Early rehabilitation in sepsis: a prospective randomised controlled trial investigating functional and physiological outcomes The i-PERFORM Trial (Protocol Article)

Return to work after hospitalization for sepsis: a nationwide, registry-based cohort study

BACKGROUND

Sepsis survivors commonly experience functional impairment, which may limit return to work. We investigated return to work (RTW) of patients hospitalized with sepsis and the associations with patient and clinical characteristics.

METHODS

Working-age patients (18-60 years) admitted to a Norwegian hospital with sepsis between 2010 and 2021 were identified using the Norwegian Patient Registry and linked to sick-leave data from the Norwegian National Social Security System Registry. The main outcome was proportion of RTW in patients hospitalized with sepsis at 6 months, 1 year, and 2 years after discharge. Secondary outcomes were time trends in age-standardized proportions of RTW and probability of sustainable RTW (31 days of consecutive work). The time trends were calculated for each admission year, reported as percentage change with 95% confidence interval (CI). Time-to-event analysis, including crude and adjusted hazard risk (HRs), was used to explore the association between sustainable RTW, characteristics and subgroups of sepsis patients (intensive care unit (ICU) vs. non-ICU and COVID-19 vs. non-COVID-19).

RESULTS

Among 35.839 hospitalizations for sepsis among patients aged 18-60 years, 12.260 (34.2%) were working prior to hospitalization and included in this study. The mean age was 43.7 years. At 6 months, 1 year, and 2 years post-discharge, overall estimates showed that 58.6%, 67.5%, and 63.4%, respectively, were working. The time trends in age-standardized RTW for ICU and non-ICU sepsis patients remained stable over the study period, except the 2-year age-standardized RTW for non-ICU patients that declined by 1.51% (95% CI - 2.22 to - 0.79) per year, from 70.01% (95% CI 67.21 to 74.80) in 2010 to 57.04% (95% CI 53.81-60.28) in 2019. Characteristics associated with sustainable RTW were younger age, fewer comorbidities, and fewer acute organ dysfunctions. The probability of sustainable RTW was lower in ICU patients compared to non-ICU patients (HR 0.56; 95% CI 0.52-0.61) and higher in patients with COVID-19-related sepsis than in sepsis patients (HR 1.31; 95% CI 1.15-1.49).

CONCLUSION

Absence of improvement in RTW proportions over time and the low probability of sustainable RTW in sepsis patients need attention, and further research to enhance outcomes for sepsis patients is required.

Roles and Molecular Mechanisms of Physical Exercise in Sepsis Treatment

Physical exercise is a planned, purposeful action to keep a healthy lifestyle and improve physical fitness. Physical exercise has been widely used as a non-pharmacological approach to preventing and improving a wide range of diseases, including cardiovascular disease, cancer, metabolic disease, and neurodegenerative disease. However, the effects of physical exercise on sepsis have not been summarized until now. In this review, we discuss the effects of physical exercise on multiple organ functions and the short- and long-time outcomes of sepsis. Furthermore, the molecular mechanisms underlying the protective effects of physical exercise on sepsis are discussed. In conclusion, we consider that physical exercise may be a beneficial and non-pharmacological alternative for the treatment of sepsis.

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.

Patient Characteristics and Acute PT and OT Utilization During the Initial Surge of COVID-19: A Retrospective Observational Study

OBJECTIVE

To describe the characteristics of patients and investigate the utilization of physical (PT) and occupational therapy (OT) intervention for those with a positive coronavirus disease-2019 (COVID-19) diagnosis compared with other patient populations during the first 6 weeks of the novel coronavirus pandemic.

METHODS

A retrospective, observational study of adult inpatients with a length of stay of 1 or more days at an urban hospital in Detroit, Michigan. Individuals with a COVID-19 diagnosis were compared with a cohort within similar diagnostic categories (respiratory, fever, and sepsis) but without COVID-19. Outcome measures included PT or OT intervention on 1 or more days, the timing of initial PT or OT visit, the average number of visits and units per patient, length of stay, discharge to home, and readmission within 30 days.

