Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up

Australian clinical practice guideline for physical rehabilitation and mobilisation in adult intensive care units

BACKGROUND

The evidence base for research on physical rehabilitation and mobilisation in the intensive care unit has led to uncertainty about best practice.

OBJECTIVE

The objective of this guideline was to develop evidence-based recommendations to support clinical decision-making for physical rehabilitation management of adults undergoing invasive mechanical ventilation in Australian intensive care units.

METHODS

The guideline development group, comprising national representation of clinical experts, methodologists, and consumers, followed a rigorous process, adhering to Australian National Health and Medical Research Council Guidelines for Guidelines, to create the recommendations. The guideline development group determined the scope of the guideline and defined the key clinical question. A systematic review was conducted to evaluate all available evidence based on the predefined outcomes. Meta-analyses were performed using a restricted maximum likelihood approach, and results were summarised in an evidence profile. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence, and the GRADE Evidence to Decision framework was used to formulate recommendations.

SUMMARY OF RECOMMENDATIONS

Based on the evidence profile and GRADE Evidence to Decision framework, the group developed three conditional recommendations and 14 Good Clinical Practice statements to guide practice. The guideline provides conditional recommendations in favour of undertaking physical rehabilitation and mobilisation in adults receiving invasive mechanical ventilation in the intensive care unit whilst acknowledging the uncertainty of evidence. It was endorsed by four key professional organisations.

CONCLUSION

The recommendations within this guideline were developed following best methodological practice. Despite the overall low certainty of evidence, the resulting guideline provides support to clinical decision-making, facilitates the translation of research into practice, and enhances the reach and impact of clinical research. Additionally, the guideline development group identified evidence gaps that could be addressed by future research.

TRIAL REGISTRATION

Not applicable.

Recruitment and retention of intensive care unit survivors in follow-up studies: A systematic review

BACKGROUND

Engaging intensive care unit survivors in research is challenging. Studies have reported recruitment and attrition rates; details are lacking on retention strategies and attrition.

OBJECTIVE

The aim of this study was to explore barriers and enablers to recruitment and retention in research of people post intensive care discharge.

METHODS

A convergent mixed-method review using the Joanna Briggs Institute (JBI) methodology considered studies that reported on recruitment, retention, and attrition rates of adult post-intensive care survivors in longitudinal studies. CINAHL Ultimate (CINAHL+), PubMed, Excerpta Medica Database (EMBASE), PsycINFO, Scopus, Proquest Health, and Medical Collection were searched in March 2024 using Medical Subject Headings terms and keywords related to post-intensive care survivors, patient selection, and research in peer-reviewed journals or theses published in English. Risk of bias was assessed with JBI's critical appraisal tools. Qualitative data were extracted and themed, and quantitative data were extracted using predefined data fields and qualitised. Synthesis was guided by the JBI mixed-method convergent integrated approach.

RESULTS

A total of 1608 records were identified; 12 high-quality articles were included, with a total of 2551 participants. Studies focussed on outcome measures following hospital discharge to the community. Three superordinate and eight subordinate themes emerged: factors influencing participation/nonengagement, retention strategies, and researcher insights. Attrition was predominantly due to mortality or ill health. Non-health-related themes included transport difficulties, expense, and inconvenience. Challenges included symptoms triggered by participation, being unaware of appointments, and not understanding study requirements. Enabling strategies included reminder calls, letters, cards, and home visits. Researcher insights included the impact of critical illness on survivors' wellbeing, finances, and communication challenges.

DISCUSSION

Recruitment and retention strategies were under-reported. Person-centred approaches considering survivors' challenges may increase recruitment and retention. Retention strategies should be evaluated to determine the impact on engagement or withdrawal from studies. The strong likelihood of attrition should be factored into sample size calculations to reduce risk of bias in longitudinal studies.

REGISTRATION

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO [CRD42022315688]).

