Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit

Extended physiotherapy after Intensive Care Unit (ICU) stay: A prospective pilot study with a before and after design

OBJECTIVE

To examine whether extended compared to standard level of physiotherapy is feasible and has beneficial effects on physical function in ICU survivors.

METHODS

This prospective pilot study with a before and after design included patients discharged from ICU to a surgical ward. The comparison group were recruited between January and April 2019 and received standard level of physiotherapy. The intervention group were recruited between May and December 2019 and received extended physiotherapy, corresponding to 50% additional physiotherapist, working 4 hours per weekday. The intervention participants received an individual rehabilitation plan developed in collaboration with a ward-based physiotherapist, and an extended number of sessions provided by the extra resource included practicing individualized exercises, for example walking and stair climbing. Physical function was measured with the Chelsea Critical Care Physical Assessment tool (CPAx) at ICU discharge, during hospital stay and discharge. Group differences were analyzed using the Mann-Whitney U-test and Chi2 test.

RESULTS

Out of 46 eligible patients, 39 (85%) fulfilled the study (comparison n = 12, intervention n = 27) and were included in the final analyses. No adverse events occurred, and the attendance rate was high (98.5%). There were no statistically significant differences between the groups regarding physical function, hospital stay, and readmissions, but there were tendencies to better outcomes in all these parameters in favor of the intervention group. Additionally, patients in the intervention group had statistically significantly higher scores in the CPAx items "transferring from bed to chair" (median 5 vs 4, p = .039) and "stepping" (median 5 vs 4, p = .005) at hospital discharge.

CONCLUSION

This pilot study indicates that extended physiotherapy after ICU discharge is feasible and does not entail patient safety risks. However, determining the potential beneficial effects for the patients remains to be evaluated in a larger trial.

Patients' experiences with early rehabilitation in intensive care units: A qualitative study about aspects that influence their participation

AIM

To explore patients' experiences with early rehabilitation in the intensive care unit and what they perceive to influence their participation.

DESIGN

A qualitative design anchored in phenomenological and hermeneutical traditions utilizing in-depth interviews.

METHODS

Thirteen patients were interviewed from 5 to 29 weeks following discharge from three units, in January-December 2022. Analysed using systematic text condensation and the pattern theory of self. Reporting adhered to consolidated criteria for reporting qualitative research.

RESULTS

Interviews described four main categories: (1) A foreign body, how the participants experienced their dysfunctional and different looking bodies. (2) From crisis to reorientation, the transformation the participants experienced from a state of crisis to acceptance and the ability to look forwards, indicating how bodily dysfunctions are interlinked to breakdowns of the patients' selves and the reorganization process. (3) Diverse expectations regarding activity: ambiguous expectations communicated by the nurses. (4) Nurse-patient: a powerful interaction, highlighting the essential significance of positive expectations and tailored bodily and verbal interaction for rebuilding the patient's outwards orientation.

CONCLUSION

Outwards orientation and reorganization of the self through a reduction in bodily dysfunctions, strengthening the patients' acceptance of the situation, providing tailored expectations and hands-on and verbal interaction appear to be fundamental aspects of patient participation in early rehabilitation.

IMPLICATIONS

Insights into patients' perceptions show how dysfunctional bodies cloud individuals' perceptual fields, causing inwards orientation and negative thoughts concerning themselves, their capabilities, environment and future. This knowledge can improve nurses' ability to tailor care to promote optimal recovery for patients.

PATIENT OR PUBLIC CONTRIBUTION

User representative contributed to the design of the study.

Rehabilitation in the intensive care unit: How amount of physical and occupational therapy affects patients' function and hospital length of stay

BACKGROUND

Patients in the intensive care unit (ICU) often experience extended periods of immobility. Following hospital discharge, many face impaired mobility and never return to their baseline function. Although the benefits of physical and occupational rehabilitation are well established in non-ICU patients, a paucity of work describes effective practices to alleviate ICU-related declines in mobility.

OBJECTIVE

To assess how rehabilitation with physical and occupational therapy (PT-OT) during ICU stays affects patients' mobility, self-care, and length of hospital stay.

DESIGN

Retrospective cohort study.

SETTING

Inpatient ICU.

PARTICIPANTS

A total of 6628 adult patients who received physical rehabilitation across multiple sites (Arizona, Florida, Minnesota, and Wisconsin) of a single institution between January 2018 and December 2021.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Descriptive statistics, linear regression models, and gradient boosting machine methods were used to determine the relationship between the amount of PT-OT received and outcomes of hospital length of stay (LOS), Activity Measure for Post-Acute Care Daily Activity and Basic Mobility scores.

RESULTS

The 6628 patients who met inclusion criteria received an average (median) of 23 (range: 1-89) minutes of PT-OT per day. Regression analyses showed each additional 10 minutes of PT-OT per day was associated with a 1.0% (95% confidence interval [CI]: 0.41-1.66, p < .001) higher final Basic Mobility score, a 1.8% (95% CI: 1.30%-2.34%, p < .001) higher final Daily Activity score, and a 1.2-day (95% CI: -1.28 to -1.09, p < .001) lower hospital LOS. One-dimensional partial dependence plots revealed an exponential decrease in predicted LOS as minutes of PT-OT received increased.

CONCLUSION

Higher rehabilitation minutes provided to patients in the ICU may reduce the LOS and improve patients' functional outcomes at discharge. The benefits of rehabilitation increased with increasing amounts of time of therapy received.

Current Concepts in Early Mobilization of Critically Ill Patients Within the Context of Neurologic Pathology

Neurocritical patients (NCPs) in the intensive care unit (ICU) rapidly progress to respiratory and peripheral muscle dysfunctions, which significantly impact morbidity and death. Early mobilization in NCPs to decrease the incidence of ICU-acquired weakness has been showing rapid growth, although pertinent literature is still scarce. With this review, we summarize and discuss current concepts in early mobilization of critically ill patients within the context of neurologic pathology in NCPs. A narrative synthesis of literature was undertaken trying to answer the following questions: How do the respiratory and musculoskeletal systems in NCPs behave? Which metabolic biomarkers influence physiological responses in NCPs? Which considerations should be taken when prescribing exercises in neurocritically ill patients? The present review detected safety, feasibility, and beneficial response for early mobilization in NCPs, given successes in other critically ill populations and many smaller intervention trials in neurocritical care. However, precautions should be taken to elect the patient for early care, as well as monitoring signs that indicate interruption for intervention, as worse outcomes were associated with very early mobilization in acute stroke trials.

Does the level of mobility on ICU discharge impact post-ICU outcomes? A retrospective analysis

PURPOSE

Mobilisation is a common intervention in Intensive Care (ICU). However, few studies have explored the relationship between mobility levels and outcomes. This study assessed the association of the level of mobility on ICU discharge with discharge destination from the hospital and hospital length of stay.

MATERIALS AND METHODS

A retrospective analysis of data from 522 patients admitted to a single UK general ICU who were ventilated for ≥5 days was performed. The level of mobility was assessed using the Manchester Mobility Score (MMS). Multivariable regression analysed demographic and clinical variables for the independence of association with discharge destination and hospital length of stay.

RESULTS

MMS ≥5 on ICU discharge was independently associated with discharge destination and hospital LOS (p < 0.001). Patients achieving MMS ≥5 on ICU discharge were more likely to be discharged home (OR 3.86 95% CI 2.1 to 6.9, p < 0.001), and had an 11.8 day shorter hospital LOS (95% CI -17.6 to -6.1, p < 0.001).

CONCLUSIONS

The ability to step transfer to a chair (MMS ≥5) before ICU discharge was independently associated with discharge to usual residence and hospital LOS, irrespective of preadmission morbidity. Increasing the level of patient mobility at ICU discharge should be a key focus of rehabilitation interventions.

Decrease in the intensive care unit-acquired weakness with a multicomponent protocol implementation: A quasi-experimental clinical trial

Introduction

Intensive care unit-acquired weakness is a frequent complication that affects the prognosis of critical illness during hospital stay and after hospital discharge.

Objectives

To determine if a multicomponent protocol of early active mobility involving adequate pain control, non-sedation, non-pharmacologic delirium prevention, cognitive stimulation, and family support, reduces intensive care unit-acquired weakness at the moment of discharge.