RESULTS

Individuals with COVID-19 had lower rates of discharge to home (P = .001), higher rates of readmission within 30 days of hospital discharge (P = .01), increased hospital length of stay (P = .001), and waited an average of 3.1 days longer for therapy evaluations than subjects in the comparison group (P = .001). The percentage of subjects who had one or more PT or OT visits during their hospital stays was comparable between groups. Once therapy was initiated, the average number of visits per patient and dosing of units in 15-minute increments were similar between the 2 groups.

CONCLUSIONS

Patients acutely ill with COVID-19 hospitalized with the virus during the first 6 weeks of the pandemic remained in the intensive care unit and hospital longer than their counterparts without COVID-19 and had a delay in initiation of PT and OT intervention. PT and OT are important members of the care team for patients with the novel coronavirus. Understanding the descriptive characteristics of patients and therapy services during the initial surge could help improve utilization and patient outcomes.

Evaluating Physical Functioning in Survivors of Critical Illness: Development of a New Continuum Measure for Acute Care

OBJECTIVES

Evaluation of physical functioning is central to patient recovery from critical illness-it may enable the ability to determine recovery trajectories, evaluate rehabilitation efficacy, and predict individuals at highest risk of ongoing disability. The Physical Function in ICU Test-scored is one of four recommended physical functioning tools for use within the ICU; however, its utility outside the ICU is poorly understood. The De Morton Mobility Index is a common geriatric mobility tool, which has had limited evaluation in the ICU population. For the field to be able to track physical functioning recovery, we need a measurement tool that can be used in the ICU and post-ICU setting to accurately measure physical recovery. Therefore, this study sought to: 1) examine the clinimetric properties of two measures (Physical Function in ICU Test-scored and De Morton Mobility Index) and 2) transform these measures into a single measure for use across the acute care continuum.

DESIGN

Clinimetric analysis.

SETTING

Multicenter study across four hospitals in three countries (Australia, Singapore, and Brazil).

PATIENTS

One hundred fifty-one ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Physical function tests (Physical Function in ICU Test-scored and De Morton Mobility Index) were assessed at ICU awakening, ICU, and hospital discharge. A significant floor effect was observed for the De Morton Mobility Index at awakening (23%) and minimal ceiling effects across all time points (5-12%). Minimal floor effects were observed for the Physical Function in ICU Test-scored across all time points (1-7%) and a significant ceiling effect for Physical Function in ICU Test-scored at hospital discharge (27%). Both measures had strong concurrent validity, responsiveness, and were predictive of home discharge. A new measure was developed using Rasch analytical principles, which involves 10 items (scored out of 19) with minimal floor/ceiling effects.

CONCLUSIONS

Limitations exist for Physical Function in ICU Test-scored and De Morton Mobility Index when used in isolation. A new single measure was developed for use across the acute care continuum.

Trajectory of Cognitive Decline After Sepsis

OBJECTIVES

Cognitive impairment is an important consequence of sepsis. We sought to determine long-term trajectories of cognitive function after sepsis.

DESIGN

Prospective study of the Reasons for Geographic and Racial Differences in Stroke cohort.

SETTING

United States.

PATIENTS

Twenty-one thousand eight-hundred twenty-three participants greater than or equal to 45 years, mean (sd) age 64.3 (9.2) years at first cognitive assessment, 30.9% men, and 27.1% Black.

