Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study

Pragmatic approach to mobilizing individuals with critical illness due to COVID-19: clinical perspective

PURPOSE

To provide pragmatic guidance for acute rehabilitation management and implementation of early mobility for individuals with critical illness due to COVID-19.

METHODS

Clinical perspective developed through reflective clinical practice and narrative review of best available evidence.

RESULTS

Current clinical practice guidelines do not provide guidance for implementation of early mobility interventions for individuals with critical illness due to COVID-19 who require enhanced ventilatory support or support of inhaled pulmonary artery vasodilators. Many individuals who may benefit from implementation of early mobility interventions are excluded by strict interpretation of current guidelines.

CONCLUSIONS

Risk vs benefit of implementing early mobility interventions in individuals with critical illness due to COVID-19 can be mitigated through coordinated efforts of interdisciplinary teams to promote shared decision-making through therapeutic alliances with patients and their families. Clinicians must clearly define the goals of care, understand the limitations of monitoring equipment in the intensive care unit, prepare to titrate levels of oxygen based on an individual's physiologic response to mobility interventions, and help individuals maintain external goal-directed focus of attention to optimize outcomes of early mobility interventions.

Impact of protocol-based physiotherapy on insulin sensitivity and peripheral glucose metabolism in critically ill patients

BACKGROUND

The impact of physiotherapy on insulin sensitivity and peripheral glucose metabolism in critically ill patients is not well understood.

METHODS

This pooled analysis investigates the impact of different physiotherapeutic strategies on insulin sensitivity in critically ill patients. We pooled data from two previous trials in adult patients with sequential organ failure assessment score (SOFA)≥ 9 within 72 h of intensive care unit (ICU) admission, who received hyperinsulinaemic euglycaemic (HE) clamps. Patients were divided into three groups: standard physiotherapy (sPT, n = 22), protocol-based physiotherapy (pPT, n = 8), and pPT with added muscle activating measures (pPT+, n = 20). Insulin sensitivity index (ISI) was determined by HE clamp. Muscle metabolites lactate, pyruvate, and glycerol were measured in the M. vastus lateralis via microdialysis during the HE clamp. Histochemical visualization of glucose transporter-4 (GLUT4) translocation was performed in surgically extracted muscle biopsies. All data are reported as median (25th/75th percentile) (trial registry: ISRCTN77569430 and ISRCTN19392591/ethics approval: Charité-EA2/061/06 and Charité-EA2/041/10).

RESULTS

Fifty critically ill patients (admission SOFA 13) showed markedly decreased ISIs on Day 17 (interquartile range) 0.029 (0.022/0.048) (mg/min/kg)/(mU/L) compared with healthy controls 0.103 (0.087/0.111), P < 0.001. ISI correlated with muscle strength measured by medical research council (MRC) score at first awakening (r = 0.383, P = 0.026) and at ICU discharge (r = 0.503, P = 0.002). Different physiotherapeutic strategies showed no effect on the ISI [sPT 0.029 (0.019/0.053) (mg/min/kg)/(mU/L) vs. pPT 0.026 (0.023/0.041) (mg/min/kg)/(mU/L) vs. pPT+ 0.029 (0.023/0.042) (mg/min/kg)/(mU/L); P = 0.919]. Regardless of the physiotherapeutic strategy metabolic flexibility was reduced. Relative change of lactate/pyruvate ratio during HE clamp is as follows: sPT 0.09 (-0.13/0.27) vs. pPT 0.07 (-0.16/0.31) vs. pPT+ -0.06 (-0.19/0.16), P = 0.729, and relative change of glycerol concentration: sPT -0.39 (-0.8/-0.12) vs. pPT -0.21 (-0.33/0.07) vs. pPT+ -0.21 (-0.44/-0.03), P = 0.257. The majority of ICU patients showed abnormal localization of GLUT4 with membranous GLUT4 distribution in 37.5% (3 of 8) of ICU patients receiving sPT, in 42.9% (3 of 7) of ICU patients receiving pPT, and in 53.8% (7 of 13) of ICU patients receiving pPT+ (no statistical testing possible).

CONCLUSIONS

Our data suggest that a higher duration of muscle activating measures had no impact on insulin sensitivity or metabolic flexibility in critically ill patients with sepsis-related multiple organ failure.

A Constructivist Grounded Theory of Staff Experiences Relating to Early Mobilisation of Mechanically Ventilated Patients in Intensive Care

Early mobilisation of mechanically ventilated patients has been suggested to be effective in mitigating muscle weakness, yet it is not a common practice. Understanding staff experiences is crucial to gain insights into what might facilitate or hinder its implementation. In this constructivist grounded theory study, data from two Scottish intensive care units were collected to understand healthcare staff experiences relating to early mobilisation in mechanical ventilation. Data included observations of mobilisation activities, individual staff interviews and two focus groups with multidisciplinary staff. Managing Risks emerged as the core category and was theorised using the concept of risk. The middle-range theory developed in this study suggests that the process of early mobilisation starts by staff defining patient status and includes a process of negotiating patient safety, which in turn enables performing accountable mobilisation within the dynamic context of an intensive care unit setting.

Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support

The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.

Validity and Usefulness of an Electronic Health Care Record-Generated Mobility Ambulation Tool: The Human Body Was Designed to Move

BACKGROUND

Mobility is a vital function of human life. Nurses have an essential role in preventing hospitalized patient complications through movement and ambulation.

PURPOSE

This study examined the integration, accuracy, and precision of a paper-based mobility/ambulation tool into an electronic health record (EHR) to assess inpatient mobility/ambulation status.

METHODS

This multisite mixed-methods study was a time-series correlational evaluation of a mobility/ambulation tool into the EHR.

RESULTS

Sustainability data revealed strong correlations between nurse responses and EHR levels (r = 0.602; scores r = 0.624). Cronbach's α values were 0.737 and 0.761. Nurses' anecdotes supported the findings.

CONCLUSION

Findings revealed that the EHR-Mobility Ambulation Tool is a valid, reliable, and stable tool. EHR-generated scores can assist in reducing charting burden, care planning, and inform the interdisciplinary health team at all patient care stages. Tool adoption could potentially assist nurses plan interventions suitable to maintain or increase hospitalized patients' mobility status and contribute to discharge planning.