Materials and methods

We carried out a non-randomized clinical trial in two mixed intensive care units in a high-complexity hospital, including patients over 14 years old with invasive mechanical ventilation for more than 48 hours. We compared the intervention –the multicomponent protocol– during intensive care hospitalization versus the standard care.

Results

We analyzed 82 patients in the intervention group and 106 in the control group. Muscle weakness acquired in the intensive care unit at the moment of discharge was less frequent in the intervention group (41.3% versus 78.9%, p<0.00001). The mobility score at intensive unit care discharge was better in the intervention group (median = 3.5 versus 2, p < 0.0138). There were no statistically significant differences in the invasive mechanical ventilation-free days at day 28 (18 versus 15 days, p<0.49), and neither in the mortality (18.2 versus 27.3%, p<0.167).

Conclusion

A multi-component protocol of early active mobility significantly reduces intensive care unit-acquired muscle weakness at the moment of discharge.

Effects of pulmonary rehabilitation in survivors of severe acute respiratory syndrome coronavirus 2. Role of vaccination

Survivors of severe COVID-19 requiring hospital admission may suffer from short- and long-term sequelae, including disability and reduced physical performance. Vaccination and pulmonary rehabilitation (PR) are effective tools against COVID-19 effects. While the beneficial effect of each of these treatments is known, there are no data about their combined effect. In people admitted to PR hospitals after severe COVID-19 disease, we retrospectively analyzed whether PR outcome might be influenced by vaccination status. Ninety-six individuals were studied (46 vaccinated, 50 unvaccinated). Unvaccinated individuals were younger and less comorbid than vaccinated ones and had needed more intensive care support during the previous hospitalization. Measures of disability and physical performance did not differ between groups at the beginning and at the end of the PR program. However, each group showed a statistically significant improvement in all outcome measures (6-minute walking test, short physical performance battery, Barthel Index). We conclude that vaccination status does not influence the outcome of in-patient PR programs for survivors of severe COVID-19.

Training effects of set- and repetition-interval rest time on recumbent-boxing exercise: Could virtual reality improve further?

This study examined the influence of set-interval and repetition-interval rest time of virtual reality (VR) boxing game in supine-lying posture. Fifty healthy middle-aged adults were randomly assigned into VR and non-VR groups to perform six different exercise protocols with varying set-interval and repetition-interval rest times (S0R0, S0R1/3, S0R2/3, S40R0, S40R1/3, and S40R2/3). Analysis on the non-VR group showed significant differences between exercise protocols for average heart rate (p < 0.001), maximum ventilation volume (p < 0.001), respiratory quotient (p < 0.001), oxygen pulse (p < 0.001), and excess post-exercise oxygen consumption (EPOC) (p = 0.003). VR appeared to have no further improvement on physical training effects in middle-aged adults, while the participants reported negative experience that might be associated with the over-exertion. Future study might need to explore game design elements that can accommodate high-exertion exercises.

Application of the Perme Score to assess mobility in patients with COVID-19 in inpatient units

Objective

To evaluate the ability of the Perme Score to detect changes in the level of mobility of patients with COVID-19 outside the intensive care unit.

Method

A retrospective cohort study was conducted in inpatient units of a private hospital. Patients older than 18, diagnosed with COVID-19, who were discharged from the intensive care unit and remained in the inpatient units were included. The variables collected included demographic characterization data, length of hospital stay, respiratory support, Perme Score values at admission to the inpatient unit and at hospital discharge and the mobilization phases performed during physical therapy.

Result

A total of 69 patients were included, 80% male and with a mean age of 61.9 years (SD=12.5 years). The comparison of the Perme Score between the times of admission to the inpatient unit and at hospital discharge shows significant variation, with a mean increase of 7.3 points (95%CI:5.7-8.8; p<0.001), with estimated mean values of Perme Score at admission of 17.5 (15.8; 19.3) and hospital discharge of 24.8 (23.3; 26.3). There was no association between Perme Score values and length of hospital stay (measure of effect and 95%CI 0.929 (0.861; 1.002; p=0.058)).

Conclusion

The Perme Score proved effective for assessing mobility in patients diagnosed with COVID-19 with prolonged hospitalization outside the intensive care setting. In addition, we demonstrated by the value of the Perme Score that the level of mobility increases significantly from the time of admission to inpatient units until hospital discharge. There was no association between the Perme Score value and length of hospital stay.

Early Mobilization for Critically Ill Patients

Advances in the field of critical care medicine have helped improve the survival rate of these ill patients. Several studies have demonstrated the potential benefits of early mobilization as an important component of critical care rehabilitation. However, there have been some inconsistent results. Moreover, the lack of standardized mobilization protocols and the associated safety concerns are a barrier to the implementation of early mobilization in critically ill patients. Therefore, determining the appropriate modalities of implementation of early mobilization is a key imperative to leverage its potential in these patients. In this paper, we review the contemporary literature to summarize the strategies for early mobilization of critically ill patients, assess the implementation and validity based on the International Classification of Functioning, Disability and Health, as well as discuss the safety aspects of early mobilization.

Mapping peripheral and abdominal sarcopenia acquired in the acute phase of COVID-19 during 7 days of mechanical ventilation

Our aim was to map acquired peripheral and abdominal sarcopenia in mechanically ventilated adults with COVID-19 through ultrasound measurements. On Days 1, 3, 5 and 7 after admission to critical care, the muscle thickness and cross-sectional area of the quadriceps, rectus femoris, vastus intermedius, tibialis anterior, medial and lateral gastrocnemius, deltoid, biceps brachii, rectus abdominis, internal and external oblique, and transversus abdominis were measured using bedside ultrasound. A total of 5460 ultrasound images were analyzed from 30 patients (age: 59.8 ± 15.6 years; 70% men). Muscle thickness loss was found in the bilateral anterior tibial and medial gastrocnemius muscles (range 11.5-14.6%) between Days 1 and 3; in the bilateral quadriceps, rectus femoris, lateral gastrocnemius, deltoid, and biceps brachii (range 16.3-39.1%) between Days 1 and 5; in the internal oblique abdominal (25.9%) between Days 1 and 5; and in the rectus and transversus abdominis (29%) between Days 1 and 7. The cross-sectional area was reduced in the bilateral tibialis anterior and left biceps brachii (range 24.6-25.6%) between Days 1 and 5 and in the bilateral rectus femoris and right biceps brachii (range 22.9-27.7%) between Days 1 and 7. These findings indicate that the peripheral and abdominal muscle loss is progressive during the first week of mechanical ventilation and is significantly higher in the lower limbs, left quadriceps and right rectus femoris muscles in critically ill patients with COVID-19.

Hemodynamic impact of early mobilization in critical patients receiving vasoactive drugs: A prospective cohort study

BACKGROUND

Vasoactive drugs are one of the most common patient-related barriers to early mobilization. Little is known about the hemodynamic effects of early mobilization on patients receiving vasoactive drugs. This study aims to observe and describe the impact of mobilization on the vital signs of critical patients receiving vasoactive drugs as well as the occurrence of adverse events.

METHODS

This is a cohort study performed in an Intensive Care Unit with patients receiving vasoactive drugs. All patients, either mobilized or non-mobilized, had their clinical data such as vital signs [heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation], type and dosage of the vasoactive drug, and respiratory support collected at rest. For mobilized patients, the vital signs were also collected after mobilization, and so was the highest level of mobility achieved and the occurrence of adverse events. The criteria involved in the decision of mobilizing the patients were registered.

RESULTS

53 patients were included in this study and 222 physiotherapy sessions were monitored. In most of the sessions (n = 150, 67.6%), patients were mobilized despite the use of vasoactive drugs. There was a statistically significant increase in heart rate and respiratory rate after mobilization when compared to rest (p<0.05). Only two (1.3%) out of 150 mobilizations presented an adverse event. Most of the time, non-mobilizations were justified by the existence of a clinical contraindication (n = 61, 84.7%).

CONCLUSIONS

The alterations observed in the vital signs of mobilized patients may have reflected physiological adjustments of patients' cardiovascular and respiratory systems to the increase in physical demand imposed by the early mobilization. The adverse events were rare, not serious, and reversed through actions such as a minimal increase of the vasoactive drug dosage.

