Impact of a Progressive Mobility Program on the Functional Status, Respiratory, and Muscular Systems of ICU Patients: A Randomized and Controlled Trial

The prevalence of perceived fatigue in burn survivors: A systematic review of cross-sectional and longitudinal studies

OBJECTIVE

Perceived fatigue significantly impacts quality of life after burns, yet how often it occurs is unknown. Therefor this study assessed the prevalence of perceived fatigue of burn survivors.

METHODS

In February 2023, a systematic literature search was performed in CINAHL, Embase, PsycInfo, PubMed and Web of Science. Studies reporting the prevalence of post-burn perceived fatigue were included.

RESULTS

In ten cross-sectional studies of moderate-high quality with measurements between 5.3 days and 42 years post burn, the prevalence of perceived fatigue varied between 5 % and 78 % with no apparent time trends. Broad study populations hindered explaining this varying prevalence by age or %TBSA. In four high-quality longitudinal studies with 3-5 measurements between 1 and 24 months post burn, the prevalence decreased over time, dropping from approximately 70 to 50 % in adults and 65 to 28 % in children. Studies used various measurement instruments and cut-off points for operationalizing perceived fatigue, severely limiting the interpretation and comparison of prevalence rates across studies.

CONCLUSIONS

The high prevalence and persistent nature of perceived fatigue among burn survivors emphasize its crucial role in burn rehabilitation. Future studies should prioritize identifying individuals with adverse trajectories of perceived fatigue and unravelling underlying mechanisms to develop effective treatments for reducing post-burn perceived fatigue.

Frailty and Long-Term Survival in Patients With Critical Illness After Nonhome Discharge: A Retrospective Cohort Study

IMPORTANCE

Patients with frailty are more frequently discharged to rehabilitation or residential aged care facility (RACF), defined as nonhome discharge, than those without frailty. An increase in nonhome discharge is considered to be one of the collateral "costs" associated with declining hospital mortality. However, it is unclear whether this association applies to patients with frailty, particularly in the long term.

OBJECTIVES

To determine the impact of frailty on long-term survival in patients who had a nonhome discharge following an ICU admission.

DESIGN

A retrospective multicenter cohort study.

SETTING AND PARTICIPANTS

All medical patients (≥ 16 yr old) admitted to Australian and Zealand ICUs, with a documented Clinical Frailty Scale (CFS) and a nonhome discharge from January 1, 2018, to March 31, 2022, were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was survival time up to 4 years. We used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty (defined as CFS = 5-8) on survival time after ICU admission between groups. We also analyzed the effect of frailty on long-term survival based on their age and nonhome discharge location. Of the 57,652 patients, 17,383 (30.2%) were frail. Overall 4-year survival was lower in patients with frailty than those without (32.5% vs. 64.3%; p < 0.001). Frailty was associated with shorter survival times (adjusted hazard ratio [aHR], 1.50; 95% CI, 1.43-1.57). Frailty was associated with a greater reduction in survival in patients younger than 65 years old (aHR, 1.73; 95% CI, 1.59-1.88), 65-80 years (aHR, 1.47; 95% CI, 1.38-1.57), or older than 80 years (aHR, 1.35; 95% CI, 1.26-1.45). Frailty was associated with greater reduction in survival in those discharged to rehabilitation (aHR, 1.52; 95% CI, 1.39-1.65) or acute hospitals (aHR, 1.56; 95% CI, 1.48-1.65) than those discharged to RACF (aHR, 0.94; 95% CI, 0.83-1.06).

CONCLUSIONS

Frailty was independently associated with shorter time to death following a nonhome discharge after an ICU admission.

RELEVANCE

There was an independent association between patients with frailty admitted to ICU and had a nonhome discharge with the shorter time to death than those without frailty.

Effects of in-bed cycling in critically ill adults: A systematic review and meta-analysis of randomised clinical trials

BACKGROUND

Impairments in intensive care unit (ICU) survivors can last up to 5 years post-discharge. Finding effective treatments to palliate and prevent them is essential, and in-bed cycling is a way to palliate the effects of prolonged immobilisation.

OBJECTIVE

To evaluate the effects of in-bed cycling in critically ill adults regarding recovery status, mortality, physical performance and quality of life.

METHODS

We followed PRISMA 2020 guidelines. The search was conducted in Cinahl, Medline, Scopus and Web of Science from their inception to October 2024. We included randomised clinical trials with critically ill adults who performed in-bed cycling alone or with another treatment while in ICU, compared to no intervention, placebo, rehabilitation or standard care, assessing recovery status, mortality, physical performance or quality of life. Methodological quality and risk of bias were evaluated. A meta-analysis was performed.

RESULTS

Thirty-two studies were included in the review, and 22 studies in the meta-analysis. A total of 3,052 participants (≥18 years old) admitted to different types of ICUs were included. Results showed significant differences regarding ICU length of stay (n = 1,564; MD -0.93; 95 % CI -1.64 to -0.21; P = 0.01) and hospital length of stay (n = 1,189; MD -1.78; 95 % CI -3.16 to -0.41; P = 0.01), mechanical ventilation duration (n = 1,024; MD -0.51; 95 % CI -0.92 to -0.11; P = 0.01) and functional status (n = 400; MD 44.88; 95 % CI 3.11-86.65; P = 0.04) favouring in-bed cycling plus rehabilitation compared to rehabilitation. However, no significant differences were found regarding mortality, muscle strength, ICU-acquired weakness or quality of life. Different programme duration did not significantly affect hospital length of stay.

CONCLUSION

In-bed cycling plus rehabilitation significantly reduced ICU and hospital length of stay, mechanical ventilation duration and improved functional status compared to rehabilitation. Further research is needed to analyse long-term effects and standardise interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022309311; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022309311.

Reporting of nutritional screening, status, and intake in trials of nutritional and physical rehabilitation following critical illness: a systematic review

BACKGROUND

Surviving critical illness leads to prolonged physical and functional recovery with both nutritional and physical rehabilitation interventions for prevention and treatment being investigated. Nutritional status and adequacy may influence outcome, but no consensus on which nutritional-related variables should be measured and reported in clinical trials exists.

OBJECTIVES

This study aimed to undertake a systematic review investigating the reporting of nutritional screening, nutritional status, and nutritional intake/delivery in randomized controlled trials (RCTs) evaluating nutritional and/or physical rehabilitation on physical and functional recovery during and following critical illness.

METHODS

Five electronic databases (MEDLINE, Web of Science, EMBASE, CINAHL, and Cochrane) were searched (last update 9 August, 2023). Search terms included both free text and standardized indexed terms. Studies included were RCTs assessing nutritional and/or physical interventions either during or following intensive care unit (ICU) admission in adults (18 y or older) with critical illness, and who required invasive mechanical ventilation for any duration during ICU admission. Study quality was assessed using the Cochrane Collaboration Risk of Bias tool for RCTs and descriptive data synthesis was performed and presented as counts (%). n t RESULTS: In total, 123 RCTs (30 nutritional, 87 physical function, and 6 combined) were included. Further, ≥1 nutritional variable was measured and/or reported in 99 (80%) of the studies including BMI (n = 69), body weight (n = 57), nutritional status (n = 11), nutritional risk (n = 10), energy delivery (n = 41), protein delivery (n = 35), handgrip strength (n = 40), and other nutritional-related muscle variables (n = 41). Only 3 studies were considered to have low risk of bias in all categories.

CONCLUSIONS

Few RCTs of physical rehabilitation measure and report nutritional or related variables. Future studies should measure and report specific nutritional factors that could impact physical and functional recovery to support interpretation where studies do not show benefit. This protocol was preregistered at PROSPERO as CRD42022315122.