Novel Strategies to Promote Intensive Care Unit Recovery via Personalized Exercise, Nutrition, and Anabolic Interventions

Survivors of critical illness experience significant morbidity, reduced physiologic reserve, and long-term complications that negatively impact quality of life. Although rehabilitative treatments are beneficial during early recovery, there is limited evidence regarding effective multimodal rehabilitation, nutrition, and anabolic nutrient/agent strategies for improving long-term outcomes. This review discusses novel personalized rehabilitation, nutrition, and anabolic nutrient/agent (ie, creatine, β-hydroxy-β-methylbutyrate, testosterone) approaches that allow for precise exercise and nutrition prescription and have potential to improve patient care, address continued medical needs, and optimize long-term recovery. Continued research is needed to further evaluate effectiveness and implementation of these strategies throughout the continuum of care.

Effect of Home Care on Physical Function in Post-Intensive Care Unit Patients: A Meta-Analysis

BACKGROUND

A decline in physical function is commonly observed after patients transition to their homes following hospital admission; this is especially true for patients requiring mechanical ventilation in an intensive care unit (ICU).

OBJECTIVE

This meta-analysis examines characteristics and effects of home-based or outpatient+home-based interventions used to improve physical function post-discharge in patients who received mechanical ventilation in an ICU.

METHODS

PRISMA guidelines were utilized. The literature search was conducted with the assistance of a medical librarian. Study inclusion criteria were post-ICU adult patients receiving mechanical ventilation who then had home-based or outpatient+home-based care to improve physical function after discharge. Effect size (Hedges' g) was calculated with random effects models.

RESULTS

Our search yielded 11 studies that met the inclusion criteria. The majority were randomized controlled trials, with 1 quasi-experimental study. All studies included physical therapists, and 2 included nurses. The 11 studies reported results for 39 physical function measurements. The overall pooled intervention effect across the 4 studies that utilized the 6-minute walk test was 0.32 (95% confidence intervals [CI]: 0.05 to 0.58), for the 3 studies that utilized the Timed Up and Go test it was 1.38 (95% CI: -0.09 to 2.84), and for the 8 studies that used the SF-36 Physical Function subscale, it was 0.31 (95% CI: 0.09 to 0.52).

CONCLUSIONS

This review's findings show that patients may improve their physical function after participating in specific intervention programs that are home-based alone or outpatient+home-based care. However, the effect sizes are small, so it may be useful to explore how to maximize the gains in physical function.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

CONCLUSIONS

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

Investigating Dose Level and Duration of Rehabilitation of Mechanically Ventilated Patients in the ICU

Background: The dose level and duration needed for early rehabilitation of mechanically ventilated patients in the ICU need to be characterized. Therefore, this study aimed to assess the association between mobilization level, rehabilitation time, and dose (defined as the mean mobilization quantification score [MQS]) during ICU admission and the end point walking independence at hospital discharge in subjects needing ICU admission. Methods: This prospective, multi-center, cohort study included 9 ICUs. Consecutive subjects admitted to the ICU between September 2022-March 2023 receiving mechanical ventilation for >48 h were included in the study. The mean MQS score, highest ICU mobility score (IMS) during the ICU stay, time to the first mobilization day, ICU rehabilitation time (minutes of each rehabilitation physical activity from start to finish), frequency/d, baseline characteristics, and walking independence at hospital discharge were assessed. Results: Among the 116 subjects, 64 did and 51 did not walk independently at hospital discharge, respectively. Multiple logistic regression analysis revealed that the mean MQS and time to first mobilization were significantly associated with walking independence at hospital discharge. We observed that mean MQS was better than IMS, rehabilitation time, frequency, and time to first mobilization predicted walking independence based on receiver operating characteristic (ROC) curve comparison. Comparison of the mean MQS with that on the first mobilization day revealed superior predicting power of the mean MQS. The ROC curve cutoff value for the mean MQS was 4.0. Conclusions: This study shows that in subjects mechanically ventilated for >48 h the dose of rehabilitation calculated using the mean MQS during ICU was a better predictor of walking independence at hospital discharge than intensity, duration, or frequency of the mobilization therapy. Mean MQS during ICU stay may be used to measure and titrate optimal mobilization therapy.

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

RATIONALE

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

OBJECTIVES

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

PANEL DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Investigating the safety of physical rehabilitation with critically ill patients receiving vasoactive drugs: An exploratory observational feasibility study

BACKGROUND

Physical rehabilitation of critically ill patients may improve physical outcomes; however, the relative benefits and risks with patients requiring vasoactive drugs is currently unknown. A feasibility study is needed to inform the design of a future trial required to address this issue.