MEASUREMENTS AND MAIN RESULTS

The main exposure was time-dependent sepsis hospitalization. The primary outcome was global cognitive function (Six-Item Screener range, 0-6). Secondary outcomes were incident cognitive impairment (Six-Item Screener score ≤ 4 [impaired] vs ≥5 [unimpaired]), new learning (Consortium to Establish a Registry for Alzheimer Disease Word List Learning range, 0-30), verbal memory (word list delayed recall range, 0-10), and executive function/semantic fluency (animal fluency test range, ≥ 30). Over a median follow-up of 10 years (interquartile range, 6-12 yr), 840 (3.8%) experienced sepsis (incidence 282 per 1,000 person-years). Sepsis was associated with faster long-term declines in Six-Item Screener (-0.02 points per year faster [95% CI, -0.01 to -0.03]; p < 0.001) and faster long-term rates of incident cognitive impairment (odds ratio 1.08 per year [95% CI, 1.02-1.15]; p = 0.008) compared with presepsis slopes. Although cognitive function acutely changed after sepsis (0.05 points [95% CI, 0.01-0.09]; p = 0.01), the odds of acute cognitive impairment (Six-Item Screener ≤ 4) immediately after sepsis was not significant (odds ratio, 0.81 [95% CI, 0.63-1.06]; p = 0.12). Sepsis hospitalization was not associated with acute changes or faster declines in word list learning, word list delayed recall, or animal fluency test.

CONCLUSIONS

Sepsis is associated with accelerated long-term decline in global cognitive function.

Effects of Early Exercise Rehabilitation on Functional Recovery in Patients with Severe Sepsis

PURPOSE

Severe sepsis is associated with functional disability among patients surviving an acute phase of infection. Efforts to improve functional impairment are important. We assessed the effects of early exercise rehabilitation on functional outcomes in patients with severe sepsis.

MATERIALS AND METHODS

A prospective, single-center, case-control study was conducted between January 2013 and May 2014 at a tertiary care center in Korea. Patients with severe sepsis and septic shock were enrolled and randomized to receive standard sepsis treatment or intervention. Intervention involved early targeted physical rehabilitation with sepsis treatment during hospitalization. Participants were assessed at enrollment, hospital discharge, and 6 months after enrollment. Functional recovery was measured using the Modified Barthel Index (MBI), Functional Independence Measure (FIM), and Instrumental Activities of Daily Living (IADL).

RESULTS

Forty participants (21 intervention patients) were included in an intention-to-treat analysis. There were no significant differences in baseline MBI, FIM, and IADL between groups. Intervention yielded greater improvement of MBI, FIM, and IADL in the intervention group at hospital discharge, but not significantly. Subgroup analysis of patients with APACHE II scores ≥10 showed significantly greater improvement of physical function at hospital discharge (MBI and FIM) in the intervention group, compared to the control group (55.13 vs. 31.75, p=0.048; 52.40 vs. 31.25, p=0.045). Intervention was significantly associated with improvement of MBI in multiple linear regression analysis (standardized coefficient 0.358, p=0.048).

CONCLUSION

Early physical rehabilitation may improve functional recovery at hospital discharge, especially in patients with high initial severity scores.

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

OBJECTIVE

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

DESIGN

A prospective observational multicenter study.

SETTING

Two mixed medical-surgical ICUs.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Septic predictor index: A novel platform to identify thermally injured patients susceptible to sepsis

BACKGROUND

During the past decades' sepsis has become the major cause of death in severely burned patients. Despite the importance of burn sepsis, its diagnosis, let alone its prediction, is difficult if not impossible. Recently, we have demonstrated burn patients have increased NLRP3 inflammasome activation in white adipose tissue. We aimed to delineate a unique immune profile that can be used to identify septic outcomes in severely burned patients.

METHODS

Adult burn patients (n = 37) admitted to our burn center between June 2013-2015 were enrolled in this study. White adipose tissue from the site of injury and plasma were collected from severely burned patients (>20% total body surface area) within 96 hours after thermal injury, indiscriminate of sex or age.

RESULTS

We found that patients exhibiting aberrantly high levels of proinflammatory interleukin-1β and decreased macrophages at the site of injury are highly susceptible to development of sepsis. Septic patients also had increased anti-inflammatory (interleukin-10, interleukin-1RA) cytokines in plasma. The Septic Predictor Index was generated as a quotient for the site of injury macrophage proportion and interleukin-1β production. All patients who eventually develop sepsis had septic predictor index values >0.5. Septic patients with Septic Predictor Index values >1 all had sepsis onset within 12 days post-injury, whereas patients with Septic Predictor Index values between 0.5-1 all had later onset (>12 days).

