Measurement of physical activity levels in the Intensive Care Unit and functional outcomes: An observational study

Daily variation in physical activity during mechanical ventilation and stay in the intensive care unit

BACKGROUND

Early mobilisation of mechanically ventilated patients during their stay at an intensive care unit (ICU) can improve physical recovery. Yet, an objective and specified description of physical activities while in the ICU is lacking. Therefore, our aim was to describe the objectively assessed type, quantity, and daily variation of physical activity among mechanically ventilated patients while in the ICU.

METHOD

In an observational study in two mixed medical/surgical ICUs, we measured body posture in 39 patients on mechanical ventilation using a thigh- and chest-worn accelerometer while in the ICU. The accelerometer describes time spent lying, sitting, moving, in-bed cycling, standing and walking. Descriptive analysis of physical activity and daily variation was done using STATA.

RESULTS

We found that mechanically ventilated patients spend 20/24 h lying in bed, 3 h sitting and only 1 h standing, moving, walking or bicycling while in the ICU. Intervals of non-lying time appeared from 9.00 to 12.00 and again from 18.00 to 21.30, with peaks at the hours of 9.00 and 18.00.

CONCLUSION

ICU patients on mechanical ventilation were primarily sedentary. Physical activity of mechanically ventilated patients seems to be related to nurse- and/or physiotherapy-initiated activities. There is a need to create an awareness of improving clinical routines, towards active mobilisation throughout the day, for this vulnerable patient population during their stay in the ICU.

Nutrition therapy in the intensive care unit during the COVID-19 pandemic: Findings from the ISIIC point prevalence study

BACKGROUND & AIMS

Nutrition therapy for Intensive Care Unit (ICU) patients involves complex decision-making, especially during the COVID-19 pandemic. We investigated the use of nutrition therapy in ICU patients with and without COVID-19 infections.

METHODS

Nutrition therapy was evaluated during a world-wide one-day prevalence study focused on implementation of the ABCDEF bundle (A: regular pain assessment, B: both spontaneous awakening and breathing trials, C: regular sedation assessment, D: regular delirium assessment, E: early mobility and exercise, and F: family engagement and empowerment) during the COVID-19 pandemic. Basic ICU and patient demographics including nutrition therapy delivery were collected on the survey day. Physical activity for patients with and without COVID infections was categorized using the ICU mobility scale (IMS). Multivariable regression analysis of nutrition was conducted using ICU parameters.

RESULTS

The survey included 627 non-COVID and 602 COVID patients. A higher proportion of COVID-19 patients received energy ≥20 kcal/kg/day (55% vs. 45%; p = 0.0007) and protein ≥1.2 g/kg/day (45% vs. 35%; p = 0.0011) compared to non-COVID patients. Enteral nutrition was provided to most COVID patients even with prone positioning (91%). Despite nutrition therapy, IMS was extremely low in both groups; median IMS was 1 in non-COVID patients and 0 in COVID patients. The rate of energy delivery ≥20 kcal/kg/day was significantly higher in patients with COVID-19 infections in the subgroup of ICU days ≤5 days and IMS ≤2. Having a dedicated ICU nutritionist/dietitian was significantly associated with appropriate energy delivery in patients both with and without COVID-19 infections, but not with protein delivery.

CONCLUSION

During the COVID-19 pandemic, patients with COVID-19 infections received higher energy and protein delivery. Generally low mobility levels highlight the need to optimize early mobilization with nutrition therapy in all ICU patients.

Attenuating Muscle Mass Loss in Critical Illness: the Role of Nutrition and Exercise

PURPOSE OF REVIEW

Impaired recovery following an intensive care unit (ICU) admission is thought related to muscle wasting. Nutrition and physical activity are considered potential avenues to attenuate muscle wasting. The aim of this review was to present evidence for these interventions in attenuating muscle loss or improving strength and function.

RECENT FINDINGS

Randomised controlled trials on the impact of nutrition or physical activity interventions in critically ill adult patients on muscle mass, strength or function are presented. No nutrition intervention has shown an effect on strength or function, and the effect on muscle mass is conflicting. RCTs on the effect of physical activity demonstrate conflicting results; yet, there is a signal for improved strength and function with higher levels of physical activity, particularly when commenced early. Further research is needed to elucidate the impact of nutrition and physical activity on muscle mass, strength and function, particularly in combination.