METHODS

A two-phase exploratory observational feasibility study was carried out: A retrospective study to clarify the current practice of rehabilitation with patients receiving vasoactive drugs to inform future trial interventions and design.A prospective study exploring recruitment and outcome measurement. Intensive care patients receiving vasoactive drugs were recruited and asked about the acceptability of a future trial. The feasibility of using an adverse event tool was measured during rehabilitation. Patients were followed up after 60 days to describe the feasibility of measuring outcomes for a future trial.

RESULTS

Retrospective study (n = 78): Twenty-one percent of patients took part in physical rehabilitation whilst receiving vasoactive drugs. Of 321 days with vasoactive drugs administered, physical rehabilitation occurred on 27 days (8%). Prospective study (n = 40): Eighty-one percent of participants indicated acceptability of being recruited into a future trial (n = 37). Eighty-eight percent of clinicians found it acceptable to randomise patients into either early rehabilitation or standard care. The adverse event tool was implemented by researchers with 2% loss of information. Finally, a 100% follow-up rate at day 60 was achieved for mortality outcomes. Follow-up rates were 70% for the EQ-5D (5 level), 65% for the World Health Organisation's Disability Assessment Schedule 2.0 and RAND 36-item Health Survey 1.0 and 26% for the 6-minute walk test.

CONCLUSIONS

This study found a low frequency of physical rehabilitation occurring with intensive care patients receiving vasoactive drugs. A high proportion of clinicians and patients found a future RCT within this patient group acceptable. Mortality and patient-reported outcomes were the most feasible to measure.

Muscle Dysfunction and Physical Recovery After Critical Illness

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

Nutritional Support in the ICU

Critical illness is a complex condition that can have a devastating impact on health and quality of life. Nutritional support is a crucial component of critical care that aims to maintain or restore nutritional status and muscle function. A one-size-fits-all approach to the components of nutritional support has not proven beneficial. Recent randomized controlled trials challenge the conventional strategy and support the safety and potential benefits of below-usual calorie and protein intakes at the early, acute phase of critical illness. Further research is needed to define optimal nutritional support throughout the intensive care unit stay. Individualized nutritional strategies relying on risk assessment tools or biomarkers deserve further investigation in rigorously designed, large, multicenter, randomized, controlled trials. Importantly, although nutritional support is crucial, it might not be sufficient to enhance the recovery of critically ill patients. Thus, achieving the greatest efficacy may require individualized nutritional support combined with early, prolonged physical rehabilitation within a multimodal, holistic care program throughout the patient's recovery journey.

Post-Intensive Care Syndrome: Physical Impairments and Function

Patients surviving critical illness are at risk of persistent physical impairments related to Post Intensive Care Syndrome. Physical impairments and symptoms have potential for recovery, but frequently impact quality of life, performance of activities of daily living and participation in societal roles. Patient and illness-related risk factors directly relate and may predict physical functional outcomes providing opportunity for clinicians and scientist to develop targeted intervention strategies. Clinicians and scientists should screen and assess physical impairments and symptoms early following Intensive care unit discharge with a serial approach to promote for targeted and individualized treatment.

Rehabilitation and Social Determinants of Health in Critical Illness Recovery Literature: A Systematic Review

OBJECTIVES

Patients who survive critical illness navigate arduous and disparate recovery pathways that include referrals and participation in community-based rehabilitation services. Examining rehabilitation pathways during recovery is crucial to understanding the relationship on patient-centered outcomes. Furthermore, an understanding of social determinants of health (SDOH) in relation to outcomes and rehabilitation use will help ensure equitable access for future care. Therefore, there is a need to define and understand patient care pathways, specifically rehabilitation after discharge, through a SDOH lens after surviving a critical illness to improve long-term outcomes.

DATA SOURCES

MEDLINE, PubMed, Web of Science Core Collection (Clarivate), the CINAHL, and the Physiotherapy Evidence Database.

STUDY SELECTION AND DATA EXTRACTION

A systematic review of the literature was completed examining literature from inception to March 2024. Articles were included if post-hospital rehabilitation utilization was reported in adult patients who survived critical illness. Discharge disposition was examined as a proxy for rehabilitation pathways. Patients were grouped by patient diagnosis for grouped analysis and reporting of data. Two independent researchers reviewed manuscripts for inclusion and data were extracted by one reviewer using Covidence. Both reviewers used the Newcastle-Ottawa Scale to assess risk of bias.

