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Schaller SJ, Scheffenbichler FT, Bein T, Blobner M, Grunow JJ, Hamsen U, Hermes C, Kaltwasser A, Lewald H, Nydahl P, Reißhauer A, Renzewitz L, Siemon K, Staudinger T, Ullrich R, Weber-Carstens S, Wrigge H, Zergiebel D, Coldewey SM. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med 2024:10.1007/s00134-024-07532-2. [PMID: 39073582 DOI: 10.1007/s00134-024-07532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.
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Affiliation(s)
- Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | | | | | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julius J Grunow
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Uwe Hamsen
- Ruhr University Bochum, Bochum, Germany
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany
- Akkon-Hochschule für Humanwissenschaften, Berlin, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Heidrun Lewald
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Nydahl
- University Hospital of Schleswig-Holstein, Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Anett Reißhauer
- Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Renzewitz
- Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Siemon
- Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Septomics Research Center, Jena University Hospital, Jena, Germany.
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Figueiredo T, Frazão M, Werlang LA, Kunz A, Peltz M, Furtado VC, Júnior EB, Júnior JM, Silva RM, Sobral Filho DC. Safety and feasibility of a functional electrical stimulation cycling-based muscular dysfunction diagnostic method in mechanically ventilated patients. Artif Organs 2024; 48:713-722. [PMID: 38400618 DOI: 10.1111/aor.14734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/18/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND A nonvolitional diagnostic method based on FES-Cycling technology has recently been demonstrated for mechanically ventilated patients. This method presents good sensitivity and specificity for detecting muscle dysfunction and survival prognosis, even in unconscious patients. As the clinical relevance of this method has already been reported, we aimed to evaluate its safety and feasibility. METHODS An observational prospective study was carried out with 20 critically ill, mechanically ventilated patients. The FES-cycling equipment was set in a specific diagnostic mode. For safety determination, hemodynamic parameters and peripheral oxygen saturation were measured before and immediately after the diagnostic protocol, as well as venous oxygen saturation and blood lactate. The creatine phosphokinase level (CPK) was measured before and 24, 48, and 72 h after the test. The time taken to carry out the entire diagnostic protocol and the number of patients with visible muscle contraction (capacity of perceptive muscular recruitment) were recorded to assess feasibility. RESULTS Heart rate [91 ± 23 vs. 94 ± 23 bpm (p = 0.0837)], systolic [122 ± 19 vs. 124 ± 19 mm Hg (p = 0.4261)] and diastolic blood pressure [68 ± 13 vs. 70 ± 15 mm Hg (p = 0.3462)], and peripheral [98 (96-99) vs. 98 (95-99) % (p = 0.6353)] and venous oxygen saturation [71 ± 14 vs. 69 ± 14% (p = 0.1317)] did not change after the diagnostic protocol. Moreover, blood lactate [1.48 ± 0.65 vs. 1.53 ± 0.71 mmol/L (p = 0.2320)] did not change. CPK did not change up to 72 h after the test [99 (59-422) vs. 125 (66-674) (p = 0.2799) vs. 161 (66-352) (p > 0.999) vs. 100 (33-409) (p = 0.5901)]. The time taken to perform the diagnostic assessment was 11.3 ± 1.1 min. In addition, 75% of the patients presented very visible muscle contractions, and 25% of them presented barely visible muscle contractions. CONCLUSIONS The FES cycling-based muscular dysfunction diagnostic method is safe and feasible. Hemodynamic parameters, peripheral oxygen saturation, venous oxygen saturation, and blood lactate did not change after the diagnostic protocol. The muscle damage marker (CPK) did not increase up to 72 h after the diagnostic protocol.
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Affiliation(s)
- Thainá Figueiredo
- Pernambuco University Heart Hospital/University of Pernambuco, Recife, Brazil
| | - Murillo Frazão
- Lauro Wanderley University Hospital, Federal University of Paraíba, João Pessoa, Brazil
- CLINAR Exercise Physiology, João Pessoa, Brazil
| | - Luís A Werlang
- INBRAMED-Brazilian Medical Equipment Industry, Porto Alegre, Brazil
| | - Adelar Kunz
- INBRAMED-Brazilian Medical Equipment Industry, Porto Alegre, Brazil
| | - Maikel Peltz
- INBRAMED-Brazilian Medical Equipment Industry, Porto Alegre, Brazil
| | - Veridiana C Furtado
- Pernambuco University Heart Hospital/University of Pernambuco, Recife, Brazil
| | - Edgar B Júnior
- Pernambuco University Heart Hospital/University of Pernambuco, Recife, Brazil
| | - Júlio M Júnior
- Pernambuco University Heart Hospital/University of Pernambuco, Recife, Brazil
| | - Rosane M Silva
- Pernambuco University Heart Hospital/University of Pernambuco, Recife, Brazil
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Kourek C, Raidou V, Antonopoulos M, Dimopoulou M, Koliopoulou A, Karatzanos E, Pitsolis T, Ieromonachos K, Nanas S, Adamopoulos S, Chamogeorgakis T, Dimopoulos S. Safety and Feasibility of Neuromuscular Electrical Stimulation in Patients with Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:3723. [PMID: 38999287 PMCID: PMC11242632 DOI: 10.3390/jcm13133723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/17/2024] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: The aim of this study was to investigate the feasibility and safety of neuromuscular electrical stimulation (NMES) in patients on extracorporeal membrane oxygenation (ECMO) and thoroughly assess any potential adverse events. Methods: We conducted a prospective observational study assessing safety and feasibility, including 16 ICU patients on ECMO support who were admitted to the cardiac surgery ICU from January 2022 to December 2023. The majority of patients were females (63%) on veno-arterial (VA)-ECMO (81%), while the main cause was cardiogenic shock (81%) compared to respiratory failure. Patients underwent a 45 min NMES session while on ECMO support that included a warm-up phase of 5 min, a main phase of 35 min, and a recovery phase of 5 min. NMES was implemented on vastus lateralis, vastus medialis, gastrocnemius, and peroneus longus muscles of both lower extremities. Two stimulators delivered biphasic, symmetric impulses of 75 Hz, with a 400 μsec pulse duration, 5 sec on (1.6 sec ramp up and 0.8 sec ramp down) and 21 sec off. The intensity levels aimed to cause visible contractions and be well tolerated. Primary outcomes of this study were feasibility and safety, evaluated by whether NMES sessions were successfully achieved, and by any adverse events and complications. Secondary outcomes included indices of rhabdomyolysis from biochemical blood tests 24 h after the application of NMES. Results: All patients successfully completed their NMES session, with no adverse events or complications. The majority of patients achieved type 4 and 5 qualities of muscle contraction. Conclusions: NMES is a safe and feasible exercise methodology for patients supported with ECMO.
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Affiliation(s)
- Christos Kourek
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Vasiliki Raidou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Michael Antonopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Kallithea, Greece
| | - Maria Dimopoulou
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Antigone Koliopoulou
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Eleftherios Karatzanos
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Theodoros Pitsolis
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Kallithea, Greece
| | - Konstantinos Ieromonachos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Serafim Nanas
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Stamatis Adamopoulos
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Themistocles Chamogeorgakis
- Heart Failure, Transplant and Mechanical Circulatory Support Units, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Stavros Dimopoulos
- Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Kallithea, Greece
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Frazão M, Figueiredo TDG, Cipriano G. Should We Use the Functional Electrical Stimulation-Cycling Exercise in Clinical Practice? Physiological and Clinical Effects Systematic Review With Meta-analysis. Arch Phys Med Rehabil 2024:S0003-9993(24)01057-8. [PMID: 38914190 DOI: 10.1016/j.apmr.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 06/26/2024]
Abstract
OBJECTIVE To examine the evidence regarding functional electrical stimulation cycling's (FES-cycling's) physiological and clinical effects. DATA SOURCES The study was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses protocol. PubMed, Embase, Cochrane Review, CINAHL, Scopus, Sport Discus, and Web of Science databases were used. STUDY SELECTION Randomized controlled trials involving FES-cycling were included. Studies that did not involve FES-cycling in the intervention group or without the control group were excluded. Two reviewers screened titles and abstracts and then conducted a blinded full-text evaluation. A third reviewer resolved the discrepancies. DATA EXTRACTION Meta-analysis was performed using inverse variance for continuous data, with effects measured using the mean difference and random effects analysis models. A 95% confidence interval was adopted. The significance level was set at P<.05, and trends were declared at P=.05 to ≤.10. The I2 method was used for heterogeneity analysis. The minimal clinically important difference was calculated. Methodological quality was assessed using the risk of bias tool for randomized trials. The Grading of Recommendations Assessment, Development, and Evaluation method was used for the quality of the evidence analysis. DATA SYNTHESIS A total of 52 studies were included. Metabolic, cardiocirculatory, ventilatory, and peripheral muscle oxygen extraction variables presented statistical (P<.05) and clinically important differences favoring FES-cycling, with moderate-to-high certainty of evidence. It also presented statistical (P<.05) and clinically important improvements in cardiorespiratory fitness, leg and total body lean mass, power, physical fitness in intensive care (moderate-to-high certainty of evidence), and torque (low certainty of evidence). It presented a trend (P=.05 to ≤.10) of improvement in muscle volume, spasticity, and mobility (low-to-moderate certainty of evidence). It showed no difference (P>.10) in 6-minute walking distance, muscle cross-sectional area, bone density, and length of intensive care unit stay (low-to-moderate certainty of evidence). CONCLUSIONS FES-cycling exercise is a more intense stimulus modality than other comparative therapeutic modalities and presented clinically important improvement in several clinical outcomes.
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Affiliation(s)
- Murillo Frazão
- Lauro Wanderley University Hospital - UFPB/EBSERH, João Pessoa-PB; Postgraduate Program in Health Sciences and Technologies, University of Brasília - UnB, Brasília.
| | | | - Gerson Cipriano
- Postgraduate Program in Health Sciences and Technologies, University of Brasília - UnB, Brasília
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Wi S, Shin HI, Hyun SE, Sung KS, Lee WH. Feasibility and safety of in-bed cycling/stepping in critically ill patients: A study protocol for a pilot randomized controlled clinical trial. PLoS One 2024; 19:e0301368. [PMID: 38728323 PMCID: PMC11086822 DOI: 10.1371/journal.pone.0301368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness (ICU-AW) is one of the most common complications of post-ICU syndrome. It is the leading cause of gait disturbance, decreased activities of daily living, and poor health-related quality of life. The early rehabilitation of critically ill patients can reduce the ICU-AW. We designed a protocol to investigate the feasibility and safety of conventional rehabilitation with additional in-bed cycling/stepping in critically ill patients. METHODS The study is designed as a single-center, single-blind, pilot, randomized, parallel-group study. After the screening, participants are randomly allocated to two groups, stratified by mechanical ventilation status. The intervention group will be provided with exercises of in-bed cycling/stepping according to the level of consciousness, motor power, and function in addition to conventional rehabilitation. In contrast, the control group will be provided with only conventional rehabilitation. The length of intervention is from ICU admission to discharge, and interventions will be conducted for 20 minutes, a maximum of three sessions per day. RESULTS The outcomes are the number and percentage of completed in-bed cycling/stepping sessions, the duration and percentage of in-bed cycling/stepping sessions, and the number of cessations of in-bed cycling/stepping sessions, the interval from ICU admission to the first session of in-bed cycling/stepping, the number and percentage of completed conventional rehabilitation sessions, the duration and percentage of conventional rehabilitation sessions, the number of cessations of conventional rehabilitation sessions, the number of adverse events, level of consciousness, functional mobility, muscle strength, activities of daily living, and quality of life. DISCUSSION This study is a pilot clinical trial to investigate the feasibility and safety of conventional rehabilitation with additional in-bed cycling/stepping in critically ill patients. If the expected results are achieved in this study, the methods of ICU rehabilitation will be enriched. TRIAL REGISTRATION clinicialtrials.gov, Clinical Trials Registration #NCT05868070.