Outcomes in early mobilisation research in critically ill children: A scoping review

OBJECTIVE

Early mobilisation in critically ill children is safe and feasible. However, the effectiveness of early mobilisation on short- and long-term outcomes is understudied. The aim of this scoping review was to generate an overview of outcomes used in previous research regarding early mobilisation in critically ill children.

DATA SOURCES

A systematic search was performed in Medline, Embase, Cochrane library, and CINAHL, without restricting on design, on April 3rd, 2023.

STUDY SELECTION

Two independent reviewers assessed titles, abstracts, and full texts. Studies were included if they described any outcomes related to early mobilisation in critically ill children.

DATA CHARTING PROCESS

One reviewer performed data extraction, which was subsequently verified by another reviewer. Seven domains were used to categorise the outcomes: mortality, physiological, life impact, resource use, adverse events, process indicators, and perception of early mobilisation.

DATA SYNTHESIS

Out of 3380 screened titles, 25 studies were included. Data extraction yielded 148 unique outcomes, which were clustered into 40 outcomes. Outcomes spanned in all seven domains, with "length of paediatric intensive care unit stay" (resource use) and "adverse events involving unintentional removal of catheters, tubes, and/or lines" (adverse events) being the most frequently reported. Process indicators such as mobilisation activities were well documented. Mortality and functionality outcomes were chosen the least.

CONCLUSIONS

This scoping review provides a categorised overview of outcomes that have been used to assess the effectiveness of early mobilisation in critically ill children. The findings show a great heterogeneity in used outcomes and are input for paediatric intensive care unit experts and parents to prioritise outcomes developing a Core Outcome Set.

A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

RATIONALE

Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.

OBJECTIVES

The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

PANEL DESIGN

The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.

METHODS

The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.

RESULTS

The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.

CONCLUSIONS

The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.

A comprehensive assessment tool of acute-phase rehabilitation is associated with clinical outcomes in patients after cardiovascular surgery

Perme intensive care unit (ICU) mobility score is a comprehensive mobility assessment tool; however, its usefulness and validity for patients after cardiovascular surgery remain unclear. We investigated the association between the Perme Score and clinical outcomes after cardiovascular surgery. We retrospectively enrolled 249 consecutive patients admitted to the ICU after cardiac and/or major vascular surgery. The Perme Score contains categories on mental status, potential mobility barriers, muscle strength and mobility level and was assessed within 2 days after surgery. The outcomes of physical recovery were the number of days until 100-m ambulation achievement and 6-min walk distance (6MWD) at hospital discharge. The endpoint was a composite outcome of all-cause mortality and/or all-cause unplanned readmission. We analyzed the associations of the Perme Score with physical recovery and the incidence of clinical events. After adjusting for clinical confounding factors, a higher Perme Score was an independent factor of earlier achievement of 100-m ambulation (hazard ratio: 1.039, 95% confidence interval [CI]: 1.012-1.066) and higher 6MWD (β: 0.293, P = .001). During the median follow-up period of 1.1 years, we observed an incidence rate of 19.4/100 person-years. In the multivariate Poisson regression analysis, a higher Perme Score was significantly and independently associated with lower rates of all-cause death/readmission (incident rate ratio: 0.961, 95% CI: 0.930-0.992). The Perme Score within 2 days after cardiovascular surgery was associated with physical recovery during hospitalization and clinical events after discharge. Thus, it may be useful for predicting clinical outcomes.

Muscle Dysfunction and Physical Recovery After Critical Illness

During critical illness, patients experience significant and rapid onsets of muscle wasting and dysfunction with loss of strength, mass, and power. These deficits often persist long after the ICU, leading to impairments in physical function including reduced exercise capacity and increased frailty and disability. While there are numerous studies describing the epidemiology of impaired muscle and physical function in the ICU, there are significantly fewer data investigating mechanisms of prolonged and persistent impairments in ICU survivors. Additionally, while several potential clinical risk factors associated with poor physical recovery have been identified, there remains a dearth of interventions that have effectively improved outcomes long-term among survivors. In this article, we aim to provide a thorough, evidence-based review of the current state of knowledge regarding muscle dysfunction and physical function after critical illness with a focus on post-ICU and post-hospitalization phase of recovery.

Identification and quantification of physical activity in critically ill burn patients: A feasibility study

BACKGROUND

Physical activity is essential in burn care to counteract the effects of severe burns and inactivity during hospitalization. However, detailed knowledge of performed physical activities is lacking. This study evaluated the feasibility of a dual accelerometer-based method to assess type, frequency, and duration of physical activity in critically ill burn patients during hospitalization.

METHODS

A prospective observational study was conducted at the burn center of the Martini Hospital, Groningen, The Netherlands. Eligible were patients with a total body surface area (TBSA) burned of ≥ 15 % or an indication for intensive care. Patients wore two accelerometers, one on the chest and one on the diagonally opposite thigh. An algorithm converted accelerometer data into type, frequency, and duration of activities common for intensive care patients. An activity diary was used to assess non-wear time and its content, e.g., surgery.

RESULTS

Five patients (20-60 years, 13-31 % TBSA burned, LOS 30-65 days) were included. Per patient, 14-49 days (17,380-61,796 min) could be analyzed of which 7-14 % was non-wear time. During wear time, 86-95 % of activities could be identified and quantified. However, processing the data was labor-intensive.

CONCLUSION

The dual accelerometer-based method proved feasible for research purposes. For clinical application, further refinement of data processing is required.

The effect of early rehabilitation on therapeutic outcomes in ICU patients on mechanical ventilation: A meta-analysis

OBJECTIVE

To evaluate the effect of early rehabilitation on therapeutic outcomes of patients in the ICU requiring mechanical ventilation.

METHODS

Electronic databases up to June 15, 2024 were searched. Randomized controlled trials (RCTs) that compared early rehabilitation with standard rehabilitation for patients in the ICU on mechanical ventilation were included. The effects of early rehabilitation on outcomes such as duration of mechanical ventilation (days), ICU length of stay (days), hospital length of stay (days), ICU and in-hospital mortality, and ICU-acquired weakness (ICU-AW) were evaluated using a random-effects model.

RESULTS

Nineteen RCTs met the inclusion criteria for this study, involving 3076 patients in the ICU on mechanical ventilation. Meta-analysis based on the random-effects model showed that early rehabilitation significantly reduced the duration of mechanical ventilation, ICU-AW risk, ICU length of stay, and total hospital length of stay. Analysis of the timing of early rehabilitation indicated that implementing early rehabilitation within ⩽48 or ⩽72 h after ICU admission or mechanical ventilation had varying effects on the duration of mechanical ventilation, ICU length of stay, and total hospital length of stay.

CONCLUSION

Early rehabilitation can improve the therapeutic outcomes for ICU patients on mechanical ventilation. The optimal time for implementing early rehabilitation appears to be 48-72 h after ICU admission or initiation of mechanical ventilation, but further research is needed.

CLINICAL TRIAL NUMBER

INPLASY202470068.

Ambulation Protocol for Adult Patients Receiving Extracorporeal Membrane Oxygenation: A Quality Improvement Initiative

BACKGROUND

For patients receiving extracorporeal membrane oxygenation, early mobility decreases mechanical ventilation time, delirium incidence, and length of intensive care unit stay and improves physical functioning. Individual centers use institutional guidelines to develop ambulation protocols. Local Problem A quality improvement initiative was used to evaluate an ambulation protocol for adult intensive care unit patients receiving extracorporeal membrane oxygenation.

