roles function in the absence of specifically defined standards of clinical practice and it is unclear where the responsibility for training provision lies. In a case example of physiotherapy practice in the intensive care unit, clinical placements and independence of practice are not core components of undergraduate physiotherapy degrees. Universities face barriers to the delivery of postgraduate specialised training and, although hospital physiotherapy departments are ideally placed, resources for training are lacking and education is not traditionally considered part of healthcare service providers’ core business. Substantial variability in training, and its evaluation, leads to variability in practice and may affect patient outcomes. Allied health professionals working in specialised roles should develop specific clinical standards of practice, restructure models of health care delivery to facilitate training, continue to develop the evidence base for their roles and target and evaluate training efficacy to achieve independent practice in a cost-effective manner. Healthcare providers must work with universities, the vocational training sector and government to optimise the ability of allied health to influence decision making and care outcomes for patients.
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285
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Sommers J, Engelbert R, Dettling D, Gosselink R, Spronk P, Horn J, Nollet F, Van der Schaaf M. Physiotherapy in the ICU: an evidence-based, expert-driven, practical statement. Crit Care 2015. [PMCID: PMC4472742 DOI: 10.1186/cc14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chao PW, Shih CJ, Lee YJ, Tseng CM, Kuo SC, Shih YN, Chou KT, Tarng DC, Li SY, Ou SM, Chen YT. Association of postdischarge rehabilitation with mortality in intensive care unit survivors of sepsis. Am J Respir Crit Care Med 2014; 190:1003-11. [PMID: 25210792 DOI: 10.1164/rccm.201406-1170oc] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Intensive care unit (ICU)-acquired weakness is a common issue for sepsis survivors that is characterized by impaired muscle strength and causes functional disability. Although inpatient rehabilitation has not been found to reduce in-hospital mortality, the impact of postdischarge rehabilitation on sepsis survivors is uncertain. OBJECTIVES To investigate the benefit of postdischarge rehabilitation to long-term mortality in sepsis survivors. METHODS We conducted a nationwide, population-based, high-dimensional propensity score-matched cohort study using Taiwan's National Health Insurance Research Database. The rehabilitation cohort comprised 15,535 ICU patients who survived sepsis and received rehabilitation within 3 months after discharge between 2000 and 2010. The control cohort consisted of 15,535 high-dimensional propensity score-matched subjects who did not receive rehabilitation within 3 months after discharge. The endpoint was mortality during the 10-year follow-up period. MEASUREMENTS AND MAIN RESULTS Compared with the control cohort, the rehabilitation cohort had a significantly lower risk of 10-year mortality (adjusted hazard ratio, 0.94; 95% confidence interval, 0.92-0.97; P < 0.001), with an absolute risk reduction of 1.4 per 100 person-years. The frequency of rehabilitation was inversely associated with 10-year mortality (≥3 vs. 1 course: adjusted hazard ratio, 0.82; P < 0.001). Compared with the control cohort, improved survival was observed in the rehabilitation cohort among ill patients who had more comorbidities, required more prolonged mechanical ventilation, and had longer ICU or hospital stays, but not among those with the opposite conditions (i.e., less ill patients). CONCLUSIONS Postdischarge rehabilitation may be associated with a reduced risk of 10-year mortality in the subset of patients with particularly long ICU courses.
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Affiliation(s)
- Pei-wen Chao
- 1 Department of Anesthesiology, Wan Fang Hospital, and
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Walkey AJ. Expanding the dimensions of effectiveness research in sepsis. Am J Respir Crit Care Med 2014; 190:970-1. [PMID: 25360724 DOI: 10.1164/rccm.201409-1710ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Allan J Walkey
- 1 Pulmonary Center, Division of Pulmonary, Allergy, and Critical Care Medicine Boston Medical Center, Boston University School of Medicine Boston, Massachusetts
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Barber EA, Everard T, Holland AE, Tipping C, Bradley SJ, Hodgson CL. Barriers and facilitators to early mobilisation in Intensive Care: a qualitative study. Aust Crit Care 2014; 28:177-82; quiz 183. [PMID: 25533868 DOI: 10.1016/j.aucc.2014.11.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/24/2014] [Accepted: 11/27/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To determine the barriers and facilitators of early mobilisation in the Intensive Care Unit. BACKGROUND It is well established that mobilising critically ill patients has many benefits, however it is not occurring as frequently as expected. The causes and ways to change this are not clearly understood. METHODS A qualitative descriptive study involving focus groups with medical, nursing and physiotherapy clinicians, from an Australian quaternary hospital Intensive Care Unit. RESULTS The major themes related to barriers included the culture of the Intensive Care Unit; communication; and a lack of resources. Major themes associated with facilitating early mobilisation included organisational change; improved communication between medical units; and improved resources. CONCLUSIONS Early mobilisation was considered an important aspect of critically ill patient's care by all clinicians. Several major barriers to mobilisation were identified, which included unit culture, lack of resources, prioritisation and leadership. A dedicated mobility team led by physiotherapists in the ICU setting could be a viable option to address the identified barriers related to mobility.