Physiotherapeutic approach and profile of patients treated in the emergency room surgical unit of a tertiary care hospital in the Federal District

Abstract Introduction The emergency room (ER) is the main entry door for the care of critically ill patients. The inclusion of physiotherapists in these sectors is being consolidated in Brazil. Objective To characterize the physiotherapeutic approach and the clinical-functional profile of patients in the ER surgical unit of a tertiary hospital. Methods This was a retrospective cross-sectional study conducted from August to December of 2020. Clinical and functional data, and the main physiotherapeutic procedures performed, were collected. Analyses were conducted by means of the Friedman and Pearson Correlation tests, using SPSS software v.23. Results The sample included 98 patients, 68% male, mean age of 52 ± 19 years. The most common (64%) physiotherapeutic diagnosis was central nervous system (CNS) deficiency with mechanical ventilation (MV) dependence. The mean time of MV use was 4 ± 5 days. Association (p < 0.05) between MV time and admission in the emergency department (r = 0.972) and between MV time and age (r = 0.330) was identified. The most used physiotherapeutic actions were: suction (69%), lung re-expansion therapy (51%), and bed kinesiotherapy (37%). Conclusion Adult men with CNS-related disabilities were the principal patient profile. The physiotherapeutic action in the surgical emergency unit was diverse, with application of motor and respiratory techniques, and the predominant activity was the management and maintenance of MV.

Abordagem fisioterapêutica e perfil dos pacientes assistidos na unidade cirúrgica do pronto-socorro de um hospital terciário do Distrito Federal

Resumo Introdução O pronto-socorro (PS) tornou-se a principal porta para o início da assistência a pacientes graves. A inserção do fisioterapeuta nesses setores está em processo de consolidação no Brasil. Objetivo Carac-terizar a abordagem fisioterapêutica e o perfil clínico-funcional dos pacientes na unidade cirúrgica PS de um hospital terciário. Métodos Trata-se de um estudo transversal retrospectivo realizado no período de agosto a dezembro de 2020. Coletaram-se dados clínicos, funcionais e as principais condutas fisioterapêuticas utilizadas. As análises foram conduzidas por meio dos testes de Friedman e Correlação de Pearson, utilizando o software Statistical Package for the Social Sciences v.23. Resultados Ao todo, a amostra foi de 98 pacientes, dos quais 68% eram homens, com idade média de 52 ± 19 anos. O principal (64%) diagnóstico fisioterapêutico foi deficiência do sistema nervoso central (SNC) com dependência de ventilação mecânica (VM). O tempo médio de uso de VM foi de 4 ± 5 dias. Houve associação (p < 0,05) entre tempo de VM e internação no PS (r = 0,972) e entre tempo de VM e idade (r = 0,330). As condutas fisioterapêuticas mais utilizadas foram a aspiração (69%), terapia de reexpansão pulmonar (51%) e cinesioterapia no leito (37%). Conclusão Os homens em faixa etária adulta e com deficiências relacionadas ao SNC constituíram o principal perfil dos usuários. A atuação fisioterapêutica na unidade de emergência cirúrgica foi ampla, com emprego de técnicas motoras e respiratórias, das quais a atuação predominante ocorreu no manejo e condução da VM.

Care and treatments related to intensive care unit-acquired muscle weakness: A cohort study

BACKGROUND

Intensive care unit-acquired muscle weakness (ICUAW) has an incidence of 40-46%. Early mobilisation is known to be a protective factor.

OBJECTIVE

The aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW.

METHODS

A 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse-patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3-5 of the ICU stay.

RESULTS

The data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53-62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00-1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00-1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38-0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95-0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97-0.99]), presence of delirium (OR = 0.98; 95% CI [0.97-0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97-0.99]).

CONCLUSIONS

The risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.

Evaluating a Muscle Ultrasound Education Program: Theoretical Knowledge, Hands-on Skills, Reliability, and Satisfaction of Critical Care Physiotherapists

OBJECTIVE

To evaluate learning results of critical care physiotherapists participating in a muscle ultrasound (MUS) educational program.

DESIGN

Cross-sectional study.