METHODS

Adult patients receiving extracorporeal membrane oxygenation who walked according to the protocol were compared with a historical control group of patients who walked without the protocol. Data analysis included descriptive statistics and independent t tests. Outcomes included adverse safety events, number of patients and ambulation sessions, standing and ambulation time, and distance.

RESULTS

From January to March 2021, 13 of 46 patients receiving extracorporeal membrane oxygenation (28%) walked according to the protocol. In the control group, 14 of 147 patients (10%) walked in 2019; 21 of 144 patients (15%) walked in 2020. Some characteristics of the control group (hospitalized before the COVID-19 pandemic) differed from those of the protocol group (hospitalized during the pandemic). Mean number of ambulation sessions was not significantly different between groups (protocol group, 10; control group, 9). Differences in mean standing time (protocol group, 121.23 minutes; control group, 210.80 minutes), ambulation time (protocol group, 11.77 minutes; control group, 198.70 minutes), and ambulation distance were not significant.

CONCLUSIONS

Standing time, ambulation time, and distance were not significantly different between the groups. The extracorporeal membrane oxygenation ambulation protocol demonstrated clinical significance by increasing the number of patients walking.

The impact of mobilization training time during the first postoperative week on the length of hospital stay in postoperative patients admitted to an intensive care unit

OBJECTIVE

To determine the impact of mobilization training time during the first postoperative week on the length of hospital stay for postoperative patients admitted to an intensive care unit.

DESIGN

A retrospective cohort study.

PATIENTS

Consecutive patients who underwent elective surgery and stayed in the intensive care unit of a university hospital for more than 48 h between July 2017 and August 2020 were enrolled.

METHODS

The total duration of mobilization training during the first postoperative week and clinical variables, including demographic information, were collected from medical records. Multivariable regression analysis was used to investigate the impact of mobilization training time on the length of hospital stay, adjusting for potentially confounding variables.

RESULTS

In total, 773 patients (504 males; median age, 70 years) were enrolled. Multivariable regression analysis showed that an increase in mobilization training time during the first postoperative week was associated with a shorter length of hospital stay (β = -0.067, 95% confidence interval: -0.120, -0.017, p = 0.010), with each 1-h increase in training time associated with a 4.02-day reduction in the length of hospital stay.

CONCLUSION

Increased mobilization training during the first postoperative week significantly reduced the length of hospital stay in postoperative patients.

Intensive care unit acquired weakness and physical rehabilitation in the ICU

Approximately half of critically ill adults experience intensive care unit acquired weakness (ICUAW). Patients who develop ICUAW may have negative outcomes, including longer duration of mechanical ventilation, greater length of stay, and worse mobility, physical functioning, quality of life, and mortality. Early physical rehabilitation interventions have potential for improving ICUAW; however, randomized trials show inconsistent findings on the efficacy of these interventions. This review summarizes the latest evidence on the definition, diagnosis, epidemiology, pathophysiology, risks factors, implications, and management of ICUAW. It specifically highlights research gaps and challenges, with considerations for future research for physical rehabilitation interventions.

Ultrasound-derived rates of muscle wasting in the intensive care unit and in the post-intensive care ward for patients with critical illness: Post hoc analysis of an international, multicentre randomised controlled trial of early rehabilitation

BACKGROUND AND AIMS

Muscle wasting results in weakness for patients with critical illness. We aim to explore ultrasound-derived rates of change in skeletal muscle in the intensive care unit (ICU) and following discharge to the post-ICU ward.

DESIGN

Post hoc analysis of a multicentre randomised controlled trial of functional-electrical stimulated cycling, recumbent cycling, and usual care delivered in intensive care.

METHOD

Participants underwent ultrasound assessment of rectus femoris at ICU admission, weekly in the ICU, upon awakening, ICU discharge, and hospital discharge. The primary outcome was rate of change in rectus femoris cross-sectional area (ΔRFCSA) in mm2/day in the ICU (enrolment to ICU discharge) and in the post-ICU ward (ICU discharge to hospital discharge). Secondary outcomes included rate of change in echo intensity (ΔEI), standard deviation of echo intensity (ΔEISD), and the intervention effect on ultrasound measures. Echo intensity is a quantitative assessment of muscle quality. Elevated echo intensity may indicate fluid infiltration, adipose tissue, and reduced muscle quality.

RESULTS

154 participants were included (mean age: 58 ± 15 years, 34% female). Rectus femoris cross-sectional area declined in the ICU (-4 mm2/day [95% confidence interval {CI}: -9 to 1]) and declined further in the ward (-9 mm2/day [95% CI: -14 to -3]) with a mean difference between ICU and ward of -5 mm2/day ([95% CI: -2, to 11]; p = 0.1396). There was a nonsignificant difference in ΔEI between in-ICU and the post-ICU ward of 1.2 ([95% CI: -0.1 to 2.6]; p = 0.0755), a statistically significant difference in ΔEISD between in-ICU and in the post-ICU ward of 1.0 ([95% CI, 0.5 to 1.5]; p = 0.0003), and no difference in rate of change in rectus femoris cross-sectional area between groups in intensive care (p = 0.411) or at hospital discharge (p = 0.1309).

CONCLUSIONS

Muscle wasting occurs in critical illness throughout the hospital admission. The average rate of loss in muscle cross-sectional area does not slow after ICU discharge, even with active rehabilitation.

Guideline on positioning and early mobilisation in the critically ill by an expert panel

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.

Impact of the health policy for interdisciplinary collaborative rehabilitation practices in intensive care units: A difference-in-differences analysis in Japan

BACKGROUND

Early rehabilitation in intensive care units (ICUs) may be beneficial but is not routinely performed for adults with critical illness. In April 2018, the Japanese government introduced a health policy to provide financial incentives to hospitals that met the requirements of interdisciplinary collaboration and had teams specialized in ICU rehabilitation practices.

OBJECTIVES

The present study aimed to investigate whether the health policy is associated with improved clinical practices of ICU rehabilitation.

METHODS

Using a nationwide administrative inpatient database and hospital statistics data from Japan, we identified hospitals that admitted adult patients to the ICU within two days of hospital admission from April 2016 to March 2019. Using hospital-level propensity score matching, we created matched cohorts of 101,203 patients from 108 intervention hospitals that introduced the health policy, and 106,703 patients from 108 control hospitals that did not. We then conducted patient-level difference-in-differences analyses to examine changes in the percentage of patients from the intervention and control hospitals, who underwent early ICU rehabilitation within two days of ICU admission before and after the implementation of the health policy.

RESULTS

In the intervention group, patients undergoing early ICU rehabilitation increased from 10% and 36% after the policy implementation. In the control group, it increased from 11% to 13%. The difference-in-difference in the percentage of patients who underwent early ICU rehabilitation between the two groups was 24% (95% confidence interval, 19%-29%).

CONCLUSIONS

Early ICU rehabilitation can be facilitated by financial incentives for hospitals that engage in interdisciplinary collaboration with specialist teams.

IMPLICATIONS FOR CLINICAL PRACTICE

Our Findings are relevant for hospital administrators, professional organizations, and policymakers in other nations considering strategies to support the additional deployment burdens of early ICU rehabilitation. Future studies need to explore the long-term effects and sustainability of the observed improvements in ICU rehabilitation practices.