Survivors of Acute Lung Injury Have Greater Impairments in Strength and Exercise Capacity Than Survivors of Other Critical Illnesses as Measured Shortly After ICU Discharge

PURPOSE

To compare the physical function on ICU discharge in adults who survived an ICU admission for acute lung injury (ALI) with those admitted for a critical illness other than ALI.

MATERIALS AND METHODS

Two groups were recruited, (i) those who survived an ICU admission for ALI and, (ii) those who survived an ICU admission for a critical illness other than ALI. Within 7 days of discharge from ICU, in all participants, measures were collected of peripheral muscle strength, balance, walking speed and functional exercise capacity.

RESULTS

Recruitment was challenging and ceased prior to achieving the desired sample size. Participants with ALI (n = 22) and critical illness (n = 33) were of similar median age (50 vs. 57 yr, p = 0.09), sex proportion (males %, 45 vs. 58, p = 0.59) and median APACHE II score (21.5 vs. 23.0, p = 0.74). Compared with the participants with critical illness, those with ALI had lower hand grip (mean ± SD, 18 ± 9 vs. 13 ± 8 kg, p = 0.018) and shoulder flexion strength (10 ± 4 vs. 7 ± 3 kg, p = 0.047), slower 10-meter walk speed (median [IQR], 1.03 [0.78 to 1.14] vs. 0.78 [0.67 to 0.94] m/s, p = 0.039) and shorter 6-minute walk distance (265 [71 to 328] vs. 165 [53 to 220] m, p = 0.037). The Berg balance scores were similar in both groups.

CONCLUSIONS

Compared with survivors of a critical illness that is not ALI, those with ALI are likely to have greater physical impairment when measured shortly after discharge to the ward.

Acute effect of passive cycling exercise on serum levels of interleukin-8 and interleukin-10 in mechanically ventilated critically ill patients

Background/aims

A growing body of evidence has demonstrated that early mobilisation is beneficial for patients in the intensive care unit. The aim of this prospective study was to investigate the acute effect of an early passive cycling exercise session on serum interleukin-8 and interleukin-10 levels in critically ill patients.

Methods

A total of 11 haemodynamically stable and deeply sedated (Richmond Agitation and Sedation Scale-4) adult patients within the first 48 hours of mechanical ventilation received a single 20-minute session of passive cycle ergometer. Serum interleukin-8 and interleukin-10 levels were measured at baseline, immediately after the intervention and 60 minutes after the intervention.

Findings

Interleukin-8 levels decreased significantly 60 minutes after the passive cycle ergometer session compared to baseline (P=0.001). The serum levels of interleukin-10 increased immediately after the end of the 20 minutes and at 60 minutes after the intervention (P<0.001).

Conclusions

A single 20-minute session of passive cycle ergometer seems to have a positive effect on the inflammatory response in critically ill patients.

Safety and Feasibility of Early Mobilization in Patients with Subarachnoid Hemorrhage and External Ventricular Drain

BACKGROUND/OBJECTIVE

In November 2014, our Neurointensive Care Unit began a multi-phased progressive early mobilization initiative for patients with subarachnoid hemorrhage and an external ventricular drain (EVD). Our goal was to transition from a culture of complete bed rest (Phase 0) to a physical and occupational therapy (PT/OT)-guided mobilization protocol (Phase I), and ultimately to a nurse-driven mobilization protocol (Phase II). We hypothesized that nurses could mobilize patients as safely as an exclusively PT/OT-guided approach.

METHODS

In Phase I, patients were mobilized only with PT/OT at bedside; no independent time out of bed occurred. In Phase II, nurses independently mobilized patients with EVDs, and patients could remain out of bed for up to 3 h at a time. Physical and occupational therapists continued routine consultation during Phase II.

RESULTS

Phase II patients were mobilized more frequently than Phase I patients [7.1 times per ICU stay (± 4.37) versus 3.0 times (± 1.33); p = 0.02], although not earlier [day 4.9 (± 3.46) versus day 6.0 (± 3.16); p = 0.32]. All Phase II patients were discharged to home PT services or acute rehabilitation centers. No patients were discharged to skilled nursing or long-term acute care hospitals, versus 12.5% in Phase I. In a multivariate analysis, odds of discharge to home/rehab were 3.83 for mobilized patients, independent of age and severity of illness. Other quality outcomes (length of stay, ventilator days, tracheostomy placement) between Phase I and Phase II patients were similar. No adverse events were attributable to early mobilization.

CONCLUSIONS

Nurse-driven mobilization for patients with EVDs is safe, feasible, and leads to more frequent ambulation compared to a therapy-driven protocol. Nurse-driven mobilization may be associated with improved discharge disposition, although exact causation cannot be determined by these data.

Early Therapeutic Mobility and Changes in Scores for Pain and Fatigue

This report is a secondary analysis of data from a larger study of a nurse-led early therapeutic mobility intervention among patients receiving mechanical ventilation. This analysis evaluated whether intervention frequency or intensity was associated with pain or fatigue. Frequency was defined as once-daily versus twice-daily interventions. Intensity was defined as low (in-bed activities) or moderate (out-of-bed activities). Thirty-nine patients self-reported pain and fatigue immediately before and after the intervention. Neither pain nor fatigue increased significantly (mean increase, <1 [scale of 0-10] for 95% of interventions). Four patients reported decrements in pain; 1 reported a decrease in fatigue. Less than 5% of enrolled patients indicated a score change of +4 to +6 for pain or fatigue, typically with the first intervention that included sitting at the edge of the bed. Future research could examine the distress associated with these symptoms in critically ill adults receiving early therapeutic mobility interventions.

Factors associated with safe patient handling practice in acute care and its relationship with patient mobilization: A cross-sectional study

BACKGROUND

Mobilizing hospital patients is associated with improved outcomes and shorter length of stay. Safe patient handling and mobility programs that include mechanical lift use facilitate mobilizing patients and reduce the likelihood of musculoskeletal disorders in staff. However, there is little information on the prevalence of lift use or why some patients are more likely to have a lift used than others. Such information is needed to inform public policy, benchmark lift use over time, and contextualize barriers for lift use.

OBJECTIVE

To determine the percentage of patients that had a lift used during care in US acute care facilities, identify attributes related to the patient and their hospital stay that affect the lift use, examine whether state legislation increased lift use, and determine whether lift use was correlated with more frequent mobilization out of bed.