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Affiliation(s)
- Soohyun Wi
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sung Eun Hyun
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kwan-Sik Sung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Woo Hyung Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
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de Gomes Figueiredo T, Frazão M, Werlang LA, Peltz M, Sobral Filho DC. Functional electrical stimulation cycling-based muscular evaluation method in mechanically ventilated patients. Artif Organs 2024; 48:254-262. [PMID: 37930042 DOI: 10.1111/aor.14677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/22/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Intensive care acquired muscle weakness is a common feature in critically ill patients. Beyond the therapeutic uses, FES-cycling could represent a promising nonvolitional evaluation method for detecting acquired muscle weakness. OBJECTIVES To assess whether FES-cycling is able to identify muscle dysfunctions, and to evaluate the survival rate in patients with detected muscle dysfunction. METHODS A prospective observational study was carried out, with 29 critically ill patients and 20 healthy subjects. Maximum torque and power achieved were recorded, in addition to the stimulation cost, and patients were followed up for six months. RESULTS Torque (2.64 [1.53 to 4.81] vs 6.03 [4.56 to 6.73] Nm) and power (3.31 [2.33 to 6.37] vs 6.35 [5.22 to 10.70] watts) were lower and stimulation cost (22 915 [5069 to 37 750] vs 3411 [2080 to 4024] μC/W) was higher in patients compared to healthy people (p < 0.05). Surviving patients showed a nonsignificant difference in power and torque in relation to nonsurvivors (p > 0.05), but they had a lower stimulation cost (4462 [3598 to 11 788] vs 23 538 [10 164 to 39 836] μC/W) (p < 0.05). In total, 34% of all patients survived during the six months of follow-up. Furthermore, 62% of patients with a stimulation cost below 15 371 μC/W and 7% of patients with a stimulation cost above 15 371 μC/W survived. CONCLUSIONS FES-cycling has good sensitivity and specificity for detecting muscle disorders. Critical patients have low torque and power and a high stimulation cost. Stimulation cost is related to survival. A low stimulation cost was related to a 3 times greater chance of survival.
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Affiliation(s)
| | - Murillo Frazão
- Lauro Wanderley University Hospital, João Pessoa, Brazil
- CLINAR Exercise Physiology, João Pessoa, Brazil
| | | | - Maikel Peltz
- INBRAMED-Brazilian Medical Equipment Industry, Porto Alegre, Brazil
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Frazão M, Cipriano G, Silva PE. Does inflammation and altered metabolism impede efficacy of functional electrical stimulation in critically ill patients? Unleashing the potential of individualized functional electrical stimulation-cycling in critical illness. Crit Care 2024; 28:8. [PMID: 38167053 PMCID: PMC10759332 DOI: 10.1186/s13054-023-04788-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Murillo Frazão
- Lauro Wanderley University Hospital, Avenida Ruy Carneiro, 412, Miramar, João Pessoa, PB, 58302-100, Brazil.
- Health Sciences and Technologies Graduate Program, University of Brasilia (UnB), Brasilia, DF, Brazil.
| | - Gerson Cipriano
- Health Sciences and Technologies Graduate Program, University of Brasilia (UnB), Brasilia, DF, Brazil
- Graduate Program in Human Movement, Rehabilitation of Evangelical University of Goias, Anapolis, Brazil
| | - Paulo Eugênio Silva
- University of São Paulo Medical School, São Paulo, SP, Brazil
- Hospital de Base Do Distrito Federal-IGESDF, Brasília, DF, Brazil
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Kho ME, Reid J, Molloy AJ, Herridge MS, Seely AJ, Rudkowski JC, Buckingham L, Heels-Ansdell D, Karachi T, Fox-Robichaud A, Ball IM, Burns KEA, Pellizzari JR, Farley C, Berney S, Pastva AM, Rochwerg B, D'Aragon F, Lamontagne F, Duan EH, Tsang JLY, Archambault P, English SW, Muscedere J, Serri K, Tarride JE, Mehta S, Verceles AC, Reeve B, O'Grady H, Kelly L, Strong G, Hurd AH, Thabane L, Cook DJ. Critical Care C ycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients. BMJ Open 2023; 13:e075685. [PMID: 37355270 PMCID: PMC10314658 DOI: 10.1136/bmjopen-2023-075685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults. METHODS AND ANALYSIS We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups. ETHICS AND DISSEMINATION Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).
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Affiliation(s)
- Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Julie Reid
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alexander J Molloy
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- University Health Network, Toronto General Research Institute, Toronto, Ontario, Canada
| | - Andrew J Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jill C Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lisa Buckingham
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Ian M Ball
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Karen E A Burns
- Li Sha King Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, Unity Health Toronto, Toronto, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Christopher Farley
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sue Berney
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amy M Pastva
- Departments of Medicine and Orthopedic Surgery, Duke University, Durham, North Carolina, USA
| | - Bram Rochwerg
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Universite de Sherbrooke Faculte de medecine et des sciences de la sante, Sherbrooke, Quebec, Canada
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Francois Lamontagne
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
- Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Erick H Duan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Jennifer L Y Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Patrick Archambault
- Anesthesiology and Intensive Care, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
- Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
| | - Shane W English
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Karim Serri
- Critical Care Division, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Québec, Canada
| | - Jean-Eric Tarride
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Toronto, Ontario, Canada
| | - Avelino C Verceles
- Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brenda Reeve
- Medicine, Brantford General Hospital, Brantford, Ontario, Canada
| | - Heather O'Grady
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Laurel Kelly
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Geoff Strong
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Abby H Hurd
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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9
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Jarman A, Chapman K, Vollam S, Stiger R, Williams M, Gustafson O. Investigating the impact of physical activity interventions on delirium outcomes in intensive care unit patients: A systematic review and meta-analysis. J Intensive Care Soc 2023; 24:85-95. [PMID: 36874288 PMCID: PMC9975810 DOI: 10.1177/17511437221103689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients. Methods Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872). Results Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62-1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality. Conclusions Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base.
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Affiliation(s)
- Annika Jarman
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Keeleigh Chapman
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
| | - Sarah Vollam
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Robyn Stiger
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Mark Williams
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Owen Gustafson
- Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
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10
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Mehler-Klamt AC, Huber J, Schmidbauer L, Warmbein A, Rathgeber I, Fischer U, Eberl I. Der Einsatz von robotischen und technischen Systemen zur Frühmobilisation von Intensivpatient_innen. Pflege 2022; 36:156-167. [DOI: 10.1024/1012-5302/a000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung. Hintergrund: Intensivpatient_innen sind oft einer langen Immobilität ausgesetzt. Wenn sie aber frühzeitig mobilisiert werden, lassen sich positive Effekte auf ihr Outcome, wie z.B. eine Verbesserung der körperlichen Funktion, nachweisen. Einer der Gründe für die späte Mobilisation ist, dass zu wenig Hilfsmittel zur Verfügung stehen. Fragestellungen/Ziel: Dieser Beitrag gibt einen Überblick über den Einsatz von robotischen oder technischen Systemen als Hilfsmittel für die Frühmobilisation. Welche robotischen und technischen Hilfsmittel werden in Studien zur Frühmobilisation von erwachsenen Intensivpatient_innen durch Pflegefachpersonen oder Physiotherapeut_innen untersucht? Über welche Effekte von Frühmobilisation mittels robotischem und technischem System auf die Patientenoutcomes wird in den Studien berichtet? Methoden: Die Datenbanken Medline, Web of Science, CINAHL, Cochrane Library, Embase, IEEE Xplore, Scopus und WTI wurden zwischen Mai und Juli 2020 und im Januar 2022 systematisch durchsucht. Zusätzlich wurde im ersten Suchlauf eine Randsuche über GoogleScolar und ResearchGate durchgeführt. Ergebnisse: Es wurden 27 Veröffentlichungen eingeschlossen (9 RCTs, 7 Expertenmeinungen, 3 quantitative Querschnittstudien, 2 Fall-Kontroll-Studien, 2 Literaturreviews, 2 klinische Einzelfallstudien, 2 Interventionsstudien im Prä-Post-Design). Hier zeigte sich, dass als Hilfsmittel vor allem elektronische Bettfahrräder und Kipptische eingesetzt werden. Es war eine uneinheitliche Datenlage in Bezug auf verschiedene Patientenoutcomes nachweisbar. Schlussfolgerungen: Weitere Forschung zum Einsatz von technischen und robotischen Systemen zur Frühmobilisation ist vor allem in Bezug auf unterschiedliche Studienpopulationen notwendig. Frühmobilisationsrobotik ist noch nicht Teil der Regelversorgung.
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Affiliation(s)
| | - Jana Huber
- Katholische Universität Eichstätt-Ingolstadt, Eichstätt, Deutschland
| | - Lena Schmidbauer
- Katholische Universität Eichstätt-Ingolstadt, Eichstätt, Deutschland
| | | | | | | | - Inge Eberl
- Katholische Universität Eichstätt-Ingolstadt, Eichstätt, Deutschland
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11
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Cupka JS, Hashemighouchani H, Lipori J, Ruppert MM, Bhaskar R, Ozrazgat-Baslanti T, Rashidi P, Bihorac A. The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review. F1000Res 2022; 9:1178. [PMID: 36110837 PMCID: PMC9449425 DOI: 10.12688/f1000research.25769.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.
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Affiliation(s)
- Julie S Cupka
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Haleh Hashemighouchani
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Jessica Lipori
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Ria Bhaskar
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Tezcan Ozrazgat-Baslanti
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Parisa Rashidi
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32608, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
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12
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Balke M, Teschler M, Schäfer H, Pape P, Mooren FC, Schmitz B. Therapeutic Potential of Electromyostimulation (EMS) in Critically Ill Patients—A Systematic Review. Front Physiol 2022; 13:865437. [PMID: 35615672 PMCID: PMC9124773 DOI: 10.3389/fphys.2022.865437] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/01/2022] [Indexed: 12/15/2022] Open
Abstract
Ample evidence exists that intensive care unit (ICU) treatment and invasive ventilation induce a transient or permanent decline in muscle mass and function. The functional deficit is often called ICU-acquired weakness with critical illness polyneuropathy (CIP) and/or myopathy (CIM) being the major underlying causes. Histopathological studies in ICU patients indicate loss of myosin filaments, muscle fiber necrosis, atrophy of both muscle fiber types as well as axonal degeneration. Besides medical prevention of risk factors such as sepsis, hyperglycemia and pneumonia, treatment is limited to early passive and active mobilization and one third of CIP/CIM patients discharged from ICU never regain their pre-hospitalization constitution. Electromyostimulation [EMS, also termed neuromuscular electrical stimulation (NMES)] is known to improve strength and function of healthy and already atrophied muscle, and may increase muscle blood flow and induce angiogenesis as well as beneficial systemic vascular adaptations. This systematic review aimed to investigate evidence from randomized controlled trails (RCTs) on the efficacy of EMS to improve the condition of critically ill patients treated on ICU. A systematic search of the literature was conducted using PubMed (Medline), CENTRAL (including Embase and CINAHL), and Google Scholar. Out of 1,917 identified records, 26 articles (1,312 patients) fulfilled the eligibility criteria of investigating at least one functional measure including muscle function, functional independence, or weaning outcomes using a RCT design in critically ill ICU patients. A qualitative approach was used, and results were structured by 1) stimulated muscles/muscle area (quadriceps muscle only; two to four leg muscle groups; legs and arms; chest and abdomen) and 2) treatment duration (≤10 days, >10 days). Stimulation parameters (impulse frequency, pulse width, intensity, duty cycle) were also collected and the net EMS treatment time was calculated. A high grade of heterogeneity between studies was detected with major cofactors being the analyzed patient group and selected outcome variable. The overall efficacy of EMS was inconclusive and neither treatment duration, stimulation site or net EMS treatment time had clear effects on study outcomes. Based on our findings, we provide practical recommendations and suggestions for future studies investigating the therapeutic efficacy of EMS in critically ill patients. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021262287].