Effects of rehabilitation treatments jointly considered by physiatrists and rehabilitation therapists in patients with severe burn injury

Rehabilitation treatments for patients with severe burn injury (SBI) are difficult owing to the lack of knowledge, skills, and experience among clinicians and physical and occupational therapists, resulting in serious patient disability. This study retrospectively evaluated the effectiveness of rehabilitation treatments jointly considered by physiatrists and rehabilitation therapists (Physiatrist and Registered therapist Operating rehabilitation: PROr) for patients with SBI admitted to our hospital's burn intensive care unit (BICU). Eligible patients were classified into the PROr and standard rehabilitation (SR) groups. Contents of the rehabilitation program in the BICU, the functional ambulation categories (FAC), and the Barthel index at the first rehabilitation, BICU discharge, and hospital discharge were collected. Of the 184 patients with severe burns admitted to the BICU, 29 (PROr group, n = 16; SR group, n = 13) met the eligibility criteria. The PROr group received more types of exercise interventions for a longer time than the SR group. No significant differences in the FAC and Barthel index scores at the first time of rehabilitation were found between the two groups; however, the scores of FAC and Barthel index at BICU and hospital discharges were higher in the PROr group than in the SR group. The PROr program may help in the functional improvement of patients with SBI.

Optimal timing for early mobilization initiatives in intensive care unit patients: A systematic review and network meta-analysis

OBJECTIVES

Analyse the effect of varying start times for early exercise interventions on the prevention of intensive care unit-acquired weakness.

RESEARCH METHODOLOGY

We conducted a comprehensive search on PubMed, Cochrane Library, Web of Science, Embase, China Biology Medicine Disc, China National Knowledge Infrastructure, Wan Fang Database, and reference lists up to May 2023.

SETTING

We systematically searched the literature for all randomized controlled trials on the effect of early mobilization in patients with critical illness.

MAIN OUTCOME MEASURES

The primary outcome assessed was the incidence of intensive care unit-acquired weakness. The secondary outcomes included: the Medical Research Council Score, the Barthel Index, duration of mechanical ventilation, length of intensive care unit stay, total length of hospital stay, mortality and incidence of intensive care unit-related complications.

RESULTS

The results of meta-analysis showed that compared with routine care, less than 24 hours after admission (RR = 0.44, 95 %CI: 0.28-0.68), more than 24 hours (RR = 0.33, 95 %CI: 0.16-0.67), less than 72 hours after admission (RR = 0.33, 95 %CI: 0.20-0.52) may lead to a lower incidence of intensive care unit-acquired weakness. The results of under surface cumulative ranking showed that early mobilization within 72 hours may have the lowest incidence of intensive care unit-acquired weakness (SUCRA = 81.9 %).

CONCLUSIONS

The current empirical evidence from intensive care unit patients suggests that initiating mobilization protocols within 24-72 hours timeframe following admission to the intensive care unit could potentially be the most beneficial strategy to reduce the incidence of intensive care unit-acquired weakness and the related medical complications. Moreover, this strategy seems to significantly improve rehabilitation and treatment outcomes for these patients.

IMPLICATIONS FOR CLINICAL PRACTICE

According to this study, medical and nursing staff in the intensive care unit have the chance to identify the most suitable timing for the implementation of early rehabilitative measures for patients. This can potentially prevent intensive care unit-acquired weakness and enhance various clinical outcomes for patients.

Nursing Care in Intensive Care Unit of a Patient Infected With Balamuthia Mandrillaris After Renal Transplantation: A Case Report

An uncommon and dangerous disease with a fatality rate of more than 95% is caused by the amoeba known as Balamuthia mandrillaris. Here, we discuss the treatment of a patient who underwent a renal transplant and contracted the amoeba B. mandrillaris. The patient had a sudden onset of high fever on the 13th day after renal transplantation; on the morning of the 16th postoperative day, the patient's condition worsened and he was transferred to the ICU for treatment; on the 17th postoperative day, the patient was given mechanical ventilation; and on the 20th postoperative day, he underwent a lumbar large-pool puncture, combined with intrathecal injection of the administered medication. In order to prevent further deterioration of the patient's condition, the main aspects of care for this patient included close monitoring of changes in the patient's condition and early detection of risk factors; prompt emergency care for the patient's seizures; close monitoring of the efficacy and side effects of the patient's medication; and precise medication administration; improved hemodynamic monitoring while administering CRRT to the patient, as well as performing exercises on the patient's limb and respiratory functions. On the 32nd postoperative day, a tracheotomy is performed following thorough monitoring and care. The ventilator was turned off on postoperative day 34, and a venturi mask was installed for tracheotomy-cannula-based oxygen administration. On surgical day 40, the intrathecal injections halted and the lumbar pool drainage tube was removed. On postoperative day 46, the patient was stabilized and transferred from the intensive care unit to the organ transplant unit for extra care. This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor source.

Association of active mobilisation variables with adverse events and mortality in patients requiring mechanical ventilation in the intensive care unit: a systematic review and meta-analysis

BACKGROUND

Mobilisation during critical illness is now included in multiple clinical practice guidelines. However, a large, randomised trial and systematic review have recently identified an increased probability of adverse events and mortality in patients who received early active mobilisation in the intensive care unit (ICU). We aimed to determine the effects of mobilisation compared with usual care on adverse events and mortality in an acute ICU setting. In subgroup analyses, we specifically aimed to investigate possible sources of harm, including the timing and duration of mobilisation achieved, ventilation status, and admission diagnosis.

METHODS

In this systematic review with frequentist and Bayesian analyses, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, SCOPUS, Web of Science, and PEDro electronic databases, as well as clinical trial registries (ICTRP and ClinicalTrials.gov), from inception to March 16, 2023, without language restrictions. Eligible studies were randomised controlled trials that examined active mobilisation compared with either no mobilisation or mobilisation commencing later, or at a lower frequency or intensity, in adults who were critically ill during or after a period of mechanical ventilation in an acute ICU setting. Two authors independently screened reports, extracted data, and assessed the risk of bias using the Cochrane risk-of-bias tool (version 1). The primary outcome was the number of adverse events that occurred during the implementation of mobilisation, with the effect of mobilisation on mortality being the secondary outcome. Risk ratios (RRs) with 95% CIs were calculated in R (version 4.0.3) using random-effects modelling, with Bayesian analysis completed to calculate the probability of treatment harm (ie, RR >1). Subgroup analyses were completed to investigate the association of various factors of mobilisation on adverse events and mortality: duration of mobilisation (longer [≥20 min per day] vs shorter [<20 min per day]), timing of commencement (early [≤72 h from ICU admission] vs late [>72 h from ICU admission]), ventilation status at commencement (all patients mechanically ventilated vs all patients extubated), and ICU admission diagnosis (surgical vs medical). This study was registered with PROSPERO, CRD42022369272.

FINDINGS

After title and abstract screening of 14 440 studies and review of 466 full texts, 67 trials with 7004 participants met inclusion criteria, with 59 trials contributing to the meta-analysis. Of the 67 included studies, 15 (22%) did not mention adverse events and 13 (19%) reported no adverse events occurring across the trial period. Overall, we found no effect of mobilisation compared with usual care on the occurrence of adverse events (RR 1·09 [95% CI 0·69-1·74], p=0·71; I2 91%; 32 731 events, 20 studies; very low certainty), with a 2·96% occurrence rate (693 events in 23 395 intervention sessions; 25 studies). Mobilisation did not have any effect on mortality (RR 0·98 [95% CI 0·87-1·12], p=0·81; I2 0%; n=6218, 58 studies; moderate certainty). Subgroup analysis was hindered by the large amount of data that could not be allocated and analysed, making the results hypothesis generating only.

INTERPRETATION

Implementation of mobilisation in the ICU was associated with a less than 3% chance of an adverse event occurring and was not found to increase adverse events or mortality overall, providing reassurance for clinicians about the safety of performing this intervention. Subgroup analyses did not clearly identify any specific variable of mobilisation implementation that increased harm.