DESIGN

Retrospective analysis of the 2018 International Pressure Ulcer Prevalence ™ data.

PARTICIPANTS

40,856 patients in 642 US acute care hospitals over the age of 18 with complete data.

METHODS

Lift use prevalence was calculated as the percentage of patients that met inclusion criteria that had a lift used for care. Prevalence was then analyzed by patient mobility level. A logistic regression examined the influence of patient and facility related attributes. For patients with limited mobility (that could not stand or turn themselves), a t-test of proportions evaluated whether lift use during a patient's stay was correlated with an increased likelihood of being out of bed at the time of the survey.

RESULTS

3.7% of patients had a lift used during their care. 11.1% of limited mobility patients had a lift used. Lift use was associated with higher body mass, longer length of stay, lower Braden score, pressure injury prevention methods in place, being in an intensive care unit, being in a smaller hospital, and being in a state with safe patient handling and mobility legislation. Limited mobility patients moved with lifts during their stay were more likely to be observed in a bedside chair and less likely to be observed in bed, as compared to patients that never had a lift used.

CONCLUSIONS

Despite the benefits to patients and caregivers, US acute care facilities are largely not using lifts to safely mobilize patients. Results suggested that safe patient handling and mobility legislation has increased the rate of lift use. Finally, lift use was correlated with patients being mobilized out of bed.

What nursing sensitive outcomes have been studied to-date among patients cared for in intensive care units? Findings from a scoping review

BACKGROUND

Although many studies have considered mortality and adverse effects as outcomes sensitive to nursing practice, it seems that other outcomes of nursing care in intensive care units have been explored less commonly.

OBJECTIVES

To describe the state-of-science in research in the field of nursing sensitive outcomes in intensive care units and to synthesize outcomes that have been documented to date as being influenced by nursing care.

DESIGN

A scoping review study based on the framework proposed by Arksey and O'Malley, further refined by the Levac and Joanna Briggs Institute was performed in 2019.

DATA SOURCES

The Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Google Scholar electronic databases were searched. In addition, the reference list of included articles was screened.

REVIEW METHODS

Two researchers independently identified publications on the basis of the following criteria: (a) articles that reported nursing sensitive outcomes on critically-ill adult patients admitted to the intensive care unit, (b) as primary and secondary studies, (c) written in English, and (d) without any time frame limitation.

RESULTS

Of the 4,231 records, 112 fully met the inclusion criteria and were included. Publications were mainly authored in the US and Canada (n = 44, 39.2%), and the majority (n = 62, 55.3%) had an observational design. A total of 233 nursing sensitive outcomes emerged, categorized in 35 outcomes, with, on average, two per study included. The most often measured outcomes were pressure ulcers (20 studies) and ventilator-associated pneumonias (19 studies); the less studied outcomes were quality of life, secretion clearance, patient-ventilator dysynchrony, and post-extubation dysphagia. When categorizing outcomes, the ones concerning safety (n = 77, 33.1%) were represented the most, followed by those concerning the clinical (n = 72, 30.9%), functional (n = 70, 30.0%), and perceptual (n = 14, 6.0%) domains. The interdependent outcomes linked to multi-professional interventions (e.g., ventilator-associated pneumonias) were the most frequently studied nursing sensitive outcomes (n = 20, 57.1%), while independent outcomes resulting from autonomous interventions performed by nurses were less often studied (n = 8, 22.9%).

CONCLUSIONS

From a clinical point of view, a large heterogeneity of outcomes influenced by nursing care emerged. However, identified outcomes have been studied with different approaches and metrics, so that future efforts will need to establish homogeneous conceptual and operative definitions. Moreover, increasing efforts in establishing perceptual outcomes, or those close to the fundamentals of nursing care, are suggested in order to better depict the contribution of critical care nurses in the field.

Feasibility, safety, and functional recovery after active rehabilitation in critically ill surgical patients

BACKGROUND

The characteristics of critically ill surgical patients differ from those of medical patients. Few studies have evaluated rehabilitation in surgical intensive care units (SICUs), particularly in non-Western countries and in elderly patients.

OBJECTIVE

The objective of this study was to investigate the rehabilitation characteristics, safety, and functional recovery in non-Western SICU patients.

METHODS

Data from patients who received active rehabilitation in 2016 were retrospectively reviewed. Clinical characteristics, functional recovery, and safety were investigated and compared in patients aged <65 or ≥65 years. Potential safety events were also compared between the two age groups and according to the reason for SICU admission.

RESULTS

Data from 157 patients were included in the analysis. The number of patients who were able to stand or walk increased from the beginning of rehabilitation to the time of ICU discharge (from 52 to 102 patients, P < 0.01). The Activity Measure for Post-Acute Care (AM-PAC) score also increased during rehabilitation (from 11.6 to 13.9, P < 0.01). Functional recovery did not differ between the two age groups. During 780 rehabilitation sessions, 23 potential safety events (3.0%) were noted; no significant differences were seen between the two age groups. A significant difference was noted when patients were grouped according to the reason for SICU admission (1.7% in postoperative care patients vs 4.5% in patients admitted for other reasons, P = 0.02).

CONCLUSIONS

Active rehabilitation in critically ill surgical patients is feasible and safe and resulted in improved mobility, regardless of age. However, the reason for SICU admission should be considered.

PROtocol-based MObilizaTION on intensive care units: stepped-wedge, cluster-randomized pilot study (Pro-Motion)

BACKGROUND

Early mobilization of patients in intensive care units (ICUs) improves patient recovery, but implementation remains challenging. Protocols may enhance the rate of out-of-bed mobilizations.

AIM

To evaluate the effect of implementing a protocol for early mobilization on the rate of out-of-bed mobilizations and other outcomes of ICU patients.

STUDY DESIGN

Multicentre, stepped-wedge, cluster-randomized pilot study.

METHODS

After a control period, five ICUs were allocated to the implementation of an inter-professional protocol for early mobilization in a randomized, monthly order. Mobilization of ICU patients was evaluated by monthly 1-day point prevalence surveys using the ICU Mobility Scale. The primary outcome was the percentage of patients mobilized out of bed, defined as level 3 on the ICU Mobility Scale (sitting on edge of bed) or higher. Secondary outcomes were mechanical ventilation, delirium and ICU- and hospital-days, as well as unwanted safety events.