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Affiliation(s)
- Maryam Balke
- St. Marien Hospital Cologne, Department of Early Rehabilitation, Cologne, Germany
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- *Correspondence: Maryam Balke,
| | - Marc Teschler
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Hendrik Schäfer
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Pantea Pape
- St. Marien Hospital Cologne, Department of Early Rehabilitation, Cologne, Germany
| | - Frank C. Mooren
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
| | - Boris Schmitz
- Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany
- DRV Clinic Königsfeld, Center for Medical Rehabilitation, Ennepetal, Germany
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13
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Effect of Combined Protein-Enriched Enteral Nutrition and Early Cycle Ergometry in Mechanically Ventilated Critically Ill Patients—A Pilot Study. Nutrients 2022; 14:nu14081589. [PMID: 35458151 PMCID: PMC9027967 DOI: 10.3390/nu14081589] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Cycle ergometry (CE) is a method of exercise used in clinical practice. Limited data demonstrate its effectiveness in critically ill patients. We aimed to evaluate the combination of CE and a high-protein diet in critically ill patients. Methods: This was an open label pilot trial comparing conventional physiotherapy with enteral nutrition (EN) (control, Group 1), CE with EN (Group 2), and CE with protein-enriched EN (Group 3). The primary outcome was length of ventilation (LOV). Secondary outcomes were intensive care unit (ICU) mortality, length of ICU stay (ICU LOS), length of hospital stay (Hospital LOS), and rate of re-intubation. Results: Per protocol, 41 ICU patients were enrolled. Thirteen patients were randomized to Group 1 (control), fourteen patients to Group 2, and fourteen patients to Group 3 (study groups). We found no statistically significant difference in LOV between the study arms (14.2 ± 9.6 days, 15.8 ± 7.1 days, and 14.9 ± 9.4 days, respectively, p = 0.89). Secondary outcomes did not demonstrate any significant differences between arms. Conclusions: In this pilot trial, CE combined with either standard EN or protein-enriched EN was not associated with better clinical outcomes, as compared to conventional physiotherapy with standard EN. Larger trials are needed in order to further evaluate this combination.
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14
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Zacarias Maldaner da Silva1,2 V, Sanches Lima1 A, Nadiele Santos Alves1 H, Pires-Neto3 R, Denehy4 L, M. Parry4 S. ERRATUM. J Bras Pneumol 2022; 47:e20180366errata. [PMID: 35081250 PMCID: PMC8946556 DOI: 10.36416/1806-3713/e20180366errata] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Vinicius Zacarias Maldaner da Silva1,2
- 1. Programa de Pós-Grauação em Ciencias da Saúde, Escola Superior de Ciências da Saúde, Brasília (DF) Brasil. 2. Instituto Hospital de Base do Distrito Federal, Brasília (DF) Brasil
| | - Amanda Sanches Lima1
- 1. Programa de Pós-Grauação em Ciencias da Saúde, Escola Superior de Ciências da Saúde, Brasília (DF) Brasil
| | | | - Ruy Pires-Neto3
- 3. Departamento de Fisioterapia, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Linda Denehy4
- 4. Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne (Vic) Australia
| | - Selina M. Parry4
- 4. Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne (Vic) Australia
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15
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Immediate Hemodynamic Responses to Transcutaneous Electrical Diaphragmatic Stimulation in Critically Ill Elderly Patients. Rehabil Res Pract 2022; 2021:9091278. [PMID: 34976410 PMCID: PMC8716245 DOI: 10.1155/2021/9091278] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 12/04/2022] Open
Abstract
Background Critically ill patients admitted to intensive care units (ICUs) may develop diaphragmatic dysfunction, especially when artificial airways are used. Positive effects have been observed when using the transcutaneous electrical diaphragmatic stimulation (TEDS) technique in different clinical conditions. However, no study has evaluated the safety of TEDS in patients admitted to ICUs. This study is aimed at evaluating the influence of TEDS on the hemodynamic and vital parameters of critically ill elderly patients under invasive mechanical ventilation (IMV). Methods Forty-seven patients aged >60 years under IMV were evaluated for hemodynamic variables before and after TEDS. The procedure lasted 30 minutes and was performed once. Results The sample consisted of 33 men and 14 women with a mean age of 69.9 ± 7.64 years. The mean systolic blood pressures pre-TEDS and post-TEDS were 126.6 ± 23.7 and 122.9 ± 25.9, respectively (p = 0.467). The mean diastolic blood pressures pre-TEDS and post-TEDS were 71.1 ± 12.2 and 67.7 ± 14.2, respectively (p = 0.223). No significant differences in the mean arterial pressure or heart rate were found between the pre-TEDS and post-TEDS time points (p = 0.335 and p = 0.846, respectively). Conclusion Our findings suggest that TEDS does not have clinically relevant impacts on hemodynamic or vital parameters in critically ill elderly patients. These findings point to the possible safety of TEDS application in this population.
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16
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Frazão M, Werlang LA, Azevedo C, Kunz A, Peltz M. Metabolic, ventilatory and cardiovascular responses to FES-cycling: A comparison to NMES and passive cycling. Technol Health Care 2021; 30:909-918. [PMID: 34744034 DOI: 10.3233/thc-213220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cyclergometry with functional electrical stimulation (FES-cycling) is a feasible method for rehabilitation. The concept is to promote exercise induced by depolarization of the motoneuron and muscular contraction. OBJECTIVE To measure acute physiological responses to FES-cycling. METHODS Retrospective study of data from ten healthy volunteers who performed FES-cycling, passive cycling and neuromuscular electrical stimulation (NMES) alone. Metabolic, ventilatory and cardiovascular parameters were analyzed. RESULTS Oxygen uptake enhanced 97 ± 15% during FES-cycling, with medium effect size compared to NMES and large effect size compared to passive cycling. Energy expenditure enhanced 102 ± 15% during FES-cycling, with medium effect size compared to NMES and large effect size compared to passive cycling. Minute ventilation enhanced 115 ± 26% during FES-cycling, with small effect size compared to NMES and medium effect size compared to passive cycling. Cardiac output enhanced 21 ± 4% during FES-cycling, with medium effect size compared to NMES and passive cycling. Arterial - mixed venous oxygen content difference enhanced 60 ± 8% during FES-cycling, with a medium effect size compared to NMES and large effect size compared to passive cycling. CONCLUSIONS FES-cycling enhances metabolic, ventilatory and cardiovascular demands and the physiological responses are higher than NMES and passive cycling.
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Affiliation(s)
- Murillo Frazão
- Lauro Wanderley Hospital, Federal University of Paraíba, João Pessoa, PB, Brazil.,CLINAR Exercise Physiology, João Pessoa, PB, Brazil
| | | | - Cássio Azevedo
- INBRAMED Brazilian Medical Equipment Industry, Porto Alegre, RS, Brazil
| | - Adelar Kunz
- INBRAMED Brazilian Medical Equipment Industry, Porto Alegre, RS, Brazil
| | - Maikel Peltz
- INBRAMED Brazilian Medical Equipment Industry, Porto Alegre, RS, Brazil
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17
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The Efficacy and Safety of In-Intensive Care Unit Leg-Cycle Ergometry in Critically Ill Adults. A Systematic Review and Meta-analysis. Ann Am Thorac Soc 2021; 17:1289-1307. [PMID: 32628501 DOI: 10.1513/annalsats.202001-059oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Survivors of critical illness may experience physical-function deficits after intensive care unit (ICU) discharge. In-ICU cycle ergometry may facilitate early mobilization and decrease functional impairment.Objective: We conducted a systematic review and meta-analysis to understand the effect of in-ICU leg-cycle ergometry on patient-important and clinically relevant outcomes.Data Sources: We searched eight electronic databases from inception until July 2019.Data Extraction: We included randomized controlled trials (RCTs) and nonrandomized studies of critically ill adults admitted to the ICU for ≥24 hours, comparing cycling interventions to control arms that did not receive cycling. Main outcomes included physical function, mechanical ventilation (MV) duration, length of stay (LOS), quality of life (QoL), mortality, and safety. We conducted independent duplicate-citation screening, data abstraction, and risk-of-bias assessments. We pooled RCTs using a random-effects model and calculated the risk ratio (RR), mean difference (MD), or standardized MD with 95% confidence intervals (CIs). We assessed certainty of outcomes using the Grading of Recommendations Assessment, Development, and Evaluation approach.Results: Of 6,531 citations, we included 12 RCTs and 2 nonrandomized studies (n = 926). Between the cycling and control groups, there were no differences in physical function at hospital discharge (3 RCTs; n = 225; standardized MD, 0.07 [95% CI, -0.38 to 0.53]; very low certainty), MV duration (9 RCTs; n = 676; MD, 0.01 [-1.04 to 1.07] days; moderate certainty), ICU LOS (10 RCTs; n = 511; MD, 0.23 [-1.44 to 1.89] days; moderate certainty), hospital LOS (7 RCTs; n = 393, MD -0.07 [-3.87 to 3.73] days; moderate certainty), QoL at 6 months after hospital discharge (2 RCTs; n = 103; MD, 9.13 [13.80 to 32.05] points higher; very low certainty), or hospital mortality (7 RCTs; n = 710; RR 1.09 [0.82 to 1.46]; moderate-certainty). The adverse event rate in cycling sessions was 0.16% across studies (10 studies; 5 of 3,117 sessions; very low certainty).Conclusions: Cycling initiated in the ICU is probably safe; however, we did not find any differences in physical function, MV duration, LOS, QoL, or mortality compared with those not receiving cycling. Rigorously designed RCTs are needed to improve precision and further investigate the effect of cycling on patient-important outcomes.
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18
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Prevalence and predictors of hospital-acquired functional decline in patients with sepsis admitted to the intensive care unit. Int J Rehabil Res 2021; 44:307-313. [PMID: 34267113 DOI: 10.1097/mrr.0000000000000490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although sepsis is known to cause functional decline, the prevalence and predictors of hospital-acquired functional decline (HAFD) in patients with sepsis are unclear. The purpose of this study was to investigate the prevalence and predictors of HAFD in patients with sepsis admitted to the ICU. This study is a single-center retrospective observational study from January 2014 to December 2019. We included all consecutive patients with sepsis who received rehabilitation in our ICU. The primary outcome was HAFD, which was defined as a decrease in at least five points of the Barthel index mobility score from prehospital to hospital discharge. We described the prevalence of HAFD and investigated the predictors of HAFD using the multivariate logistic regression analysis adjusting for potential confounders. Among 134 patients, 57 patients (42.5%) had HAFD. The longer time to initial ambulation and lower prehospital walking ability were associated with HAFD (adjusted odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.10 and adjusted OR 0.79; 95% CI, 0.66-0.95, respectively). In conclusion, nearly half of the patients with sepsis who received rehabilitation developed HAFD. Lower functional status prior to hospitalization and the longer time to initial ambulation was associated with HAFD, indicating the potential importance of early ambulation among septic patients in the ICU.