FUNDING

None.

Effects of the High-Intensity Early Mobilization on Long-Term Functional Status of Patients with Mechanical Ventilation in the Intensive Care Unit

Objective

Intensive care unit (ICU)-acquired weakness often occurs in patients with invasive mechanical ventilation (IMV). Early active mobility may reduce ICU-acquired weakness, improve functional status, and reduce disability. The aim of this study was to investigate whether high-intensity early mobility improves post-ICU discharge functional status of IMV patients.

Methods

132 adult patients in the ICU who were undergoing IMV were randomly assigned into two groups with a ratio of 1 : 1, with one group received high-intensity early mobility (intervention group, IG), while the other group received conventional treatment (control group, CG). The functional status (Barthel Index (BI)), capacity of mobility (Perme score and ICU Mobility Scale (IMS)), muscle strength (Medical Research Council sum scores (MRC-SS)), mortality, complication, length of ICU stay, and duration of IMV were evaluated at ICU discharge or after 3-month of ICU discharge.

Results

The patient's functional status was improved (BI scores 90.6 ± 18.0 in IG vs. 77.7 ± 27.9 in CG; p=0.005), and capacity of mobility was increased (Perme score 17.6 ± 7.1 in IG vs. 12.2 ± 8.5 in CG, p < 0.001; IMS 4.7 ± 2.6 in IG vs. 3.0 ± 2.6 in CG, p < 0.001). The IG had a higher muscle strength and lower incidence of ICU-acquired weakness (ICUAW) than that in the CG. The incidence of mortality and delirium was also lower than CG at ICU discharge. However, there were no differences in terms of length of ICU stay, duration of IMV, ventilator-associated pneumonia, and venous thrombosis.

Conclusions

High-intensity early mobility improved the patient's functional status and increased capacity of mobility with IMV. The benefits to functional status remained after 3 month of ICU discharge. Other benefits included higher muscle strength, lower incidence of ICUAW, mortality, and delirium in IG.

Early mobilisation within 72 hours after admission of critically ill patients in the intensive care unit: A systematic review with network meta-analysis

INTRODUCTION

Early mobilisation within 72 hours of intensive care unit admission counteracts complications caused by critical illness. The effect of different interventions on intensive care unit length of stay and other outcomes is unclear. We aimed to investigate the effectiveness of various early mobilisation interventions within 72 hours of admission to the intensive care unit on length of stay and other outcomes.

METHODS

A systematic review and (network) meta-analysis examining the effect of early mobilisation on length of stay in the intensive care unit and other outcomes, conducting searches in four databases. Randomised controlled trials were included from inception to 10/08/2022. Early mobilisation was defined as interventions that initiates and/or supports passive/active range-of-motion exercises within 72 hours of admission. In multi-arm studies, interventions used in other studies were declared as early intervention and were included in subgroup meta-analysis. Risk-of-bias was assessed using RoB2.

RESULTS

Of 29,680 studies screened, 18 studies with 1923 patients (three high, eleven some, four low risk-of-bias) and seven discriminable interventions of early mobilisation met inclusion criteria. Early mobilisation alone (WMD 0.78 days, 95 %CI [-1.38;-0.18], 11 studies, n = 1124) and early mobilisation with early nutrition (WMD -1.19 days, 95 %CI [-2.34;-0.03], 1 study, n = 100) were able to significantly shorten length of stay. Early mobilisation alone could also substantially shorten hospital length of stay (WMD -1.05 days, 95 %CI [-1.74;-0.36], 8 studies, n = 977). This effect in hospital length of stay was furthermore seen in the early intervention group compared with standard care (WMD -1.71 days, 95 %CI [-2.99;-0.43], 14 studies, n = 1587). Also, functionality and quality of life could significantly be improved by an early start of mobilisation.

CONCLUSION

In the network meta-analysis, early mobilisation alone and early mobilisation with early nutrition demonstrated a significant effect on intensive care length of stay. Early mobilisation could also reduce hospital length of stay and positively influence functionality and quality of life.

IMPLICATION FOR CLINICAL PRACTICE

Early mobilisation and early mobilisation with early nutrition seemed to be beneficial compared to other interventions like cycling on intensive care length of stay.

The optimal dose of mobilisation therapy in the ICU: a prospective cohort study

BACKGROUND

This study aimed to assess the impact of duration of early mobilisation on survivors of critical illness. The hypothesis was that interventions lasting over 40 min, as per the German guideline, positively affect the functional status at ICU discharge.

METHODS

Prospective single-centre cohort study conducted in two ICUs in Germany. In 684 critically ill patients surviving an ICU stay > 24 h, out-of-bed mobilisation of more than 40 min was evaluated.

RESULTS

Daily mobilisation ≥ 40 min was identified as an independent predictor of an improved functional status upon ICU discharge. This effect on the primary outcome measure, change of Mobility-Barthel until ICU discharge, was observed in three different models for baseline patient characteristics (average treatment effect (ATE), all three models p < 0.001). When mobilisation parameters like level of mobilisation, were included in the analysis, the average treatment effect disappeared [ATE 1.0 (95% CI - 0.4 to 2.4), p = 0.16].

CONCLUSIONS

A mobilisation duration of more than 40 min positively impacts functional outcomes at ICU discharge. However, the maximum level achieved during ICU stay was the most crucial factor regarding adequate dosage, as higher duration did not show an additional benefit in patients with already high mobilisation levels.

TRIAL REGISTRATION

Prospective Registry of Mobilization-, Routine- and Outcome Data of Intensive Care Patients (MOBDB), NCT03666286. Registered 11 September 2018-retrospectively registered, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03666286 .

Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023)

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Physical rehabilitation, mobilization and patient-centred outcomes: what is new?

PURPOSE OF REVIEW

Physical rehabilitation and mobilization interventions aim to reduce the incidence of intensive care unit (ICU)-acquired weakness and subsequently reduce morbidity in critically ill patients. This chapter will explore the evidence for physical rehabilitation and mobilization with an emphasis on patient-centred outcomes selected in randomized controlled trials. This is particularly pertinent at a time when clinicians are deciding how to implement physical rehabilitation and mobilization into the treatment of critically ill patients.

RECENT FINDINGS

Multiple trials of physical rehabilitation and mobilization were published in 2022 and 2023 with conflicting results. Analysing the complexities of physical rehabilitation research provides an insight into these results and will aid in the interpretation of trials of physical rehabilitation and mobilization.

SUMMARY

Patient-centred outcomes are often utilized in physical rehabilitation and mobilization research, but this does not automatically correspond to an increase in research quality. Improving consistency in trials of physical rehabilitation will aid in the interpretation and translation of physical rehabilitation research.

Early goal-directed mobilization in patients with acute type A aortic dissection: A randomized controlled trial

OBJECTIVE

To determine the safety and efficacy of early postoperative mobilization in patients who have undergone surgical repair of acute type A aortic dissection.

DESIGN

Randomized controlled trial.

SETTING

Heart Medical Center.

SUBJECTS

Seventy-seven patients with acute type A aortic dissection were assessed.

INTERVENTION

Patients were randomly allocated into: (1) the control group (usual care) (n  =  38) and (2) the intervention group (early goal-directed mobilization) (n  =  39).

MAIN MEASURES

The primary outcome was the patient's functional status. The secondary outcomes included vital signs, serious adverse events, muscle strength, intensive care unit-acquired weakness, grip strength, duration of mechanical ventilation, length of stay, readmission rate, and health-related quality of life after 3 months.

