Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation*:

Sedation in the ICU

AbstractSedation practices are key to improving intensive care unit (ICU) outcomes. Adequate treatment of pain, minimization of sedation, delirium prevention, and improved patient interaction to ensure early rehabilitation and faster ventilator liberation are evidenced-based components of ICU care. Here we review components of appropriate ICU sedation including the use of multicomponent care bundles such as the ABCDEF bundle with a focus on changes in ICU practice that followed the Covid-19 pandemic.

Rehabilitation in children with home invasive mechanical ventilation

Children with home invasive mechanical ventilation need special health care and rehabilitation services due to complications caused by both the pulmonary system and physical inactivity. Children who are dependent on invasive mechanical ventilators due to breathing difficulties and lung problems can benefit from rehabilitation programs. Rehabilitation requires a close relationship between the child, parents and/or caregivers, and healthcare professionals. The main goal of rehabilitation is to improve breathing, lung function and overall quality of life. In this review, although full standard approaches have not been determined yet, rehabilitation approaches for children dependent on home-type invasive mechanical ventilator will be discussed.

The barriers to and facilitators of implementing early mobilisation for patients with delirium on intensive care units: A systematic review

Background

Early mobilisation of critically ill patients remains variable across practice. This study set out to determine barriers to and facilitators of early mobilisation for patients diagnosed with delirium in the intensive care unit (ICU).

Methods

A mixed-methods descriptive systematic review. Electronic databases (AMED, BNI, CINAHL Plus, Cochrane Library, Medline and EMBASE) were searched for publications up to 22nd December 2021. Independent reviewers screened studies and extracted data using Covidence Systematic Review Management software. Data were summarised according to frequency (n/%) of barriers and facilitators. Thematic analysis of qualitative studies was carried out in order to address the secondary aim. Quantitative studies were assessed using the GRADE quality assessment tool. Qualitative studies were analysed according to the GRADE-CERQual quality assessment tool. This study was prospectively registered on PROSPERO (CRD 42021227655).

Results

Ten studies met the inclusion criteria. Quantitative findings demonstrated the presence of delirium was the most common reported barrier to early mobilisation. The most common facilitator was ICU staff experience of positive outcomes as a result of early mobilisation interventions. Thematic analysis identified six main themes that may describe potential meanings behind these findings: (1) knowledge, (2) personal preferences, (3) perceived burden of delirium, (4) perceived complexity, (5) decision-making and (6) culture.

Conclusion

These findings highlight the reported need to further understand the impact and value of early mobilisation as a non-pharmacological intervention for patients diagnosed with delirium in ICU. Evaluation of early mobilisation interventions involving key stakeholders may address these concerns and provide effective implementation strategies.

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

BACKGROUND

Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.

METHODS

A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.

RESULTS

Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions.

CONCLUSIONS

The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention

Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.

Relationship Between Regional Cerebral Oxygen Saturation and Percutaneous Oxygen Saturation at Initial Mobilisation in Patients with Acute Heart Failure

In patients with acute heart failure, early mobilisation is performed according to physical condition, biometric information, and haemodynamic stability. Regional cerebral oxygen saturation (rSO2) is useful in monitoring patients during assisted circulation and cardiac arrest, but the measurement of rSO2 during early mobilisation is not standardised, and its relationship with percutaneous oxygen saturation (SpO2) has not been investigated. This study aimed to investigate the relationship between rSO2 and SpO2 during initial mobilisation in patients with acute heart failure. Patients with acute heart failure who presented to our emergency centre and were referred for physical therapy were included in this study. Data from 21 of the 24 patients who decided to start mobilisation based on the criteria of the Japanese Society of Intensive Care Medicine were analysed. The resting rSO2 was 58.6%, and it significantly changed (p < 0.001), with a decrease in the first half of sitting on the edge of the bed (SEB) and an increase from the second half to the end of the SEB. The resting SpO2 was 96.0%, with a trend towards an increase in the latter half of the SEB (p = 0.05608). Changes in rSO2 during initial mobilisation in patients with acute heart failure differed from those in SpO2.

Pathophysiology and Therapeutic Management of Bone Loss in Patients with Critical Illness

Patients with critical illnesses are at higher risk of comorbidities, which can include bone mineral density loss, bone turnover marker increase, and fragility fractures. Patients admitted to intensive care units (ICUs) have a higher risk of bone fractures. Since hypermetabolism is a characteristic of ICU patients, such patients are often rapidly affected by systemic deterioration, which often results in systemic wasting disease. Major risk factors for ICU-related bone loss include physical restraint, inflammation, neuroendocrine stress, malnutrition, and medications. A medical history of critical illness should be acknowledged as a risk factor for impaired bone metabolism. Bone loss associated with ICU admission should be recognized as a key component of post-intensive care syndrome, and further research that focuses on treatment protocols and prevention strategies is required. Studies aimed at maintaining gut integrity have emphasized protein administration and nutrition, while research is ongoing to evaluate the therapeutic benefits of anti-resorptive agents and physical therapy. This review examines both current and innovative clinical strategies that are used for identifying risk factors of bone loss. It provides an overview of perioperative outcomes and discusses the emerging novel treatment modalities. Furthermore, the review presents future directions in the treatment of ICU-related bone loss.

Efficacy of Early Enhanced Occupational Therapy in an Intensive Care Unit (EFFORT-ICU): A Single-Site Feasibility Trial

IMPORTANCE

This research trial contributes to the evidence for occupational therapy service delivery in intensive care settings.

OBJECTIVE

To explore the feasibility of a trial to evaluate the impact of early enhanced occupational therapy on mechanically ventilated patients in intensive care.

DESIGN

Single-site assessor-blinded randomized controlled feasibility trial.

SETTING

Level 5 8-bed adult medical-surgical intensive care unit (ICU) at Logan Hospital, Brisbane, Australia.

PARTICIPANTS

Participants were 30 mechanically ventilated patients randomly allocated to two groups.

OUTCOMES AND MEASURES

We compared standard care with enhanced occupational therapy with outcomes measured at discharge from the ICU, hospital discharge, and 90 days post randomization. The primary outcome measure was the FIM®. Secondary outcomes included the Modified Barthel Index (MBI); Montreal Cognitive Assessment; grip strength, measured using a dynamometer; Hospital Anxiety and Depression Scale; and the 36-Item Short-Form Health Survey (Version 2). The intervention group received daily occupational therapy, including cognitive stimulation, upper limb retraining, and activities of daily living. Data were analyzed using independent groups t tests and effect sizes.