RESULTS

Out-of-bed mobilizations increased non-significantly from 36·2% (n = 55) of 152 patients during the control period to 45·8% (n = 55) of 120 patients during the intervention period (difference 9·6%; 95% confidence interval -2·1 to 21·3%). Of 55 mobilized patients per group, more patients were mobilized once per day during the intervention period (intervention: n = 41 versus control: n = 23 patients). Multiple daily mobilizations decreased (control: n = 32 control versus intervention: n = 14 patients). Secondary outcomes, such as days with mechanical ventilation, delirium and in ICU and hospital, did not significantly differ. Adherence to the protocol was >90%; unwanted safety events were rare.

CONCLUSIONS

Implementing a protocol for early mobilization of ICU patients showed a trend towards more patients being mobilized. Without additional staff in participating ICUs, a significant increase in ICU mobilizations was not to be anticipated. More research should address whether more staff would increase the number of frequent mobilizations and if this is relevant to outcomes.

RELEVANCE TO CLINICAL PRACTICE

Implementing inter-professional protocols for mobilization is feasible and safe and may contribute to an increase of ICU patients mobilized out of bed.

Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities

Background

Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature.

Methods

Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies.

Results

Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation.

Conclusions

This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.

Management of early mobilization in intensive care units: a multicenter cross-sectional study

Objective

The aim of this study was to assess the management of early mobilization (EM) in Chinese intensive care units (ICUs).

Methods

This survey used a cross-sectional, observational design. A total of 65 tertiary and secondary hospitals were enrolled by convenience sampling and investigated using self-designed questionnaires.

Results

We identified 69 ICUs in Jiangsu, China (response rate: 94.2%). 74.2% (1,004/1,353) of the nurses and nursing managers from 65 ICUs reported mobility practice. For the mobility level, 98.1% (1,327) reported use of in-bed exercise, 5.7% (77) sitting on a side of bed, 21.7% (294) transfer to chair, and 2.4% (33) walking. The most frequently reported barriers to early mobility were unplanned extubation, nursing resource, and absence of physical therapist. Nurses’ educational backgrounds, nursing experience, the lack of nursing resources, absence of physician, and the weakness of patient were the factors that influenced ICU early rehabilitation (P<0.01).

Conclusions

Although implementation rates for EM in critically ill patients are high, the activity level is generally poor in most of the involved ICUs.

Feasibility of Muscle Activity Assessment With Surface Electromyography During Bed Cycling Exercise In Intensive Care Unit Patients

Introduction: Intensive care unit (ICU) patients often develop weakness. Rehabilitation is initiated early to prevent physical deterioration, but knowledge of optimal training schedules is lacking. A reliable method to assess muscle activity during exercise is needed. In this study we explored the feasibility of electrical activity measurement by surface electromyography (sEMG) during bed cycling in ICU patients. Methods: SEMG was performed in 9 ICU patients and 6 healthy controls. A standardized 1‐minute incremental resistance bedside cycle ergometer protocol was used. Results: The median cycle time was 5.3 minutes in patients and 12.0 minutes in controls. The maximum sEMG increased in both groups; the minimal sEMG activity remained the same in patients, whereas an increase in the control group was found. Discussion: sEMG is feasible and can detect muscle activity during bed cycling in ICU patients. It may be a useful monitoring tool. Repeated measurements could possibly provide information on the effects of training. Muscle Nerve58: 688–693, 2018

Dose of Early Therapeutic Mobility: Does Frequency or Intensity Matter?

OBJECTIVE

Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults.

DESIGN

Randomized interventional study with repeated measures and blinded assessment of outcomes.

SETTING

Four adult intensive care units (ICUs) in two academic medical centers.

SUBJECTS

Fifty-four patients with > 48 hr of mechanical ventilation (MV).

INTERVENTION

Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment.

MEASUREMENTS

Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes.

MAIN RESULTS

Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium.

CONCLUSION

Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.

Feasibility of Exercise Testing in Patients Who Are Critically Ill: A Prospective, Observational Multicenter Study

OBJECTIVE

To evaluate the feasibility and safety of exercise testing and to describe the physiological response to exercise of patients in the Intensive Care Unit (ICU).

DESIGN

A prospective observational multicenter study.

SETTING

Two mixed medical-surgical ICUs.

PARTICIPANTS

Patients (N=37; with no primary neurological disorders, 59% men; median age 50y; ICU length of stay 14.5d; Acute Physiology and Chronic Health Evaluation IV 73.0) who had been mechanically ventilated for more than 48 hours and were hemodynamically stable enough to perform physical exercise.

INTERVENTIONS

A passive or active incremental exercise test, depending on muscle strength, on a bed-based cycle ergometer.

MAIN OUTCOME MEASURES

Feasibility and safety were evaluated based on protocol adherence and adverse events. Physiological responses to exercise quantified as changes in respiratory frequency (RF), oxygen uptake (Vo₂), carbon dioxide output (Vco₂), respiratory exchange ratio (RER), and blood lactate.

RESULTS

Thirty-seven patients of whom 18 were mechanically ventilated underwent the exercise test. The active incremental test was performed by 28, and the passive test by 9 participants. Thirty-three (89%) accomplished the test according to the protocol and 1 moderate severe adverse event (bradycardia; heart rate 44) occurred shortly after the test. RF, Vo₂, Vco₂, and lactate increased significantly, whereas RER did not change during the active incremental exercise test. No changes were observed during the passive exercise test.

CONCLUSIONS

It is safe and feasible to perform exercise testing on a bed-based cycle ergometer in patients who are critically ill and a physiological response could be measured. Future research should investigate the clinical value of exercise testing in daily ICU practice and whether exercise capacity and its limiting factors could be determined by incremental exercise testing.

Mobilisation is feasible in intensive care patients receiving vasoactive therapy: An observational study

BACKGROUND

Mobilisation of intensive care unit (ICU) patients reduces ICU-acquired weakness and is associated with better functional outcomes. However, the prevalence of mobilisation of ICU patients remains low. A known barrier to mobilisation is haemodynamic instability, frequently with patients requiring vasoactive therapy. There is a lack of published data to guide clinicians about the safety and feasibility of mobilising patients receiving vasoactive therapy.