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19
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Waldauf P, Hrušková N, Blahutova B, Gojda J, Urban T, Krajčová A, Fric M, Jiroutková K, Řasová K, Duška F. Functional electrical stimulation-assisted cycle ergometry-based progressive mobility programme for mechanically ventilated patients: randomised controlled trial with 6 months follow-up. Thorax 2021; 76:664-671. [PMID: 33931570 PMCID: PMC8223653 DOI: 10.1136/thoraxjnl-2020-215755] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 03/15/2021] [Accepted: 04/06/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Functional electrical stimulation-assisted cycle ergometry (FESCE) enables in-bed leg exercise independently of patients' volition. We hypothesised that early use of FESCE-based progressive mobility programme improves physical function in survivors of critical care after 6 months. METHODS We enrolled mechanically ventilated adults estimated to need >7 days of intensive care unit (ICU) stay into an assessor-blinded single centre randomised controlled trial to receive either FESCE-based protocolised or standard rehabilitation that continued up to day 28 or ICU discharge. RESULTS We randomised in 1:1 ratio 150 patients (age 61±15 years, Acute Physiology and Chronic Health Evaluation II 21±7) at a median of 21 (IQR 19-43) hours after admission to ICU. Mean rehabilitation duration of rehabilitation delivered to intervention versus control group was 82 (IQR 66-97) versus 53 (IQR 50-57) min per treatment day, p<0.001. At 6 months 42 (56%) and 46 (61%) patients in interventional and control groups, respectively, were alive and available to follow-up (81.5% of prespecified sample size). Their Physical Component Summary of SF-36 (primary outcome) was not different at 6 months (50 (IQR 21-69) vs 49 (IQR 26-77); p=0.26). At ICU discharge, there were no differences in the ICU length of stay, functional performance, rectus femoris cross-sectional diameter or muscle power despite the daily nitrogen balance was being 0.6 (95% CI 0.2 to 1.0; p=0.004) gN/m2 less negative in the intervention group. CONCLUSION Early delivery of FESCE-based protocolised rehabilitation to ICU patients does not improve physical functioning at 6 months in survivors. TRIAL REGISTRATION NUMBER NCT02864745.
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Affiliation(s)
- Petr Waldauf
- Department of Anaesthesiology and Intensive Care Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Natália Hrušková
- Department of Rehabilitation, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Barbora Blahutova
- Department of Anaesthesiology and Intensive Care Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Jan Gojda
- Department of Internal Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Tomáš Urban
- Department of Anaesthesiology and Intensive Care Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Adéla Krajčová
- Department of Anaesthesiology and Intensive Care Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Michal Fric
- Department of Anaesthesiology and Intensive Care Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Kateřina Jiroutková
- Department of Anaesthesiology and Intensive Care Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - Kamila Řasová
- Department of Rehabilitation, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
| | - František Duška
- Department of Anaesthesiology and Intensive Care Medicine, 3rd Faculty of Medicine and FNKV University Hospital, Charles University, Prague, Czech Republic
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20
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Said CM, Delahunt M, Hardidge A, Smith P, Tran P, McDonald L, Kefalianos E, Daniel C, Berney S. Recumbent cycling to improve outcomes in people with hip fracture: a feasibility randomized trial. BMC Geriatr 2021; 21:394. [PMID: 34187387 PMCID: PMC8244148 DOI: 10.1186/s12877-021-02321-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/20/2021] [Indexed: 11/14/2022] Open
Abstract
Background Early mobilization after surgery is a key recommendation for people with hip fracture, however this is achieved by only 50% of people. Recumbent bike riding has been used in other populations with limited mobility and has potential to allow early exercise in people post hip fracture. The primary aim of this pilot trial was to demonstrate the feasibility of a trial protocol designed to determine the effect of early post-operative cycling in bed on outcomes in people with hip fracture. Methods Single-blinded, multi-site randomized controlled pilot trial. Fifty-one people with hip fracture were recruited within 4 days of surgery from two sites in Victoria. Participants were randomly allocated to receive either usual care (n = 25) or usual care plus active cycling in bed (n = 26). The cycling intervention was delivered on weekdays until the participant could walk 15 m with assistance of one person. The primary outcomes were trial feasibility and safety. Clinical outcomes, including mobility (Modified Iowa Level of Assistance Scale) and delirium were measured at day seven post-operatively and at hospital discharge by an assessor blinded to group. Additional outcomes at discharge included gait speed, cognition and quality of life. Results The intervention was safe, feasible and acceptable to patients and staff. Delivery of the intervention was ceased on (median) day 9.5 (IQR 7, 12); 73% of scheduled sessions were delivered; (median) 4 sessions (IQR 2.0, 5.5) were delivered per participant with (median) 9 min 34 s (IQR 04:39, 17:34) of active cycling per session. The trial protocol was feasible, however at day seven 75% of participants had not met the criterion (able to walk 15 m with assistance of one person) to cease the cycling intervention.. Conclusion In bed cycling is feasible post-operatively following hip fracture, however seven days post-operatively is too early to evaluate the impact of the cycling intervention as many participants were still receiving the intervention. A fully powered RCT to explore the effectiveness and cost efficiency of this novel intervention is warranted. Trial registration The trial was prospectively registered (25/09/2017) with the Australian New Zealand Clinical Trials Registry ACTRN12617001345370.
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Affiliation(s)
- Catherine M Said
- Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia. .,Physiotherapy Department, Western Health, St Albans, Australia. .,Australian Institute for Musculoskeletal Science (AIMSS), St Albans, Australia. .,Physiotherapy Department, Austin Health, Heidelberg, Australia.
| | - Marisa Delahunt
- Physiotherapy Department, Austin Health, Heidelberg, Australia
| | - Andrew Hardidge
- Orthopaedics, Austin Health, Heidelberg, Australia.,The University of Melbourne, Melbourne, Australia
| | - Paul Smith
- Physiotherapy Department, Austin Health, Heidelberg, Australia
| | - Phong Tran
- Australian Institute for Musculoskeletal Science (AIMSS), St Albans, Australia.,Department of Orthopaedic Surgery, Western Health, Footscray, Australia
| | - Luke McDonald
- Physiotherapy Department, Austin Health, Heidelberg, Australia
| | | | - Cathy Daniel
- Nursing, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Australia
| | - Sue Berney
- Physiotherapy Department, Austin Health, Heidelberg, Australia
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21
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Stutz MR, Kress JP, Wolfe KS. ICU mobility and improved outcomes: still searching for the Holy Grail. Thorax 2021; 76:640-641. [PMID: 33986145 DOI: 10.1136/thoraxjnl-2021-217009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Matthew R Stutz
- Department of Medicine, Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - John P Kress
- Department of Medicine, Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Krysta S Wolfe
- Department of Medicine, Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
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22
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Berney S, Hopkins RO, Rose JW, Koopman R, Puthucheary Z, Pastva A, Gordon I, Colantuoni E, Parry SM, Needham DM, Denehy L. Functional electrical stimulation in-bed cycle ergometry in mechanically ventilated patients: a multicentre randomised controlled trial. Thorax 2020; 76:656-663. [PMID: 33323480 DOI: 10.1136/thoraxjnl-2020-215093] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/23/2020] [Accepted: 08/04/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the effect of functional electrical stimulation-assisted cycle ergometry (FES-cycling) on muscle strength, cognitive impairment and related outcomes. METHODS Mechanically ventilated patients aged ≥18 years with sepsis or systemic inflammatory response syndrome were randomised to either 60 min of FES-cycling >5 days/week while in the intensive care unit (ICU) plus usual care rehabilitation versus usual care rehabilitation alone, with evaluation of two primary outcomes: (1) muscle strength at hospital discharge and (2) cognitive impairment at 6-month follow-up. RESULTS We enrolled 162 participants, across four study sites experienced in ICU rehabilitation in Australia and the USA, to FES-cycling (n=80; mean age±SD 59±15) versus control (n=82; 56±14). Intervention participants received a median (IQR) of 5 (3-9) FES-cycling sessions with duration of 56 (34-63) min/day plus 15 (10-23) min/day of usual care rehabilitation. The control group received 15 (8-15) min/day of usual care rehabilitation. In the intervention versus control group, there was no significant differences for muscle strength at hospital discharge (mean difference (95% CI) 3.3 (-5.0 to 12.1) Nm), prevalence of cognitive impairment at 6 months (OR 1.1 (95% CI 0.30 to 3.8)) or secondary outcomes measured in-hospital and at 6 and 12 months follow-up. CONCLUSION In this randomised controlled trial, undertaken at four centres with established rehabilitation programmes, the addition of FES-cycling to usual care rehabilitation did not substantially increase muscle strength at hospital discharge. At 6 months, the incidence of cognitive impairment was almost identical between groups, but potential benefit or harm of the intervention on cognition cannot be excluded due to imprecision of the estimated effect. TRIAL REGISTRATION NUMBER ACTRN 12612000528853, NCT02214823.
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Affiliation(s)
- Sue Berney
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia .,Department of Physiotherapy, The University of Melbourne, Parkville, Victoria, Australia
| | - Ramona O Hopkins
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA.,Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah, USA.,Center for Humanizing Critical Care, Intermountain Health Care, Provo, Utah, USA
| | - Joleen Wyn Rose
- Department of Physiotherapy, The University of Melbourne, Parkville, Victoria, Australia
| | - Rene Koopman
- Department of Physiology, The University of Melbourne, Parkville, Victoria, Australia
| | - Zudin Puthucheary
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Amy Pastva
- Departments of Medicine, Orthopedic Surgery and Cell Biology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ian Gordon
- Statistical Consulting Centre, The University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Selina M Parry
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Linda Denehy
- Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Allied Health, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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23
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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24
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Souron R, Morel J, Gergelé L, Infantino P, Brownstein CG, Lapole T, Millet GY. Relationship between intensive care unit-acquired weakness, fatigability and fatigue: What role for the central nervous system? J Crit Care 2020; 62:101-110. [PMID: 33316555 DOI: 10.1016/j.jcrc.2020.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/24/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE To provide a comprehensive review of studies that have investigated fatigue in intensive care unit (ICU) survivors and questions the potential link between intensive care unit-acquired weakness (ICUAW), fatigability and fatigue. We also question whether the central nervous system (CNS) may be the link between these entities. MATERIAL AND METHODS A narrative review of the literature that investigated fatigue in ICU survivors and review of clinical trials enabling understanding of CNS alterations in response to ICU stays. RESULTS Fatigue is a pervasive and debilitating symptom in ICU survivors that can interfere with rehabilitation. Due to the complex pathophysiology of fatigue, more work is required to understand the roles of ICUAW and/or fatigability in fatigue to provide a more holistic understanding of this symptom. While muscle alterations have been well documented in ICU survivors, we believe that CNS alterations developing early during the ICU stay may play a role in fatigue. CONCLUSIONS Fatigue should be considered and treated in ICU survivors. The causes of fatigue are likely to be specific to the individual. Understanding the role that ICUAW and fatigability may have in fatigue would allow to tailor individual treatment to prevent this persistent symptom and improve quality of life.