SETTING

A custom-made 20-hour MUS course was performed over a 2-week time period, including knobs familiarization, patient positioning, anatomic landmarks, image acquisition, and limb muscle measurements.

PARTICIPANTS

Nineteen critical care physiotherapists with little to no prior experience in ultrasound (N=19).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Theoretical knowledge, hands-on skills acquisition, and satisfaction were assessed. Inter- and intrarater reliability on landmarks, thickness, and pennation angle of quadriceps between participants was evaluated using intraclass correlation coefficients (ICCs). Reliability among instructors measured prior to the course was also reported as a reference.

RESULTS

The percentage score (mean±SD) of knowledge questionnaires was 69±11 (pre-course), 89±10 (post-course), and 92±9 (hands-on skills). Course satisfaction scores ranged from 90%-100%. Pooled interrater reliability of participants (median ICC [interquartile range]) was good (0.70 [0.59-0.79]) for thickness, moderate (0.47 [0.46-0.92]) for landmarks, and absent (0.00 [0.00-0.05]) for pennation angle and the intrarater reliability was good (0.76 [0.51-0.91]) for thickness and weak (0.35 [0.29-0.52]) for pennation angle. Interrater ICC values for instructors were excellent (0.90) for thickness, good (0.67) for landmarks, and moderate (0.41) for pennation angle and intrarater ICC values were excellent (0.94) for thickness and good (0.75) for pennation angle.

CONCLUSIONS

Although our sample was quite small and homogeneous, increased theoretical knowledge, high hands-on performance acquisition, and good satisfaction of physiotherapists were observed. Reliability was moderate to excellent for thickness and landmarks and absent to weak for pennation angle. Landmarking and pennation angle remain challenges for physiotherapist training in the application of MUS. Further studies are needed to identify variables that could modify reliability during MUS training.

Physical activity of patients with critical illness undergoing rehabilitation in intensive care and on the acute ward: An observational cohort study

BACKGROUND

There are limited published data on physical activity of survivors of critical illness engaged in rehabilitation in hospital, despite it plausibly influencing outcome.

OBJECTIVE

The aims of this study were to measure physical activity of patients with critical illness engaged in rehabilitation in the intensive care unit (ICU) and on the acute ward and report discharge destination, muscle strength, and functional outcomes.

METHODS

This was a single-centre, prospective observational study. Adults with critical illness, who received ≥48 h of invasive mechanical ventilation, and who were awake and able to participate in rehabilitation were eligible. To record physical activity, participants wore BodyMedia SenseWear Armbands (BodyMedia Incorporated, USA), during daylight hours, from enrolment until hospital discharge or day 14 of ward stay (whichever occurred first). The primary outcome was time (minutes) spent performing physical activity at an intensity of greater than 1.5 Metabolic Equivalent Tasks. Secondary outcomes included discharge destination, muscle strength, and physical function.

RESULTS

We collected 807 days of physical activity data (363 days ICU, 424 days ward) from 59 participants. Mean (standard deviation) duration of daily physical activity increased from the ICU, 17.8 (22.8) minutes, to the ward, 52.8 (51.2) minutes (mean difference [95% confidence interval] = 35 [23.8-46.1] minutes, P < .001). High levels of activity in the ICU were associated with higher levels of activity on the ward (r = .728), n = 48, P < .001.

CONCLUSIONS

Patients recovering from critical illness spend less than 5% of the day being physically active throughout hospital admission, even when receiving rehabilitation. Physical activity increased after discharge from intensive care, but had no relationship with discharge destination. Only the absence of ICU-acquired weakness on awakening was associated with discharge directly home from the acute hospital. Future studies could target early identification of ICU-acquired weakness and the preservation of muscle strength to improve discharge outcomes.

Family participation during physical activity in the intensive care unit: A longitudinal qualitative study

PURPOSE

Family-centered care has been implemented in the ICU to meet relatives' needs concerning information, support, participation and shared decision making. This study explores the needs, beliefs, feelings and behaviors of relatives of patients admitted to the ICU regarding participation during physical activity.

METHODS

Longitudinal qualitative study design following a grounded theory approach. Relatives were interviewed at 4, 8 and 12 days after the patient's ICU-admission. Data were analyzed using constant comparison.