OBJECTIVES

To describe our mobilisation practice in ICU patients receiving vasoactive therapy and identify factors associated with mobilisation and adverse events.

METHODS

Retrospective cohort study of patients undergoing vasoactive therapy in a 31-bed tertiary ICU (October-December, 2016). Details of vasoactive drug dosage, mobilisation, and adverse events were extracted from databases, including mobilisation intensity (ICU Mobility Scale [IMS]). Two generalised linear mixed models were used: first, to describe factors associated with mobilisation and second, to describe factors associated with adverse events during mobilisation, adjusting for age, gender, and acute physiology and chronic health evaluation II score as co-variates.

RESULTS

In 119 patients undergoing vasoactive therapy on 371 cumulative vasoactive days, 195 mobilisation episodes occurred (37.5% of vasoactive days). Low (76.8%) and moderate (13.7%) dose vasoactive therapies were associated with a higher probability of mobilisation relative to high (9.4%) dose therapy (odds ratio = 5.50, 95% confidence interval = 2.23-13.59 and odds ratio = 2.50, 95% confidence interval = 0.95-6.59, respectively). For patients who mobilised on vasoactive therapy (n = 72), maximum mobilisation intensity was low (IMS = 1-2) in 31%, moderate (IMS = 3-5) in 51%, and high (IMS = 6-10) in 18% of vasoactive days. While no serious adverse events occurred, there were 14 occurrences of reversible hypotension requiring transient escalation of vasoactive therapy (7.3%), associated with lower mean arterial pressure (p = 0.001).

CONCLUSION

In our ICU, patients mobilised on approximately one-third of vasoactive days. Clinicians should anticipate a higher risk of hypotension during mobilisation in patients receiving vasoactive therapy, which may require transient escalation of vasoactive therapy.

A systematic review evaluating the role of nurses and processes for delivering early mobility interventions in the intensive care unit

OBJECTIVES

To investigate processes for delivering early mobility interventions in adult intensive care unit patients used in research and quality improvement studies and the role of nurses in early mobility interventions.

METHODS

A systematic review was conducted. Electronic databases PubMED, CINAHL, PEDro, and Cochrane were searched for studies published from 2000 to June 2017 that implemented an early mobility intervention in adult intensive care units. Included studies involved progression to ambulation as a component of the intervention, included the role of the nurse in preparing for or delivering the intervention, and reported at least one patient or organisational outcome measure. The System Engineering Initiative for Patient Safety (SEIPS) model, a framework for understanding structure, processes, and healthcare outcomes, was used to evaluate studies.

RESULTS

25 studies were included in the final review. Studies consisted of randomised control trials, prospective, retrospective, or mixed designs. A range of processes to support the delivery of early mobility were found. These processes include forming interdisciplinary teams, increasing mobility staff, mobility protocols, interdisciplinary education, champions, communication, and feedback.

CONCLUSION

Variation exists in the process of delivering early mobility in the intensive care unit. In particular, further rigorous studies are needed to better understand the role of nurses in implementing early mobility to maintain a patient's functional status.

Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis

BACKGROUND

Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation.

OBJECTIVES

To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation.

DATA SOURCES

Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events.

DATA EXTRACTION

Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy).

SYNTHESIS

Heterogeneity was assessed by I² statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions.

CONCLUSIONS

Patient mobilization and physical rehabilitation in the ICU appears safe, with a low incidence of potential safety events, and only rare events having any consequences for patient management. Heterogeneity in the definition of safety events across studies emphasizes the importance of implementing existing consensus-based definitions.

The ICU Mobility Scale Has Construct and Predictive Validity and Is Responsive. A Multicenter Observational Study

RATIONALE

The ICU Mobility Scale (IMS) is a measure of mobility milestones in critically ill patients.

OBJECTIVES

This study aimed to determine the validity and responsiveness of the IMS from a prospective cohort study of adults admitted to the intensive care unit (ICU).

METHODS

Construct and predictive validity were assessed by comparing IMS values at ICU discharge in 192 patients to other variables using Spearman rank correlation coefficient, Mann-Whitney U tests, and logistic regression. Responsiveness was assessed using change over time, effect size, floor and ceiling effects, and percentage of patients showing change.

MEASUREMENTS AND MAIN RESULTS

The IMS at ICU discharge demonstrated a moderate correlation with muscle strength (r = 0.64, P < 0.001). There was a significant difference between the IMS at ICU discharge in patients with ICU-acquired weakness (median, 4.0; interquartile range, 3.0-5.0) compared with patients without (median, 8.0; interquartile range, 5.0-8.0; P < 0.001). Increasing IMS values at ICU discharge were associated with survival to 90 days (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.14-1.66) and discharge home (OR, 1.16; 95% CI, 1.02-1.32) but not with return to work at 6 months (OR, 1.09; 95% CI, 0.92-1.28). The IMS was responsive with a significant change from study enrollment to ICU discharge (d = 0.8, P < 0.001), with IMS values increasing in 86% of survivors during ICU admission. No substantial floor (14% scored 0) or ceiling (4% scored 10) effects were present at ICU discharge.

CONCLUSIONS

Our findings support the validity and responsiveness of the IMS as a measure of mobility in the ICU.

Influence of muscle strength on early mobility in critically ill adult patients: Systematic literature review

BACKGROUND

Muscle strength may be one indicator of readiness to mobilize that can be used to guide decisions regarding early mobility efforts and to progressively advance mobilization.

OBJECTIVES

To provide a synthesis of current measures of muscle strength in the assessment of early mobilization in critically ill adult patients who are receiving MV therapy.

METHODS

Research studies conducted between 2000-2015 were identified using PubMed, CINHAL, MEDLINE, and the Cochrane Database of Systematic Reviews databases using the search terms "muscle strength", "intensive care", "mechanical ventilation" and "muscle weakness".

RESULTS

Nine articles used manual muscle testing, the Medical Research Council scale and/or hand-held dynamometer to provide objective measures for assessing muscle strength in the critically ill adult patient population.

CONCLUSIONS

Further research is needed to examine the application of standardized measures of muscle strength for guiding decisions regarding early and progressive advancement of mobility goals in adult ICU patients on MV.

Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial. However, implementation of early mobility as part of routine clinical care can be challenging. The objective of this review is to identify barriers to early mobilization and discuss strategies to overcome such barriers. Based on a literature search, we synthesize data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were patient-related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%) process-related barriers. These barriers varied across ICUs and within disciplines, depending on the ICU patient population, setting, attitude, and ICU culture. To overcome the identified barriers, over 70 strategies were reported and are synthesized in this review, including: implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and involvement of physician champions. Systematic efforts to change ICU culture to prioritize early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.

Can proportional ventilation modes facilitate exercise in critically ill patients? A physiological cross-over study : Pressure support versus proportional ventilation during lower limb exercise in ventilated critically ill patients

Background

Early exercise of critically ill patients may have beneficial effects on muscle strength, mass and systemic inflammation. During pressure support ventilation (PSV), a mismatch between demand and assist could increase work of breathing and limit exercise. A better exercise tolerance is possible with a proportional mode of ventilation (Proportional Assist Ventilation, PAV+ and Neurally Adjusted Ventilatory Assist, NAVA). We examined whether, in critically ill patients, PSV and proportional ventilation have different effects on respiratory muscles unloading and work efficiency during exercise.

Methods

Prospective pilot randomized cross-over study performed in a medico-surgical ICU. Patients requiring mechanical ventilation >48 h were enrolled. At initiation, the patients underwent an incremental workload test on a cycloergometer to determine the maximum level capacity. The next day, 2 15-min exercise, at 60% of the maximum capacity, were performed while patients were randomly ventilated with PSV and PAV+ or NAVA. The change in oxygen consumption (ΔVO₂, indirect calorimetry) and the work efficiency (ratio of ΔVO₂ per mean power) were computed.

Results

Ten patients were examined, 6 ventilated with PSV/PAV+ and 4 with PSV/NAVA. Despite the same mean inspiratory pressure at baseline between the modes, baseline VO₂ (median, IQR) was higher during proportional ventilation (301 ml/min, 270–342) compared to PSV (249 ml/min, 206–353). Exercise with PSV was associated with a significant increase in VO₂ (ΔVO₂, median, IQR) (77.6 ml/min, 59.9–96.5), while VO₂ did not significantly change during exercise with proportional modes (46.3 ml/min, 5.7–63.7, p < 0.05). As a result, exercise with proportional modes was associated with a better work efficiency than with PSV. The ventilator modes did not affect patient’s dyspnea, limb fatigue, distance, hemodynamics and breathing pattern.

Conclusions

Proportional ventilation during exercise results in higher work efficiency and less increase in VO₂ compared to ventilation with PSV. These preliminary findings suggest that proportional ventilation could enhance the training effect and facilitate rehabilitation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0289-y) contains supplementary material, which is available to authorized users.

Implementing a Mobility Program to Minimize Post-Intensive Care Syndrome

Immobility in the intensive care unit (ICU) is associated with neuromuscular weakness, post-intensive care syndrome, functional limitations, and high costs. Early mobility-based rehabilitation in the ICU is feasible and safe. Mobility-based rehabilitation varied widely across 5 ICUs in 1 health care system, suggesting a need for continuous training and evaluation to maintain a strong mobility-based rehabilitation program. Early mobility-based rehabilitation shortens ICU and hospital stays, reduces delirium, and increases muscle strength and the ability to ambulate. Long-term effects include increased ability for self-care, faster return to independent functioning, improved physical function, and reduced hospital readmission and death. Factors that influence early mobility-based rehabilitation include having an interdisciplinary team; strong unit leadership; access to physical, occupational, and respiratory therapists; a culture focused on patient safety and quality improvement; a champion of early mobility; and a focus on measuring performance and outcomes.

Intensive Early Rehabilitation in the Intensive Care Unit for Liver Transplant Recipients: A Randomized Controlled Trial

OBJECTIVE

To validate the feasibility and tolerance of an intensive rehabilitation protocol initiated during the postoperative period in an intensive care unit (ICU) in liver transplant recipients.

DESIGN

Prospective randomized study.

SETTING

ICU.

PARTICIPANTS

Liver transplant recipients over a period of 1 year (N=40).

INTERVENTIONS

The "usual treatment group" (n=20), which benefited from the usual treatment applied in the ICU (based on physician prescription for the physiotherapist, with one session a day), and the experimental group (n=20), which followed a protocol of early and intensive rehabilitation (based on a written protocol validated by physicians and an evaluation by physiotherapist, with 2 sessions a day), were compared.

MAIN OUTCOME MEASURES

Our primary aims were tolerance, assessed from the number of adverse events during rehabilitation sessions, and feasibility, assessed from the number of sessions discontinued.

RESULTS

The results revealed a small percentage of adverse events (1.5% in the usual treatment group vs 1.06% in the experimental group) that were considered to be of low intensity. Patients in the experimental group sat on the edge of their beds sooner (2.6 vs 9.7d; P=.048) and their intestinal transit resumed earlier (5.6 vs 3.7d; P=.015) than patients in the usual treatment group. There was no significant difference between the 2 arms regarding length of stay (LOS), despite a decrease in duration in the experimental group.

CONCLUSIONS

The introduction of an intensive early rehabilitation program for liver transplant recipients was well tolerated and feasible in the ICU. We noted that the different activities proposed were introduced sooner in the experimental group. Moreover, there is a tendency to decreased LOS in the ICU for the experimental group. These results now need to be confirmed by studies on a larger scale.

Implementation of a Progressive Mobilization Program in a Medical-Surgical Intensive Care Unit

BACKGROUND

Current literature supports implementation of progressive mobility protocols in intensive care units. Education can help nurses overcome barriers to mobility and increase knowledge about the positive effects of mobility.

OBJECTIVE

To evaluate the effect of education for a progressive mobilization program for intensive care nurses on knowledge and performance.

METHODS

A pretest-posttest evaluation was conducted for 41 nurses, and a chart review was performed before and after implementation of the educational intervention to evaluate changes in knowledge and mobilization.

RESULTS

Scores after the educational intervention were significantly higher than scores before the intervention (t = 2.02; P < .001). Overall mobilization (P = .04) and dangling (P = .01) increased significantly after the education. No significant increases occurred in ambulating or getting patients up to a chair.