RESULTS

Measures and procedures were feasible. A significant difference was found between groups on FIM Motor score at 90 days with a large effect size (p = .05, d = 0.76), and MBI scores for the intervention group approached significance (p = .051) with a large effect size (d = 0.75) at 90 days. Further moderate to large effect sizes were obtained for the intervention group for cognitive status, functional ability, and quality of life.

CONCLUSIONS AND RELEVANCE

This trial demonstrated that occupational therapy is feasible and beneficial in the ICU. Criteria to progress to a full-scale randomized controlled trial were met. This study contributes to embedding ongoing consistency of practice and scope of service delivery for occupational therapy in this field. What This Article Adds: Occupational therapists should be considered core team members in the critical care-ICU, with funding to support ongoing service provision and optimization of patient outcomes based on effective and feasible service delivery.

The effects of early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis

Background

The effects of early mobilization (EM) on intensive care unit (ICU) patients remain unclear. A meta-analysis of randomized controlled trials was performed to evaluate its effect in mechanically ventilated adult ICU patients.

Methods

We searched randomized controlled trials (RCTs) published in Medline, Embase, and CENTRAL databases (from inception to November 2022). According to the difference in timing and type, the intervention group was defined as a systematic EM group, and comparator groups were divided into the late mobilization group and the standard EM group. The primary outcome was mortality. The secondary outcomes were ICU length of stay, duration of mechanical ventilation (MV), and adverse events. EM had no impact on 180-day mortality and hospital mortality between intervention groups and comparator groups (RR 1.09, 95% CI 0.89-1.33, p = 0.39). Systemic EM reduced the ICU length of stay (LOS) (MD -2.18, 95% CI -4.22--0.13, p = 0.04) and the duration of MV (MD -2.27, 95% CI -3.99--0.56, p = 0.009), but it may increase the incidence of adverse events in patients compared with the standard EM group (RR 1.99, 95% CI 1.25-3.16, p = 0.004).

Conclusion

Systematic EM has no significant effect on short- or long-term mortality in mechanically ventilated adult ICU patients, but systematic EM could reduce the ICU LOS and duration of MV.

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.

Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial

BACKGROUND

Patients who have received mechanical ventilation can have prolonged cognitive impairment for which there is no known treatment. We aimed to establish whether early mobilisation could reduce the rates of cognitive impairment and other aspects of disability 1 year after critical illness.

METHODS

In this single-centre, parallel, randomised controlled trial, patients admitted to the adult medical-surgical intensive-care unit (ICU), at the University of Chicago (IL, USA), were recruited. Inclusion criteria were adult patients (aged ≥18 years) who were functionally independent and mechanically ventilated at baseline and within the first 96 h of mechanical ventilation, and expected to continue for at least 24 h. Patients were randomly assigned (1:1) via computer-generated permuted balanced block randomisation to early physical and occupational therapy (early mobilisation) or usual care. An investigator designated each assignment in consecutively numbered, sealed, opaque envelopes; they had no further involvement in the trial. Only the assessors were masked to group assignment. The primary outcome was cognitive impairment 1 year after hospital discharge, measured with a Montreal Cognitive Assessment. Patients were assessed for cognitive impairment, neuromuscular weakness, institution-free days, functional independence, and quality of life at hospital discharge and 1 year. Analysis was by intention to treat. This trial was registered with ClinicalTrials.gov, number NCT01777035, and is now completed.

FINDINGS

Between Aug 11, 2011, and Oct 24, 2019, 1222 patients were screened, 200 were enrolled (usual care n=100, intervention n=100), and one patient withdrew from the study in each group; thus 99 patients in each group were included in the intention-to-treat analysis (113 [57%] men and 85 [43%] women). 65 (88%) of 74 in the usual care group and 62 (89%) of 70 in the intervention group underwent testing for cognitive impairment at 1 year. The rate of cognitive impairment at 1 year with early mobilisation was 24% (24 of 99 patients) compared with 43% (43 of 99) with usual care (absolute difference -19·2%, 95% CI -32·1 to -6·3%; p=0·0043). Cognitive impairment was lower at hospital discharge in the intervention group (53 [54%] 99 patients vs 68 [69%] 99 patients; -15·2%, -28·6 to -1·7; p=0·029). At 1 year, the intervention group had fewer ICU-acquired weaknesses (none [0%] of 99 patients vs 14 [14%] of 99 patients; -14·1%; -21·0 to -7·3; p=0·0001) and higher physical component scores on quality-of-life testing than did the usual care group (median 52·4 [IQR 45·3-56·8] vs median 41·1 [31·8-49·4]; p<0·0001). There was no difference in the rates of functional independence (64 [65%] of 99 patients vs 61 [62%] of 99 patients; 3%, -10·4 to 16·5%; p=0·66) or mental component scores (median 55·9 [50·2-58·9] vs median 55·2 [49·5-59·7]; p=0·98) between the intervention and usual care groups at 1 year. Seven adverse events (haemodynamic changes [n=3], arterial catheter removal [n=1], rectal tube dislodgement [n=1], and respiratory distress [n=2]) were reported in six (6%) of 99 patients in the intervention group and in none of the patients in the usual care group (p=0·029).

INTERPRETATION

Early mobilisation might be the first known intervention to improve long-term cognitive impairment in ICU survivors after mechanical ventilation. These findings clearly emphasise the importance of avoiding delays in initiating mobilisation. However, the increased adverse events in the intervention group warrants further investigation to replicate these findings.

FUNDING

None.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

BACKGROUND

While early mobilization is commonly implemented in intensive care unit treatment guidelines to improve functional outcome, the characterization of the optimal individual dosage (frequency, level or duration) remains unclear. The aim of this study was to demonstrate that artificial intelligence-based clustering of a large ICU cohort can provide individualized mobilization recommendations that have a positive impact on the likelihood of being discharged home.

METHODS

This study is an analysis of a prospective observational database of two interdisciplinary intensive care units in Munich, Germany. Dosage of mobilization is determined by sessions per day, mean duration, early mobilization as well as average and maximum level achieved. A k-means cluster analysis was conducted including collected parameters at ICU admission to generate clinically definable clusters.