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Affiliation(s)
| | | | | | | | | | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Australia; The Alfred, Australia.
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Jolley SE, Regan-Baggs J, Dickson RP, Hough CL. Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study. BMC Anesthesiol 2014; 14:84. [PMID: 25309124 PMCID: PMC4192294 DOI: 10.1186/1471-2253-14-84] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 09/25/2014] [Indexed: 01/22/2023] Open
Abstract
Background Early mobilization (EM) of patients on mechanical ventilation (MV) is shown to improve outcomes after critical illness. Little is known regarding clinician knowledge of EM or multi-disciplinary barriers to use of EM in the intensive care unit (ICU). The goal of this study was to assess clinician knowledge regarding EM and identify barriers to its provision. Methods Simultaneous cross-sectional surveys of medical ICU (MICU) nurses (RN)/physical therapists (PT) respondents and physician (MD) respondents in a single MICU at an academic hospital in Seattle, WA in 2010–2011. Responses were indicated on a 5 point Likert scale and reported as proportion of respondents agreeing or disagreeing. Chi-square testing and Fisher’s exact testing was performed to determine whether responses differed by duration of employment or prior EM experience. Results A total of 120 clinicians responded to the survey (91 MDs (response rate 82% (91/111)), 17 RNs (response rate 22%, (17/78)), and 12 PTs (response rate 86%, (12/14)), overall response rate 86%). Most clinicians indicated knowledge regarding benefits of EM. More attending physicians reported knowledge of EM benefits, but also that risks of EM outweigh the benefits compared to trainees (p = 0.02 and 0.01). Clinicians across disciplines reported near universal agreement to use of EM for patients on MV, while the minority reported agreement to EM for patients on vasoactive agents. The most frequently reported cross-disciplinary barriers to EM were staffing and time. Risk of self-injury and excess work stress were indicated as barriers by RN and PT respondents. Conclusions MICU clinicians, at our institution, reported knowledge of EM in the ICU. Staffing and clinician time were frequently identified cross-disciplinary barriers. Risk of self-injury and excess work stress were frequently reported RN and PT barriers. Electronic supplementary material The online version of this article (doi:10.1186/1471-2253-14-84) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah E Jolley
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA ; Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Campus Box 356522, Seattle, WA 98195-6522 USA
| | | | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA
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Needham DM, Wozniak AW, Hough CL, Morris PE, Dinglas VD, Jackson JC, Mendez-Tellez PA, Shanholtz C, Ely EW, Colantuoni E, Hopkins RO. Risk factors for physical impairment after acute lung injury in a national, multicenter study. Am J Respir Crit Care Med 2014; 189:1214-24. [PMID: 24716641 DOI: 10.1164/rccm.201401-0158oc] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Existing studies of risk factors for physical impairments in acute lung injury (ALI) survivors were potentially limited by single-center design or relatively small sample size. OBJECTIVES To evaluate risk factors for three measures of physical impairments commonly experienced by survivors of ALI in the first year after hospitalization. METHODS A prospective, longitudinal study of 6- and 12-month physical outcomes (muscle strength, 6-minute-walk distance, and Short Form [SF]-36 Physical Function score) for 203 survivors of ALI enrolled from 12 hospitals participating in the ARDS Network randomized trials. Multivariable regression analyses evaluated the independent association of critical illness-related variables and intensive care interventions with impairments in each physical outcome measure, after adjusting for patient demographics, comorbidities, and baseline functional status. MEASUREMENTS AND MAIN RESULTS At 6 and 12 months, respectively, mean (± SD) values for strength (presented as proportion of maximum strength score evaluated using manual muscle testing) was 92% (± 8%) and 93% (± 9%), 6-minute-walk distance (as percent-predicted) was 64% (± 22%) and 67% (± 26%), and SF-36 Physical Function score (as percent-predicted) was 61% (± 36%) and 67% (± 37%). After accounting for patient baseline status, there was significant association and statistical interaction of mean daily dose of corticosteroids and intensive care unit length of stay with impairments in physical outcomes. CONCLUSIONS Patients had substantial impairments, from predicted values, for 6-minute-walk distance and SF-36 Physical Function outcome measures. Minimizing corticosteroid dose and implementing existing evidence-based methods to reduce duration of intensive care unit stay and associated patient immobilization may be important interventions for improving ALI survivors' physical outcomes.