CONCLUSIONS

Mobilization education was effective and increased nurses' knowledge about the benefits of mobility for critically ill patients. The educational program also affected how nurses performed mobility interventions. Although provision of education had positive effects on patients' mobility, leadership and coaching are still important components in implementing change.

Feasibility and Effectiveness of a Delirium Prevention Bundle in Critically Ill Patients

BACKGROUND

Strategies for preventing delirium include early identification and avoiding or modifying patient, environmental, and iatrogenic factors. Minimal research exists on a prescriptive delirium prevention bundle that details elements or strategies for each bundle component. Even less research has been focused on nurse-driven interventions or components.

OBJECTIVE

To evaluate the effectiveness of a delirium prevention bundle in decreasing delirium incidence in 2 medical-surgical intensive care units in a large Texas medical center.

METHODS

Researchers used the Confusion Assessment Method for the Intensive Care Unit to assess delirium incidence by using a controlled interventional cohort design with 447 delirium-negative critically ill patients. Bundle components consist of sedation cessation, pain management, sensory stimulation, early mobilization, and sleep promotion.

RESULTS

The intervention, analyzed by using a logistic regression model, reduced the odds of delirium by 78% (odds ratio, 0.22; P = .001).

CONCLUSIONS

The delirium prevention bundle was effective in reducing the incidence of delirium in critically ill medical-surgical patients. Further validation studies are under way.

Determination of functional prognosis in hospitalized patients following an intensive care admission

AIM

To investigate the factors associated with the functional progress of hospitalized patients following an intensive care admission.

METHODS

Retrospective study including data from a cohort of 198 hospitalized patients following an intensive care admission and not requiring mechanical ventilation in a single tertiary referral hospital. A generalized linear model was used to identify the main effects of clinical and demographic variables on the outcomes of functionality (KATZ Index of Independence in Activities of Daily Living) and muscle strength (MRC Scale). The covariates identified as independent predictors were analysed using the receiver operating characteristic curves. The analysis differentiated the periods in the intensive care unit (ICU), in the Ward (WARD) and the total time of hospital stay (TOT).

RESULTS

Considering the functional outcome (ΔKATZ), the variables that significantly contributed to the model (P < 0.05) were the KATZ and MRC on admission, age, sepsis (no), and total length of stay (TLS). Regarding the muscle strength outcome model (ΔMRC), the predictors were MRC on admission, Simplified Acute Physiology Score III, previous stroke, TLS, and sex (female). The variable age (AUC = 0.664) discriminated the ΔKATZ_ICU. The variables age (AUC = 0.712), KATZ in ICU (AUC = 0.590) and on ward admission (AUC = 0.746), and MRC on ward admission (AUC = 0.721) were discriminative for ΔKATZ_WARD. For ΔKATZ_TOT the variables KATZ on ICU admission (AUC = 0.621) and TLS (AUC = 0.617) were discriminative. For ΔMRC_ICU the variables SAPSIII (AUC = 0.661) and MRC on ICU admission (AUC = 0.653) were discriminative. MRC on ICU (AUC = 0.681) and ward admission (AUC = 0.553) were discriminative for ΔMRC_WARD. TLS (AUC = 0.649) and MRC on ward admission (AUC = 0.696) discriminative for the ΔMRC_TOT.

CONCLUSION

Specific functional, clinical and demographical variables at ICU admission are associated with the functional prognosis during the hospitalization period.

Nursing Strategies for Effective Weaning of the Critically Ill Mechanically Ventilated Patient

The risks imposed by mechanical ventilation can be mitigated by nurses' use of strategies that promote early but appropriate reduction of ventilatory support and timely extubation. Weaning from mechanical ventilation is confounded by the multiple impacts of critical illness on the body's systems. Effective weaning strategies that combine several interventions that optimize weaning readiness and assess readiness to wean, and use a weaning protocol in association with spontaneous breathing trials, are likely to reduce the requirement for mechanical ventilatory support in a timely manner. Weaning strategies should be reviewed and updated regularly to ensure congruence with the best available evidence.

[Principles and challenges of mobilisation in intensive care]

The harmful consequences of bed rest and inactivity in patients in intensive care have been widely described. The point at which these patients should be mobilised and the methods used however still remain unclear. It is nevertheless important that the mobilisation is implemented early and often, adapted to the condition of the patient and overseen by a cross-disciplinary team.

The German Validation Study of the Surgical Intensive Care Unit Optimal Mobility Score

PURPOSE

Immobilization of critically ill patients leads to muscle weakness, which translates to increased costs of care and long-term functional disability. We tested the validity of a German Surgical Intensive Care Unit (ICU) Optimal Mobilization Score (SOMS) in 2 different cohorts (neurocritical and nonneurocritical care patients).

MATERIALS AND METHODS

Physical therapists estimated the patients' mobilization capacity by using the German version of the SOMS the morning after admission. We tested the prognostic value of the prediction for ICU and hospital length of stay (LOS) as well as for mortality, and built a model to account for other known predictors of these outcomes in the 2 cohorts.

RESULTS

A total of 128 patients were included in the analysis, 48 of these were neurocritical care patients. The SOMS predicted mortality and ICU and hospital LOS. Neurocritical care patients stayed significantly longer in the ICU (median 12 vs 4 days, P < .001) and in the hospital (25 vs 17 days, P = .02). The SOMS predicted ICU and hospital LOS. It predicted mortality only in nonneurocritical patients.

CONCLUSIONS

The German SOMS assessed by physical therapists on the day after ICU admission predicts ICU and hospital LOS, and mortality. Our data suggest that the association between early mobilization and mortality is more complex in neurocritical care patients.

Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations

OBJECTIVE

To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units.

METHODS

We used the EBRO method, as recommended by the 'Dutch Evidence Based Guideline Development Platform' to develop an 'evidence statement for physiotherapy in the intensive care unit'. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts.

RESULTS

Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment.

CONCLUSIONS

These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.