RESULTS

The vital signs of the patients were within the tolerable ranges during the entire intervention. No serious exercise-related adverse events were observed in the intervention group. The Barthel Index score (P  =  0.013), Medical Research Council score (P  =  0.001), grip strength (P  =  0.001), and health-related quality of life (P  =  0.001) were higher in the intervention group. Intensive care unit acquired weakness (P  =  0.019), duration of mechanical ventilation (P  =  0.002), intensive care unit stay (P  =  0.002), and total length of stay (P  =  0.010) were lower in the intervention group. Patients in the intervention group had a higher physical health-related quality of life (P  =  0.015) at 3 months post-surgery. There was no difference in readmission rates.

CONCLUSIONS

Delivery of early goal-directed mobilization in acute type A aortic dissection was safe and facilitated the recovery of daily living ability, shorter hospital stay, and improved quality of life after discharge.

Effects of Mobilization within 72 h of ICU Admission in Critically Ill Patients: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Previous systematic review and meta-analysis indicates that rehabilitation within a week of intensive care unit (ICU) admission benefits physical function in critically ill patients. This updated systematic review and meta-analysis aim to clarify effects of initiating rehabilitation within 72 h of ICU admission on long-term physical, cognitive, and mental health. We systematically searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for randomized controlled trials (RCTs) between April 2019 and November 2022 to add to the previous review. Two investigators independently selected and extracted data. Pooled effect estimates for muscle strength, cognitive function, mental health after discharge, and adverse events were calculated. Evidence certainty was assessed via Grading of Recommendations, Assessment, Development, and Evaluations. Eleven RCTs were included in the meta-analysis. Early rehabilitation may improve muscle strength (three trials; standard mean difference [SMD], 0.16; 95% confidence interval [CI], -0.04-0.36) and cognitive function (two trials; SMD, 0.54; 95% CI, -0.13-1.20). Contrastingly, early mobilization showed limited impact on mental health or adverse events. In summary, initiating rehabilitation for critically ill patients within 72 h may improve physical and cognitive function to prevent post-intensive care syndrome without increasing adverse events. The effect on mental function remains uncertain.

Implementation of a nurse-led multidisciplinary huddle meeting for improvement of early rehabilitation in ICU: a healthcare quality improvement project

The physical decline of critically ill patients affects their discharge from the intensive care unit (ICU) and their subsequent lives. Therefore, it is essential to actively provide rehabilitation at an early stage through multidisciplinary cooperation and protocols. This paper aims to describe the results of a project to improve the implementation rate of early rehabilitation. We established the ICU Early Rehabilitation Group, consisting of nurses, intensivists and physical therapists, and developed a protocol to perform early rehabilitation. According to this protocol, a nurse-led 'multidisciplinary rehabilitation huddle meeting' was introduced for early rehabilitation. Rehabilitation status, muscle strength and physical function were compared 9 months before and after the introduction of the huddle meeting. In addition, we assessed adverse events during rehabilitation. Since the introduction of huddle meetings, the implementation rate has been 100%. Furthermore, rehabilitation was implemented earlier and at a higher level after introducing huddle meetings. However, no significant difference was detected in muscle strength and physical function of the patients. In addition, no adverse events occurred during rehabilitation. This quality improvement project facilitated an earlier start to rehabilitation and a higher level of rehabilitation practice. Huddle meetings were smoothly introduced and settled in through multiprofessional communication. The lack of adverse events also suggested the programme's effectiveness in safely implementing this type of rehabilitation at an early and high level.

Identifying Comorbid Subtypes of Patients With Acute Respiratory Failure

BACKGROUND

Patients with acute respiratory failure have multiple risk factors for disability following their intensive care unit stay. Interventions to facilitate independence at hospital discharge may be more effective if personalized for patient subtypes.

OBJECTIVES

To identify subtypes of patients with acute respiratory failure requiring mechanical ventilation and compare post-intensive care functional disability and intensive care unit mobility level among subtypes.

METHODS

Latent class analysis was conducted in a cohort of adult medical intensive care unit patients with acute respiratory failure receiving mechanical ventilation who survived to hospital discharge. Demographic and clinical medical record data were collected early in the stay. Clinical characteristics and outcomes were compared among subtypes by using Kruskal-Wallis tests and χ2 tests of independence.

RESULTS

In a cohort of 934 patients, the 6-class model provided the optimal fit. Patients in class 4 (obesity and kidney impairment) had worse functional impairment at hospital discharge than patients in classes 1 through 3. Patients in class 3 (alert patients) had the lowest magnitude of functional impairment (P < .001) and achieved the earliest out-of-bed mobility and highest mobility level of all subtypes (P < .001).

CONCLUSIONS

Acute respiratory failure survivor subtypes identified from clinical data available early in the intensive care unit stay differ in post-intensive care functional disability. Future research should target high-risk patients in early rehabilitation trials in the intensive care unit. Additional investigation of contextual factors and mechanisms of disability is critical to improving quality of life in acute respiratory failure survivors.

A systematic review of the effect of early mobilisation on length of stay for adults in the intensive care unit

BACKGROUND

EM has been hypothesized to help prevent the development of ICU acquired weakness and may therefore result in positive outcomes for ICU patients.

AIM

To establish the impact of Early mobilisation (EM) on adult Intensive Care Unit (ICU) patients in terms of ICU length of stay (LOS), as well as hospital LOS, duration of mechanical ventilation, mortality, and functional independence.

STUDY DESIGN

A Systematic Review. EMBASE, MEDLINE, CINAHL, and the Cochrane Library were searched on 24th November 2020. Included studies and other systematic reviews were hand-searched for further includable studies. The primary outcome was ICU LOS whilst secondary outcomes were duration of MV, mortality, hospital LOS and functional independence. The PRISMA guidelines were utilized to perform the review. Ten randomized controlled trials with a combined total of 1291 patients met inclusion criteria and were scrutinized using the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews. Revman 5.4.1 was used to conduct meta-analysis were possible.

RESULTS

Results were limited by the evidence available for inclusion, in particular small sample sizes. However, a trend towards a shorter duration of ICU LOS and duration of mechanical ventilation emerged. There was also a trend towards higher rates of functional independence for intervention groups. Mortality rates appeared unaffected and results of meta-analysis were statistically non-significant (p = 0.90).

CONCLUSION

By applying a stricter time limit than previous systematic reviews a trend emerged that the commencement of EM has a positive effect on patient outcomes, in particular ICU LOS.

RELEVANCE TO CLINICAL PRACTICE

The evidence base surrounding EM remains poor; however on the balance of the available evidence the application of EM should not be delayed.

Current Practice and Barriers to the Implementation of Mobilization in ICUs in Japan: A Multicenter Prospective Cohort Study

Background: Limited information is currently available on the barriers to implementing mobilization at the bedside for critically ill patients. Therefore, we investigated the current practice of and barriers to the implementation of mobilization in intensive care units (ICU). Methods: A multicenter prospective observational study was conducted at nine hospitals between June 2019 and December 2019. Consecutive patients admitted to the ICU for more than 48 h were enrolled. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically. Results: The 203 patients enrolled in the present study were divided into 69 elective surgical patients and 134 unplanned admission patients. The mean periods of time until the initiation of rehabilitation programs after ICU admission were 2.9 ± 7.7 and 1.7 ± 2.0 days, respectively. Median ICU mobility scales were five (Interquartile range: three and eight) and six (Interquartile range: three and nine), respectively. The most common barriers to mobilization in the ICU were circulatory instability (29.9%) and a physician's order for postoperative bed rest (23.4%) in the unplanned admission and elective surgery groups, respectively. Conclusions: Rehabilitation programs were initiated later for unplanned admission patients and were less intense than those for elective surgical patients, irrespective of the time after ICU admission.