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Wang YT, Haines TP, Ritchie P, Walker C, Ansell TA, Ryan DT, Lim PS, Vij S, Acs R, Fealy N, Skinner EH. Early mobilization on continuous renal replacement therapy is safe and may improve filter life. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R161. [PMID: 25069952 PMCID: PMC4262200 DOI: 10.1186/cc14001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/30/2014] [Indexed: 02/07/2023]
Abstract
Introduction Despite studies demonstrating benefit, patients with femoral vascular catheters placed for continuous renal replacement therapy are frequently restricted from mobilization. No researchers have reported filter pressures during mobilization, and it is unknown whether mobilization is safe or affects filter lifespan. Our objective in this study was to test the safety and feasibility of mobilization in this population. Methods A total of 33 patients undergoing continuous renal replacement therapy via femoral, subclavian or internal jugular vascular access catheters at two general medical-surgical intensive care units in Australia were enrolled. Patients underwent one of three levels of mobilization intervention as appropriate: (1) passive bed exercises, (2) sitting on the bed edge or (3) standing and/or marching. Catheter dislodgement, haematoma and bleeding during and following interventions were evaluated. Filter pressure parameters and lifespan (hours), nursing workload and concern were also measured. Results No episodes of filter occlusion or failure occurred during any of the interventions. No adverse events were detected. The intervention filters lasted longer than the nonintervention filters (regression coefficient = 13.8 (robust 95% confidence interval (CI) = 5.0 to 22.6), P = 0.003). In sensitivity analyses, we found that filter life was longer in patients who had more position changes (regression coefficient = 2.0 (robust 95% CI = 0.6 to 3.5), P = 0.007). The nursing workloads between the intervention shift and the following shift were similar. Conclusions Mobilization during renal replacement therapy via a vascular catheter in patients who are critically ill is safe and may increase filter life. These findings have significant implications for the current mobility restrictions imposed on patients with femoral vascular catheters for renal replacement therapy. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12611000733976 (registered 13 July 2011) Electronic supplementary material The online version of this article (doi:10.1186/cc14001) contains supplementary material, which is available to authorized users.
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Wageck B, Nunes GS, Silva FL, Damasceno MCP, de Noronha M. Application and effects of neuromuscular electrical stimulation in critically ill patients: systematic review. Med Intensiva 2014; 38:444-54. [PMID: 25060511 DOI: 10.1016/j.medin.2013.12.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 11/28/2013] [Accepted: 12/08/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate the applications and effects of neuromuscular electrical stimulation (NMES) in critically ill patients in ICU by means of a systematic review. MATERIALS AND METHODS Electronic searches were conducted in the databases Medline, CINAHL, Cochrane Central Register of Controlled Trials, Web of Science, Embase, ProQuest Health and Medical Complete, AMED, and PEDro. The PEDro score was used to assess the methodological quality of the eligible studies. RESULTS The search yielded a total of 9759 titles and nine articles satisfied the eligibility criteria. These studies showed that NMES can maintain or increase muscle mass, strength and volume, reduce time in mechanical ventilation and weaning time, and increase muscle degradation in critically ill patients in ICU. Two studies allowed a meta-analysis of the effects of NMES on quadriceps femoris strength and it showed a significant effect in favor of NMES in the Medical Research Council (MRC) Scale (standardized mean difference 0.77 points; p=0.02; 95% CI: 0.13-1.40). CONCLUSIONS The selected studies showed that NMES has good results when used for the maintenance of muscle mass and strength in critically ill patients in ICU. Future studies with high methodological quality should be conducted to provide more evidence for the use of NMES in an ICU setting.