RESULTS

Twenty-five interviews were conducted in ten relatives. Relatives believed that physical activity in the ICU improves recovery. Participating in physical activity decreased their feelings of powerlessness and uselessness. Relatives mentioned that they would be stimulated to participate if they were invited, guided and informed by healthcare providers. The perceived reticence of healthcare providers, patient's health-changing capacity and the inability to communicate led to a more passive attitude towards participation.

CONCLUSIONS

The conceptual model shows how family participation during physical activity changes from a passive role, with negative beliefs and feelings of uselessness and powerlessness, to a more proactive participatory role. Relatives felt more useful and like they were part of the team. Providing relatives with additional information might be a viable strategy to help and stimulate participation.

Variables associated with mobility levels in critically ill patients: A cohort study

BACKGROUND

Early mobilization in the intensive care unit (ICU) helps improve patients' functional status at discharge. However, many barriers hinder this practice.

AIM AND OBJECTIVES

To identify mobility levels acquired by critically ill patients and their variables.

DESIGN

A multi-centre cohort study was conducted in adult patients receiving invasive mechanical ventilation for at least 48 hours.

METHODS

The primary outcome was level of mobility according to the ICU mobility scale. The secondary outcome was human resource availability and existence of ABCDEF bundle guidelines. A logistic regression was performed, based on days 3 to 5 of the ICU stay and significant association with active mobility.

RESULTS

Six hundred and forty-two patients were included from 80 ICUs. Active moving in and out of bed was found on 9.9% of patient-days from day 8 of the ICU stay. Bed exercises, or passive transfers, and immobility were observed on 45.6% and 42.2% of patient-days, respectively. Patients achieving active mobility (189/642, 29.4%) were in ICUs with more physiotherapist hours. Active mobility was more likely with a 1:4 nurse-patient ratio (odds ratio [OR] 3.7 95% confidence interval [CI] [1.2-11.2]), high MRC sum-score (OR 1.05 95% CI [1.04-1.06]) and presence of delirium (OR 1.01 95% CI [1.00-1.02]). By contrast, active mobility was hindered by higher BMI (OR 0.92 95% CI [0.88-0.97]), a 1:3 nurse-patient ratio (OR 0.54 95% CI [0.32-0.93]), or a shift-dependent nurse-patient ratio (OR 0.27 95% CI [0.12-0.62]).

CONCLUSIONS

Immobility and passive mobilization were prevalent. A high MRC sum-score and presence of delirium are protective factors of mobilization. A 1:4 nurse-patient ratio shows a stronger association with active mobility than a 1:3 ratio.

RELEVANCE TO CLINICAL PRACTICE

Severity-criteria-based nurse-patient ratios hinder mobilization. Active mobilization may be enhanced by using nursing-intervention-based ratios, increasing physiotherapist hours, and achieving wider application of the ABCDEF bundle, resulting in more awake, cooperative patients.

Searching for the Responder, Unpacking the Physical Rehabilitation Needs of Critically Ill Adults: A REVIEW

Survivors of critical illness can experience persistent deficits in physical function and poor health-related quality of life and utilize significant health care resources. Short-term improvements in these outcomes have been reported following physical rehabilitation. Safety and feasibility of delivering physical rehabilitation are established; however, low physical activity levels are observed throughout the recovery of patients. We provide examples on how physical activity may be increased through interdisciplinary models of service delivery. Recently, however, there has been an emergence of large randomized controlled trials reporting no effect on long-term patient outcomes. In this review, we use a proposed theoretical construct to unpack the findings of 12 randomized controlled trials that delivered physical rehabilitation during the acute hospital stay. We describe the search for the responder according to modifiers of treatment effect for physical function, health-related quality of life, and health care utilization outcomes. In addition, we propose tailoring and timing physical rehabilitation interventions to patient subgroups that may respond differently based on their impairments and perpetuating factors that hinder recovery. We examine in detail the timing, components, and dosage of the trial intervention arms. We also describe facilitators and barriers to physical rehabilitation implementation and factors that are influential in recovery from critical illness. Through this theoretical construct, we anticipate that physical rehabilitation programs can be better tailored to the needs of survivors to deliver appropriate interventions to patients who derive greatest benefit optimally timed in their recovery trajectory.

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

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

Rehabilitation through virtual reality: physical activity of patients admitted to the intensive care unit

Objective

To evaluate the level of activity that Nintendo Wii^TM can elicit in intensive care unit patients and its associated safety and patient satisfaction.