RESULTS

Between April 2017 and May 2019, 948 patients were included. Four different clusters were identified, comprising "Young Trauma," "Severely ill & Frail," "Old non-frail" and "Middle-aged" patients. Early mobilization (< 72 h) was the most important factor to be discharged home in "Young Trauma" patients (OR_adj 10.0 [2.8 to 44.0], p < 0.001). In the cluster of "Middle-aged" patients, the likelihood to be discharged home increased with each mobilization level, to a maximum 24-fold increased likelihood for ambulating (OR_adj 24.0 [7.4 to 86.1], p < 0.001). The likelihood increased significantly when standing or ambulating was achieved in the older, non-frail cluster (OR_adj 4.7 [1.2 to 23.2], p = 0.035 and OR_adj 8.1 [1.8 to 45.8], p = 0.010).

CONCLUSIONS

An artificial intelligence-based learning approach was able to divide a heterogeneous critical care cohort into four clusters, which differed significantly in their clinical characteristics and in their mobilization parameters. Depending on the cluster, different mobilization strategies supported the likelihood of being discharged home enabling an individualized and resource-optimized mobilization approach.

TRIAL REGISTRATION

Clinical Trials NCT03666286, retrospectively registered 04 September 2018.

Changes in Physiological Indices Before and After Nursing Care of Postoperative Patients With Esophageal Cancer in the ICU

Introduction

Various stressors have been identified in patients in the intensive care unit (ICU), including postoperative pain, ventilatory management, and nursing care. However, sedated patients are less responsive, and nurses have difficulty capturing their stressors.

Objective

To investigate patient stress caused by nursing care performed in the ICU on sedated patients based on changes in physiological indices.

Methods

We observed nursing care performed on patients with postoperative esophageal cancer under sedation in the ICU. This included endotracheal suctioning and turning, the time required for the care, and the patients' behavioral responses. Information on arousal levels, autonomic nervous system indices, and vital signs were also obtained. The changes in indicators before and after care were then compared and analyzed.

Results

There were 14 patients in the study. The mean age of the patients was 68 years. Ninety-nine scenes of nursing care were observed, and in six of these, additional bolus sedation was administered because of the patient's significant body movements. In endotracheal suctioning, no significant changes were observed in all indicators. In turning, vital signs changed significantly, and when both were continued, all indicators changed significantly.

Conclusion

Our study found that different types and combinations of nursing care may cause different stresses to the patients. Moreover, the autonomic nervous system indices may be more likely to react to stresses in a variety of nursing care, while arousal levels may be more likely to react to burdensome stresses. If the characteristics of these physiological indicators can be understood and effectively utilized during care, it may be possible to better identify and reduce patient stress during sedation management.

Early Intensive Physical Rehabilitation Combined with a Protocolized Decannulation Process in Tracheostomized Survivors from Severe COVID-19 Pneumonia with Chronic Critical Illness

(1) Background: Intensive care unit (ICU) survivors from severe COVID-19 acute respiratory distress syndrome (CARDS) with chronic critical illness (CCI) may be considered vast resource consumers with a poor prognosis. We hypothesized that a holistic approach combining an early intensive rehabilitation with a protocol of difficult weaning would improve patient outcomes (2) Methods: A single-center retrospective study in a five-bed post-ICU weaning and intensive rehabilitation center with a dedicated fitness room specifically equipped to safely deliver physical activity sessions in frail patients with CCI. (3) Results: Among 502 CARDS patients admitted to the ICU from March 2020 to March 2022, 50 consecutive tracheostomized patients were included in the program. After a median of 39 ICU days, 25 days of rehabilitation were needed to restore patients’ autonomy (ADL, from 0 to 6; p < 0.001), to significantly improve their aerobic capacity (6-min walking test distance, from 0 to 253 m; p < 0.001) and to reduce patients’ vulnerability (frailty score, from 7 to 3; p < 0.001) and hospital anxiety and depression scale (HADS, from 18 to 10; p < 0.001). Forty-eight decannulated patients (96%) were discharged home. (4) Conclusions: A protocolized weaning strategy combined with early intensive rehabilitation in a dedicated specialized center boosted the physical and mental recovery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Changes in barriers to implementing early mobilization in the intensive care unit: a single center retrospective cohort study

This study was undertaken to investigate the rate of mobilization, defined as a rehabilitation level of sitting on the edge of a bed or higher, and its association with changes in barriers in the intensive care unit (ICU). Consecutive patients from January 2016 to March 2019 admitted to the ICU, 18 years old or older, who did not meet exclusion criteria, were eligible. The primary outcome was the rate of mobilization. Barriers, their changes on a daily basis, and clinical outcomes, such as walking independence at hospital discharge, were also investigated. The association between the barriers and mobilization, and walking independence were analyzed by multivariate logistic regression analysis. During the study period, 177 patients were enrolled. Mobilization was achieved by 116 patients (66%) by the 7th ICU day. The barrier to mobilization was circulatory status on days 1 and 2, consciousness level on days 3 to 5, and medical staff factors on days 6 and 7. Multivariate analysis showed that consciousness level (OR: 0.38, p=0.01), and medical staff factors (OR: 0.49, p=0.01) were significantly associated with mobilization. By hospital discharge 125 patients (71%) could walk independently. Consciousness level was associated (OR: 0.52, p=0.04) with walking independence. In this study, over half of patients could achieve mobilization within the first 7 days. Barriers to mobilization in the ICU change over time. Consciousness level is significantly associated with both mobilization and independent walking at discharge.

Choosing Wisely For Critical Care: The Next Five

OBJECTIVES

To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care.

DATA SOURCES

Semistructured narrative literature review and quantitative survey assessments.

STUDY SELECTION

English language publications that examined critical care practices in relation to reducing cost or waste.

DATA EXTRACTION

Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking.

DATA SYNTHESIS

Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices.

CONCLUSIONS

Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.

Early Mobility for Critically Ill Patients: Building Staff Commitment Through Appreciative Inquiry

BACKGROUND

Immobility contributes to many adverse effects in critically ill patients. Early progressive mobility can mitigate these negative sequelae but is not widely implemented. Appreciative inquiry is a quality improvement method/change philosophy that builds on what works well in an organization.

OBJECTIVES

To explore whether appreciative inquiry would reinvigorate an early progressive mobility initiative in a medical intensive care unit and improve and sustain staff commitment to providing regular mobility therapy at the bedside. Secondary goals were to add to the literature about appreciative inquiry in health care and to determine whether it can be adapted to critical care.

METHODS

Staff participated in appreciative inquiry workshops, which were conducted by a trained facilitator and structured with the appreciative inquiry 4-D cycle. Staff members' attitudes toward and knowledge of early progressive mobility were evaluated before and after the workshops. Performance of early progressive mobility activities was recorded before and 3 and 10 months after the workshops.