DATA SYNTHESIS

Of 72 articles included, only four articles reported detailed rehabilitation utilization. The majority of the studies included were cohort studies (91.7%) with most articles using a retrospective design (56.9%). The most common patient population was acute respiratory diagnoses (51.4%). Most patients were discharged directly home from the hospital (75.4%). Race/ethnicity was the most frequently reported SDOH (43.1%) followed by insurance status (13.9%) and education (13.9%).

CONCLUSIONS

The small number of articles describing rehabilitative utilization allows for limited understanding of rehabilitation pathways following critical illness. The reporting of detailed rehabilitation utilization and SDOH are limited in the literature but may play a vital role in the recovery and outcomes of survivors of critical illness.

Efficacy of Enhanced Rehabilitation Initiated After Hospital Discharge to Improve Quality of Life in Survivors of Critical Care: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review and meta-analysis evaluated the effects of enhanced rehabilitation initiated after hospital discharge on the quality of life (QOL) in survivors of critical care. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedure. MEDLINE, CENTRAL, Ichushi, Embase, PEDro, and Cumulated Index to Nursing and Allied Health Literature (CINAHL) databases and the International Clinical Trials Registry Platform and ClinicalTrials.gov (for ongoing or unpublished trials) were searched till January 2024. We identified randomized controlled trials (RCTs) with intensive care unit (ICU) survivors focusing on the effects of enhanced rehabilitation initiated after hospital discharge. Enhanced rehabilitation encompasses protocolized programs offering more intensive, frequent, or longer sessions than standard care. Primary outcomes were physical and mental components of the summary of the standardized QOL scale (SF-36) and adverse events. We calculated pooled-effect estimates for these components, expressing the mean difference (MD) and 95% confidence interval (CI). Risk of bias was evaluated using the Risk of Bias 2 tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Nine RCTs (573 patients) were included. Enhanced rehabilitation resulted in no difference in the physical component-summary score (two studies: n=79, MD=3.03, 95% CI: -1.37 to 7.43, I2=0%, low-certainty evidence) and a higher mental component-summary score (two studies: n=79, MD=7.27, 95% CI: 2.08-12.46, I2=0%, low-certainty evidence). The evidence on the effect of enhanced rehabilitation on adverse events was very uncertain (nine studies: n=558, risk difference: 0.04, 95% CI: 0.00-0.07, I2=65%, very low-certainty evidence). Seven studies reported no adverse event occurrence, one reported a serious event requiring hospitalization in the intervention group, and another reported a minor event in the intervention group with none in controls. Enhanced rehabilitation initiated after hospital discharge may improve the mental component of QOL for survivors in the critical care. Due to the smaller number of studies included, the results need further confirmation.

PRACTICE: Development of a Core Outcome Set for Trials of Physical Rehabilitation in Critical Illness

Rationale: Findings from individual trials of physical rehabilitation interventions in critically ill adults have limited potential for meta-analysis and informing clinical decision-making because of the heterogeneity in selection and reporting of outcomes used for evaluation. Objectives: The objective of this study was to determine a core outcome set (COS) for use in all future trials evaluating physical rehabilitation interventions delivered across the critical illness continuum of recovery. Methods: An international, two-round, online, modified Delphi consensus process, following recommended standards, was conducted. Participants (N = 329) comprised three stakeholder groups-researchers, n = 58 (18%); clinicians, n = 247 (75%); and patients and caregivers, n = 24 (7%)-and represented 26 countries and nine healthcare professions. Participants rated the importance of a range of relevant outcomes. Outcomes included in the COS were those prioritized of "critical importance" by all three stakeholder groups. Results: Survey response rates were 88% (Round 1) and 91% (Round 2). From a total of 32 initial outcomes, the following outcomes reached consensus for inclusion in the COS: physical function, activities of daily living, survival, health-related quality of life, exercise capacity, cognitive function, emotional and mental well-being, and frailty. Conclusions: This study developed a consensus-generated COS for future clinical research evaluating physical rehabilitation interventions in critically ill adults across the continuum of recovery. Ascertaining recommended measurement instruments for these core outcomes is now required to facilitate implementation of the COS.