Methods

Experimental, single-center study performed at a tertiary care hospital. Patients ≥ 18 years old who were admitted to the intensive care unit, participated in videogames as part of their physical therapy sessions and did not have mobility restrictions were included. Th exclusion criteria were the inability to comprehend instructions and the inability to follow simple commands. We included n = 60 patients and performed 100 sessions. We used the Nintendo Wii^TM gaming system in the sessions. An accelerometer measured the level of physical activity of patients while they played videogames. We evaluated the level of activity, the modified Borg scale scores, the adverse events and the responses to a questionnaire on satisfaction with the activity.

Results

One hundred physical therapy sessions were analyzed. When the patients played the videogame, they reached a light level of activity for 59% of the session duration and a moderate level of activity for 38% of the session duration. No adverse events occurred. A total of 86% of the patients reported that they would like to play the videogame in their future physical therapy sessions.

Conclusion

Virtual rehabilitation elicited light to moderate levels of activity in intensive care unit patients. This therapy is a safe tool and is likely to be chosen by the patient during physical therapy.

Effect of in-bed cycling on acute muscle wasting in critically ill adults: A randomised clinical trial

PURPOSE

To examine whether in-bed cycling assists critically ill adults to reduce acute muscle wasting, improve function and improve quality of life following a period of critical illness.

MATERIALS AND METHODS

A single-centre, two-group, randomised controlled trial with blinded assessment of the primary outcome was conducted in a tertiary ICU. Critically ill patients expected to be mechanically ventilated for at least 48 h were randomised to 30 min daily in-bed cycling in addition to usual-care physiotherapy (n = 37) or usual-care physiotherapy (n = 37). The primary outcome was muscle atrophy of rectus femoris cross-sectional area (RF_CSA) measured by ultrasound at Day 10 following study enrolment. Secondary outcomes included manual muscle strength, handgrip strength, ICU mobility score, six-minute walk test distance and health-related quality of life up to six-months following hospital admission.

RESULTS

Analysis included the 72 participants (mean age, 56-years; male, 68%) who completed the study. There were no significant between-group differences in muscle atrophy of RF_CSA at Day 10 (mean difference 3.4, 95% CI -6.9% to 13.6%; p = .52), or for secondary outcomes (p-values ranged p = .11 to p = .95).

CONCLUSIONS AND RELEVANCE

In-bed cycling did not reduce muscle wasting in critically ill adults, but this study provides useful effect estimates for large-scale clinical trials.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12616000948493.

Effects of an exercise intervention for patients with advanced inoperable lung cancer undergoing chemotherapy: A randomized clinical trial

OBJECTIVE

Exercise can improve treatment-related side effects, quality of life, and function in patients with various types of cancer; however, more evidence is needed for patients with advanced inoperable lung cancer.

MATERIAL AND METHODS

We randomized 218 patients with advanced inoperable lung cancer to a 12-week supervised, structured exercise training program (aerobic, strength, and relaxation training) twice weekly versus usual care. Primary outcome was change in maximal oxygen uptake (VO₂ peak). Secondary outcomes were muscle strength, functional capacity, forced expiratory volume in 1 s, health-related quality of life, anxiety, and depression.

RESULTS

There was no significant difference between the intervention and control groups in VO₂ peak. There was a significant improvement in muscle strength. There was also a significant difference between the two for social well-being (Functional Assessment of Cancer Therapy-Lung, FACT-L), anxiety, and depression.

CONCLUSION

There was a significant reduction in the level of anxiety and depression and a significant increase in all muscle strength outcomes in the intervention group compared to patients randomized to usual care. There was a significant difference between the groups for social well-being. The primary outcome did not show a significant improvement in VO₂ peak. Based on our results, future patients with advanced inoperable lung cancer should be considered for supervised exercise during the course of their disease.

Use of actigraphy to characterize inactivity and activity in patients in a medical ICU

BACKGROUND

In the intensive care unit (ICU), inactivity is common, contributing to ICU-acquired weakness and poor outcomes. Actigraphy may be useful for measuring activity in the ICU.

OBJECTIVES

To use actigraphy to characterize inactivity and activity in critically ill patients.