Critical Care Rehabilitation of the Burn Patient

Despite the fact that modern burn care has significantly reduced the mortality associated with severe burn injuries, the rehabilitation and community reintegration of survivors continues to be a challenge. An interprofessional team approach is essential for optimal outcomes. This includes early occupational and physical therapy, beginning in the intensive care unit (ICU). Burn-specific techniques (edema management, wound healing, and contracture prevention) are successfully integrated into the burn ICU. Research demonstrates that early intensive rehabilitation of critically ill burn patients is safe and effective. Further work on the physiologic, functional, and long-term impact of this care is needed.

Impact of a multifaceted early mobility intervention for critically ill children - the PICU Up! trial: study protocol for a multicenter stepped-wedge cluster randomized controlled trial

BACKGROUND

Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery.

METHODS

The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial's primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery.

DISCUSSION

This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04989790. Registered on August 4, 2021.

Association of early mobility with the incidence of deep-vein thrombosis and mortality among critically ill patients: a post hoc analysis of PREVENT trial

BACKGROUND

This study assessed the mobility levels among critically ill patients and the association of early mobility with incident proximal lower-limb deep-vein thrombosis and 90-day mortality.

METHODS

This was a post hoc analysis of the multicenter PREVENT trial, which evaluated adjunctive intermittent pneumatic compression in critically ill patients receiving pharmacologic thromboprophylaxis with an expected ICU stay ≥ 72 h and found no effect on the primary outcome of incident proximal lower-limb deep-vein thrombosis. Mobility levels were documented daily up to day 28 in the ICU using a tool with an 8-point ordinal scale. We categorized patients according to mobility levels within the first 3 ICU days into three groups: early mobility level 4-7 (at least active standing), 1-3 (passive transfer from bed to chair or active sitting), and 0 (passive range of motion). We evaluated the association of early mobility and incident lower-limb deep-vein thrombosis and 90-day mortality by Cox proportional models adjusting for randomization and other co-variables.

RESULTS

Of 1708 patients, only 85 (5.0%) had early mobility level 4-7 and 356 (20.8%) level 1-3, while 1267 (74.2%) had early mobility level 0. Patients with early mobility levels 4-7 and 1-3 had less illness severity, femoral central venous catheters, and organ support compared to patients with mobility level 0. Incident proximal lower-limb deep-vein thrombosis occurred in 1/85 (1.3%) patients in the early mobility 4-7 group, 7/348 (2.0%) patients in mobility 1-3 group, and 50/1230 (4.1%) patients in mobility 0 group. Compared with early mobility group 0, mobility groups 4-7 and 1-3 were not associated with differences in incident proximal lower-limb deep-vein thrombosis (adjusted hazard ratio [aHR] 1.19, 95% confidence interval [CI] 0.16, 8.90; p = 0.87 and 0.91, 95% CI 0.39, 2.12; p = 0.83, respectively). However, early mobility groups 4-7 and 1-3 had lower 90-day mortality (aHR 0.47, 95% CI 0.22, 1.01; p = 0.052, and 0.43, 95% CI 0.30, 0.62; p < 0.0001, respectively).

CONCLUSIONS

Only a small proportion of critically ill patients with an expected ICU stay ≥ 72 h were mobilized early. Early mobility was associated with reduced mortality, but not with different incidence of deep-vein thrombosis. This association does not establish causality, and randomized controlled trials are required to assess whether and to what extent this association is modifiable.

TRIAL REGISTRATION

The PREVENT trial is registered at ClinicalTrials.gov, ID: NCT02040103 (registered on 3 November 2013) and Current controlled trials, ID: ISRCTN44653506 (registered on 30 October 2013).

Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey

BACKGROUND

Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM.

METHODS

A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists).

RESULTS

Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained.

CONCLUSION

Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.

Critical illness-associated weakness and related motor disorders

Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.

Effects of different types and frequencies of early rehabilitation on ventilator weaning among patients in intensive care units: A systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the effects of different types and frequencies of physiotherapy on ventilator weaning among patients in the intensive care unit (ICU) and to identify the optimal type and frequency of intervention.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, and Airiti Library.

STUDY SELECTION

Randomized controlled trials that provided information on the dosage of ICU rehabilitation and the parameters related to ventilator weaning were included.

DATA EXTRACTION AND MANAGEMENT

Treatment types were classified into conventional physical therapy, exercise-based physical therapy, neuromuscular electrical stimulation (NEMS), progressive mobility, and multi-component. The frequencies were divided into high (≥ 2 sessions/day or NEMS of > 60 minutes/day), moderate (one session/day, 3-7 days/week or NEMS of 30-60 minutes/day), and low (one session/day, < 3 days/week, or NEMS of < 30 minutes/day).

DATA SYNTHESIS

Twenty-four articles were included for systematic review and 15 out of 24 articles were analyzed in the meta-analysis. Early rehabilitation, especially the progressive mobility treatment exerted an optimal effect in reducing the ventilator duration in patients in the ICU (standardized mean difference [SMD] = 0.91; 95% confidence interval [CI] = 0.23-1.58; P < 0.01). Regarding the treatment frequency, the high-frequency intervention did not result in a favorable effect on ventilator duration compared with the moderate frequency of treatment (SMD = 0.75; 95% CI = -1.13-2.64; P = 0.43).

CONCLUSION

Early rehabilitation with progressive mobility is highly recommended to decrease the ventilation duration received by patients in the ICU. Depending on clinical resources and the tolerance of patients, the frequency of interventions should reach moderate-to-high frequency, that is, at least one session per day and 3 days a week.

TRIAL REGISTRATION

Registration number: PROSPERO (CRD42021243331).

Functional Recovery Groups in Critically Ill COVID-19 Patients and Their Associated Factors: From ICU to Hospital Discharge

OBJECTIVES

To analyze functional recovery groups of critically ill COVID-19 survivors during their hospital stay and to identify the associated factors.

DESIGN

Prospective observational multicenter study.

SETTING

Demographic, clinical, and therapeutic variables were collected, and physical and functional status were evaluated. The Barthel index was evaluated at three time points: 15 days before hospitalization, at ICU discharge, and at hospital discharge from the ward.

PATIENTS

Patients with functional independence before COVID-19 diagnosis were recruited from four hospitals and followed up until hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Three groups of functional recovery were described for 328 patients: functional independence ( n = 144; 44%), which included patients who preserved their functional status during hospitalization; recovered functionality ( n = 109; 33.2%), which included patients who showed dependence at ICU discharge but recovered their independence by hospital discharge; and functional dependency ( n = 75; 22.8%), which included patients who were dependent at ICU discharge and had not recovered their functional status at hospital discharge. The factors associated with becoming functionally dependent at ICU discharge were time to out-of-bed patient mobilization (odds ratio [OR], 1.20; 95% CI, 1.11-1.29), age (OR, 1.02; 95% CI, 1.01-1.04), hyperglycemia (OR, 2.52; 95% CI, 1.56-4.07), and Simplified Acute Physiology Score (OR, 1.022; 95% CI, 1.01-1.04). Recovery to baseline independence during ward stays was associated with ICU length of stay (OR, 0.97; 95% CI, 0.94-0.99) and muscle strength (Medical Research Council test) at ICU discharge (OR, 1.13; 95% CI, 1.08-1.18).