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Affiliation(s)
- Robin Souron
- Univ Lyon, UJM Saint-Etienne, Inter-university Laboratory of Human Movement Biology, EA 7424, F-42023 Saint-Etienne, France; Laboratory of Impact of Physical Activity on Health (IAPS), UR n°201723207F, University of Toulon, France
| | - Jérôme Morel
- Univ Lyon, UJM Saint-Etienne, Inter-university Laboratory of Human Movement Biology, EA 7424, F-42023 Saint-Etienne, France; Département d'anesthésie et réanimation, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France.
| | - Laurent Gergelé
- Ramsay Générale de Santé, Hôpital privé de la Loire, Saint Etienne, France
| | - Pascal Infantino
- Département d'anesthésie et réanimation, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Callum G Brownstein
- Univ Lyon, UJM Saint-Etienne, Inter-university Laboratory of Human Movement Biology, EA 7424, F-42023 Saint-Etienne, France.
| | - Thomas Lapole
- Univ Lyon, UJM Saint-Etienne, Inter-university Laboratory of Human Movement Biology, EA 7424, F-42023 Saint-Etienne, France
| | - Guillaume Y Millet
- Univ Lyon, UJM Saint-Etienne, Inter-university Laboratory of Human Movement Biology, EA 7424, F-42023 Saint-Etienne, France.
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25
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Cupka JS, Hashemighouchani H, Lipori J, Ruppert MM, Bhaskar R, Ozrazgat-Baslanti T, Rashidi P, Bihorac A. The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review. F1000Res 2020; 9:1178. [PMID: 36110837 PMCID: PMC9449425 DOI: 10.12688/f1000research.25769.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 08/26/2023] Open
Abstract
Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.
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Affiliation(s)
- Julie S Cupka
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Haleh Hashemighouchani
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Jessica Lipori
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Ria Bhaskar
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Tezcan Ozrazgat-Baslanti
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Parisa Rashidi
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32608, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
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26
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Cupka JS, Hashemighouchani H, Lipori J, Ruppert MM, Bhaskar R, Ozrazgat-Baslanti T, Rashidi P, Bihorac A. The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review. F1000Res 2020; 9:1178. [PMID: 36110837 PMCID: PMC9449425 DOI: 10.12688/f1000research.25769.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 08/01/2023] Open
Abstract
Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.
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Affiliation(s)
- Julie S Cupka
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Haleh Hashemighouchani
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Jessica Lipori
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Ria Bhaskar
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Tezcan Ozrazgat-Baslanti
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Parisa Rashidi
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32608, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
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27
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Acceptability, safety, and feasibility of in-bed cycling with critically ill patients. Aust Crit Care 2020; 33:236-243. [PMID: 32317212 DOI: 10.1016/j.aucc.2020.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In-bed cycling is a promising intervention that may assist critically ill patients to maintain muscle mass and improve their trajectory of recovery. The acceptability of in-bed cycling from the different perspectives of patients, clinicians, and families are unknown. In addition, the safety and feasibility of in-bed cycling in an Australian tertiary intensive care unit (ICU) is relatively unknown. OBJECTIVES The objective of this study was to examine the acceptability, safety, and feasibility of in-bed cycling in an Australian tertiary, adult, mixed medical, surgical, trauma ICU. METHODS An observational process evaluation was embedded in one arm of a two-arm parallel phase II randomised controlled trial that was conducted in an Australian tertiary ICU. The process evaluation was of the acceptability, safety, and feasibility of passive and active in-bed cycling for participants allocated to the trial intervention group. In-bed cycling acceptability questionnaires were designed through a three-step Delphi process. Questionnaire responses from patients, family members, and clinicians who participated in or observed the intervention during the Critical Care Cycling Study (CYCLIST) were evaluated to determine the acceptability of in-bed cycling. The congruence of responses between respondents was also compared. Safety and feasibility of the in-bed cycling intervention were assessed against predetermined criteria. RESULTS Acceptability questionnaire responses demonstrated that in-bed cycling was an acceptable intervention from the perspectives of patients, family members, and clinicians. Questionnaire responses were congruent across the respondent groups. Safety was demonstrated with two minor transient adverse events occurring during 276 in-bed cycling sessions (adverse event rate: 0.7%). In-bed cycling sessions were feasible with 276 of 304 (90%) planned sessions conducted. CONCLUSIONS Acceptability questionnaire responses found that in-bed cycling was regarded as an acceptable intervention to patients, family members, and clinicians. The implementation of in-bed cycling was safe and feasible to complete with critically ill patients during the early stages of their critical illness in an Australian tertiary ICU setting.
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28
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Waldauf P, Gojda J, Urban T, Hrušková N, Blahutová B, Hejnová M, Jiroutková K, Fric M, Jánský P, Kukulová J, Stephens F, Řasová K, Duška F. Functional electrical stimulation-assisted cycle ergometry in the critically ill: protocol for a randomized controlled trial. Trials 2019; 20:724. [PMID: 31842936 PMCID: PMC6915865 DOI: 10.1186/s13063-019-3745-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/23/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness is the most important cause of failed functional outcome in survivors of critical care. Most damage occurs during the first week when patients are not cooperative enough with conventional rehabilitation. Functional electrical stimulation-assisted cycle ergometry (FES-CE) applied within 48 h of ICU admission may improve muscle function and long-term outcome. METHODS An assessor-blinded, pragmatic, single-centre randomized controlled trial will be performed. Adults (n = 150) mechanically ventilated for < 48 h from four ICUs who are estimated to need > 7 days of critical care will be randomized (1:1) to receive either standard of care or FES-CE-based intensified rehabilitation, which will continue until ICU discharge. PRIMARY OUTCOME quality of life measured by 36-Item Short Form Health Survey score at 6 months. SECONDARY OUTCOMES functional performance at ICU discharge, muscle mass (vastus ultrasound, N-balance) and function (Medical Research Council score, insulin sensitivity). In a subgroup (n = 30) we will assess insulin sensitivity and perform skeletal muscle biopsies to look at mitochondrial function, fibre typing and regulatory protein expression. TRIAL REGISTRATION ClinicalTrials.gov, NCT02864745. Registered on 12 August 2016.
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Affiliation(s)
- Petr Waldauf
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
| | - Jan Gojda
- Department of Internal Medicine II, Charles University, 3rd Faculty of Medicine and FNKV University Hospital, Prague, Czech Republic
| | - Tomáš Urban
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
| | - Natália Hrušková
- Department of Rehabilitation, Charles University, 3rd Faculty of Medicine and FNKV University Hospital, Prague, Czech Republic
| | - Barbora Blahutová
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
- Department of Rehabilitation, Charles University, 3rd Faculty of Medicine and FNKV University Hospital, Prague, Czech Republic
| | - Marie Hejnová
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
- Department of Rehabilitation, Charles University, 3rd Faculty of Medicine and FNKV University Hospital, Prague, Czech Republic
| | - Kateřina Jiroutková
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
| | - Michal Fric
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
| | - Pavel Jánský
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
| | - Jana Kukulová
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic
| | - Francis Stephens
- College of Life and Environmental Sciences, Sport and Health Sciences, University of Exeter, Exeter, UK
| | - Kamila Řasová
- Department of Rehabilitation, Charles University, 3rd Faculty of Medicine and FNKV University Hospital, Prague, Czech Republic
| | - František Duška
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, 3rd Faculty of Medicine and KAR FNKV University Hospital, Fac Med 3, Srobarova 50, 10034, Prague, Czech Republic.
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Therapist perceptions of a rehabilitation research study in the intensive care unit: a trinational survey assessing barriers and facilitators to implementing the CYCLE pilot randomized clinical trial. Pilot Feasibility Stud 2019; 5:131. [PMID: 31741746 PMCID: PMC6849178 DOI: 10.1186/s40814-019-0509-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/01/2019] [Indexed: 01/02/2023] Open
Abstract
Background Rehabilitation interventions, including novel technologies such as in-bed cycling, could reduce critical illness-associated morbidity. Frontline intensive care unit (ICU) therapists often implement these interventions; however, little is known about their perceptions of engaging in clinical research evaluating these technologies. Objective To understand frontline therapist perceptions of barriers and facilitators to implementing a pilot randomized controlled trial (RCT) of early in-bed cycling with mechanically ventilated patients in the ICU and outcome measures (CYCLE Pilot RCT; NCT02377830). Methods We developed a 115-item, self-administered, electronic survey informed by 2 complementary knowledge translation (KT) models: the Capability-Opportunity-Motivation-Behaviour (COM-B) system and the Theoretical Domains Framework (TDF). We included demographics and 3 sections: Rehabilitation Practice and Research, Cycling, and Physical Outcome Measures. Each section contained items related to the COM-B system and TDF domains. Item formats included 7-point Likert-type scale questions (1 = strongly disagree, 7 = strongly agree) and free-text responses. We invited therapists (physiotherapists, occupational therapists, and therapy assistants) who participated in the international, multi-center, CYCLE Pilot RCT to complete this cross-sectional survey. We descriptively analyzed results by survey section, COM-B attribute, TDF domain, and individual question within and across sections. We identified barriers based on items with median scores < 4/7. Results Our response rate was 85% (45/53). Respondents were from Canada (67%), the USA (21%), and Australia (11%). The majority had a physiotherapy background (87%) and previous research experience (87%). By section, Rehabilitation Practice and Research (85%; 95% confidence interval (CI) [82%, 87%]) was higher than Cycling (77%; 95% CI [73%, 80%]) and Outcome Measures (78%; 95% CI [75%, 82%]). Across the 3 sections, Motivation was lower than Capability and Opportunity. The most common Motivation barrier was the emotion TDF domain, related to the time required to conduct cycling and outcome measures (median [1st, 3rd quartiles] 3/7 [2, 6]). Conclusions Frontline ICU therapists had positive perceptions of research engagement. However, we identified barriers related to Motivation, and concerns regarding time to implement the research protocol. Our results can inform specific KT strategies to engage frontline ICU therapists and optimize protocol implementation in critical care rehabilitation research.
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Differential contractile response of critically ill patients to neuromuscular electrical stimulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:308. [PMID: 31506074 PMCID: PMC6737711 DOI: 10.1186/s13054-019-2540-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/15/2019] [Indexed: 12/22/2022]
Abstract
Background Neuromuscular electrical stimulation (NMES) has been investigated as a preventative measure for intensive care unit-acquired weakness. Trial results remain contradictory and therefore inconclusive. As it has been shown that NMES does not necessarily lead to a contractile response, our aim was to characterise the response of critically ill patients to NMES and investigate potential outcome benefits of an adequate contractile response. Methods This is a sub-analysis of a randomised controlled trial investigating early muscle activating measures together with protocol-based physiotherapy in patients with a SOFA score ≥ 9 within the first 72 h after admission. Included patients received protocol-based physiotherapy twice daily for 20 min and NMES once daily for 20 min, bilaterally on eight muscle groups. Electrical current was increased up to 70 mA or until a contraction was detected visually or on palpation. Muscle strength was measured by a blinded assessor at the first adequate awakening and ICU discharge. Results One thousand eight hundred twenty-four neuromuscular electrical stimulations in 21 patients starting on day 3.0 (2.0/6.0) after ICU admission were included in this sub-analysis. Contractile response decreased from 64.4% on day 1 to 25.0% on day 7 with a significantly lower response rate in the lower extremities and proximal muscle groups. The electrical current required to elicit a contraction did not change over time (day 1, 50.2 [31.3/58.8] mA; day 7, 45.3 [38.0/57.5] mA). The electrical current necessary for a contractile response was higher in the lower extremities. At the first awakening, patients presented with significant weakness (3.2 [2.5/3.8] MRC score). When dividing the cohort into responders and non-responders (> 50% vs. ≤ 50% contractile response), we observed a significantly higher SOFA score in non-responders. The electrical current necessary for a muscle contraction in responders was significantly lower (38.0 [32.8/42.9] vs. 54.7 [51.3/56.0] mA, p < 0.001). Muscle strength showed higher values in the upper extremities of responders at ICU discharge (4.4 [4.1/4.6] vs. 3.3 [2.8/3.8] MRC score, p = 0.036). Conclusion Patients show a differential contractile response to NMES, which appears to be dependent on the severity of illness and also relevant for potential outcome benefits. Trial registration ISRCTN ISRCTN19392591, registered 17 February 2011 Electronic supplementary material The online version of this article (10.1186/s13054-019-2540-4) contains supplementary material, which is available to authorized users.