More is less: Effect of ICF-based early progressive mobilization on severe aneurysmal subarachnoid hemorrhage in the NICU

Introduction

Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that occurs due to a ruptured intracranial aneurysm. Although advanced therapies have been applied to treat aSAH, patients still suffer from functional impairment leading to prolonged stays in the NICU. The effect of early progressive mobilization as an intervention implemented in the ICU setting for critically ill patients remains unclear.

Methods

This retrospective study evaluated ICF-based early progressive mobilization's validity, safety, and feasibility in severe aSAH patients. Sixty-eight patients with aSAH with Hunt-Hess grades III-IV were included. They were divided into two groups-progressive mobilization and passive movement. Patients in the progressive mobilization group received progressive ICF-based mobilization intervention, and those in the passive movement group received passive joint movement training. The incidence of pneumonia, duration of mechanical ventilation, length of NICU stay, and incidence of deep vein thrombosis were evaluated for validity. In contrast, the incidence of cerebral vasospasm, abnormally high ICP, and other safety events were assessed for safety. We also described the feasibility of the early mobilization initiation time and the rate of participation at each level for patients in the progressive mobilization group.

Results

The results showed that the incidence of pneumonia, duration of mechanical ventilation, and length of NICU stay were significantly lower among patients in the progressive mobilization group than in the passive movement group (P = 0.031, P = 0.004, P = 0.012), but the incidence of deep vein thrombosis did not significantly differ between the two groups. Regarding safety, patients in the progressive mobilization group had a lower incidence of cerebral vasospasm than those in the passive movement group. Considering the effect of an external ventricular drain on cerebral vasospasm (P = 0.015), we further analyzed those patients in the progressive mobilization group who had a lower incidence of cerebral vasospasm in patients who did not have an external ventricular drain (P = 0.011). Although we found 2 events of abnormally increased intracranial pressure in the progressive mobilization group, there was no abnormal decrease in cerebral perfusion pressure in the 2 events. In addition, among other safety events, there was no difference in the occurrence of adverse events between the two groups (P = 0.073), but the number of potential adverse events was higher in the progressive mobilization group (P = 0.001). Regarding feasibility, patients in the progressive mobilization group were commonly initiated 72 h after admission to the NICU, and 47.06% were in the third level of the mobilization protocol.

Discussion

We conclude that the ICF-based early progressive mobilization protocol is an effective and feasible intervention tool. For validity, more mobilization interventions might lead to less pneumonia, duration of mechanical ventilation and length of stay for patients with severe aSAH in the NICU, Moreover, it is necessary to pay attention over potential adverse events (especially line problems), although we did not find serious safety events.

Impact of Falls Within 3 Months on the Short-Term Prognoses of Elderly Patients in Intensive Care Units: A Retrospective Cohort Study Using Stabilized Inverse Probability Treatment Weighting

Background

Falls are a major public health problem in the older adults that can lead to poor clinical outcomes. There have been few reports on the short-term prognoses of older critically ill patients, and so we sought to determine the impact of falls on elderly patients in intensive care units (ICUs).

Patients and Methods

This retrospective study of 4503 patients (aged 65 years or older) analyzed data in the Medical Information Mart for Intensive Care-III critical care database. Of those, 2459 (54.6%) older adults are males, and 2044 (45.4%) older adults are females. Based on information from the medical care record assessment forms, patients were classified into the following two groups based on whether they had a fall within the previous 3 months: falls (n=1142) and nonfalls (n=3361). The primary outcomes of this study were 30- and 90-day mortality. Associations between the results of the Kaplan-Meier (KM) survival analysis, Cox proportional-hazards regression models, and subgroup analysis and its outcomes were analyzed using stabilized inverse probability treatment weighting (IPTW).

Results

KM survival curves with stabilized IPTW indicated that 30- and 90-day survival rates were significantly lower in elderly critically ill patients with a history of falls within the previous 3 months than in those patients without a history of falls (all p<0.001). Multivariate Cox proportional-hazards regression analysis indicated that 30- and 90-day mortality rates were 1.35 times higher (95% confidence interval [CI]=1.16-1.57, p<0.001) and 1.36 times higher (95% CI=1.19-1.55, p<0.001), respectively, in elderly critically ill patients with a history of falls within the previous 3 months than in those patients without a history of falls.

Conclusion

Experience of falls within the previous 3 months prior to ICU admission increased the risk of short-term mortality and affected the prognoses of elderly patients. Falls should therefore receive adequate attention from clinical healthcare providers and management decision-makers.

ICU quasi-speciality nurses' knowledge, attitudes and practices regarding early mobilization: A cross-sectional survey

AIM

Early mobilization (EM) improves critical illness survivors' clinical outcomes. This study examines ICU quasi-specialty nurses' EM-related knowledge, attitudes and practices (KAP).

DESIGN

This cross-sectional study was conducted at a provincial ICU specialty nurse training site from 2019 to 2021. KAP data were collected using a self-report questionnaire.

METHODS

Participants were registered nurses enrolled in the training programme; 485 nurses from 188 hospitals completed the questionnaire.

RESULTS

Of the participants, 37.7% had EM training, and 30.7% reported their wards performed EM. Median (IQR) scores for knowledge, attitudes and practices were 14.0 (4.0), 47.0 (9.0) and 37.0 (8.0), belonging to medium, high and medium levels. Scores were lowest for EM scope, implementation indicators and out-of-bed mobilization. There were significant deviations in KAP scores amongst nurses at different levels of hospitals with EM training and whose departments performed EM. Significant positive correlations between knowledge and practice, and attitude and practice were identified.

Clinical utility and future direction of speaking valve: A review

This paper summarizes and analyzes the clinical research progress of the speaking valve in recent years, including the structure and function of the speaking valve, the impact of the speaking valve on the patient’s vocalization or speech, the impact on ventilator weaning and tracheal intubation and extubation, and the effect on aspiration and swallowing function, the impact on patient mobility and quality of life. Related issues in clinical use are also described.

Evaluation of progressive early rehabilitation training mode in intensive care unit patients with mechanical ventilation

BACKGROUND

Mechanical ventilation is a common resuscitation method in the intensive care unit (ICU). Unfortunately, this treatment process prolongs the ICU stay of patients with an increased incidence of delirium, which ultimately affects the prognosis.

AIM

To evaluate the effect of progressive early rehabilitation training on treatment and prognosis of patients with mechanical ventilation in ICU.

METHODS

The convenience sampling method selected 190 patients with mechanical ventilation admitted to the Fourth Hospital of Hebei Medical University from March 2020 to March 2021. According to the random number table method, they were divided into the control and intervention groups. The control group received routine nursing and rehabilitation measures, whereas the intervention group received progressive early rehabilitation training. In addition, the incidence and duration of delirium were compared for the two groups along with mechanical ventilation time, ICU hospitalization time, functional independence measure (FIM) score, Barthel index, and the incidence of complications (deep venous thrombosis, pressure sores, and acquired muscle weakness).

RESULTS

In the intervention group, the incidence of delirium was significantly lower than in the control group (28% vs 52%, P < 0.001). In the intervention group, the duration of delirium, mechanical ventilation time, and ICU stay were shorter than in the control group (P < 0.001). The FIM and Barthel index scores were significantly higher in the intervention group than the control group (P < 0.001). The total incidence of complications in the intervention group was 3.15%, which was lower than 17.89% in the control group (P < 0.001).

CONCLUSION

Progressive early rehabilitation training reduced the incidence of delirium and complications in ICU patients with mechanical ventilation, which improved prognosis and quality of life.

ARDS Clinical Practice Guideline 2021

Background

The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021.

Methods

The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method.

Results

Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO₂ (PaO₂) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D).

Conclusions

This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00615-6.