RESULTS

Sixty-seven participants completed the program. They rated the workshops as successfully helping them to understand the importance of early progressive mobility (98%), explain their responsibility to improve patient outcomes (98%), and engender a greater commitment to patients and the organization (96%). Regarding mobility treatments, at 3 months orders had improved from 62% to 88%; documentation, from 52% to 89%; and observation, from 39% to 87%. These improvements were maintained at 10 months.

CONCLUSION

Participation in the workshops improved the staff's attitude toward and performance of mobility treatments. Appreciative inquiry may provide an adjunct to problem-based quality improvement techniques.

Implementation of an Interdisciplinary AACN Early Mobility Protocol

BACKGROUND

Increasing mobility in the intensive care unit is an important part of the ABCDEF bundle. Objective To examine the impact of an interdisciplinary mobility protocol in 7 specialty intensive care units that previously implemented other bundle components.

METHODS

A staggered quality improvement project using the American Association of Critical-Care Nurses mobility protocol was conducted. In phase 1, data were collected on patients with intensive care unit stays of 24 hours or more for 2 months before and 2 months after protocol implementation. In phase 2, data were collected on a random sample of 20% of patients with an intensive care unit stay of 3 days or more for 2 months before and 12 months after protocol implementation.

RESULTS

The study population consisted of 1266 patients before and 1420 patients after implementation in phase 1 and 258 patients before and 1681 patients after implementation in phase 2. In phase 1, the mean (SD) mobility level increased in all intensive care units, from 1.45 (1.03) before to 1.64 (1.03) after implementation (P < .001). Mean (SD) ICU Mobility Scale scores increased on initial evaluation from 4.4 (2.8) to 5.0 (2.8) (P = .01) and at intensive care unit discharge from 6.4 (2.5) to 6.8 (2.3) (P = .04). Complications occurred in 0.2% of patients mobilized. In phase 2, 84% of patients had out-of-bed activity after implementation. The time to achieve mobility levels 2 to 4 decreased (P = .05). Intensive care unit length of stay decreased significantly in both phases.

CONCLUSIONS

Implementing the American Association of Critical-Care early mobility protocol in intensive care units with ABCDEF components in place can increase mobility levels, decrease length of stay, and decrease delirium with minimal complications.

Nurses' Perceptions of Barriers to Out-of-Bed Activities Among Patients Receiving Mechanical Ventilation

BACKGROUND

Delays in early patient mobility are common in critical care areas. Oral intubation with mechanical ventilation is negatively associated with out-of-bed activities.

OBJECTIVES

To explore nurses' mobility practices for patients with oral intubation and mechanical ventilation and identify barriers related to patient, nurse, and environment-of-care factors specific to this population.

METHODS

In this cross-sectional, descriptive study in a medical intensive care unit, mobility was defined as standing, sitting in a chair, or walking. A total of 105 patients who met predefined mobility criteria and their 48 nurses were enrolled. Nurses were interviewed about mobility practices at the ends of shifts. Descriptive statistics summarized nurse and patient characteristics and mobility barriers.

RESULTS

Patients were deemed ready to begin mobility within a mean (SD) of 41.5 (34.8) hours after oral endotracheal intubation. Two-thirds of nurses reported that they never or rarely got these patients out of bed. Only 12.4% of patients had a clinician's activity order. Common patient-related barriers were uncooperative behavior (21.9%) and active medical issues (15%), even in patients who met mobility criteria. Nurse-related barriers were concerns for patient safety, specifically falls (14.3% of patients) and harm (9.5%). The environment of care posed very few barriers; nurses rarely mentioned that lack of help (13.3% of patients) or lack of clinician's activity order (5.7%) impeded mobility.

CONCLUSIONS

Mobility practices were nonexistent in these patients despite patients' being deemed ready to begin out-of-bed activities. Nurses must be attentive to their unit's mobility culture to overcome these barriers.

Risk Factors of Patient-Related Safety Events during Active Mobilization for Intubated Patients in Intensive Care Units-A Multi-Center Retrospective Observational Study

The aim of this study is to clarify the incidence and risk factors of patient-related safety events (PSE) in situations limited to intubated patients in which active mobilization, such as sitting on the edge of the bed/standing/walking, was carried out. A multi-center retrospective observational study was conducted at nine hospitals between January 2017 and March 2018. The safety profiles and PSE of 87 patients were analyzed. PSE occurred in 10 out of 87 patients (11.5%) and 13 out of 198 sessions (6.6%). The types of PSE that occurred were hypotension (8, 62%), heart rate instability (3, 23%), and desaturation (2, 15%). Circulation-related events occurred in 85% of overall cases. No accidents, such as line/tube removal or falls, were observed. The highest incidence of PSE was observed during the mobilization level of standing (8 out of 39 sessions, 20.5%). The occurrence of PSE correlated with the highest activity level under logistic regression analysis. Close vigilance is required for intubated patients during active mobilization in the standing position with regard to circulatory dynamics.

Adverse Events in Intensive Care and Continuing Care Units During Bed-Bath Procedures: The Prospective Observational NURSIng during critical carE (NURSIE) Study

OBJECTIVES

Standard nursing interventions, especially bed-baths, in ICUs can lead to complications or adverse events defined as a physiologic change that can be life-threatening or that prolongs hospitalization. However, the frequency and type of these adverse events are rarely reported in the literature. The primary objective of our study was to describe the proportion of patients experiencing at least one serious adverse event during bed-bath. The secondary objectives were to determine the incidence of each type of serious adverse event and identify risk factors for these serious adverse events.

DESIGN

Prospective multicenter observational study.

SETTING

Twenty-four ICUs in France, Belgium, and Luxembourg.

PATIENTS

The patients included in this study had been admitted to an ICU for less than 72 hours and required at least one of the following treatments: invasive ventilation, vasopressors, noninvasive ventilation, high-flow oxygen therapy. Serious adverse events were defined as cardiac arrest, accidental extubation, desaturation and/or mucus plugging/inhalation, hypotension and/or arrhythmia and/or agitation requiring therapeutic intervention, acute pain, accidental disconnection or dysfunction of equipment, and patient fall requiring additional assistance.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The study included 253 patients from May 1, 2018, to July 31, 2018 in 24 ICUs, representing 1,529 nursing procedures. The mean Simplified Acute Physiology Score II was 54 ± 19. Nursing care was administered by an average of 2 ± 1 caregivers and lasted between 11 and 20 minutes. Of the 253 patients included, 142 (56%) experienced at least one serious adverse event. Of the 1,529 nursing procedures, 295 (19%) were complicated by at least one serious adverse event. In multivariate analysis, the factors associated with serious adverse event were as follows: presence of a specific protocol (p = 0.011); tracheostomy (p = 0.032); administration of opioids (p = 0.007); presence of a physician (p = 0.0004); duration of nursing care between 6 and 10 minutes (p = 0.003), duration of nursing care between 11 and 20 minutes (p = 0.005), duration of nursing care greater than 40 minutes (p = 0.04) with a reference duration of nursing care between 20 and 40 minutes.