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Affiliation(s)
- B Wageck
- Department of Physiotherapy, Center of Health and Sport Sciences, Santa Catarina State University, Florianópolis, Brazil.
| | - G S Nunes
- Department of Physiotherapy, Center of Health and Sport Sciences, Santa Catarina State University, Florianópolis, Brazil
| | - F L Silva
- Santa Casa de Misericórdia Dona Carolina Malheiros, São João da Boa Vista, Brazil
| | - M C P Damasceno
- Santa Casa de Misericórdia Dona Carolina Malheiros, São João da Boa Vista, Brazil
| | - M de Noronha
- Department of Physiotherapy, Center of Health and Sport Sciences, Santa Catarina State University, Florianópolis, Brazil; Department of Allied Health, La Trobe University, Bendigo, Australia
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293
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Abstract
OBJECTIVE To evaluate acute rehabilitation practices in pediatric critical care units across Canada. DESIGN Retrospective cohort study. SETTING Six Canadian, tertiary care pediatric critical care units. PATIENTS/SUBJECTS Six hundred children aged under 17 years admitted to pediatric critical care unit during a winter and summer month of 2011 with a greater than 24-hour length of stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome of interest was the nature and timing of pediatric critical care unit rehabilitation practices.Rehabilitation was classified according to mobility and nonmobility interventions. Predictors of mobilization and the time to mobilization were evaluated through regression and time-dependent survival analyses, respectively. The most common form of rehabilitation provided in pediatric critical care unit was physical therapy (45.5% patients) followed by occupational therapy (4.5%) and speech and language therapy (1.5%). Interventions were primarily nonmobility in nature (69.7% of sessions), most frequently in the form of chest physiotherapy (42.7% of sessions). The median time to mobilization was 2 days (interquartile range, 1-6) as compared with 1 day for nonmobility interventions (interquartile range, 1-3). Only 57 patients (9.5%) received early mobilization. Regression analyses revealed that increasing age, admission during winter, neuromuscular blockade, and sedative infusions were associated with an increased likelihood of receiving mobility therapy. Increasing age was a predictor of early mobilization, while neuromuscular blockade was associated with delayed mobilization. No significant differences in adverse events were found between nonmobility and mobility interventions. CONCLUSIONS Only half of the children receive rehabilitation while in the pediatric critical care unit, and when it occurs, therapy is primarily focused on respiratory function. Mobilization appears to be reserved for at-risk children who were muscle relaxed and sedated; however, its implementation in these patients is delayed. Future pediatric-specific research is essential to identify patients at risk and to understand treatment priorities and rehabilitation strategies to improve functional recovery in critically ill children.
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294
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McCredie VA, Adhikari NK. Early tracheostomy in critically ill patients: still too fast. THE LANCET RESPIRATORY MEDICINE 2014; 3:95-96. [PMID: 24981964 DOI: 10.1016/s2213-2600(14)70141-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Victoria A McCredie
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Neill Kj Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
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295
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Turnbull AE, Parker AM, Needham DM. Supporting small steps toward big innovations: the importance of rigorous pilot studies in critical care. J Crit Care 2014; 29:669-70. [PMID: 24930365 DOI: 10.1016/j.jcrc.2014.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Ann M Parker
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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296
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Ramsay P, Salisbury LG, Merriweather JL, Huby G, Rattray JE, Hull AM, Brett SJ, Mackenzie SJ, Murray GD, Forbes JF, Walsh TS. A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial. Trials 2014; 15:38. [PMID: 24476530 PMCID: PMC4016544 DOI: 10.1186/1745-6215-15-38] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 01/08/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Increasing numbers of patients are surviving critical illness, but survival may be associated with a constellation of physical and psychological sequelae that can cause ongoing disability and reduced health-related quality of life. Limited evidence currently exists to guide the optimum structure, timing, and content of rehabilitation programmes. There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period. This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness. The intervention is currently being evaluated in a randomised trial (ISRCTN09412438; funder Chief Scientists Office, Scotland). METHODS The intervention was developed using the Medical Research Council (MRC) framework for developing complex healthcare interventions. We ensured representation from a wide variety of stakeholders including content experts from multiple specialties, methodologists, and patient representation. The intervention construct was initially based on literature review, local observational and audit work, qualitative studies with ICU survivors, and brainstorming activities. Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline (No. 83), publicly available patient stories (Healthtalkonline), a stakeholder event in collaboration with the James Lind Alliance, and local piloting. Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant (GRA) role. Several rounds of external peer review during successive funding applications also contributed to development. RESULTS The final construct for the complex intervention involved a dedicated GRA trained to pre-defined competencies across multiple rehabilitation domains (physiotherapy, dietetics, occupational therapy, and speech/language therapy), with specific training in post-critical illness issues. The intervention was from ICU discharge to 3 months post-discharge, including inpatient and post-hospital discharge elements. Clear strategies to provide information to patients/families were included. A detailed taxonomy was developed to define and describe the processes undertaken, and capture them during the trial. The detailed process measure description, together with a range of patient, health service, and economic outcomes were successfully mapped on to the modified CONSORT recommendations for reporting non-pharmacologic trial interventions. CONCLUSIONS The MRC complex intervention framework was an effective guide to developing a novel post-ICU rehabilitation intervention. Combining a clearly defined new healthcare role with a detailed taxonomy of process and activity enabled the intervention to be clearly described for the purpose of trial delivery and reporting. These data will be useful when interpreting the results of the randomised trial, will increase internal and external trial validity, and help others implement the intervention if the intervention proves clinically and cost effective.