METHODS

This prospective observational study involved 48-h wrist actigraphy in medical ICU (MICU) patients, with activity data captured across 30-s epochs. Inactivity (zero-activity epochs) and activity (levels of non-zero activity) were summarized across key patient (e.g., age) and clinical (e.g., mechanical ventilation status) variables, and compared using multivariable regression.

RESULTS

Overall, 189,595 30-s epochs were collected in 34 MICU patients. Zero-activity (inactivity) comprised 122,865 (65%) of epochs; these epochs were 24% and 13% more prevalent, respectively, in patients receiving mechanical ventilation (versus none, p < 0.001) and in the highest (versus lowest) organ failure score tertile (p = 0.03). Ambulatory (versus non-ambulatory) patients exhibited more non-zero activity (35 more movements per epoch, p < 0.001), while those in the highest (versus lowest) organ failure score tertile exhibited less activity (22 fewer movements per epoch, p = 0.03). Significant inactivity/activity differences were not observed when evaluated based on age, sedation, or restraint status.

CONCLUSIONS

Actigraphy demonstrated that MICU patients are profoundly inactive, including those who are young, non-sedated and non-restrained. Hence, ICU-specific, non-patient-related factors may contribute to inactivity, an issue requiring further investigation.

Associations between nutritional energy delivery, bioimpedance spectroscopy and functional outcomes in survivors of critical illness

BACKGROUND

Patients who survive critical illness frequently develop muscle weakness that can impact on quality of life; nutrition is potentially a modifiable risk factor. The present study aimed to explore the associations between cumulative energy deficits (using indirect calorimetry and estimated requirements), nutritional and functional outcomes.

METHODS

A prospective single-centre observational study of 60 intensive care unit (ICU) patients, who were mechanically ventilated for at least 48 h, was conducted. Cumulative energy deficit was determined from artificial nutrition delivery compared to targets. Measurements included: (i) at recruitment and ICU discharge, weight, fat-free mass (bioimpedance spectroscopy) and malnutrition (Subjective Global Assessment score B/C); (ii) at awakening and ICU discharge, physical function (Physical Function in Intensive Care Test-scored) and muscle strength (Medical Research Council sum-score (MRC-SS). ICU-acquired weakness was defined as a MRC-SS score of less than 48/60.

RESULTS

The median (interquartile range) cumulative energy deficit compared to the estimated targets up to ICU day 12 was 3648 (2514-5650) kcal. Adjusting for body mass index, age and severity of illness, cumulative energy deficit (per 1000 kcal) was independently associated with greater odds of ICU-acquired weakness [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.4-3.3, P = 0.001] and malnutrition (OR = 1.9, 95% CI = 1.1-3.2, P = 0.02). In similar multivariable linear models, cumulative energy deficit was associated with reductions in fat-free mass (-1.3 kg; 95% CI = -2.4 to -0.2, P = 0.02) and physical function scores (-0.6 points; 95% CI = -0.9 to -0.3, P = 0.001).

CONCLUSIONS

Cumulative energy deficit from artificial nutrition support was associated with reduced functional outcomes and greater loss of fat-free mass in ventilated ICU patients.

An observational study investigating the use of patient-owned technology to quantify physical activity in survivors of critical illness

BACKGROUND

Physical activity after intensive care unit (ICU) discharge is challenging to measure but could inform research and practice. A patient's smartphone may provide a novel method to quantify physical activity.

OBJECTIVES

We aimed to evaluate the feasibility and accuracy of using smartphone step counts among survivors of critical illness.

METHODS

We performed a prospective observational cohort study in 50 patients who had an ICU length of stay>48 h, owned a smartphone, were ambulatory before admission, and were likely to attend follow-up at 3 and 6 months after discharge. At follow-up, daily step counts were extracted from participants' smartphones and two FitBit pedometers, and exercise capacity (6-min walk test) and quality of life (European Quality of Life-5 Dimensions) were measured.

RESULTS

Thirty-nine (78%) patients returned at 3 months and 33 (66%) at 6 months, the median [interquartile range] smartphone step counts being 3372 [1688-5899] and 2716 [1717-5994], respectively. There was a strong linear relationship, with smartphone approximating 0.71 (0.58, 0.84) of FitBit step counts, P < 0.0001, R-squared = 0.87. There were weak relationships between step counts and the 6-min walk test distance.