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Gojda J, Waldauf P, Hrušková N, Blahutová B, Krajčová A, Urban T, Tůma P, Řasová K, Duška F. Lactate production without hypoxia in skeletal muscle during electrical cycling: Crossover study of femoral venous-arterial differences in healthy volunteers. PLoS One 2019; 14:e0200228. [PMID: 30822305 PMCID: PMC6396965 DOI: 10.1371/journal.pone.0200228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/11/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Aim of the study was to compare metabolic response of leg skeletal muscle during functional electrical stimulation-driven unloaded cycling (FES) to that seen during volitional supine cycling. METHODS Fourteen healthy volunteers were exposed in random order to supine cycling, either volitional (10-25-50 W, 10 min) or FES assisted (unloaded, 10 min) in a crossover design. Whole body and leg muscle metabolism were assessed by indirect calorimetry with concomitant repeated measurements of femoral venous-arterial differences of blood gases, glucose, lactate and amino acids. RESULTS Unloaded FES cycling, but not volitional exercise, led to a significant increase in across-leg lactate production (from -1.1±2.1 to 5.5±7.4 mmol/min, p<0.001) and mild elevation of arterial lactate (from 1.8±0.7 to 2.5±0.8 mM). This occurred without widening of across-leg veno-arterial (VA) O2 and CO2 gaps. Femoral SvO2 difference was directly proportional to VA difference of lactate (R2 = 0.60, p = 0.002). Across-leg glucose uptake did not change with either type of exercise. Systemic oxygen consumption increased with FES cycling to similarly to 25W volitional exercise (138±29% resp. 124±23% of baseline). There was a net uptake of branched-chain amino acids and net release of Alanine from skeletal muscle, which were unaltered by either type of exercise. CONCLUSIONS Unloaded FES cycling, but not volitional exercise causes significant lactate production without hypoxia in skeletal muscle. This phenomenon can be significant in vulnerable patients' groups.
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Affiliation(s)
- Jan Gojda
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
- 2 Department of Internal Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
- * E-mail:
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Natália Hrušková
- Department of Rehabilitation, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Barbora Blahutová
- Department of Rehabilitation, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adéla Krajčová
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
- 2 Department of Internal Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomáš Urban
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Tůma
- Department of Hygiene, The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Kamila Řasová
- Department of Rehabilitation, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - František Duška
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Parry SM, Chapple LAS, Mourtzakis M. Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review. Nutr Clin Pract 2018; 33:772-789. [PMID: 30358183 DOI: 10.1002/ncp.10213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital, South Australia, Australia
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Bertazone TMA, Aguiar GCSD, Bueno Júnior CR, Stabile AM. Physical fitness and physical function in survivors of sepsis after hospital discharge. FISIOTERAPIA EM MOVIMENTO 2018. [DOI: 10.1590/1980-5918.031.ao04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: Severe sepsis may be accompanied by long-term sequelae, and physical aspects related to physical fitness and physical function of sepsis survivors after discharge are still poorly explored. Objective: This is an integrative review aimed at analyzing if sepsis survivors present impairment of the physical fitness components and/or physical conditioning and physical function after hospital discharge. Methods: The search was performed in six electronic databases: LILACS, PubMed, CINAHL, Cochrane Library, Web of Science and Scopus. Controlled descriptors (Sepsis, Septic Shock, Physical Fitness and Activities of Daily Living) and uncontrolled descriptors or keywords (Severe Sepsis, Physical Function, and Physical Status) were used. Results: The search resulted in a total of 434 articles, of which seven were eligible for analysis. Of these, none applied a specific physical test to assess the components of physical fitness. Regarding physical function, it was verified that four studies applied specific tests to evaluate the activities of daily living. However, it was observed in most of the studies that the physical aspects were only subjectively assessed through health-related quality of life questionnaires. Overall, all studies analyzed showed that the health-related quality of life of sepsis survivors may be impaired after long periods of hospital discharge. Conclusion: Most sepsis survivors presented impairments related to physical fitness and physical function after hospital discharge, as they showed impairments in their functional autonomy, resulting in loss of independence and autonomy in performing the activities of daily living.
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Medrinal C, Combret Y, Prieur G, Robledo Quesada A, Bonnevie T, Gravier FE, Dupuis Lozeron E, Frenoy E, Contal O, Lamia B. Comparison of exercise intensity during four early rehabilitation techniques in sedated and ventilated patients in ICU: a randomised cross-over trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:110. [PMID: 29703223 PMCID: PMC5923017 DOI: 10.1186/s13054-018-2030-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/06/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND In the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity. Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the highest intensity. The aim of this study was to compare the physiological effects of four common types of bed exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most intensive. METHODS A randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the microcirculation of the vastus lateralis muscle. RESULTS The results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output, with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or systemic effects were induced by the passive techniques. CONCLUSION Most bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies of the effect of FES cycling on functional outcomes should be carried out. TRIAL REGISTRATION ClinicalTrials.gov, NCT02920684 . Registered on 30 September 2016. Prospectively registered.
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Affiliation(s)
- Clément Medrinal
- Normandie Univ, UNIROUEN, UPRES EA3830 - GRHV, Institute for Research and Innovation in Biomedicine (IRIB), 76000, Rouen, France. .,Intensive Care Unit Department, Groupe Hospitalier du Havre, Hôpital Jacques Monod, Pierre Mendes France, 76290, Montivilliers, France.
| | - Yann Combret
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, Université Catholique de Louvain, 1200, Brussels, Belgium.,Physiotherapy Department, Groupe Hospitalier du Havre, avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Guillaume Prieur
- Intensive Care Unit Department, Groupe Hospitalier du Havre, Hôpital Jacques Monod, Pierre Mendes France, 76290, Montivilliers, France
| | - Aurora Robledo Quesada
- Intensive Care Unit Department, Groupe Hospitalier du Havre, Hôpital Jacques Monod, Pierre Mendes France, 76290, Montivilliers, France
| | - Tristan Bonnevie
- Normandie Univ, UNIROUEN, EA3830 - GRHV, 76000, Rouen, France.,Institute for Research and Innovation in Biomedicine (IRIB), 76000, Rouen, France.,ADIR Association, Bois Guillaume, France
| | | | - Elise Dupuis Lozeron
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Eric Frenoy
- Intensive Care Unit Department Department, Groupe Hospitalier du Havre, Hôpital Jacques Monod, 76290, Montivilliers, France
| | - Olivier Contal
- University of Applied Sciences and Arts Western Switzerland (HES-SO), avenue de Beaumont, 1011, Lausanne, Switzerland
| | - Bouchra Lamia
- Normandie Univ, UNIROUEN, EA3830 - GRHV, 76000, Rouen, France.,Institute for Research and Innovation in Biomedicine (IRIB), 76000, Rouen, France.,Intensive Care Unit, Respiratory Department, Rouen University Hospital, Rouen, France.,Pulmonology Department, Groupe Hospitalier du Havre, avenue Pierre Mendes France, 76290, Montivilliers, France
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Sachetti A, Carpes MF, Dias AS, Sbruzzi G. Safety of neuromuscular electrical stimulation among critically ill patients: systematic review. Rev Bras Ter Intensiva 2018; 30:219-225. [PMID: 29995088 PMCID: PMC6031422 DOI: 10.5935/0103-507x.20180036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 02/05/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To review the evidence on the safety of neuromuscular electrical stimulation when used in the intensive care unit. METHODS A systematic review was conducted; a literature search was performed of the MEDLINE (via PubMed), PEDro, Cochrane CENTRAL and EMBASE databases, and a further manual search was performed among the references cited in randomized studies. Randomized clinical trials that compared neuromuscular electrical stimulation to a control or placebo group in the intensive care unit and reporting on the technique safety in the outcomes were included. Hemodynamic variables and information on adverse effects were considered safety parameters. Articles were independently analyzed by two reviewers, and the data analysis was descriptive. RESULTS The initial search located 1,533 articles, from which only four randomized clinical trials were included. Two studies assessed safety based on hemodynamic variables, and only one study reported an increase in heart rate, respiratory rate and blood lactate, without clinical relevance. The other two studies assessed safety based on reported adverse effects. In one, 15% of patients described a prickling sensation, without any clinically relevant abnormalities. In the other, one patient suffered a superficial burn due to improper parameter configuration. CONCLUSION Neuromuscular electrical stimulation is safe for critically ill patients; however, it should be applied by duly trained professionals and with proper evidence-based parameters.
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Affiliation(s)
- Amanda Sachetti
- Curso de Medicina, Escola de Saúde, IMED - Passo Fundo (RS),
Brasil
| | | | - Alexandre Simões Dias
- Hospital de Clínicas de Porto Alegre, Universidade Federal
do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Graciele Sbruzzi
- Hospital de Clínicas de Porto Alegre, Universidade Federal
do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Nussbaum EL, Houghton P, Anthony J, Rennie S, Shay BL, Hoens AM. Neuromuscular Electrical Stimulation for Treatment of Muscle Impairment: Critical Review and Recommendations for Clinical Practice. Physiother Can 2017; 69:1-76. [PMID: 29162949 PMCID: PMC5683854 DOI: 10.3138/ptc.2015-88] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose: In response to requests from physiotherapists for guidance on optimal stimulation of muscle using neuromuscular electrical stimulation (NMES), a review, synthesis, and extraction of key data from the literature was undertaken by six Canadian physical therapy (PT) educators, clinicians, and researchers in the field of electrophysical agents. The objective was to identify commonly treated conditions for which there was a substantial body of literature from which to draw conclusions regarding the effectiveness of NMES. Included studies had to apply NMES with visible and tetanic muscle contractions. Method: Four electronic databases (CINAHL, Embase, PUBMED, and SCOPUS) were searched for relevant literature published between database inceptions until May 2015. Additional articles were identified from bibliographies of the systematic reviews and from personal collections. Results: The extracted data were synthesized using a consensus process among the authors to provide recommendations for optimal stimulation parameters and application techniques to address muscle impairments associated with the following conditions: stroke (upper or lower extremity; both acute and chronic), anterior cruciate ligament reconstruction, patellofemoral pain syndrome, knee osteoarthritis, and total knee arthroplasty as well as critical illness and advanced disease states. Summaries of key details from each study incorporated into the review were also developed. The final sections of the article outline the recommended terminology for describing practice using electrical currents and provide tips for safe and effective clinical practice using NMES. Conclusion: This article provides physiotherapists with a resource to enable evidence-informed, effective use of NMES for PT practice.