CONCLUSION

The Septic Predictor Index can determine sepsis onset accurately in thermally injured patients a priori and further enables surgeons to develop clinical studies and focused therapies specifically designed for septic cohorts.

Intensive Care Unit-Acquired Weakness: Implications for Case Management

PURPOSE

The purpose of this case study is to provide a specific example of the disease trajectory for one patient's experience with intensive care unit-acquired weakness (ICUAW). This case study provides those in case management with an overview of some of the common signs and symptoms of ICUAW, as well as the possible prognosis and recovery from ICUAW.

PRIMARY PRACTICE SETTING

The events in this case study take place in the acute care setting including the intensive care unit of a mid-sized health center, a general medical-surgical (med-surg) unit, and a long-term acute care facility.

CONCLUSIONS

ICUAW affects the clinical, functional, and financial outcomes of patients. If the patient survives, their quality of life and the quality of life of their family members could be severely impacted. Case management practice has a significant role in coordinating care for those diagnosed with ICUAW. Case managers can use knowledge about ICUAW to improve the patient's transition throughout the hospital stay, improve discharge recommendations, and improve the patient's short-term and long-term outcomes. This may reduce unnecessary utilization of health care resources.

What factors affect implementation of early rehabilitation into intensive care unit practice? A qualitative study with clinicians

PURPOSE

To identify the barriers and enablers that influence clinicians' implementation of early rehabilitation in critical care.

MATERIALS AND METHODS

Qualitative study involving 26 multidisciplinary participants who were recruited using purposive sampling. Four focus groups were conducted using semistructured questions to explore attitudes, beliefs, and experiences. Data were transcribed verbatim and thematic analysis was performed.

RESULTS

Six themes emerged, as follows: (1) the clinicians' expectations and knowledge (including rationale for rehabilitation, perceived benefits, and experience), (2) the evidence for and application of rehabilitation (including beliefs regarding when to intervene), (3) patient factors (including prognosis, sedation, delirium, cooperation, motivation, goals, and family), (4) safety considerations (including physiological stability and presence of devices or lines), (5) environmental influences (staffing, resources, equipment, time, and competing priorities), and (6) culture and teamwork. Key strategies identified to facilitate rehabilitation included addressing educational needs for all multidisciplinary team members, supporting junior nursing staff, and potential expansion of physiotherapy staffing hours to closer align with the 24-hour patient care model.

CONCLUSIONS

Key barriers to implementation of early rehabilitation in critical care are diverse and include both clinician- and health care system-related factors. Research targeted at bridging this evidence-practice gap is required to improve provision of rehabilitation.

Assessment and predictors of physical functioning post-hospital discharge in survivors of critical illness

Background

Prior studies of physical functioning after critical illness have been mostly limited to survivors of acute respiratory distress syndrome. The purpose of this study was to objectively assess muscle strength and physical functioning in survivors of critical illness from a general ICU and the associations of these measures to health-related quality of life (HRQL), mental health and critical illness variables.

Methods

This was a prospective cohort study of 56 patients admitted to a medical ICU (length of stay ≥4 days) from April 1, 2009, and March 31, 2010. Patients were assessed in clinic at 3 months post-hospital discharge. Muscle strength and physical functioning were measured using hand-held dynamometry and the 6-min walk test. HRQL was assessed using the short-form 36 (SF-36) and EuroQol-5D (EQ-5D) questionnaires.

Results

Three months post-hospital discharge, median age- and sex-matched muscle strength was reduced across all muscle groups. The median 6-min walk distance was 72 % of predicted. Physical functioning was associated with reductions in self-reported HRQL (SF-36, EQ-5D) and increased anxiety. Univariate regression modeling showed that reduced muscle strength and 6-min walk distance were associated with sepsis but not ICU length of stay. Multivariate regression modeling showed that sepsis and corticosteroid use were associated with a reduced 6-min walk distance, but again ICU length of stay was not.