CONCLUSION

Although smartphone ownership and data acquisition limit the viability of using extracted smartphone steps at this time, mean daily step counts recorded using a smartphone may act as a surrogate for a dedicated pedometer; however, the relationship between step counts and other measures of physical recovery remains unclear.

Evaluation of the description of active mobilisation protocols for mechanically ventilated patients in the intensive care unit: A systematic review of randomized controlled trials

BACKGROUND

The complete description of exercise interventions is essential to allow for the replication of clinical trials and to the correct application in clinical practice.

OBJECTIVES

The aim of this review was to evaluate of the description of the active mobilisation protocols in patients on invasive mechanical ventilation at intensive care units (ICU).

METHODS

Systematic review of randomised controlled trials (RCTs) using the Consensus on Exercise Reporting Template.

RESULTS

We identified 16 RCTs (n = 1,850). None sufficiently described the intervention for all items required for replication. The frequency, intensity, time, volume, and progression of active mobilisation as well as other important components of the intervention such as the instructor's qualifications/expertise, the types and incidence of adverse events, and the adherence to the exercise intervention were not adequately reported.

CONCLUSION

Active mobilisation interventions were only incompletely described in RCTs, which can compromise replication in both, clinical and research settings.

REGISTRATION

PROSPRERO (CRD42017068762).

Can the critically ill patient generate sufficient energy to facilitate exercise in the ICU?

PURPOSE OF REVIEW

Trials of physical rehabilitation post critical illness have yet to deliver improved health-related quality of life in critical illness survivors. Muscle mass and strength are lost rapidly in critical illness and a proportion of patients continue to do so resulting in increased mortality and functional disability. Addressing this issue is therefore fundamental for recovery from critical illness.

RECENT FINDINGS

Altered mitochondrial function occurs in the critically ill and is likely to result in decreased adenosine tri-phosphate (ATP) production. Muscle contraction is a process that requires ATP. The metabolic demands of exercise are poorly understood in the ICU setting. Recent research has highlighted that there is significant heterogeneity in energy requirements between critically ill individuals undertaking the same functional activities, such as sit-to-stand. Nutrition in the critically ill is currently thought of in terms of carbohydrates, fat and protein. It may be that we need to consider nutrition in a more contextual manner such as energy generation or management of protein homeostasis.

SUMMARY

Current nutritional support practices in critically ill patients do not lead to improvements in physical and functional outcomes, and it may be that alternative methods of delivery or substrates are needed.

Targeted full energy and protein delivery in critically ill patients: a study protocol for a pilot randomised control trial (FEED Trial)

BACKGROUND

Current guidelines for the provision of protein for critically ill patients are based on incomplete evidence, due to limited data from randomised controlled trials. The present pilot randomised controlled trial is part of a program of work to expand knowledge about the clinical effects of protein delivery to critically ill patients. The primary aim of this pilot study is to determine whether an enteral feeding protocol using a volume target, with additional protein supplementation, delivers a greater amount of protein and energy to mechanically ventilated critically ill patients than a standard nutrition protocol. The secondary aims are to evaluate the potential effects of this feeding strategy on muscle mass and other patient-centred outcomes.

METHODS

This prospective, single-centred, pilot, randomised control trial will include 60 participants who are mechanically ventilated and can be enterally fed. Following informed consent, the participants receiving enteral nutrition in the intensive care unit (ICU) will be allocated using a randomisation algorithm in a 1:1 ratio to the intervention (high-protein daily volume-based feeding protocol, providing 25 kcal/kg and 1.5 g/kg protein) or standard care (hourly rate-based feeding protocol providing 25 kcal/kg and 1 g/kg protein). The co-primary outcomes are the average daily protein and energy delivered to the end of day 15 following randomisation. The secondary outcomes include change in quadriceps muscle layer thickness (QMLT) from baseline (prior to randomisation) to ICU discharge and other nutritional and patient-centred outcomes.

DISCUSSION

This trial aims to examine whether a volume-based feeding protocol with supplemental protein increases protein and energy delivery. The potential effect of such increases on muscle mass loss will be explored. These outcomes will assist in formulating larger randomised control trials to assess mortality and morbidity.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12615000876594 UTN: U1111-1172-8563.