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Affiliation(s)
- Ethne L. Nussbaum
- Department of Physical Therapy, University of Toronto
- Toronto Rehab, University Health Network, Toronto, Ontario
| | - Pamela Houghton
- School of Physical Therapy, University of Western Ontario, London
| | - Joseph Anthony
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Sandy Rennie
- Department of Physical Therapy, University of Toronto
- School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia
| | - Barbara L. Shay
- Department of Physical Therapy, University of Manitoba, Winnipeg, Manitoba
| | - Alison M. Hoens
- School of Physical Therapy, University of Western Ontario, London
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Nickels MR, Aitken LM, Walsham J, Barnett AG, McPhail SM. Critical Care Cycling Study (CYCLIST) trial protocol: a randomised controlled trial of usual care plus additional in-bed cycling sessions versus usual care in the critically ill. BMJ Open 2017; 7:e017393. [PMID: 29061618 PMCID: PMC5665265 DOI: 10.1136/bmjopen-2017-017393] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION In-bed cycling with patients with critical illness has been shown to be safe and feasible, and improves physical function outcomes at hospital discharge. The effects of early in-bed cycling on reducing the rate of skeletal muscle atrophy, and associations with physical and cognitive function are unknown. METHODS AND ANALYSIS A single-centre randomised controlled trial in a mixed medical-surgical intensive care unit (ICU) will be conducted. Adult patients (n=68) who are expected to be mechanically ventilated for more than 48 hours and remain in ICU for a further 48 hours from recruitment will be randomly allocated into either (1) a usual care group or (2) a group that receives usual care and additional in-bed cycling sessions. The primary outcome is change in rectus femoris cross-sectional area at day 10 in comparison to baseline measured by blinded assessors. Secondary outcome measures include muscle strength, incidence of ICU-acquired weakness, handgrip strength, time to achieve functional milestones (sitting out of bed, walking), Functional Status Score in ICU, ICU Mobility Scale, 6 min walk test 1 week post-ICU discharge, incidence of delirium and quality of life (EuroQol Five Dimensions questionnaire Five Levels scale). Quality of life assessments will be conducted post-ICU admission at day 10, 3 and 6 months after acute hospital discharge. Participants in the intervention group will complete an acceptability of intervention questionnaire. ETHICS AND DISSEMINATION Appropriate ethical approval from Metro South Health Human Research Ethics Committee has been attained. Results will be published in peer-reviewed publications and presented at scientific conferences to assist planning of future multicentre randomised controlled trials (if indicated) that will test in-bed cycling as an intervention to improve the physical, cognitive and health-related quality of life outcomes of patients with critical illness. TRIAL REGISTRATION NUMBER This trial has been prospectively registered on the Australian and New Zealand Clinical Trial Registry (ACTRN12616000948493); Pre-results.
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Affiliation(s)
- Marc R Nickels
- Department of Physiotherapy, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, London, UK
- National Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
| | - James Walsham
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Functioning and Health Research, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
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Muscle mass and physical recovery in ICU: innovations for targeting of nutrition and exercise. Curr Opin Crit Care 2017; 23:269-278. [PMID: 28661414 DOI: 10.1097/mcc.0000000000000431] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW We have significantly improved hospital mortality from sepsis and critical illness in last 10 years; however, over this same period we have tripled the number of 'ICU survivors' going to rehabilitation. Furthermore, as up to half the deaths in the first year following ICU admission occur post-ICU discharge, it is unclear how many of these patients ever returned home or a meaningful quality of life. For those who do survive, recent data reveals many 'ICU survivors' will suffer significant functional impairment or post-ICU syndrome (PICS). Thus, new innovative metabolic and exercise interventions to address PICS are urgently needed. These should focus on optimal nutrition and lean body mass (LBM) assessment, targeted nutrition delivery, anabolic/anticatabolic strategies, and utilization of personalized exercise intervention techniques, such as utilized by elite athletes to optimize preparation and recovery from critical care. RECENT FINDINGS New data for novel LBM analysis technique such as computerized tomography scan and ultrasound analysis of LBM are available showing objective measures of LBM now becoming more practical for predicting metabolic reserve and effectiveness of nutrition/exercise interventions. 13C-Breath testing is a novel technique under study to predict infection earlier and predict over-feeding and under-feeding to target nutrition delivery. New technologies utilized routinely by athletes such as muscle glycogen ultrasound also show promise. Finally, the role of personalized cardiopulmonary exercise testing to target preoperative exercise optimization and post-ICU recovery are becoming reality. SUMMARY New innovative techniques are demonstrating promise to target recovery from PICS utilizing a combination of objective LBM and metabolic assessment, targeted nutrition interventions, personalized exercise interventions for prehabilitation and post-ICU recovery. These interventions should provide hope that we will soon begin to create more 'survivors' and fewer victim's post-ICU care.
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Functional Status Score for the ICU: An International Clinimetric Analysis of Validity, Responsiveness, and Minimal Important Difference. Crit Care Med 2017; 44:e1155-e1164. [PMID: 27488220 DOI: 10.1097/ccm.0000000000001949] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To evaluate the internal consistency, validity, responsiveness, and minimal important difference of the Functional Status Score for the ICU, a physical function measure designed for the ICU. DESIGN Clinimetric analysis. SETTINGS Five international datasets from the United States, Australia, and Brazil. PATIENTS Eight hundred nineteen ICU patients. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Clinimetric analyses were initially conducted separately for each data source and time point to examine generalizability of findings, with pooled analyses performed thereafter to increase power of analyses. The Functional Status Score for the ICU demonstrated good to excellent internal consistency. There was good convergent and discriminant validity, with significant and positive correlations (r = 0.30-0.95) between Functional Status Score for the ICU and other physical function measures, and generally weaker correlations with nonphysical measures (|r| = 0.01-0.70). Known group validity was demonstrated by significantly higher Functional Status Score for the ICU scores among patients without ICU-acquired weakness (Medical Research Council sum score, ≥ 48 vs < 48) and with hospital discharge to home (vs healthcare facility). Functional Status Score for the ICU at ICU discharge predicted post-ICU hospital length of stay and discharge location. Responsiveness was supported via increased Functional Status Score for the ICU scores with improvements in muscle strength. Distribution-based methods indicated a minimal important difference of 2.0-5.0. CONCLUSIONS The Functional Status Score for the ICU has good internal consistency and is a valid and responsive measure of physical function for ICU patients. The estimated minimal important difference can be used in sample size calculations and in interpreting studies comparing the physical function of groups of ICU patients.
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Galea MP, Panisset MG, El-Ansary D, Dunlop SA, Marshall R, Clark JM, Churilov L, Hurley M, Nunn A, Alexander J, Buchanan J, Nolan S, Atresh S, Pick V, Acland R, Nunnerley J. SCIPA Switch-On: A Randomized Controlled Trial Investigating the Efficacy and Safety of Functional Electrical Stimulation–Assisted Cycling and Passive Cycling Initiated Early After Traumatic Spinal Cord Injury. Neurorehabil Neural Repair 2017; 31:540-551. [DOI: 10.1177/1545968317697035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background. Substantial skeletal muscle atrophy after spinal cord injury (SCI) carries significant repercussions for functional recovery and longer-term health. Objective. To compare the efficacy, safety, and feasibility of functional electrical stimulation–assisted cycling (FESC) and passive cycling (PC) to attenuate muscle atrophy after acute SCI. Methods. This multicenter, assessor-blinded phase I/II trial randomized participants at 4 weeks post-SCI to FESC or PC (4 sessions per week, 1 hour maximum per session, over 12 weeks). The primary outcome measure was mean maximum cross-sectional area (CSA) of thigh and calf muscles (magnetic resonance imaging), and secondary outcome measures comprised body composition (dual energy X-ray absorptiometry), anthropometry, quality of life, and adverse events (AEs). Results. Of 24 participants, 19 completed the 12-week trial (10 FESC, 9 PC, 18 male). Those participants completed >80% of training sessions (FESC, 83.5%; PC, 85.9%). No significant between-group difference in postintervention muscle CSA was found. No significant between-group difference was found for any other tissue, anthropometric parameter, or behavioral variable or AEs. Six participants experienced thigh hypertrophy (FESC = 3; PC = 3). Atrophy was attenuated (<30%) in 15 cases (FESC = 7; PC = 8). Conclusions. Both cycle ergometry regimens examined were safe, feasible, and well tolerated early after SCI. No conclusions regarding efficacy can be drawn from our data. Further investigation of both modalities early after SCI is required.
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Affiliation(s)
- Mary P. Galea
- The University of Melbourne, Parkville, VIC, Australia
| | | | - Doa El-Ansary
- The University of Melbourne, Parkville, VIC, Australia
| | - Sarah A. Dunlop
- The University of Western Australia, Crawley, Western Australia, Australia
| | - Ruth Marshall
- Hampstead Rehabilitation Centre, Northfield, South Australia, Australia
| | - Jillian M. Clark
- Hampstead Rehabilitation Centre, Northfield, South Australia, Australia
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Puthucheary ZA, Wischmeyer P. Predicting critical illness mortality and personalizing therapy: moving to multi-dimensional data. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:20. [PMID: 28132646 PMCID: PMC5278572 DOI: 10.1186/s13054-016-1597-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- Zudin A Puthucheary
- Institute of Sports and Exercise Health, University College London Hospitals, 1st Floor, 170 Tottenham Court Road, London, W1T 7HA, UK. .,Division of Critical Care, University College London Hospitals, London, UK.
| | - Paul Wischmeyer
- Department of Anesthesiology, Duke University of Medicine, Durham, USA.,Duke Clinical Research Institute, Duke University of Medicine, Durham, USA
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Evidence based expert consensus for early rehabilitation in the intensive care unit. ACTA ACUST UNITED AC 2017. [DOI: 10.3918/jsicm.24_255] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, Murphy C, Camposilvan L, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Zanni JM, Mourtzakis M, Piraino T, Cook DJ. TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients. PLoS One 2016; 11:e0167561. [PMID: 28030555 PMCID: PMC5193383 DOI: 10.1371/journal.pone.0167561] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022] Open
Abstract
Introduction The objective of this study was to assess the safety and feasibility of in-bed cycling started within the first 4 days of mechanical ventilation (MV) to inform a future randomized clinical trial. Methods We conducted a 33-patient prospective cohort study in a 21-bed adult academic medical-surgical intensive care unit (ICU) in Hamilton, ON, Canada. We included adult patients (≥ 18 years) receiving MV who walked independently pre-ICU. Our intervention was 30 minutes of in-bed supine cycling 6 days/week in the ICU. Our primary outcome was Safety (termination), measured as events prompting cycling termination; secondary Safety (disconnection or dislodgement) outcomes included catheter/tube dislodgements. Feasibility was measured as consent rate and fidelity to intervention. For our primary outcome, we calculated the binary proportion and 95% confidence interval (CI). Results From 10/2013-8/2014, we obtained consent from 34 of 37 patients approached (91.9%), 33 of whom received in-bed cycling. Of those who cycled, 16(48.4%) were female, the mean (SD) age was 65.8(12.2) years, and APACHE II score was 24.3(6.7); 29(87.9%) had medical admitting diagnoses. Cycling termination was infrequent (2.0%, 95% CI: 0.8%-4.9%) and no device dislodgements occurred. Cycling began a median [IQR] of 3 [2, 4] days after ICU admission; patients received 5 [3, 8] cycling sessions with a median duration of 30.7 [21.6, 30.8] minutes per session. During 205 total cycling sessions, patients were receiving invasive MV (150 [73.1%]), vasopressors (6 [2.9%]), sedative or analgesic infusions (77 [37.6%]) and dialysis (4 [2.0%]). Conclusions Early cycling within the first 4 days of MV among hemodynamically stable patients is safe and feasible. Research to evaluate the effect of early cycling on patient function is warranted. Trial Registration Clinicaltrials.gov: NCT01885442
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Affiliation(s)
- Michelle E. Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- * E-mail:
| | - Alexander J. Molloy
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - France J. Clarke
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daana Ajami
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Magda McCaughan
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Kristy Obrovac
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Christina Murphy
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Laura Camposilvan
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Margaret S. Herridge
- Department of Medicine, University of Toronto, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen K. Y. Koo
- Swedish Early Mobility Program in Critical Care, First Hill Campus, Swedish Medical Group, Seattle, Washington
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jill Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J. E. Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer M. Zanni
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Thomas Piraino
- Respiratory Therapy Service, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Deborah J. Cook
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Ferreira NA, Lopes AJ, Ferreira AS, Ntoumenopoulos G, Dias J, Guimaraes FS. Determination of functional prognosis in hospitalized patients following an intensive care admission. World J Crit Care Med 2016; 5:219-227. [PMID: 27896146 PMCID: PMC5109025 DOI: 10.5492/wjccm.v5.i4.219] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/01/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
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 ΔKATZICU. 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 ΔKATZWARD. For ΔKATZTOT the variables KATZ on ICU admission (AUC = 0.621) and TLS (AUC = 0.617) were discriminative. For ΔMRCICU 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 ΔMRCWARD. TLS (AUC = 0.649) and MRC on ward admission (AUC = 0.696) discriminative for the ΔMRCTOT.