Association Between Restricting Symptoms and Disability After Critical Illness Among Older Adults

OBJECTIVES

Older adults who survive critical illness are at risk for increased disability, limiting their independence and quality of life. We sought to evaluate whether the occurrence of symptoms that restrict activity, that is, restricting symptoms, is associated with increased disability following an ICU hospitalization.

DESIGN

Prospective longitudinal study of community-living adults 70 years old or older who were interviewed monthly between 1998 and 2018.

SETTING

South Central Connecticut, United States.

PATIENTS

Two hundred fifty-one ICU admissions from 202 participants who were discharged alive from the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Occurrence of 15 restricting symptoms (operationalized as number of symptoms and presence of ≥ 2 symptoms) and disability in activities of daily living, instrumental activities of daily living, and mobility was ascertained during monthly interviews throughout the study period. We constructed multivariable Poisson regression models to evaluate the association between post-ICU restricting symptoms and subsequent disability over the 6 months following ICU hospitalization, adjusting for known risk factors for post-ICU disability including pre-ICU disability, frailty, cognitive impairment, mechanical ventilation, and ICU length of stay. The mean age of participants was 83.5 years ( sd , 5.6 yr); 57% were female. Over the 6 months following ICU hospitalization, each unit increase in the number of restricting symptoms was associated with a 5% increase in the number of disabilities (adjusted rate ratio, 1.05; 95% CI, 1.04-1.06). The presence of greater than or equal to 2 restricting symptoms was associated with a 29% greater number of disabilities over the 6 months following ICU hospitalization as compared with less than 2 symptoms (adjusted rate ratio, 1.29; 95% CI, 1.22-1.36).

CONCLUSIONS

In this longitudinal cohort of community-living older adults, symptoms restricting activity were independently associated with increased disability after ICU hospitalization. These findings suggest that management of restricting symptoms may enhance functional recovery among older ICU survivors.

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

BACKGROUND AND AIMS

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

DESIGN

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Early In-Bed Cycle Ergometry With Critically Ill, Mechanically Ventilated Patients: Statistical Analysis Plan for CYCLE (Critical Care Cycling to Improve Lower Extremity Strength), an International, Multicenter, Randomized Clinical Trial

BACKGROUND

Survivors of critical illness are at risk of developing physical dysfunction following intensive care unit (ICU) discharge. ICU-based rehabilitation interventions, such as early in-bed cycle ergometry, may improve patients' short-term physical function.

OBJECTIVE

Before unblinding and trial database lock, we describe a prespecified statistical analysis plan (SAP) for the CYCLE (Critical Care Cycling to Improve Lower Extremity Strength) randomized controlled trial (RCT).

METHODS

CYCLE is a 360-patient, international, multicenter, open-label, parallel-group RCT (1:1 ratio) with blinded primary outcome assessment at 3 days post-ICU discharge. The principal investigator and statisticians of CYCLE prepared this SAP with approval from the steering committee and coinvestigators. The SAP defines the primary and secondary outcomes (including adverse events) and describes the planned primary, secondary, and subgroup analyses. The primary outcome of the CYCLE trial is the Physical Function Intensive Care Unit Test-scored (PFIT-s) at 3 days post-ICU discharge. The PFIT-s is a reliable and valid performance-based measure. We plan to use a frequentist statistical framework for all analyses. We will conduct a linear regression to evaluate the primary outcome, incorporating randomization as an independent variable and adjusting for age (≥65 years versus <65 years) and center. The regression results will be reported as mean differences in PFIT-s scores with corresponding 95% CIs and P values. We consider a 1-point difference in PFIT-s score to be clinically important. Additionally, we plan to conduct 3 subgroup analyses: age (≥65 years versus <65 years), frailty (Baseline Clinical Frailty Scale ≥5 versus <5), and sex (male versus female).

RESULTS

CYCLE was funded in 2017, and enrollment was completed in May 2023. Data analyses are complete, and the first results were submitted for publication in 2024.

CONCLUSIONS

We developed and present an SAP for the CYCLE RCT and will adhere to it for all analyses. This study will add to the growing body of evidence evaluating the efficacy and safety of ICU-based rehabilitation interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03471247; https://clinicaltrials.gov/ct2/show/NCT03471247 and NCT02377830; https://clinicaltrials.gov/ct2/show/NCT02377830.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/54451.