Safety and Feasibility Assessment of Repetitive Vascular Occlusion Stimulus (RVOS) Application to Multi-Organ Failure Critically Ill Patients: A Pilot Randomised Controlled Trial

Muscle wasting is implicated in the pathogenesis of intensive care unit acquired weakness (ICU-AW), affecting 40% of patients and causing long-term physical disability. A repetitive vascular occlusion stimulus (RVOS) limits muscle atrophy in healthy and orthopaedic subjects, thus, we explored its application to ICU patients. Adult multi-organ failure patients received standard care +/- twice daily RVOS {4 cycles of 5 min tourniquet inflation to 50 mmHg supra-systolic blood pressure, and 5 min complete deflation} for 10 days. Serious adverse events (SAEs), tolerability, feasibility, acceptability, and exploratory outcomes of the rectus femoris cross-sectional area (RFCSA), echogenicity, clinical outcomes, and blood biomarkers were assessed. Only 12 of the intended 32 participants were recruited. RVOS sessions (76.1%) were delivered to five participants and two could not tolerate it. No SAEs occurred; 75% of participants and 82% of clinical staff strongly agreed or agreed that RVOS is an acceptable treatment. RFCSA fell significantly and echogenicity increased in controls (n = 5) and intervention subjects (n = 4). The intervention group was associated with less frequent acute kidney injury (AKI), a greater decrease in the total sequential organ failure assessment score (SOFA) score, and increased insulin-like growth factor-1 (IGF-1), and reduced syndecan-1, interleukin-4 (IL-4) and Tumor necrosis factor receptor type II (TNF-RII) levels. RVOS application appears safe and acceptable, but protocol modifications are required to improve tolerability and recruitment. There were signals of possible clinical benefit relating to RVOS application.

Non-Pharmacological Nursing Interventions to Prevent Delirium in ICU Patients-An Umbrella Review with Implications for Evidence-Based Practice

Delirium in ICU patients is a complication associated with many adverse consequences. Given the high prevalence of this complication in critically ill patients, it is essential to develop and implement an effective management protocol to prevent delirium. Given that the cause of delirium is multifactorial, non-pharmacological multicomponent interventions are promising strategies for delirium prevention. (1) Background: To identify and evaluate published systematic review on non-pharmacological nursing interventions to prevent delirium in intensive care unit patients. (2) Methods: An umbrella review guided by the Joanna Briggs Institute was utilized. Data were obtained from PubMed, Scopus, EBSCO, Web of Science, Cochrane Library, and Google Scholar. The last search was conducted on 1 May 2022. (3) Results: Fourteen reviews met the inclusion criteria. Multicomponent interventions are the most promising methods in the fight against delirium. The patient's family is an important part of the process and should be included in the delirium prevention scheme. Light therapy can improve the patient's circadian rhythm and thus contribute to reducing the incidence of delirium. (4) Conclusions: Non-pharmacological nursing interventions may be effective in preventing and reducing the duration of delirium in ICU patients.

Non-Pharmacological Interventions for Minimizing Physical Restraints Use in Intensive Care Units: An Umbrella Review

Background

There is a relationship between the application of physical restraints and negative physiological and psychological effects on critically ill patients. Many organizations have supported and advocated minimizing the use of physical restraints. However, it is still common practice in many countries to apply physical restraints to patients in intensive care.

Objective

This study aimed to assess the effectiveness of various non-pharmacological interventions used to minimize physical restraints in intensive care units and provide a supplement to the evidence summary for physical restraints guideline adaptation.

Methods

Based on the methodology of umbrella review, electronic databases, including Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, MEDLINE, EMBASE, CINAHL, Web of Science, PsycInfo/Psyc Articles/Psychology and Behavioral Science Collection, China National Knowledge Infrastructure, SinoMed, and Wanfang Data, were searched to identify systematic reviews published from January 2016 to December 2020. Two independent reviewers undertook screening, data extraction, and quality appraisal. The methodological quality of systematic reviews was evaluated by AMSTAR 2. Evidence quality of each intervention was assessed according to GRADE. The corrected covered area was calculated as a measure of overlap.

Results

A total of 47 systematic reviews were included in the umbrella review, of which six were evaluated as high quality, five were of moderate quality, and the rest were of low or critically low quality. The corrected covered area range was from 0.0 to 0.269, which indicated that there was mild overlap between systematic reviews. The included systematic reviews evaluated various types of non-pharmacological interventions for minimizing physical restraints in intensive care units, which included multicomponent interventions involving healthcare professionals' education, family engagement/support, specific consultations and communication, rehabilitation and mobilization (rehabilitation techniques, early mobilization, inspiratory muscle training), interventions related to reducing the duration of mechanical ventilation (weaning modes or protocols, ventilator bundle or cough augmentation techniques, early tracheostomy, high-flow nasal cannula), and management of specific symptoms (delirium, agitation, pain, and sleep disturbances).

Conclusion

The number of systematic reviews related to physical restraints was limited. Multicomponent interventions involving healthcare professionals' education may be the most direct non-pharmacological intervention for minimizing physical restraints use in intensive care units. However, the quality of evidence was very low, and conclusions should be taken with caution. Policymakers should consider incorporating non-pharmacological interventions related to family engagement/support, specific consultations and communication, rehabilitation and mobilization, interventions related to reducing the duration of mechanical ventilation, and management of specific symptoms as part of the physical restraints minimization bundle. All the evidence contained in the umbrella review provides a supplement to the evidence summary for physical restraints guideline adaptation.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242586, identifier: CRD42021242586.

Feasibility of critical care ergometry: Exercise data of patients on mechanical ventilation analyzed as nine-panel plots

Nine-panel plots are standard displays of cardiopulmonary exercise data, used in cardiac and pulmonary medicine to investigate the nature of exercise limitation. We explored whether this approach could be used to analyze the data of critically ill patients on mechanical ventilation, capable of exercising actively. Patients followed an incremental exercise protocol using a bedside cycle ergometer. Respiratory gases were analyzed using indirect calorimetry, and blood gases were sampled from arterial catheters. Data of seven patients were combined into nine-panel plots. Systematic analysis clarified the nature of exercise limitation in six cases. Resting metabolic rate was increased in all patients, with a median oxygen uptake ( V˙O2 ) of 5.52 (IQR 4.29-6.31) ml/kg/min. Unloaded cycling increased the V˙O2 by 19.8% to 6.61 (IQR 5.99-7.08) ml/kg/min. Adding load to the ergometer increased the V˙O2 by another 20.0% to reach V˙O2peak at a median of 7.14 (IQR 6.67-10.75) ml/kg/min, corresponding to a median extrinsic workload of 7 W. This was accompanied by increased CO₂ production, respiratory minute volume, heart rate, and oxygen pulse. Three patients increased their V˙O2 to >40% of predicted V˙O2max , two patients passed the anaerobic threshold. Dead space ventilation was 44%, decreasing to 42% and accompanied by lower ventilatory equivalents during exercise. Exercise produced no net change in alveolo-arterial PO₂ difference. We concluded that diagnostic ergometry in mechanically ventilated patients was feasible. Analysis of the data as nine-panel plots provided insight into individual limitations to exercise.

[Intensive Care Unit-Acquired Weakness : A nationwide survey on diagnostics, monitoring and treatment strategies on German intensive care units]

Hintergrund

Die „Intensive Care Unit-Acquired Weakness“ (ICU-AW) ist eine der häufigsten Ursachen für eine neuromuskuläre Dysfunktion in der Intensivmedizin. Gegenwärtig fehlen evidenzbasierte Empfehlungen zur Diagnostik, zum Monitoring und zu therapeutischen Maßnahmen.

Ziel der Arbeit

Die Erfassung des derzeitigen Vorgehens bei Diagnostik, Monitoring und präventiven und therapeutischen Ansätzen bei der ICU-AW auf deutschen Intensivstationen.

Material und Methoden

Onlinebefragung von 448 Mitgliedern des Wissenschaftlichen Arbeitskreises Intensivmedizin (WAKI) und des Wissenschaftlichen Arbeitskreises Neuroanästhesie (WAKNA).

Ergebnisse

Insgesamt wurden 68/448 (15,2 %) Fragebogen ausgewertet. Bei 13,4 % (9/67) der Befragten existiert ein strukturiertes diagnostisches Vorgehen zur Detektion der ICU-AW. Für Screening (60/68; 88,2 %) und Verlaufsbeurteilung (57/65; 87,7 %) wird die klinische Untersuchung präferiert. Etablierte Scores, wie der „Medical Research Council sum score“ (MRC-SS) spielen für Screening und Verlaufskontrolle der ICU-AW eine untergeordnete Rolle (7/68; 10,3 % und 7/65; 10,8 %). Mobilisation (45/68; 66,2 %) und Sedativareduktion (38/68; 55,9 %) stellen die häufigsten präventiven und therapeutischen Ansätze dar. Ein Mangel an Physiotherapeuten (64/68; 94,1 %) und Pflegekräften (57/68; 83,8 %) wird als Hauptdefizit bei der Versorgung von Patienten mit ICU-AW identifiziert. Insgesamt 91,2 % (62/68) der Befragten befürworten die Erstellung evidenzbasierter Empfehlungen zur Diagnostik, zum Monitoring und zu therapeutischen Ansätzen bei ICU-AW.