CONCLUSIONS

Serious adverse events were observed in one-half of patients and concerned one-fifth of nurses, confirming the need for caution. Further studies are needed to test systematic serious adverse event prevention strategies.

Effect of Graded Early Mobilization on Psychomotor Status and Length of Intensive Care Unit Stay in Mechanically Ventilated Patients

Introduction

The main purpose of this study was to evaluate the effectiveness of graded early mobilization on psychomotor status and duration of ICU stay of patients with mechanical ventilation.

Materials and methods

Results

In the control group mean FIM score was 17.40 (SD±4.88), and in the intervention group mean score was 65.70 (SD±12.18). The mean difference was statistically significant in the ‘t’ test (p-value > 0.001). In the control group, the mean GAD-7 score was 19.50 (SD±2.71), and in the intervention group the mean GAD-7 score was 7.5 (SD±2.59). The mean difference was statistically significant in the ‘t’ test. (p-value > 0.001). The mean length of ICU stay in the control group was 5.60 (SD±1.07) and in the intervention group it was 3.10 (SD±0.56). The mean difference was statistically significant in the ‘t’ test (p-value > 0.001).

Conclusion

This research showed that graded early mobilization was highly effective to improve the motor and psychological status of mechanically ventilated patients and reduce their length of ICU stay.

How to cite this article

Das B, Saha S, Kabir F, Hossain S. Effect of Graded Early Mobilization on Psychomotor Status and Length of Intensive Care Unit Stay in Mechanically Ventilated Patients. Indian J Crit Care Med 2021;25(4):416–420.

Safety and Feasibility of Physical Rehabilitation and Active Mobilization in Patients Requiring Continuous Renal Replacement Therapy: A Systematic Review

OBJECTIVES

To evaluate the safety and feasibility of physical rehabilitation and active mobilization in patients requiring continuous renal replacement therapy in the ICU.

DATA SOURCES

Medline, CINAHL, PubMed, Pedro, and Cochrane Library were used to extract articles focused on physical activity and mobility in this population.

STUDY SELECTION

Research articles were included in this review if 1) included adult patients greater than or equal to 18 years old requiring continuous renal replacement therapy located in the ICU; 2) described physical rehabilitation, active mobilization, or physical activity deliverables; 3) reported data on patient safety and/or feasibility. The primary outcome was safety, defined as number of adverse events per total number of sessions.

DATA EXTRACTION

Five-hundred seven articles were evaluated based on title and abstract with reviewers selecting 46 to assess by full text. Fifteen observational studies were included for final analysis with seven studies focused solely on physical activity in patients requiring continuous renal replacement therapy.

DATA SYNTHESIS

Four-hundred thirty-seven adult ICU patients requiring continuous renal replacement therapy participated in some form of physical rehabilitation, physical activity, or active mobilization. Two major adverse events (hypotension event requiring vasopressor and continuous renal replacement therapy tube disconnection, pooled occurrence rate 0.24%) and 13 minor adverse events (pooled occurrence rate 1.55%) were reported during a total of 840 individual mobility or activity sessions. Intervention fidelity was limited by a low prevalence of higher mobility with only 15.5% of incidences occurring at or above level 5 of ICU Mobility Scale (transfer to chair, marching in place or ambulation away from bed, 122/715 reports). Feasibility in the provision of these interventions and/or continuous renal replacement therapy-specific deliverables was inconsistently reported.

CONCLUSIONS

Early rehabilitation and mobilization, specifically activity in and near the hospital bed, appears safe and mostly feasible in ICU patients requiring continuous renal replacement therapy. A cautious interpretation of these data is necessary due to limited aggregate quality of included studies, heterogeneous reporting, and overall low achieved levels of mobility potentially precluding the occurrence or detection of adverse events.

Patient-Level Barriers and Facilitators to Early Mobilization and the Relationship With Physical Disability Post-Intensive Care: Part 2 of an Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health

BACKGROUND

Early mobilization (EM) is associated with reduced physical disability post-intensive care (PD PIC). Yet, contextual factors facilitate or impede delivery of EM in the intensive care unit (ICU). Only 45% of ICUs in the United States routinely practice EM despite its recognized benefits.

OBJECTIVES

To analyze the evidence on the relationship between critical care EM, PD PIC, and personal (patient-level) factors, using the theoretical lens of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF).

METHOD

The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the World Health Organization ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized.

RESULTS

Early mobilization delivery was influenced by personal factors. Deeper sedation level, the presence of delirium, higher patient acuity, the presence of medical devices, and patient weight were identified barriers to EM delivery. Patient engagement in EM was associated with improved delivery. Patients who enjoyed rehabilitation were more likely to demonstrate improvement in functional impairment than those who did not enjoy rehabilitation.

DISCUSSION

Early mobilization is associated with reduced PD PIC, yet numerous contextual factors affect the delivery of EM in the ICU. Further study of patient-level factors and EM must explore the relationship between patient engagement, baseline demographics, and functional status at ICU admission, patient-level considerations for decisions to mobilize, and EM in the ICU. This research is critical to improving the delivery of EM in the ICU and reducing PD PIC.

Respiratory Support Adjustments and Monitoring of Mechanically Ventilated Patients Performing Early Mobilization: A Scoping Review

Supplemental Digital Content is available in the text.

Objectives:

This scoping review is aimed to summarize current knowledge on respiratory support adjustments and monitoring of metabolic and respiratory variables in mechanically ventilated adult patients performing early mobilization.

Data Sources:

Eight electronic databases were searched from inception to February 2021, using a predefined search strategy.

Study Selection:

Two blinded reviewers performed document selection by title, abstract, and full text according to the following criteria: mechanically ventilated adult patients performing any mobilization intervention, respiratory support adjustments, and/or monitoring of metabolic/respiratory real-time variables.

Data Extraction:

Four physiotherapists extracted relevant information using a prespecified template.