Meeting complex multidimensional needs in older patients and their families during and beyond critical illness

PURPOSE OF REVIEW

To highlight the emerging crisis of critically ill elderly patients and review the unique burden of multidimensional morbidity faced by these patients and caregivers and potential interventions.

RECENT FINDINGS

Physical, psychological, and cognitive sequelae after critical illness are frequent, durable, and robust across the international ICU outcome literature. Elderly patients are more vulnerable to the multisystem sequelae of critical illness and its treatment and the resultant multidimensional morbidity may be profound, chronic, and significantly affect functional independence, transition to the community, and quality of life for patients and families. Recent data reinforce the importance of baseline functional status, health trajectory, and chronic illness as key determinants of long-term functional disability after ICU. These risks are even more pronounced in older patients.

SUMMARY

The current article is an overview of the outcomes of older survivors of critical illness, putative interventions to mitigate the long-term morbidity of patients, and the consequences for families and caregivers. A multimodal longitudinal approach designed to follow patients for one or more years may foster a better understanding of multidimensional morbidity faced by vulnerable older patients and families and provides a detailed understanding of recovery trajectories in this unique population to optimize outcome, goals of care directives, and ongoing informed consent to ICU treatment.

Recovery from Sepsis: Management beyond Acute Care

Recovery from sepsis is a key global health issue, impacting 38 million sepsis survivors worldwide per year. Sepsis survivors face a wide range of physical, cognitive, and psychosocial sequelae. Readmissions to hospital following sepsis are an important driver of global healthcare utilization and cost. Family members of sepsis survivors also experience significant stressors related to their role as informal caregivers. Increasing recognition of the burdens of sepsis survivorship has led to the development of postsepsis recovery programs to better support survivors and their families, although optimal models of care remain uncertain. The goal of this article is to perform a narrative review of recovery from sepsis from the perspective of patients, families, and health systems.

Impact of Protein Intake after Intensive Care Unit on Discharge Destination for Critically Ill Patients: A Single-Center Prospective Observational Study

INTRODUCTION

Although nutritional therapy may be able to enable intensive care unit (ICU) survivors to return home instead of being discharged to a rehabilitation facility, post-ICU discharge nutritional therapy lacks investigation. This study evaluated the impact of nutritional therapy after ICU on discharge destination in critically ill patients.

METHODS

We enrolled consecutive adult patients who spent >72 h in the ICU from December 2020 to March 2023. The primary outcome was discharge destination. Energy and protein intake during the ICU stay and on days 7 and 14 after ICU discharge were evaluated. The target protein intake during the intensive treatment and general ward phases were 0.8 and 1.0 g/kg/day, respectively. Patients were categorized into home discharge (group A) and rehabilitation transfer (group B) groups. Factors affecting the discharge destination were evaluated using logistic regression analysis.

RESULTS

Of the 183 patients included, 134 belonged to group A and 49 to group B. In group A, more patients reached the protein intake target than in group B. Logistic regression analysis identified achieving the protein intake target as an independent predictor of home discharge.

CONCLUSION

Further studies are required to confirm the relationship between nutritional therapy during general ward and patient outcomes.

Effects of exercise interventions on functioning and health-related quality of life following hospital discharge for recovery from critical illness: A systematic review and meta-analysis of randomized trials

OBJECTIVE

This systematic review and meta-analysis aimed to analyze the published randomized controlled trials (RCTs) that investigated the effects of exercise interventions on functioning and health-related quality of life following hospital discharge for recovery from critical illness.

DESIGN

Systematic review and meta-analysis of RCTs.

DATA SOURCES

We searched PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, PEDro data base, and SciELO (from the earliest date available to January 2023) for RCTs that evaluated the effects of physical rehabilitation interventions following hospital discharge for recovery from critical illness.

REVIEW METHODS

Study quality was evaluated using the PEDro Scale. Mean differences (MDs), standard MDs (SMD), and 95% confidence intervals (CIs) were calculated.