Diskussion

Ein einheitliches Konzept für Diagnostik, Monitoring, Prävention und Therapie der ICU-AW auf deutschen Intensivstationen fehlt weitgehend. Innovative diagnostische Ansätze könnten in Zukunft helfen, Patienten mit einem hohem Risiko für eine ICU-AW frühzeitig zu detektieren, präventive Maßnahmen einzuleiten sowie wertvolle prognostische Informationen zu gewinnen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00101-022-01089-9) enthält den der Studie zugrunde liegenden Fragebogen.

The prevention of pressure injuries in the positioning and mobilization of patients in the ICU: a good clinical practice document by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

BACKGROUND

The aim of this document is to support clinical decision-making concerning positioning and mobilization of the critically ill patient in the early identification and resolution of risk factors (primary prevention) and in the early recognition of those most at risk (secondary prevention). The addresses of this document are physicians, nurses, physiotherapists, and other professionals involved in patient positioning in the intensive care unit (ICU).

METHODS

A consensus pathway was followed using the Nominal Focus Group and the Delphi Technique, integrating a phase of focused group discussion online and with a pre-coded guide to an individual phase. A multidisciplinary advisory board composed by nine experts on the topic contributed to both the phases of the process, to reach a consensus on four clinical questions positioning and mobilization of the critically ill patient.

RESULTS

The topics addressed by the clinical questions were the risks associated with obligatory positioning and therapeutic positions, the effective interventions in preventing pressure injuries, the appropriate instruments for screening for pressure injuries in the ICU, and the cost-effectiveness of preventive interventions relating to ICU positioning. A total of 27 statements addressing these clinical questions were produced by the panel. Among the statements, nine provided guidance on how to manage safely some specific patients' positions, including the prone position; five suggested specific screening tools and patients' factors to consider when assessing the individual risk of developing pressure injuries; five gave indications on mobilization and repositioning; and eight focused on the use of devices, such as positioners and preventive dressings.

CONCLUSIONS

The statements may represent a practical guidance for a broad public of healthcare professionals involved in the management of critically ill patients.

Building a culture of early mobilization in the pediatric intensive care unit-a nuts and bolts approach

The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU. Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient- and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.

Implementation of a Follow-Up Program for Intensive Care Unit Survivors

In Intensive Care Unit (ICU) survivors, critical illness has an impact on an individual’s long-term health status and quality of life. Adults who have recovered from intensive care management could develop muscle weakness, neurocognitive impairment, difficulties in managing activities of daily living and to returning to work, and psychological problems such as depression and anxiety. A prospective, observational study was designed. Data were collected from January to December 2018 from a structured follow-up program, at 3 time points after ICU discharge: at seven days, a visit in the general ward, a phone interview at three months and an ambulatory visit at six months. A total of 95 patients were enrolled, 36% female, with a median age of 65 (55–73) years and a median ICU length of stay of 13 (8–20) days. At the seven days follow-up, patients who had a positive Hospital Anxiety and Depression Scale showed a significantly longer time of intubation (p = 0.048) and length of ICU stay (p = 0.023). At three months, we observed a significant relationship between a positive Hospital Anxiety and Depression Scale and a median value of EuroQol-5D (p = 0.048). At six months, we observed that patients who had a positive Post-Traumatic Symptom Scale were significantly younger than the other group. Findings from the present study suggest that a longer time of intubation and length of ICU stay are associated with a higher level of anxiety and depression immediately after ICU discharge. Follow-up programs are recommended to assess and rehabilitate cognitive function at ICU discharge.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient's physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard 'run chart rules' to detect changes in outcomes over time and Welch's t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient's physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard 'run chart rules' to detect changes in outcomes over time and Welch's t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Usefulness of Respiratory Mechanics and Laboratory Parameter Trends as Markers of Early Treatment Success in Mechanically Ventilated Severe Coronavirus Disease: A Single-Center Pilot Study

Whether a patient with severe coronavirus disease (COVID-19) will be successfully liberated from mechanical ventilation (MV) early is important in the COVID-19 pandemic. This study aimed to characterize the time course of parameters and outcomes of severe COVID-19 in relation to the timing of liberation from MV. This retrospective, single-center, observational study was performed using data from mechanically ventilated COVID-19 patients admitted to the ICU between 1 March 2020 and 15 December 2020. Early liberation from ventilation (EL group) was defined as successful extubation within 10 days of MV. The trends of respiratory mechanics and laboratory data were visualized and compared between the EL and prolonged MV (PMV) groups using smoothing spline and linear mixed effect models. Of 52 admitted patients, 31 mechanically ventilated COVID-19 patients were included (EL group, 20 (69%); PMV group, 11 (31%)). The patients’ median age was 71 years. While in-hospital mortality was low (6%), activities of daily living (ADL) at the time of hospital discharge were significantly impaired in the PMV group compared to the EL group (mean Barthel index (range): 30 (7.5–95) versus 2.5 (0–22.5), p = 0.048). The trends in respiratory compliance were different between patients in the EL and PMV groups. An increasing trend in the ventilatory ratio during MV until approximately 2 weeks was observed in both groups. The interaction between daily change and earlier liberation was significant in the trajectory of the thrombin–antithrombin complex, antithrombin 3, fibrinogen, C-reactive protein, lymphocyte, and positive end-expiratory pressure (PEEP) values. The indicator of physiological dead space increases during MV. The trajectory of markers of the hypercoagulation status, inflammation, and PEEP were significantly different depending on the timing of liberation from MV. These findings may provide insight into the pathophysiology of COVID-19 during treatment in the critical care setting.

Stress-Induced Behavioral Quiescence and Abnormal Rest-Activity Rhythms During Critical Illness

OBJECTIVES

To characterize acute alterations of circadian and ultradian rest-activity rhythms in critically ill patients and their association with brain dysfunction, systemic multiple organ dysfunction, and melatonin rhythms.

DESIGN

Prospective study observing a cohort for 48 hours beginning within the first day of ICU admission.

SETTING

ICUs within an academic medical center.

PATIENTS

Patients presenting from the community with acute onset of either intracerebral hemorrhage or sepsis as representative neurologic and systemic critical illnesses. Healthy control patients were studied in the community, during hospital bedrest, and during sleep deprivation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Circadian and ultradian characteristics of rest-activity patterns were measured by wrist actigraphy, severity of neurologic and systemic illness by Glasgow Coma Scale and Sequential Organ Failure Assessment, and central circadian rhythm by melatonin profile. We studied 112 critically ill patients, including 53 with sepsis and 59 with intracerebral hemorrhage, along with 53 control participants. Total daily activity was markedly reduced and rest-activity rhythmicity was undetectable, neither of which was replicated by hospital bedrest in healthy controls. Circadian rest-activity rhythm fragmentation and attenuation and ultradian disorganization was associated with Glasgow Coma Scale and Sequential Organ Failure Assessment in adjusted models. Rest-activity rhythms showed no detectable phase coherence with melatonin rhythms.

CONCLUSIONS

Critically ill patients rapidly enter a state of behavioral quiescence proportionate to their illness severity with concomitant disturbance of circadian and ultradian rest-activity rhythms and loss of phase coherence with the melatonin rhythm. Quiescence characteristics in rest-activity rhythms were not different in patients with and without delirium, suggesting them to be distinct phenomena. Animal models of severe physiologic stress have shown that specific neural pathway separate from the sleep-wake regulatory pathway induce behavioral quiescence and rest-activity arrhythmia, and facilitate recovery of cellular homeostasis. Whether quiescence is a conserved protective response pathway in humans is not yet understood.

The Feasibility of High-Intensity Interval Training in Patients with Intensive Care Unit-Acquired Weakness Syndrome Following Long-Term Invasive Ventilation

Background

Intensive care unit-acquired weakness syndrome (ICUAWS) can be a consequence of long-term mechanical ventilation. Despite recommendations of early patient mobilisation, little is known about the feasibility, safety and benefit of interval training in early rehabilitation facilities (ERF) after long-term invasive ventilation.