Data Synthesis:

From 1,208 references screened, 35 documents were selected for analysis, where 20 (57%) were published between 2016 and 2020. Respiratory support settings (ventilatory modes or respiratory variables) were reported in 21 documents (60%). Reported modes were assisted (n = 11) and assist-control (n = 9). Adjustment of variables and modes were identified in only seven documents (20%). The most frequent respiratory variable was the Fio₂, and only four studies modified the level of ventilatory support. Mechanical ventilator brand/model used was not specified in 26 documents (74%). Monitoring of respiratory, metabolic, and both variables were reported in 22 documents (63%), four documents (11%) and 10 documents (29%), respectively. These variables were reported to assess the physiologic response (n = 21) or safety (n = 13). Monitored variables were mostly respiratory rate (n = 26), pulse oximetry (n = 22), and oxygen consumption (n = 9). Remarkably, no study assessed the work of breathing or effort during mobilization.

Conclusions:

Little information on respiratory support adjustments during mobilization of mechanically ventilated patients was identified. Monitoring of metabolic and respiratory variables is also scant. More studies on the effects of adjustments of the level/mode of ventilatory support on exercise performance and respiratory muscle activity monitoring for safe and efficient implementation of early mobilization in mechanically ventilated patients are needed.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.

A cross-sectional study of early mobility practice in intensive care units in Sarawak Hospitals, Malaysia

Aims

To determine the prevalence, characteristics of EM activities, the relationship between level of activity and mode of ventilation and adherence rate of EM protocol.

Background

Mobilizing ICU patients remains a challenge, despite its safety, feasibility and positive short-term outcomes.

Design

A cross-sectional point prevalence study.

Methods

All patients who were eligible and admitted to the adult ICUs during March 2018 were recruited. Data were analysed by using the Statistical Package for Social Sciences version 24 for Windows.

Results

The prevalence of EM practice was 65.6%. The most frequently reported avoidable and unavoidable factors inhibit mobility were deep sedation and vasopressor infusion, respectively. Level II of activity was the most common level of activity performed in ICU patients. The invasive ventilated patient had 12.53 the odds to stay in bed as compared to non-invasive ventilated patient. An average adherence rate of EM protocol was 52.5%.

Effect of non-sedation on physical function in survivors of critical illness - A substudy of the NONSEDA randomized trial

PURPOSE

Critical illness impairs physical function. The NONSEDA trial was a multicenter randomized trial, assessing non-sedation versus sedation during mechanical ventilation. The aim of this sub-study was to assess the effect of non-sedation on physical function.

METHODS

All patients from one NONSEDA trial site were included. At ICU discharge and three months thereafter, survivors were assessed for physical function.

RESULTS

205 patients were included, 118 survived to follow-up, 116 participated (98%).

PRIMARY OUTCOME

Three months after ICU-discharge, health-related quality of life (SF-36, physical component score) was similar (non-sedated 38.3 vs sedated 36.6, mean difference 1.7, 95% CI -1.7 to 5.1), as was function in activities of daily living (Barthel Index, non-sedated 19.5 vs sedated 18, median difference 1.5, 95% CI -0.2 to 3.2).

SECONDARY OUTCOMES

Non-sedated patients had a better Barthel Index at ICU-discharge (median 9 vs 4, median difference 5, 95% CI 2.5 to 7.5). At three months post-ICU discharge, the two groups did not differ regarding handgrip strength, walking distance, muscle size or biomechanical data.

CONCLUSION

Non-sedation did not lead to improved quality of life regarding physical function or better function in activities of everyday living. Non-sedated patients had a better physical recovery at ICU discharge.

TRIAL REGISTRATION

Clinicaltrials.govNCT02034942, registered January 14., 2014.

The Economic and Clinical Impact of an Early Mobility Program in the Trauma Intensive Care Unit: A Quality Improvement Project

Traumatic injury survivors often face a difficult recovery. Surgical and invasive procedures, prolonged monitoring in the intensive care unit (ICU), and constant preventive vigilance by medical staff guide standards of care to promote positive outcomes. Recently, patients with traumatic injuries have benefited from early mobilization, a multidisciplinary approach to increasing participation in upright activity and walking. The purpose of this project was to determine the impact of an early mobility program in the trauma ICU on length of stay (LOS), ventilator days, cost, functional milestones, and rehabilitation utilization. A quality improvement project compared outcomes and cost before and after the implementation of an early mobility program. The trauma team assigned daily mobility levels to trauma ICU patients. Nursing and rehabilitation staff collaborated to set daily goals and provide mobility-based interventions. Forty-four patients were included in the preintervention group and 43 patients in the early mobility group. Physical therapy and occupational therapy were initiated earlier in the early mobilization group (p = .044 and p = .026, respectively). Improvements in LOS, duration of mechanical ventilation, time to out-of-bed activity and walking, and discharge disposition were not significant. There were no adverse events related to the early mobility initiative. Activity intolerance resulted in termination of 7.1% of mobility sessions. The development and initiation of a trauma-specific early mobility program proved to be safe and reduce patient care costs. In addition, the program facilitated earlier initiation of physician and occupational therapies. Although not statistically significant, retrospective data abstraction provides evidence of fewer ICU and total hospital days, earlier extubations, and greater proactive participation in functional activities.

Chemoradiation therapy for oesophageal cancer with airway stenosis under mechanical ventilation with light sedation using dexmedetomidine alone

For malignant tumours, treatment is rarely indicated in cases requiring mechanical ventilation management because such intensive care would engender a decrease in performance status. However, light sedation using dexmedetomidine might enable chemoradiation while accommodating activities of daily living. We experienced two cases of fatal tracheal invasion and airway stenosis of stage Ⅳ oesophageal cancer that were treated with chemoradiation or radiation under mechanical ventilation (one case was differential lung ventilation.) with dexmedetomidine alone and rehabilitation was performed under a ventilator. Early mobilisation by light sedation with dexmedetomidine can inhibit performance status decline attributable to mechanical ventilation. Bridging tracheal intubation with light sedation by dexmedetomidine for temporary chemoradiation therapy to reduce tumour volume might present a good alternative for patients with malignant tumour.

Impressions of aquatic therapy treatment in children with prolonged mechanical ventilation - clinician and family perspectives: a qualitative case study

PURPOSE

To describe the experiences of applying aquatic therapy (AT) to children with ventilation needs after discharge from the paediatric intensive care unit (PICU).

MATERIAL AND METHODS

A qualitative and descriptive case study with integrated units. Purposive sampling was carried out, including the parents of the children participating in the AT programme and the healthcare professionals treating them. Fourteen participants were included: four parents, five physicians, three physiotherapists and two nurses. The study was carried out as part of a program on AT in critically ill children. Semi-structured interviews were conducted. A thematic analysis was performed.