CONCLUSIONS

Age, hyperglycemia, and time for patient mobilization out of bed were independent factors associated with becoming physically dependent after their ICU stay. Recovery of physical function at hospital discharge was associated with muscle strength at ICU discharge and length of ICU stay.

A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures

Background

Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post–intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes.

Objective

To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures.

Methods

This integrative review used Whittemore and Knafl’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded.

Results

Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes.

Conclusion

Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post–intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.

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.

Barriers and perceived benefits of early mobilisation programmes in Dutch paediatric intensive care units

BACKGROUND

Early mobilisation of critically ill adults has been proven effective and is safe and feasible for critically ill children. However, barriers and perceived benefits of paediatric intensive care unit (PICU) staff involvement in mobilising critically ill children are largely unknown. In this study, we explored the barriers and perceived benefits regarding early mobilisation of critically ill children as perceived by PICU staff.

METHODS

A cross-sectional survey study among staff from seven PICUs in the Netherlands has been carried out.

RESULTS

Two hundred and fifteen of the 641 health care professionals (33.5%) who were invited to complete a questionnaire responded, of whom 159 (75%) were nurses, 40 (19%) physicians, and 14 (6%) physical therapists. Respondents considered early mobilisation potentially beneficial to shorten the duration of mechanical ventilation (86%), improve wake/sleep rhythm (86%) and shorten the length of stay in the PICU (85%). However, staff were reluctant to mobilize patients on extracorporeal membrane oxygenation (ECMO) (63%), and patients with traumatic brain injury (49%). Perceived barriers to early mobilisation were hemodynamic instability (78%), risk of dislocation of lines/tubes (74%), and level of sedation (62%). In total, 40.3% of PICU nurses stated that physical therapists provided enough support in their PICU, but 84.6% of the physical therapists believed support was sufficient.

CONCLUSION

Participating PICU staff considered early mobilisation as potentially beneficial in improving patient outcomes, although barriers were noted in certain patient groups.

RELEVANCE TO PRACTICE

We identified barriers to early mobilisation which should be addressed in implementation research projects in order to make early mobilisation in critically ill children work.

Effect of early mobilization combined with early nutrition on acquired weakness in critically ill patients (EMAS): A dual-center, randomized controlled trial

AIM

The study aimed to investigate the effect of early mobilization combined with early nutrition (EMN) on intensive care unit-acquired weakness (ICU-AW) in intensive care unit (ICU) settings compared with early mobilization (EM) or routine care.

METHODS

A prospective, dual-center, randomized controlled trial was conducted. The control group underwent standard care without a pre-established routine for mobilization and nutrition. The EM group underwent early, individualized, progressive mobilization within 24 h of ICU admission. The EMN group underwent early mobilization, similar to the EM group plus guideline-based early nutrition (within 48 h of ICU admission). The primary outcome was the occurrence of ICU-AW at discharge from the ICU. Secondary outcomes included muscle strength, functional independence, organ failure, nutritional status, duration of mechanical ventilation (MV), length of ICU stay, and ICU mortality at ICU discharge.

RESULTS

A total of 150 patients were enrolled and equally distributed into the three groups. Patients undergoing routine care only were more susceptible to ICU-AW upon ICU discharge than those in the EM or EMN groups (16% vs. 2%; p = 0.014 for both), and had a lower Barthel Index than others (control vs. EM/EMN: 57.5 vs 70.0; p = 0.022). The EMN group had improved muscle strength (p = 0.028) and better nutritional status than the control group (p = 0.031). Both interventions were associated with a lower ICU-AW (EM vs. control: p = 0.027, OR [95% CI] = 0.066 [0.006-0.739]; EMN vs. control: p = 0.016, OR [95% CI] = 0.065 [0.007-0.607]).

CONCLUSION

EM and EMN had positive effects. There was little difference between the effects of EM and EMN, except for muscle strength improvement. Both EM and EMN may lead to a lower occurrence of ICU-AW and better functional independence than standard care. EMN might benefit nutritional status more than usual care and promote improvement in muscle strength.

Functional status recovery trajectories in hospitalised older adults with pneumonia

BACKGROUND AND OBJECTIVES

Pneumonia is associated with significant mortality and morbidity in older adults. We investigated changes in functional status over 6 months after pneumonia hospitalisation by frailty status.

METHODS AND MEASUREMENTS

This single-centre prospective cohort study enrolled 201 patients (mean age 79.4, 37.3% women) who were hospitalised with pneumonia. A deficit-accumulation frailty index (range: 0-1; robust <0.15, pre-frail 0.15-0.24, mild-to-moderately frail 0.25-0.44, severely frail ≥0.45) was calculated on admission. Functional status, defined as self-reported ability to perform 21 activities and physical tasks independently, was measured by telephone at 1, 3 and 6 months after discharge. Group-based trajectory model was used to identify functional trajectories. We examined the probability of each trajectory based on frailty levels.

RESULTS

On admission, 51 (25.4%) were robust, 43 (21.4%) pre-frail, 40 (20.0%) mild-to-moderately frail and 67 (33.3%) severely frail patients. Four trajectories were identified: excellent (14.4%), good (25.4%), poor (28.9%) and very poor (31.3%). The trajectory was more strongly correlated with frailty level on admission than pneumonia severity. The most common trajectory was excellent trajectory (59.9%) in robust patients, good trajectory (74.4%) in pre-frail patients, poor trajectory (85.0%) in mild-to-moderately frail patients and very poor trajectory (89.6%) in severely frail patients. The risk of poor or very poor trajectory from robust to severely frail patients was 11.8%, 25.6%, 92.5% and 100%, respectively.

CONCLUSIONS

Frailty was a strong determinant of lack of functional recovery over 6 months after pneumonia hospitalisation in older adults. Our results call for hospital-based and post-acute care interventions for frail patients.

Improving physical function of patients following intensive care unit admission (EMPRESS): protocol of a randomised controlled feasibility trial

INTRODUCTION

Physical rehabilitation delivered early following admission to the intensive care unit (ICU) has the potential to improve short-term and long-term outcomes. The use of supine cycling together with other rehabilitation techniques has potential as a method of introducing rehabilitation earlier in the patient journey. The aim of the study is to determine the feasibility of delivering the designed protocol of a randomised clinical trial comparing a protocolised early rehabilitation programme including cycling with usual care. This feasibility study will inform a larger multicentre study.

METHODS AND ANALYSIS

90 acute care medical patients from two mixed medical-surgical ICUs will be recruited. We will include ventilated patients within 72 hours of initiation of mechanical ventilation and expected to be ventilated a further 48 hours or more. Patients will receive usual care or usual care plus two 30 min rehabilitation sessions 5 days/week.Feasibility outcomes are (1) recruitment of one to two patients per month per site; (2) protocol fidelity with >75% of patients commencing interventions within 72 hours of mechanical ventilation, with >70% interventions delivered; and (3) blinded outcome measures recorded at three time points in >80% of patients. Secondary outcomes are (1) strength and function, the Physical Function ICU Test-scored measured on ICU discharge; (2) hospital length of stay; and (3) mental health and physical ability at 3 months using the WHO Disability Assessment Schedule 2. An economic analysis using hospital health services data reported with an embedded health economic study will collect and assess economic and quality of life data including the Hospital Anxiety and Depression Scales core, the Euroqol-5 Dimension-5 Level and the Impact of Event Score.

ETHICS AND DISSEMINATION

The study has ethical approval from the South Central Hampshire A Research Ethics Committee (19/SC/0016). All amendments will be approved by this committee. An independent trial monitoring committee is overseeing the study. Results will be made available to critical care survivors, their caregivers, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT03771014.