Methods and Results

We retrospectively analysed two established training protocols of bicycle ergometry in ERF patients after long-term (> 7 days) invasive ventilation (n = 46). Patients conducted moderate continuous (MCT, n = 24, mean age 70.3 ± 10.1 years) or high-intensity interval training (HIIT, n = 22, mean age 63.6 ± 12.6 years). The intensity of training was monitored with the BORG CR10 scale (intense phases ≥ 7/10 and moderate phases ≤ 4/10 points). The primary outcome was improvement (∆-values) of six-minute-walk-test (6 MWT), while the secondary outcomes were improvement of vital capacity (VC_max), forced expiratory volume in 1 s (FEV₁), maximal inspiratory pressure (PI_max) and functional capabilities (functional independence assessment measure, FIM/FAM and Barthel scores) after 3 weeks of training. No adverse events were observed. There was a trend towards a greater improvement of 6 MWT in HIIT than MCT (159.5 ± 64.9 m vs. 120.4 ± 60.4 m; p = .057), despite more days of invasive ventilation (39.6 ± 16.8 days vs. 26.8 ± 16.2 days; p = .009). VC_max (∆0.5l ± 0.6 vs. ∆0.5l ± 0.3; p = .462), FEV₁ (∆0.2l ± 0.3 vs. ∆0.3l ± 0.2; p = .218) PI_max (∆0.8 ± 1.1 kPa vs. ∆0.7 ± 1.3pts; p = .918) and functional status (FIM/FAM: ∆29.0 ± 14.8pts vs. ∆30.9 ± 16.0pts; p = .707; Barthel: ∆28.9 ± 16.0 pts vs. ∆25.0 ± 10.5pts; p = .341) improved in HIIT and MCT.

Conclusions

We demonstrate the feasibility and safety of HIIT in the early rehabilitation of ICUAWS patients. Larger trials are necessary to find adequate dosage of HIIT in ICUAWS patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00299-6.

Physical rehabilitation in Intensive Care Unit in acute respiratory distress syndrome patients with COVID-19

BACKGROUND

The risk of muscle weakness is high in the survivors of acute respiratory distress syndrome with COVID-19 following discharge from intensive care unit.

AIM

To evaluate the effects of early rehabilitation program in intensive care unit in patients with acute respiratory distress syndrome secondary to COVID-19.

DESIGN

The design of the study is observational.

SETTING

The setting of the study is inpatient.

POPULATION

Thirty-five patients with acute respiratory distress syndrome secondary to COVID-19 were enrolled.

METHODS

This study was performed in an intensive care unit of a university hospital. Early rehabilitation program consisting of passive or active range of motion exercises and neuromuscular electrical stimulation in addition to standard intensive care (N.=18) compared to standard intensive care (N.=17). Primary outcome was hand grip strength following discharge.

RESULTS

Rehab group had higher prevalence of chronic pulmonary diseases and neurologic diseases. There was no difference in hand grip or manual muscle strength following discharge between rehab and non-rehab groups. No adverse event was noted.

CONCLUSIONS

The results did not support the beneficial effects of early rehabilitation in intensive care unit on improving muscle strength. More patients with pulmonary and neurologic diseases in rehab group might impede the impact of rehabilitation on outcomes. On the other hand, these comorbidities underline the role and need of rehabilitation. It is safe both for the patients and the health care workers when necessary precautions are taken.

CLINICAL REHABILITATION IMPACT

This study guide how to rehabilitate patients with acute respiratory distress syndrome with COVID-19 during intensive care unit in a safe way.

Role of anabolic testosterone agents and structured exercise to promote recovery in ICU survivors

PURPOSE OF REVIEW

ICU survivors frequently suffer significant, prolonged physical disability. 'ICU Survivorship', or addressing quality-of-life impairments post-ICU care, is a defining challenge, and existing standards of care fail to successfully address these disabilities. We suggest addressing persistent catabolism by treatment with testosterone analogues combined with structured exercise is a promising novel intervention to improve 'ICU Survivorship'.

RECENT FINDINGS

One explanation for lack of success in addressing post-ICU physical disability is most ICU patients exhibit severe testosterone deficiencies early in ICU that drives persistent catabolism despite rehabilitation efforts. Oxandrolone is an FDA-approved testosterone analogue for treating muscle weakness in ICU patients. A growing number of trials with this agent combined with structured exercise show clinical benefit, including improved physical function and safety in burns and other catabolic states. However, no trials of oxandrolone/testosterone and exercise in nonburn ICU populations have been conducted.

SUMMARY

Critical illness leads to a catabolic state, including severe testosterone deficiency that persists throughout hospital stay, and results in persistent muscle weakness and physical dysfunction. The combination of an anabolic agent with adequate nutrition and structured exercise is likely essential to optimize muscle mass/strength and physical function in ICU survivors. Further research in ICU populations is needed.

Systematic early versus late mobilization or standard early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to determine the effectiveness of systematic early mobilization in improving muscle strength and physical function in mechanically ventilated intensive care unit (ICU) patients.

METHODS

We conducted a two-stage systematic literature search in MEDLINE, EMBASE and the Cochrane Library until January 2019 for randomized controlled trials (RCTs) examining the effects of early mobilization initiated within 7 days after ICU admission compared with late mobilization, standard early mobilization or no mobilization. Priority outcomes were Medical Research Council Sum Score (MRC-SS), incidence of ICU-acquired weakness (ICUAW), 6-min walk test (6MWT), proportion of patients reaching independence, time needed until walking, SF-36 Physical Function Domain Score (PFS) and SF-36 Physical Health Component Score (PCS). Meta-analysis was conducted where sufficient comparable evidence was available. We evaluated the certainty of evidence according to the GRADE approach.

RESULTS

We identified 12 eligible RCTs contributing data from 1304 participants. Two RCTs were categorized as comparing systematic early with late mobilization, nine with standard early mobilization and one with no mobilization. We found evidence for a benefit of systematic early mobilization compared to late mobilization for SF-36 PFS (MD 12.3; 95% CI 3.9-20.8) and PCS (MD 3.4; 95% CI 0.01-6.8), as well as on the proportion of patients reaching independence and the time needed to walking, but not for incidence of ICUAW (RR 0.62; 95% CI 0.38-1.03) or MRC-SS. For systematic early compared to standard early mobilization, we found no statistically significant benefit on MRC-SS (MD 5.8; 95% CI - 1.4 to 13.0), incidence of ICUAW (RR 0.90; 95% CI 0.63-1.27), SF-36 PFS (MD 8.1; 95% CI - 15.3 to 31.4) or PCS (MD - 2.4; 95% CI - 6.1 to 1.3) or other priority outcomes except for change in 6MWT from baseline. Generally, effects appeared stronger for systematic early compared to late mobilization than to standard early mobilization. We judged the certainty of evidence for all outcomes as very low to low.

CONCLUSION

The evidence regarding a benefit of systematic early mobilization remained inconclusive. However, our findings indicate that the larger the difference in the timing between the intervention and the comparator, the more likely an RCT is to find a benefit for early mobilization.

STUDY REGISTRATION

PROSPERO (CRD42019122555).

[Effect of rehabilitation initiation timing in the intensive care unit on outcomes in patients with pneumonia]

Early rehabilitation in the intensive care unit is a promising component of post-intensive care syndrome (PICS) treatment and prevention. However, the optimal time to start mobilizing critically ill patients is still to be determined.

OBJECTIVE

To evaluate the effect of rehabilitation initiation timing on outcomes in patients with pneumonia.

MATERIAL AND METHODS

The study included 106 patients with pneumonia (27 patients with community-acquired pneumonia and 79 patients with early-onset healthcare associated pneumonia) who received daily rehabilitation treatment for at least 7 days in the intensive care unit. All patients were retrospectively assigned to the early rehabilitation (ER) group if rehabilitation treatment was started within the first 48 hours of admission to the intensive care unit or the delayed rehabilitation (DR) group if mobilization was not initiated within this time frame.

RESULTS

The baseline clinical and demographic characteristics of the patients did not differ between the groups. During rehabilitation, rates of catecholamine use and the psychiatric signs of PICS frequency were also comparable. The duration of mechanical ventilation was 1.5 times shorter in ER group patients than in DR group (8 vs. 6 days and 13 vs. 9 days, respectively; p=0.003). The ICU and hospital stay were also significantly shorter in ER group compared with the DR group (12 (9-16) vs. 19 (13-30), respectively; p<0.001; 23 (12) vs. 31 (13) as inpatients, respectively; p=0.005). Mortality and severe complications rate were comparable between the groups.