Conclusions

Survivors of critical illness have reduced strength in multiple muscle groups and impaired exercise tolerance impacting both HRQL and mental health. These outcomes were worsened by sepsis and corticosteroid use in the ICU but not ICU length of stay. Interventions to minimizing the burden of sepsis in critically ill patients may improve long-term outcomes.

Preventive effects of kilohertz frequency electrical stimulation on sepsis-induced muscle atrophy

OBJECTIVES

The present study sought to evaluate the effect of electrical stimulation (ES) by using kilohertz frequency on muscle atrophy induced by sepsis.

METHODS

Seventeen male ICR mice were randomly divided into 3 groups: control, lipopolysaccharide (LPS)-injected for 4 days, LPS plus ES (LPS+ES). Sepsis was induced by 4 days of an intraperitoneal LPS injection (10 μg/g body weight/day). LPS+ES animals received the LPS injections and ES twice a day for 4 days. ELISA and western blot analysis determined the plasma levels of inflammatory cytokines and ubiquitinated proteins, while the tibialis anterior muscles were weighed and muscle fiber cross-sectional area (CSA) were measured to assess muscle atrophy, which were analyzed by Student's t-test and ANOVA.

RESULTS

LPS induced increased plasma levels of inflammatory cytokines, significant muscle mass loss (LPS: -29.0%, LPS+ES: -23.1%), decreased fiber cross-sectional area, and an up-regulation of atrogin-1 and ubiquitinated proteins in the tibialis anterior muscle compared with the control. ES attenuated the sepsis-induced loss of muscle mass and decreased fiber CSA, as well as attenuated the atrogin-1 and ubiquitinated protein up-regulation.

CONCLUSIONS

Electrical stimulation may prevent sepsis-induced muscle atrophy through ubiquitin-proteasome pathway inhibition.

Mobilization in severe sepsis: an integrative review

Severe sepsis is a leading cause of long-term morbidity in the United States. Up to half of severe sepsis is treated in non–intensive care unit (ICU) settings, making it applicable to hospitalist practice. Evidence has demonstrated benefits from physical therapy (PT) in myriad conditions; whether PT may benefit severe sepsis patients either within or outside the ICU is unknown. Therefore, we conducted a review of the literature to understand whether early mobilization improves outcomes in patients with severe sepsis in non-ICU settings. We summarized the pathophysiology of functional decline in severe sepsis, the efficacy of PT in other patient populations, and the potential rationale for PT interventions in patients with severe sepsis. Multiple databases were searched for keywords including length of stay, mortality,costs, mobilization, and PT. Two authors (S.G. and V.C.) independently determined the eligibility of each study.A secondary review including studies of any infectious pathology with PT interventions or sepsis patients within the ICU was also conducted. Our search did not yield any primary literature regarding the impact of mobilization on severe sepsis outcomes in non-ICU settings. Only 1 retrospective study showed potential benefit of therapy in sepsis patients in the ICU. Similarly, in non-ICU settings, only 1 study that included patients with bacterial pneumonia reported outcomes after implementing an intervention consisting of early mobilization. These findings suggest that scant data regarding the efficacy of early mobilization following severe sepsis exist. Because hospitalists often care for this patient population, an opportunity for research in this area exists.

Association of postdischarge rehabilitation with mortality in intensive care unit survivors of sepsis

RATIONALE

Intensive care unit (ICU)-acquired weakness is a common issue for sepsis survivors that is characterized by impaired muscle strength and causes functional disability. Although inpatient rehabilitation has not been found to reduce in-hospital mortality, the impact of postdischarge rehabilitation on sepsis survivors is uncertain.

OBJECTIVES

To investigate the benefit of postdischarge rehabilitation to long-term mortality in sepsis survivors.

METHODS

We conducted a nationwide, population-based, high-dimensional propensity score-matched cohort study using Taiwan's National Health Insurance Research Database. The rehabilitation cohort comprised 15,535 ICU patients who survived sepsis and received rehabilitation within 3 months after discharge between 2000 and 2010. The control cohort consisted of 15,535 high-dimensional propensity score-matched subjects who did not receive rehabilitation within 3 months after discharge. The endpoint was mortality during the 10-year follow-up period.