Strategies for weaning from mechanical ventilation: a state of the art review

Identification and adoption of strategies to promote timely and successful weaning from mechanical ventilation remain a research and quality improvement priority. The most important steps in the weaning process to prevent unnecessary prolongation of mechanical ventilation are timely recognition of both readiness to wean and readiness to extubate. Strategies shown to be effective in promoting timely weaning include weaning protocols and use of spontaneous breathing trials. This review explores various other strategies that also may promote timely and successful weaning including bundling of spontaneous breathing trials with sedation and delirium monitoring/management as well as early mobility, the use of automated weaning systems and modes that improve patient-ventilator interaction, mechanical insufflation-exsufflation as a weaning adjunct, early extubation to non-invasive ventilation and high flow humidified oxygen. As most critically ill patients requiring mechanical ventilation will tolerate extubation with minimal weaning, identification of strategies to improve management of those patients experiencing difficult and prolonged weaning should be a priority for clinical practice, quality improvement initiatives and weaning research.

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults

Introduction

The aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients.

Methods

A systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients.

Results

Safety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations.

Conclusion

Consensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults

INTRODUCTION

The aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients.

METHODS

A systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients.

RESULTS

Safety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations.

CONCLUSION

Consensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

Early mobility in the intensive care unit: Standard equipment vs a mobility platform

BACKGROUND

Despite the general belief that mobility and exercise play an important role in the recovery of functional status, mobility is difficult to implement in patients in intensive care units.

OBJECTIVES

To compare a mobility platform with standard equipment, assessing efficiency (decreased time and staff required to prepare patient), effectiveness (increased activity time), and safety (no falls, unplanned tube removals, or emergency situations) for intensive care patients.

METHODS

This observational study was approved by the institutional review board, and informed consent was obtained from the patient or the medical decision maker. Intensive care patients were assigned to a room in the usual manner, with platforms in odd-numbered rooms and standard equipment in even-numbered rooms. Standardized data collection tools were designed to collect data for 24 hours for each patient. The nurses caring for the patients completed the data collection tools in real time during the activity. The stages of activity and the physiological states that would preclude mobility were very specifically defined for the research study.

RESULTS

Data were collected for a total of 71 patients and 238 activities. Important (although not significant) descriptive statistics regarding early mobility in the intensive care unit were discovered. The unintended result of the research study was a change in the culture and practice regarding early mobility in the intensive care unit.

CONCLUSIONS

Early mobility can be implemented in intensive care units. Standard equipment can be used to mobilize such patients safely; however, for patients who ambulate, a platform may increase efficiency and effectiveness.

Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: a quality improvement project

PURPOSE

Prolonged periods of mechanical ventilation are associated with significant physical and psychosocial adverse effects. Despite increasing evidence supporting early rehabilitation strategies, uptake and delivery of such interventions in Europe have been variable. The objective of this study was to evaluate the impact of an early and enhanced rehabilitation program for mechanically ventilated patients in a large tertiary referral, mixed-population intensive care unit (ICU).

METHOD

A new supportive rehabilitation team was created within the ICU in April 2012, with a focus on promoting early and enhanced rehabilitation for patients at high risk for prolonged ICU and hospital stays. Baseline data on all patients invasively ventilated for at least 5 days in the previous 12 months (n = 290) were compared with all patients ventilated for at least 5 days in the 12 months after the introduction of the rehabilitation team (n = 292). The main outcome measures were mobility level at ICU discharge (assessed via the Manchester Mobility Score), mean ICU, and post-ICU length of stay (LOS), ventilator days, and in-hospital mortality.

RESULTS

The introduction of the ICU rehabilitation team was associated with a significant increase in mobility at ICU discharge, and this was associated with a significant reduction in ICU LOS (16.9 vs 14.4 days, P = .007), ventilator days (11.7 vs 9.3 days, P < .05), total hospital LOS (35.3 vs 30.1 days, P < .001), and in-hospital mortality (39% vs 28%, P < .05).

CONCLUSION

A quality improvement strategy to promote early and enhanced rehabilitation within this European ICU improved levels of mobility at critical care discharge, and this was associated with reduced ICU and hospital LOS and reduced days of mechanical ventilation.

Associations between muscle-related cytokines and selected patient outcomes in the ICU

INTRODUCTION

Systemic cytokines produced by contracting skeletal muscles may affect the onset and severity of intensive care unit (ICU)-acquired weakness after critical illness.

AIMS

The purpose of this research was to determine the serum levels of interleukin (IL)-8, IL-15, and tumor necrosis factor-α (TNF-α) among patients receiving mechanical ventilation for >48 hr and examine the relationships of these myokines to outcomes of patient delirium, muscle strength, activities of daily living (ADLs), duration of mechanical ventilation, and length of ICU stay.

METHODS

In this exploratory, repeated-measures interventional study, the 36 participants received 20 min of once-daily in-bed or out-of-bed activity using an established early progressive mobility protocol after physiologic stability had been demonstrated for >4 hr in the ICU. Blood samples were drawn on 3 consecutive days, beginning on the day of study enrollment, for serum cytokine quantification.

RESULTS

IL-8, IL-15, and TNF-α were highly variable and consistently elevated in participants compared to normal healthy adults. About 1/3 of participants were positive for significant muscle weakness at discharge from ICU. Repeated values of mean postactivity IL-8 serum values were significantly associated only with ADL following ICU discharge. There were no significant associations with repeated values of mean postactivity IL-15 or TNF-α serum values and outcomes.

CONCLUSION

Results provide preliminary data for exploring the potential effects of elevated serum values IL-8 and IL-15 in muscle health and TNF-α for muscle damage, including effect sizes to calculate the sample sizes needed for future studies.

ICU early mobilization: from recommendation to implementation at three medical centers

OBJECTIVE

To compare and contrast the process used to implement an early mobility program in ICUs at three different medical centers and to assess their impact on clinical outcomes in critically ill patients.

DESIGN

Three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement framework of Plan-Do-Study-Act.

INTERVENTION

Each of the three ICU early mobilization programs required an interprofessional team-based approach to plan, educate, and implement the ICU early mobility program. Champions from each profession-nursing, physical therapy, physician, and respiratory care-were identified to facilitate changes in ICU culture and clinical practice and to identify and address barriers to early mobility program implementation at each institution.

SETTING

The medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center.

RESULTS

Establishing an ICU early mobilization quality improvement program resulted in a reduced ICU and hospital length of stay at all three institutions and decreased rates of delirium and the need for sedation for the patients enrolled in the Johns Hopkins ICU early mobility program.

CONCLUSION

Instituting a planned, structured ICU early mobility quality improvement project can result in improved outcomes and reduced costs for ICU patients across healthcare systems.