CONCLUSIONS

The earliest possible start of rehabilitation provided the patient's condition is stable, can reduce the duration of respiratory support and hospital stay for patients with pneumonia.

Simplified Diagnosis of Critical Illness Polyneuropathy in Patients with Prolonged Mechanical Ventilation: A Prospective Observational Cohort Study

Background: Although early identification of critical illness polyneuropathy (CIP) is necessary, the established diagnostic criteria have several limitations in the intensive care unit (ICU) setting. The purpose of this study was to define simplified diagnostic criteria of CIP that best predict clinical outcomes. Methods: This prospective, single-center study included 41 ICU patients with prolonged mechanical ventilation (≥21 days). We applied three different sets of diagnostic criteria (combining the results of the Medical Research Council (MRC) sum score and nerve conduction studies (NCS)) for CIP in order to identify the criteria with the best predictive power for clinical outcomes. Results: The simplified diagnosis of CIP meeting the criteria, i.e., that the MRC sum score < 48 and amplitudes of the tibial and sural nerve < 80% of the lower limit of normal, showed the strongest association with 0 ventilator-free days at day 60 (odds ratio, 6.222; p = 0.029). Conclusions: The diagnostic criteria combining the MRC sum score and the tibial and the sural NCS were identified as the simplified criteria of CIP that best predicted the clinical outcomes. The implementation of these simplified criteria may allow for early identification of CIP in the ICU, thereby contributing to prompt interventions for patients with a poor prognosis.

Effectiveness, Safety, and Barriers to Early Mobilization in the Intensive Care Unit

Purpose

Patients admitted to the intensive care unit (ICU) are generally confined to bed leading to limited mobility that may have detrimental effects on different body systems. Early mobilization prevents or reduces these effects and improves outcomes in patients following critical illness. The purpose of this review is to summarize different aspects of early mobilization in intensive care.

Methods

Electronic databases of PubMed, Google Scholar, ScienceDirect, and Scopus were searched using a combination of keywords. Full-text articles meeting the inclusion criteria were selected.

Results

Fifty-six studies on various aspects such as the effectiveness of early mobilization in various intensive care units, newer techniques in early mobilization, outcome measures for physical function in the intensive care unit, safety, and practice and barriers to early mobilization were included. Conclusion: Early mobilization is found to have positive effects on various outcomes in patients with or without mechanical ventilation. The newer techniques can be used to facilitate early mobilization. Scoring systems—specific to the ICU—are available and should be used to quantify patients' status at different intervals of time. Early mobilization is not commonly practiced in many countries. Various barriers to early mobilization have been identified, and different strategies can be used to overcome them.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial

Background

Although early ambulation (EA) is associated with improved outcomes in post-operative patients, implementation of EA in elderly patients is still a challenge. In this study, we aimed to design and assess a precision early ambulation program for cardiac rehabilitation.

Methods

We conducted a single-center, randomized and controlled clinical trial in elderly patients aged over 60 years after off-pump coronary artery bypass graft (OPCABG) surgery. Patients were randomly assigned to a precision early ambulation (PEA) group or a routine ambulation (Control) group. Age-predicted maximal heart rate (APMHR) and maximal oxygen uptake (VO_2max) were used as a reference to formulate and monitor the PEA regimen. The primary end-point was the postoperative length of stay in hospital (PLOS). The secondary end-points included 90-day mortality, incidence of early discharge, laboratory tests, length of ICU stay, the incidence of multiple organ complications and post-traumatic stress disorder (PTSD). Ambulation outcomes were also recorded.

Results

In total, 178 patients were enrolled (n = 89 per group). In the intent-to-treat analysis, PLOS in the PEA group was shorter than that in the Control group (9.04 ± 3.08 versus 10.09 ± 3.32 days, respectively. Mean difference 1.045 days; 95% confidence interval [CI] 0.098–1.992; P = 0.031 in the unadjusted model; mean difference 0.957 days; CI 0.007–1.907; P = 0.048 in adjusted model). The incidence of early discharge differed significantly between the PEA and control groups (41[46.1%] versus 24[27.0%] patients, respectively. Odds ratio [OR] 0.432; CI 0.231–0.809; P = 0.009 in unadjusted model; OR 0.466; CI 0.244–0.889, P = 0.02 in adjusted model). The time of first bowel movement, partial pressure O₂ and post-traumatic stress disorder score in the PEA group were better than those in the Control group. Participants walked much longer distances on day 3 in the PEA group than those in the Control group (76.12 ± 29.02 versus 56.80 ± 24.40 m, respectively, P < 0.001).

Conclusion

APMHR and VO_2max are valuable for implementation of PEA according to an established security threshold. PEA after OPCAPG surgery is safe and reliable for elderly patients, not only reducing the hospital stay, but also improving their physiological and psychological symptoms.

Trial registration

This study is a component of a protocol retrospectively registered: Application of ERAS in cardiovascular surgery. Trial registration number: ChiCTR1800018167. Date of registration: 3rd September, 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx

Progressive active mobilization with dose control and training load in critically ill patients (PROMOB): Protocol for a randomized controlled trial

The dose of progressive active mobilization is still uncertain. The purpose of this study is to identify if the addition of a protocol of progressive active mobilization with dose and training load control to usual care is effective in reducing the length of stay in intensive care unit (ICU) and the improvement of the functioning, incidence of ICU-acquired weakness (ICUAW), mechanical ventilation duration and mortality rate in patients hospitalized in ICU. It is Double-blind randomised clinical trial. The setting for this trial will be medical and surgical ICU of a university hospital. The study participants will be 118 patients aged> 18 years admitted to ICU for less than 72 hours. Participants will be randomized to either an experimental or control group. The experimental group will undertake addition of a protocol of progressive active mobilization with dose and training load control to usual care, while the control group will undertake only usual care. The primary outcome will be length of ICU stay. The secondary outcomes will be Cross-sectional area and muscle thickness of the rectus femoris and biceps brachii, Change in muscle strength from the baseline, Functional Status, incidence of ICUAW, Days with mechanical ventilation and Mortality. All statistical analyses will be conducted following intention-to-treat principles. It has a detailed description of the dose of exercise, was designed with the strictest methodological criteria. These characteristics allow to investigate with greater certainty the results progressive active mobilization in critical patients, allowing replication and future combinations in meta-analyzes.

Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19

OBJECTIVE

The COVID-19 pandemic is rapidly evolving and has led to increased numbers of hospitalizations worldwide. Hospitalized patients with COVID-19 experience a variety of symptoms, including fever, muscle pain, tiredness, cough, and difficulty breathing. Elderly people and those with underlying health conditions are considered to be more at risk of developing severe symptoms and have a higher risk of physical deconditioning during their hospital stay. Physical therapists have an important role in supporting hospitalized patients with COVID-19 but also need to be aware of challenges when treating these patients. In line with international initiatives, this article aims to provide guidance and detailed recommendations for hospital-based physical therapists managing patients hospitalized with COVID-19 through a national approach in the Netherlands.

METHODS

A pragmatic approach was used. A working group conducted a purposive scan of the literature and drafted initial recommendations based on the knowledge of symptoms in patients with COVID-19 and current practice for physical therapist management for patients hospitalized with lung disease and patients admitted to the intensive care unit. An expert group of hospital-based physical therapists in the Netherlands provided feedback on the recommendations, which were finalized when consensus was reached among the members of the working group.

RESULTS

The recommendations include safety recommendations, treatment recommendations, discharge recommendations, and staffing recommendations. Treatment recommendations address 2 phases of hospitalization: when patients are critically ill and admitted to the intensive care unit, and when patients are severely ill and admitted to the COVID ward. Physical therapist management for patients hospitalized with COVID-19 comprises elements of respiratory support and active mobilization. Respiratory support includes breathing control, thoracic expansion exercises, airway clearance techniques, and respiratory muscle strength training. Recommendations toward active mobilization include bed mobility activities, active range-of-motion exercises, active (assisted) limb exercises, activities-of-daily-living training, transfer training, cycle ergometer, pre-gait exercises, and ambulation.

Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation

Coronavirus disease 2019 (COVID-19) is a contagious infection disease, which may cause respiratory, physical, psychological, and generalized systemic dysfunction. The severity of disease ranges from an asymptomatic infection or mild illness to mild or severe pneumonia with respiratory failure and/or death. COVID-19 dramatically affects the pulmonary system. There is a lack of knowledge about the long-term outcomes of the disease and the possible sequelae and rehabilitation. This clinical practice guideline includes pulmonary rehabilitation (PR) recommendations for adult COVID-19 patients and has been developed in the light of the guidelines on the diagnosis and treatment of COVID-19 provided by the World Health Organization and Republic of Turkey, Ministry of Health, recently published scientific literature, and PR recommendations for COVID-19 regarding basic principles of PR. In this guideline, the contagiousness of COVID-19, recommendations on limited contact of patient with healthcare providers, and the evidence about possible benefits of PR were taken into consideration.

Evaluation on the effect of acupuncture on patients with sepsis-induced myopathy (ACU-SIM pilot study): A single center, propensity-score stratified, assessor-blinded, prospective pragmatic controlled trial

BACKGROUND

Sepsis-induced myopathy (SIM) is a disease that causes motor dysfunction in patients with sepsis. There is currently no targeted treatment for this disease. Acupuncture has shown considerable efficacy in the treatment of sepsis and muscle weakness. Therefore, our research aims to explore the effects of acupuncture on the improvement of muscle structure and function in SIM patients and on activities of daily living.

METHODS

The ACU-SIM pilot study is a single-center, propensity-score stratified, assessor-blinded, prospective pragmatic controlled trial (pCT) with a 1-year follow-up period. This study will be deployed in a multi-professional critical care department at a tertiary teaching hospital in Guangzhou, China. Ninety-eight intensive care unit subjects will be recruited and assigned to either the control group or the acupuncture group. Both groups will receive basic treatment for sepsis, and the acupuncture group will additionally receive acupuncture treatment. The primary outcomes will be the rectus femoris cross-sectional area, the Medical Research Council sum-score and time-to-event (defined as all-cause mortality or unplanned readmission to the intensive care unit due to invasive ventilation). The activities of daily living will be accessed by the motor item of the Functional Independence Measure. Recruitment will last for 2 years, and each patient will have a 1-year follow-up after the intervention.

DISCUSSION

There is currently no research on the therapeutic effects of acupuncture on SIM. The results of this study may contribute to new knowledge regarding early muscle atrophy and the treatment effect of acupuncture in SIM patients, and the results may also direct new approaches and interventions in these patients. This trial will serve as a pilot study for an upcoming multicenter real-world study.

TRIAL REGISTRATION

Chinese Clinical Trials Registry: ChiCTR-1900026308, registered on September 29th, 2019.

Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.

What is rehabilitation? An empirical investigation leading to an evidence-based description

BACKGROUND

There is no agreement about or understanding of what rehabilitation is; those who pay for it, those who provide it, and those who receive it all have different interpretations. Furthermore, within each group, there will be a variety of opinions. Definitions based on authority or on theory also vary and do not give a clear description of what someone buying, providing, or receiving rehabilitation can actually expect.

METHOD

This editorial extracts information from systematic reviews that find rehabilitation to be effective, to discover the key features and to develop an empirical definition.

FINDINGS

The evidence shows that rehabilitation may benefit any person with a long-lasting disability, arising from any cause, may do so at any stage of the illness, at any age, and may be delivered in any setting. Effective rehabilitation depends on an expert multidisciplinary team, working within the biopsychosocial model of illness and working collaboratively towards agreed goals. The effective general interventions include exercise, practice of tasks, education of and self-management by the patient, and psychosocial support. In addition, a huge range of other interventions may be needed, making rehabilitation an extremely complex process; specific actions must be tailored to the needs, goals, and wishes of the individual patient, but the consequences of any action are unpredictable and may not even be those anticipated.

CONCLUSION

Effective rehabilitation is a person-centred process, with treatment tailored to the individual patient's needs and, importantly, personalized monitoring of changes associated with intervention, with further changes in goals and actions if needed.

ICU-acquired weakness

Critically ill patients often acquire neuropathy and/or myopathy labeled ICU-acquired weakness. The current insights into incidence, pathophysiology, diagnostic tools, risk factors, short- and long-term consequences and management of ICU-acquired weakness are narratively reviewed. PubMed was searched for combinations of “neuropathy”, “myopathy”, “neuromyopathy”, or “weakness” with “critical illness”, “critically ill”, “ICU”, “PICU”, “sepsis” or “burn”. ICU-acquired weakness affects limb and respiratory muscles with a widely varying prevalence depending on the study population. Pathophysiology remains incompletely understood but comprises complex structural/functional alterations within myofibers and neurons. Clinical and electrophysiological tools are used for diagnosis, each with advantages and limitations. Risk factors include age, weight, comorbidities, illness severity, organ failure, exposure to drugs negatively affecting myofibers and neurons, immobility and other intensive care-related factors. ICU-acquired weakness increases risk of in-ICU, in-hospital and long-term mortality, duration of mechanical ventilation and of hospitalization and augments healthcare-related costs, increases likelihood of prolonged care in rehabilitation centers and reduces physical function and quality of life in the long term. RCTs have shown preventive impact of avoiding hyperglycemia, of omitting early parenteral nutrition use and of minimizing sedation. Results of studies investigating the impact of early mobilization, neuromuscular electrical stimulation and of pharmacological interventions were inconsistent, with recent systematic reviews/meta-analyses revealing no or only low-quality evidence for benefit. ICU-acquired weakness predisposes to adverse short- and long-term outcomes. Only a few preventive, but no therapeutic, strategies exist. Further mechanistic research is needed to identify new targets for interventions to be tested in adequately powered RCTs.

Patient functionality and walking speed after discharge from the intensive care unit

Objective

To measure and compare the functionality of patients after discharge from the intensive care unit and at the time of hospital discharge.

Methods

Quantitative study of a prospective cohort performed between August of 2016 and December of 2017 at a university hospital. A 10-meter walk test was performed at 2 timepoints: after discharge from the intensive care unit and prior to hospital discharge. The data were analyzed using Student's t-test and Pearson or Spearman correlation. Statistical Package for Social Science (SPSS) version 21.0 was used for the analysis, and p ≤ 0.05 was adopted as the level of significance.

Results

Forty patients, with a mean age of 57.1 ± 12.2 years and with a predominance of males (60%), were evaluated. For the post-intensive care unit test, a mean speed of 0.48m/s was observed, and for the pre-hospital discharge test, there was an increase to 0.71m/s, evidencing functional evolution during the hospital stay (p < 0.001).

Conclusion

There was significant improvement in walking speed at the time of hospital discharge when compared to the walking speed at the time of intensive care unit discharge.

Early Mobilization Interventions in the Intensive Care Unit: Ongoing and Unpublished Randomized Trials

Background

Critical care societies recommend early mobilization (EM) as standard practice in the intensive care unit (ICU) setting. However, there is limited randomized controlled trial (RCT) evidence supporting EM's effectiveness. Our objective was to identify ongoing or completed RCTs assessing EM's effectiveness in the ICU.

Method

We searched ClinicalTrials.gov and the Australian New Zealand Clinical Trials Registry for ongoing or completed but not published RCTs in an ICU setting with objective outcome measures.

Results

There were 14 RCTs included in the analysis. All studies were in the general or mixed ICU setting (N=14). Half of the studies (N=7) were small RCTs (<100 projected participants) and half (N=7) were medium-sized RCTs (100–999 participants). Inclusion criteria included mechanical ventilation use or expected use (N=13) and prehospital functional status (N=7). Primary EM interventions were standard physiotherapist-based activities (N=4), cycling (N=9), and electrical muscle stimulation (N=1). Only one study involved nurse-led EM. The most common assessment tool was the 6-minute walk test (N=6). Primary outcome measures were physiological (N=3), clinical (N=3), patient-centered (N=7), and healthcare resource use (N=1). Most studies (N=8) involved post-ICU follow-up measures up to 1-year posthospitalization. There were no studies targeting older adults or people with acute cardiac disease.

Conclusion

Identified studies will further the evidence base for EM's effectiveness. There is a need for studies looking at specific patient populations that may benefit from EM, such as older adults and cardiac patients, as well as for novel EM delivery strategies, such as nurse-led EM.