RESULTS

Fourteen studies met the study criteria, including 1259 patients. Exercise interventions improved aerobic capacity SMD 0.2 (95% CI: 0.03-0.3, I2 = 0% N = 880, nine studies, high-quality evidence), and physical component score of health-related quality of life MD 3.3 (95% CI: 1.0-5.6, I2 = 57%, six studies N = 669, moderate-quality evidence). In addition, a significant reduction in depression was observed MD -1.4 (95% CI: -2.7 to -0.1, I2 = 0% N = 148, three studies, moderate-quality evidence). No serious adverse events were reported.

CONCLUSION

Exercise intervention was associated with improvement of aerobic capacity, depression, and physical component score of health-related quality of life after hospital discharge for survivors of critical illness.

Early In-Bed Cycle Ergometry in Mechanically Ventilated Patients

BACKGROUND

Critical illness requiring invasive mechanical ventilation can precipitate important functional disability, contributing to multidimensional morbidity following admission to an intensive care unit (ICU). Early in-bed cycle ergometry added to usual physiotherapy may mitigate ICU-acquired physical function impairment.

METHODS

We randomly assigned 360 adult ICU patients undergoing invasive mechanical ventilation to receive 30 minutes of early in-bed Cycling + Usual physiotherapy (n=178) or Usual physiotherapy alone (n=182). The primary outcome was the Physical Function ICU Test-scored (PFIT-s) at 3 days after discharge from the ICU (the score ranges from 0 to 10, with higher scores indicating better function).

RESULTS

Cycling began within a median (interquartile range) of 2 (1 to 3) days of starting mechanical ventilation; patients received 3 (2 to 5) cycling sessions for a mean (±standard deviation) of 27.2 ± 6.6 minutes. In both groups, patients started Usual physiotherapy within 2 (2 to 4) days of mechanical ventilation and received 4 (2 to 7) Usual physiotherapy sessions. The duration of Usual physiotherapy was 23.7 ± 15.1 minutes in the Cycling + Usual physiotherapy group and 29.1 ± 13.2 minutes in the Usual physiotherapy group. No serious adverse events occurred in either group. Among survivors, the PFIT-s at 3 days after discharge from the ICU was 7.7 ± 1.7 in the Cycling + Usual physiotherapy group and 7.5 ± 1.7 in the Usual physiotherapy group (absolute difference, 0.23 points; 95% confidence interval, -0.19 to 0.65; P=0.29).

CONCLUSIONS

Among adults receiving mechanical ventilation in the ICU, adding early in-bed Cycling to usual physiotherapy did not improve physical function at 3 days after discharge from the ICU compared with Usual physiotherapy alone. Cycling did not cause any serious adverse events. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov numbers, NCT03471247 [full randomized clinical trial] and NCT02377830 [CYCLE Vanguard 46-patient internal pilot].).

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

OBJECTIVES

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

RESEARCH METHODOLOGY

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

SETTING

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR CLINICAL PRACTICE

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

Early mobility and family partnerships in the intensive care unit: A scoping review of reviews

BACKGROUND

Critical illness significantly impacts the well-being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families.

AIM

In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature.

STUDY DESIGN

In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA-ScR guidelines were adhered to for reporting.

RESULTS

Thirty-three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies.

CONCLUSIONS

There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions.

RELEVANCE TO CLINICAL PRACTICE

Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

None.

Effects of education, income and employment on ICU and post-ICU survival - A nationwide Swedish cohort study of individual-level data with 1-year follow up

PURPOSE

The aim of this study was to examine relationships between education, income, and employment (socioeconomic status, SES) and intensive care unit (ICU) survival and survival 1 year after discharge from ICU (Post-ICU survival).

METHODS

Individual data from ICU patients were linked to register data of education level, disposable income, employment status, civil status, foreign background, comorbidities, and vital status. Associations between SES, ICU survival and 1-year post-ICU survival was analysed using Cox's regression.

RESULTS

We included 58,279 adults (59% men, median length of stay in ICU 4.0 days, median SAPS3 score 61). Survival rates at discharge from ICU and one year after discharge were 88% and 63%, respectively. Risk of ICU death (Hazard ratios, HR) was significantly higher in unemployed and retired compared to patients who worked prior to admission (1.20; 95% CI: 1.10-1.30 and 1.15; (1.07-1.24), respectively. There was no consistent association between education, income and ICU death. Risk of post-ICU death decreased with greater income and was roughly 16% lower in the highest compared to lowest income quintile (HR 0.84; 0.79-0.88). Higher education levels appeared to be associated with reduced risk of death during the first year after ICU discharge.