RESULTS

Three themes were identified. Theme (1) Difficulties for implementation: AT was not perceived as a viable therapeutic modality; lack of knowledge and resources. Theme (2) Risks and challenges: Perceptions of anxiety at the beginning; planning and precautions. Theme (3) AT facilitates new possibilities and benefits: The necessity of the presence of parents during the AT session; a sense of "normalcy;" outcomes of AT in relation to post-intensive care syndrome.

CONCLUSIONS

Our results will help to better understand a safe and feasible way to work with children with PPMV, even though this approach is not yet widespread due to its special circumstances. These results can be used in future AT programmes in children undergoing special treatments.IMPLICATIONS FOR REHABILITATIONChildren with ventilation needs after discharge from the intensive care unit present physical, cognitive, and mental alterations that decrease functional capacity and quality of life.In a relatively small sample, positive outcomes were found for AT in relation to post-intensive care syndrome, enabling children to participate in aquatic therapy activities with the involvement of parents.This study highlighted the positive impact on the quality of life of both children and their parents.Aquatic therapy is a feasible intervention in children requiring prolonged mechanical ventilation, although certain difficulties should be addressed in terms of implementation, together with challenges regarding safety and planning.These difficulties may be overcome by promoting coordination between professionals, creating security protocols, and/or facilitating specialised education for therapists.

Very early exercise tailored by decisional algorithm helps relieve discomfort in ICU patients: an open-label pilot study

BACKGROUND

Existing algorithms do not allow for setting up finely tuned progression or intensity for exercise training in intensive care units (ICUs).

AIM

We aimed to assess the feasibility and tolerance of a very early exercise program tailored by using decisional algorithm that integrated both progression and intensity.

DESIGN

Open-label pilot study.

SETTING

ICU.

POPULATION

Thirty adults hospitalized in ICU.

METHODS

Once a day, patients performed manual range of motion, cycloergometry, and functional training exercises. The progression and intensity of training were standardized by using the constructed algorithm. The main outcome, discomfort on a 0-100 Visual Analog Scale, was assessed before and after each exercise session. Secondary outcomes were muscle strength, ICU length of stay and adverse events related to exercise.

RESULTS

Overall, 125 exercise sessions were performed. Discomfort during exercise sessions decreased significantly by the fifth session (P=0.049). Early exercise sessions were feasible and did not produce major adverse events.

CONCLUSIONS

We confirmed the safety and feasibility of very early exercise programs in ICUs. Early exercise tailored by using a decisional algorithm helps relieve the discomfort of ICU patients.

CLINICAL REHABILITATION IMPACT

In everyday practice, the use of decisional algorithms should be encouraged to initiate and standardize early exercise in ICUs.

The Effects of Early Mobilization on Patients Requiring Extended Mechanical Ventilation Across Multiple ICUs

Objectives

1) To successfully implement early mobilization of individuals with prolonged mechanical ventilation in multiple ICUs at a tertiary care hospital and 2) to reduce length of stay and improve quality of care to individuals in the ICUs.

Design

Comparative effectiveness cohort study based on a quality improvement project.

Setting

Five ICUs at a tertiary care hospital.

Patients

A total of 541 mechanically ventilated patients over a 2-year period (2014-2015): 280 and 261, respectively. Age ranged from 19 to 94 years (mean, 63.84; sd, 14.96).

Interventions

A hospital-based initiative spurred development of a multidisciplinary team, tasked with establishing early mobilization in ICUs.

Measurements and Main Results

Early mobilization in the ICUs was evaluated by the number of physical therapy consults, length of stay, individual treatment sessions utilizing functional outcomes, and follow-up visits. Implementation of an early mobilization protocol across all ICUs led to a significant increase in the number of physical therapy consults, a significant decrease in ICU and overall lengths of stay, significantly shorter days to implement physical therapy, and a significantly higher physical therapy follow-up rate.

Conclusions

Mobilizing individuals in an intensive care setting decreases length of stay and hospital costs. With an interdisciplinary team to plan, implement, and evaluate stages of the program, a successful early mobilization program can be implemented across all ICUs simultaneously and affect change in patients who will require prolonged mechanical ventilation.

Occupational Therapy in the ICU: A Scoping Review of 221 Documents

OBJECTIVES

Occupational therapists have specialized expertise to enable people to perform meaningful "occupations" that support health, well-being, and participation in life roles. Given the physical, cognitive, and psychologic disability experienced by ICU survivors, occupational therapists could play an important role in their recovery. We conducted a scoping review to determine the state of knowledge of interventions delivered by occupational therapists in adult ICU patients.

DATA SOURCES

Eight electronic databases from inception to 05/2018.

STUDY SELECTION

We included reports of adult patients receiving direct patient care from an occupational therapist in the ICU, all study designs, and quantitative and qualitative traditions.

DATA EXTRACTION

Independently in duplicate, interprofessional team members screened titles, abstracts, and full texts and extracted report and intervention characteristics. From original research articles, we also extracted study design, number of patients, and primary outcomes. We resolved disagreements by consensus.

DATA SYNTHESIS

Of 50,700 citations, 221 reports met inclusion criteria, 74 (79%) published after 2010, and 125 (56%) appeared in critical care journals. The three most commonly reported types of interventions were mobility (81%), physical rehabilitation (61%), and activities of daily living (31%). We identified 46 unique original research studies of occupational therapy interventions; the most common study research design was before-after studies (33%).

CONCLUSIONS

The role of occupational therapists in ICU rehabilitation is not currently well established. Current interventions in the ICU are dominated by physical rehabilitation with a growing role in communication and delirium prevention and care. Given the diverse needs of ICU patients and the scope of occupational therapy, there could be an opportunities for occupational therapists to expand their role and spearhead original research investigating an enriched breadth of ICU interventions.

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

BACKGROUND/OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exercise is feasible in patients receiving vasoactive medication in a cardiac surgical intensive care unit: A prospective observational study

BACKGROUND

Patients may require vasoactive medication after cardiac surgery. The effect and safety profile of exercise on haemodynamic parameters in these patients is unclear.

OBJECTIVES

The objective of this study was to measure the effect of upright positioning and low-level exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoactive therapy and to determine the incidence of adverse events.

METHODS

This was a prospective, single-centre, observational study conducted in an adult intensive care unit of a tertiary, cardiothoracic university-affiliated hospital in Australia. The Flotrac-Vigileo™ system was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke volume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-normally distributed variables are presented as median [interquartile range].