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Affiliation(s)
| | - Lisa G Salisbury
- Edinburgh Critical Care Research group, Edinburgh University and NHS Lothian, Chancellors Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK.
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297
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Abstract
BACKGROUND Rehabilitation as soon as possible after trauma decreases sedentary behavior, deconditioning, length of stay, and risk of rehospitalization. OBJECTIVE The study objectives were to describe exposure of older patients with trauma to rehabilitation and to explore factors associated with the number and initiation of therapy sessions. DESIGN This was a retrospective study of data from electronic medical records. METHODS Randomly selected older patients with trauma were described with regard to demographics, trauma diagnoses, comorbidities, preadmission function, and exposure to therapy. Regression analyses explored factors associated with number of therapy sessions and days until therapy was ordered and completed. RESULTS Records for 137 patients were randomly selected from records for 1,387 eligible patients who had trauma and were admitted over a 2-year period to a level I trauma center. The 137 patients received 303 therapy sessions. The sample included 63 men (46%) and 74 women (54%) who were 78 (SD=10) years of age; most patients were white (n=115 [84%]). All patients had orders for therapy, although 3 patients (2%) were never seen. An increase in comorbidities was associated with an increase in therapy sessions, a decrease in the number of days until an order was written, but an increase in the number of days from admission to evaluation. Injury severity was associated with a decrease in the number of days from admission to an order being written. A postponed or canceled therapy session was associated with increases in the number of days from admission to evaluation and in the number of days from an order being written to evaluation. LIMITATIONS This study was a retrospective review of a small sample with subjective measures and several dichotomous variables. CONCLUSIONS Increased injury severity, increased numbers of comorbidities, and postponed or canceled therapy sessions were associated with decreased time from admission to therapy orders, increased time from admission and orders to evaluation, and increased number of therapy sessions.
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298
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Abstract
OBJECTIVE To compare and contrast the process used to implement an early mobility program in ICUs at three different medical centers and to assess their impact on clinical outcomes in critically ill patients. DESIGN Three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement framework of Plan-Do-Study-Act. INTERVENTION Each of the three ICU early mobilization programs required an interprofessional team-based approach to plan, educate, and implement the ICU early mobility program. Champions from each profession-nursing, physical therapy, physician, and respiratory care-were identified to facilitate changes in ICU culture and clinical practice and to identify and address barriers to early mobility program implementation at each institution. SETTING The medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center. RESULTS Establishing an ICU early mobilization quality improvement program resulted in a reduced ICU and hospital length of stay at all three institutions and decreased rates of delirium and the need for sedation for the patients enrolled in the Johns Hopkins ICU early mobility program. CONCLUSION Instituting a planned, structured ICU early mobility quality improvement project can result in improved outcomes and reduced costs for ICU patients across healthcare systems.
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299
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Eikermann M, Latronico N. What is new in prevention of muscle weakness in critically ill patients? Intensive Care Med 2013; 39:2200-3. [PMID: 24154675 DOI: 10.1007/s00134-013-3132-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 10/04/2013] [Indexed: 01/17/2023]
Affiliation(s)
- Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital, and Harvard Medical School, 55 Fruit Street, Boston, MA, 02115, USA,
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300
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