MEASUREMENTS AND MAIN RESULTS

Compared with the control cohort, the rehabilitation cohort had a significantly lower risk of 10-year mortality (adjusted hazard ratio, 0.94; 95% confidence interval, 0.92-0.97; P < 0.001), with an absolute risk reduction of 1.4 per 100 person-years. The frequency of rehabilitation was inversely associated with 10-year mortality (≥3 vs. 1 course: adjusted hazard ratio, 0.82; P < 0.001). Compared with the control cohort, improved survival was observed in the rehabilitation cohort among ill patients who had more comorbidities, required more prolonged mechanical ventilation, and had longer ICU or hospital stays, but not among those with the opposite conditions (i.e., less ill patients).

CONCLUSIONS

Postdischarge rehabilitation may be associated with a reduced risk of 10-year mortality in the subset of patients with particularly long ICU courses.

IMPOSE (IMProving Outcomes after Sepsis)-the effect of a multidisciplinary follow-up service on health-related quality of life in patients postsepsis syndromes-a double-blinded randomised controlled trial: protocol

INTRODUCTION

Patients post sepsis syndromes have a poor quality of life and a high rate of recurring illness or mortality. Follow-up clinics have been instituted for patients postgeneral intensive care but evidence is sparse, and there has been no clinic specifically for survivors of sepsis. The aim of this trial is to investigate if targeted screening and appropriate intervention to these patients can result in an improved quality of life (Short Form 36 health survey (SF36V.2)), decreased mortality in the first 12 months, decreased readmission to hospital and/or decreased use of health resources.

METHODS AND ANALYSIS

204 patients postsepsis syndromes will be randomised to one of the two groups. The intervention group will attend an outpatient clinic two monthly for 6 months and receive screening and targeted intervention. The usual care group will remain under the care of their physician. To analyse the results, a baseline comparison will be carried out between each group. Generalised estimating equations will compare the SF36 domain scores between groups and across time points. Mortality will be compared between groups using a Cox proportional hazards (time until death) analysis. Time to first readmission will be compared between groups by a survival analysis. Healthcare costs will be compared between groups using a generalised linear model. Economic (health resource) evaluation will be a within-trial incremental cost utility analysis with a societal perspective.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Royal Brisbane and Women's Hospital Human Research Ethics Committee (HREC; HREC/13/QRBW/17), The University of Queensland HREC (2013000543), Griffith University (RHS/08/14/HREC) and the Australian Government Department of Health (26/2013). The results of this study will be submitted to peer-reviewed intensive care journals and presented at national and international intensive care and/or rehabilitation conferences.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry ACTRN12613000528752.

Clinical review: early patient mobilization in the ICU

Early mobilization (EM) of ICU patients is a physiologically logical intervention to attenuate critical illness-associated muscle weakness. However, its long-term value remains controversial. We performed a detailed analytical review of the literature using multiple relevant key terms in order to provide a comprehensive assessment of current knowledge on EM in critically ill patients. We found that the term EM remains undefined and encompasses a range of heterogeneous interventions that have been used alone or in combination. Nonetheless, several studies suggest that different forms of EM may be both safe and feasible in ICU patients, including those receiving mechanical ventilation. Unfortunately, these studies of EM are mostly single center in design, have limited external validity and have highly variable control treatments. In addition, new technology to facilitate EM such as cycle ergometry, transcutaneous electrical muscle stimulation and video therapy are increasingly being used to achieve such EM despite limited evidence of efficacy. We conclude that although preliminary low-level evidence suggests that EM in the ICU is safe, feasible and may yield clinical benefits, EM is also labor-intensive and requires appropriate staffing models and equipment. More research is thus required to identify current standard practice, optimal EM techniques and appropriate outcome measures before EM can be introduced into the routine care of critically ill patients.