RESULTS

There were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years. Upright positioning caused significant increases (p = 0.018) in the mean arterial pressure (MAP), with MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume, or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse event was transient hypotension of low severity.

CONCLUSIONS

Low-level exercise in patients after cardiac surgery receiving vasoactive medication was well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright positioning and low-level exercise appeared safe and feasible in this patient cohort.

Early Mobility in the Intensive Care Unit: Evidence, Barriers, and Future Directions

Early mobility is an element of the ABCDEF bundle designed to improve outcomes such as ventilator-free days and decreased length of stay. Evidence indicates that adherence to an early mobility protocol can prevent delirium and reduce length of stay in the intensive care unit and the hospital and may decrease length of stay in a rehabilitation facility. Yet many barriers exist to implementing early mobility effectively, including patient acuity, uncertainty about when to start mobilizing the patient, staffing and equipment needs, increased costs, and limited nursing time. Implementation of early mobility requires interdisciplinary collaboration, commitment, and tools that facilitate mobility and prevent injury to nurses. This article focuses on aspects of care that can affect patient outcomes, such as preventing delirium, reducing sedation, monitoring the patient's ability to wean from the ventilator, and encouraging early mobility. It also addresses the effects of immobility as well as challenges in achieving mobility and how to overcome them.

Early versus delayed mobilization for in-hospital mortality and health-related quality of life among critically ill patients: a systematic review and meta-analysis

Background

This systematic review and meta-analysis of randomized clinical trials aimed to investigate the efficacy of early mobilization among critically ill adult patients.

Methods

We searched CENTRAL, MEDLINE, and Igaku-Chuo-Zasshi (a Japanese bibliographic database) databases until April 2019 and included randomized control trials to compare early mobilization started within 1 week of intensive care unit (ICU) admission and earlier-than-usual care with the usual care or mobilization initiated later than the intervention. Two authors independently extracted the data of the included studies and assessed their quality. The primary outcomes were in-hospital mortality, length of ICU/hospital stay, and health-related quality of life (QOL).

Results

Among 1085 titles/abstracts screened, 11 studies (including 1322 patients) were included in the meta-analysis, which was conducted using the random-effects model. The pooled relative risk for in-hospital mortality comparing early mobilization to usual care (control) was 1.12 (95% CI [confidence interval]: 0.80 to 1.58, I ² = 0%). The pooled mean differences for duration of ICU and hospital stay were -1.54 (95% CI: -3.33 to 0.25, I ² = 90%) and -2.86 (95% CI: -5.51 to -0.21, I ² = 85%), respectively. The pooled mean differences at 6 months post-discharge, as measured by the Short Form 36-Item Health Survey and Euro-QOL EQ-5D, were 4.65 (95% CI: -16.13 to 25.43, I ² = 86%) for physical functioning and 0.29 (95% CI: -11.19 to 11.78, I ² = 66%) for the visual analog scale.

Conclusions

Our study indicated no apparent differences between early mobilization and usual care in terms of in-hospital mortality and health-related QOL. Detailed larger studies are warranted to evaluate the impact of early mobilization on in-hospital mortality and health-related QOL in critically ill patients.

Trial registration

PROSPERO (identifier CRD42019139265).

Factors Associated With Discharge Home Among Medical ICU Patients in an Early Mobilization Program

Objectives

One goal of early mobilization programs is to facilitate discharge home after an ICU hospitalization, but little is known about which factors are associated with this outcome. Our objective was to evaluate factors associated with discharge home among medical ICU patients in an early mobilization program who were admitted to the hospital from home.

Design

Retrospective cohort study of medical ICU patients in an early mobilization program.

Setting

Tertiary care center medical ICU.

Patients

Medical ICU patients receiving early mobilization who were community-dwelling prior to admission.

Interventions

None.

Measurements and Main Results

A comprehensive set of baseline, ICU-related, and mobilization-related factors were tested for their association with discharge home using multivariable logistic regression. Among the analytic cohort (n = 183), the mean age was 61.9 years (sd 16.67 yr) and the mean Acute Physiology and Chronic Health Evaluation II score was 23.5 (sd 7.11). Overall, 65.0% of patients were discharged home after their critical illness. In multivariable analysis, each incremental increase in the maximum level of mobility achieved (range, 1-6) during the medical ICU stay was associated with nearly a 50% greater odds of discharge home (odds ratio, 1.46; 95% CI, 1.13-1.88), whereas increased age (odds ratio, 0.95; 95% CI, 0.93-0.98) and greater hospital length of stay (odds ratio, 0.94; 95% CI, 0.90-0.99) were associated with decreased odds of discharge home. Prehospital ambulatory status was not associated with discharge home.

Conclusions

Among medical ICU patients who resided at home prior to their ICU admission, the maximum level of mobility achieved in the medical ICU was the factor most strongly associated with discharge back home. Identification of this factor upon ICU-to-ward transfer may help target mobilization plans on the ward to facilitate a goal of discharge home.

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

INTRODUCTION

Early rehabilitation in critically ill patients is associated with improved outcomes. Recent research demonstrates that patients requiring continuous renal replacement therapy (CRRT) can safely engage in mobility. The purpose of this study was to assess safety and feasibility of early rehabilitation with focus on mobility in patients requiring CRRT.

METHODS

Study design was a mixed methods analysis of a quality improvement protocol. The setting was an intensive care unit (ICU) at a tertiary medical center. Safety was prospectively recorded by incidence of major adverse events including dislodgement of CRRT catheter, accidental extubation, bleeding, and hemodynamic emergency; and minor adverse events such as transient oxygen desaturation >10% of resting. Limited efficacy testing was performed to determine if rehabilitation parameters were associated with clinical outcomes.

RESULTS

A total of 67 patients (54.0 ± 15.6 years old, 44% women, body mass index 29.2 ± 9.3 kg/m²) received early rehabilitation under this protocol. The median days of CRRT were 6.0 (interquartile range [IQR], 2-11) and 72% of patients were on mechanical ventilation concomitantly with CRRT at the time of rehabilitation. A total of 112 rehabilitation sessions were performed of 152 attempts (74% completion rate). No major adverse events occurred. Patients achieving higher levels of mobility were more likely to be alive at discharge (P = 0.076).

CONCLUSIONS

The provision of early rehabilitation in critically ill patients requiring CRRT is safe and feasible. Further, these preliminary results suggest that early rehabilitation with focus on mobility may improve patient outcomes in this susceptible population.