CONCLUSION Specific functional, clinical and demographical variables at ICU admission are associated with the functional prognosis during the hospitalization period.
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Silva PE, Babault N, Mazullo JB, de Oliveira TP, Lemos BL, Carvalho VO, Durigan JLQ. Safety and feasibility of a neuromuscular electrical stimulation chronaxie-based protocol in critical ill patients: A prospective observational study. J Crit Care 2016; 37:141-148. [PMID: 27732921 DOI: 10.1016/j.jcrc.2016.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 08/23/2016] [Accepted: 09/14/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the safety and feasibility of a neuromuscular electrical stimulation (NMES) protocol based on neuromuscular excitability and applied in numerous muscle groups of critical ill patients. MATERIALS AND METHODS We performed a prospective observational study using an NMES applied daily and bilaterally into 5 muscle groups in lower limbs for 3 consecutive days. The characteristics of NMES were 90 contractions per muscle, pulse width equal to chronaxie, and a pulse frequency of 100 Hz. We assessed safety with central venous oxygen saturation, serum lactate, and creatine phosphokinase measurements. To evaluate feasibility, we recorded the time spent for the entire NMES protocol and the number of NMES sessions completed. RESULTS Eleven male patients finished the study. There were no significant changes observed in creatine phosphokinase from baseline up to 96 hours: 470(±270) IU/L and 455(±240) IU/L (P>.99). Central venous oxygen saturation and serum lactate had the same pattern with no significant variations (P=.23 and P=.8, respectively). The time spent during the whole procedure and the number of complete NMES sessions performed were 107±24 minutes and 84 sessions (85%), respectively. CONCLUSIONS We demonstrated that NMES chronaxie-based protocol is safe and feasible.
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Affiliation(s)
- Paulo Eugênio Silva
- Physical Therapy Division, University Hospital of Brasília, University of Brasília, Brasília, Federal District, Brazil; Health Sciences and Technologies PhD Program, University of Brasilia, Federal District, Brazil.
| | - Nicolas Babault
- Centre d'Expertise de la Performance G. Cometti, UFR STAPS, Université de Bourgogne-Franche-Comté, Dijon, France
| | | | | | | | - Vitor Oliveira Carvalho
- Physical Therapy Division, Federal University of Sergipe, The GrEAt Group (Grupo de Estudos de Atividade Fisica), Sergipe, Brazil
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Hashem MD, Parker AM, Needham DM. Early Mobilization and Rehabilitation of Patients Who Are Critically Ill. Chest 2016; 150:722-31. [PMID: 26997241 PMCID: PMC6026260 DOI: 10.1016/j.chest.2016.03.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/28/2016] [Accepted: 03/01/2016] [Indexed: 11/17/2022] Open
Abstract
Neuromuscular disorders are increasingly recognized as a cause of both short- and long-term physical morbidity in survivors of critical illness. This recognition has given rise to research aimed at better understanding the risk factors and mechanisms associated with neuromuscular dysfunction and physical impairment associated with critical illness, as well as possible interventions to prevent or treat these issues. Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of patients who are critically ill may help prevent or mitigate the sequelae of bed rest and improve patient outcomes. Research studies and quality improvement projects have demonstrated that early mobilization and rehabilitation are safe and feasible in patients who are critically ill, with potential benefits including improved physical functioning and decreased duration of mechanical ventilation, intensive care, and hospital stay. Despite these findings, early mobilization and rehabilitation are still uncommon in routine clinical practice, with many perceived barriers. This review summarizes potential risk factors for neuromuscular dysfunction and physical impairment associated with critical illness, highlights the potential role of early mobilization and rehabilitation in improving patient outcomes, and discusses some of the commonly perceived barriers to early mobilization and strategies for overcoming them.
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Affiliation(s)
- Mohamed D Hashem
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Ann M Parker
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD.
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Ten reasons why ICU patients should be mobilized early. Intensive Care Med 2016; 43:86-90. [PMID: 27562244 DOI: 10.1007/s00134-016-4513-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
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Kho ME, Molloy AJ, Clarke F, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Pellizzari JR, Tarride JE, Mourtzakis M, Karachi T, Cook DJ. CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients. BMJ Open 2016; 6:e011659. [PMID: 27059469 PMCID: PMC4838736 DOI: 10.1136/bmjopen-2016-011659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Early exercise with in-bed cycling as part of an intensive care unit (ICU) rehabilitation programme has the potential to improve physical and functional outcomes following critical illness. The objective of this study is to determine the feasibility of enrolling adults in a multicentre pilot randomised clinical trial (RCT) of early in-bed cycling versus routine physiotherapy to inform a larger RCT. METHODS AND ANALYSIS 60-patient parallel group pilot RCT in 7 Canadian medical-surgical ICUs. We will include all previously ambulatory adult patients within the first 0-4 days of mechanical ventilation, without exclusion criteria. After informed consent, patients will be randomised using a web-based, centralised electronic system, to 30 min of in-bed leg cycling in addition to routine physiotherapy, 5 days per week, for the duration of their ICU stay (28 days maximum) or routine physiotherapy alone. We will measure patients' muscle strength (Medical Research Council Sum Score, quadriceps force) and function (Physical Function in ICU Test (scored), 30 s sit-to-stand, 2 min walk test) at ICU awakening, ICU discharge and hospital discharge. Our 4 feasibility outcomes are: (1) patient accrual of 1-2 patients per month per centre, (2) protocol violation rate <20%, (3) outcome measure ascertainment >80% at the 3 time points and (4) blinded outcomes ascertainment >80% at hospital discharge. Hospital outcome assessors are blinded to group assignment, whereas participants, ICU physiotherapists, ICU caregivers, research coordinators and ICU outcome assessors are not blinded to group assignment. We will analyse feasibility outcomes with descriptive statistics. ETHICS AND DISSEMINATION Each participating centre will obtain local ethics approval, and results of the study will be published to inform the design and conduct of a future multicentre RCT of in-bed cycling to improve physical outcomes in ICU survivors. TRIAL REGISTRATION NUMBER NCT02377830; Pre-results.
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Affiliation(s)
- Michelle E Kho
- McMaster University, School of Rehabilitation Science, Hamilton, Ontario, Canada
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander J Molloy
- Department of Physiotherapy, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - France Clarke
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- Department of Medicine, University of Toronto, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen K Y Koo
- Swedish Early Mobility Program in Critical Care, Swedish Medical Group, First Hill Campus, Seattle, Washington, USA
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jill Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Timothy Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Fischer A, Spiegl M, Altmann K, Winkler A, Salamon A, Themessl-Huber M, Mouhieddine M, Strasser EM, Schiferer A, Paternostro-Sluga T, Hiesmayr M. Muscle mass, strength and functional outcomes in critically ill patients after cardiothoracic surgery: does neuromuscular electrical stimulation help? The Catastim 2 randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:30. [PMID: 26825278 PMCID: PMC4733279 DOI: 10.1186/s13054-016-1199-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 01/18/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effects of neuromuscular electrical stimulation (NMES) in critically ill patients after cardiothoracic surgery are unknown. The objectives were to investigate whether NMES prevents loss of muscle layer thickness (MLT) and strength and to observe the time variation of MLT and strength from preoperative day to hospital discharge. METHODS In this randomized controlled trial, 54 critically ill patients were randomized into four strata based on the SAPS II score. Patients were blinded to the intervention. In the intervention group, quadriceps muscles were electrically stimulated bilaterally from the first postoperative day until ICU discharge for a maximum of 14 days. In the control group, the electrodes were applied, but no electricity was delivered. The primary outcomes were MLT measured by ultrasonography and muscle strength evaluated with the Medical Research Council (MRC) scale. The secondary functional outcomes were average mobility level, FIM score, Timed Up and Go Test and SF-12 health survey. Additional variables of interest were grip strength and the relation between fluid balance and MLT. Linear mixed models were used to assess the effect of NMES on MLT, MRC score and grip strength. RESULTS NMES had no significant effect on MLT. Patients in the NMES group regained muscle strength 4.5 times faster than patients in the control group. During the first three postoperative days, there was a positive correlation between change in MLT and cumulative fluid balance (r = 0.43, P = 0.01). At hospital discharge, all patients regained preoperative levels of muscle strength, but not of MLT. Patients did not regain their preoperative levels of average mobility (P = 0.04) and FIM score (P = 0.02) at hospital discharge, independent of group allocation. CONCLUSIONS NMES had no effect on MLT, but was associated with a higher rate in regaining muscle strength during the ICU stay. Regression of intramuscular edema during the ICU stay interfered with measurement of changes in MLT. At hospital discharge patients had regained preoperative levels of muscle strength, but still showed residual functional disability and decreased MLT compared to pre-ICU levels in both groups. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT02391103. Registered on 7 March 2015.
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Affiliation(s)
- Arabella Fischer
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.
| | - Matthias Spiegl
- Kantonsspital Sankt Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
| | - Klaus Altmann
- Krankenhaus der Barmherzigen Schwestern Ried, Schlossberg 1, 4910, Ried im Innkreis, Austria.
| | - Andreas Winkler
- University Hospital Landeskrankenhaus Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
| | - Anna Salamon
- Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Michael Themessl-Huber
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Mohamed Mouhieddine
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.
| | - Eva Maria Strasser
- Institute for Physical Medicine and Rehabilitation, Kaiser-Franz-Josef-Spital Wien, Kundratstrasse 3, 1100, Vienna, Austria.
| | - Arno Schiferer
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.
| | - Tatjana Paternostro-Sluga
- Institute for Physical Medicine and Rehabilitation, Donauspital Wien, Langobardenstraße 122, 1220, Vienna, Austria.
| | - Michael Hiesmayr
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.
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Ambrosino N, Casaburi R, Chetta A, Clini E, Donner CF, Dreher M, Goldstein R, Jubran A, Nici L, Owen CA, Rochester C, Tobin MJ, Vagheggini G, Vitacca M, ZuWallack R. 8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – part 2. Multidiscip Respir Med 2015. [PMCID: PMC4594967 DOI: 10.1186/s40248-015-0027-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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