CONCLUSIONS

Significant relationships between low SES in the critically ill and increased risk of death indicate that it is important to identify and support patients with low SES to improve survival after intensive care. Studies of survival after critical illness need to account for participants SES.

Survivorship outcomes for critically ill patients in Australia and New Zealand: A scoping review

INTRODUCTION

Impairments after critical illness, termed the post-intensive care syndrome, are an increasing focus of research in Australasia. However, this research is yet to be cohesively synthesised and/or summarised.

OBJECTIVE

The aim of this scoping review was to explore patient outcomes of survivorship research, identify measures, methodologies, and designs, and explore the reported findings in Australasia.

INCLUSION CRITERIA

Studies reporting outcomes for adult survivors of critical illness from Australia and New Zealand in the following domains: physical, functional, psychosocial, cognitive, health-related quality of life (HRQoL), discharge destination, health care use, return to work, and ongoing symptoms/complications of critical illness.

METHODS

The Joanna Briggs Institute scoping review methodology framework was used. A protocol was published on the open science framework, and the search used Ovid MEDLINE, Scopus, ProQuest, and Google databases. Eligible studies were based on reports from Australia and New Zealand published in English between January 2000 and March 2022.

RESULTS

There were 68 studies identified with a wide array of study aims, methodology, and designs. The most common study type was nonexperimental cohort studies (n = 17), followed by studies using secondary analyses of other study types (n = 13). HRQoL was the most common domain of recovery reported. Overall, the identified studies reported that impairments and activity restrictions were associated with reduced HRQoL and reduced functional status was prevalent in survivors of critical illness. About 25% of 6-month survivors reported some form of disability. Usually, by 6 to12 months after critical illness, impairments had improved.

CONCLUSIONS

Reports of long-term outcomes for survivors of critical illness in Australia highlight that impairments and activity limitations are common and are associated with poor HRQoL. There was little New Zealand-specific research related to prevalence, impact, unmet needs, ongoing symptoms, complications from critical illness, and barriers to recovery.

Quality of life after acute kidney injury

PURPOSE OF REVIEW

Deciphering the effect of acute kidney injury (AKI) during critical illness on long-term quality of life versus the impact of conditions that brought on critical illness is difficult.

RECENT FINDINGS

Reports on patient-centred outcomes such as health-related quality of life (HRQOL) have provided insight into the long-lasting impact of critical illness complicated by AKI. However, these data stem from observational studies and randomized controlled trials, which have been heterogeneous in their patient population, timing, instruments used for assessment and reporting. Recent studies have corroborated these findings including lack of effect of renal replacement therapy compared to severe AKI on outcomes and worse physical compared to cognitive dysfunction.

SUMMARY

In adults, more deficits in physical than mental health domains are found in survivors of AKI in critical care, whereas memory deficits and learning impairments have been noted in children. Further study is needed to understand and develop interventions that preserve or enhance the quality of life for individual patients who survive AKI following critical illness, across all ages.

A Retrospective Analysis of Ischemic Stroke Patients Supports That Very Early Mobilization Within 24 Hours After Intravenous Alteplase Is Safe and Possibly Beneficial

ABSTRACT

BACKGROUND: Stroke care guidelines recommend early mobilization of acute ischemic stroke patients, but there are sparse data regarding early mobilization of stroke patients receiving thrombolytic therapy. We developed the Providence Early Mobility for Stroke (PEMS) protocol to mobilize patients to their highest individual tolerance within 24 hours of stroke admission in 2010, and it has been in continuous use at our primary and comprehensive stroke centers for over a decade. In this study, we evaluated the PEMS protocol in all patients treated with intravenous alteplase without endovascular treatment. METHODS : This retrospective study includes 318 acute ischemic stroke patients treated with alteplase who were admitted to 2 urban stroke centers between January 2013 and December of 2017 and were mobilized with the PEMS protocol within 24 hours of receiving alteplase. Safety of PEMS was assessed by change in National Institutes of Health Stroke Scale at 24 hours by time first mobilized. Using multivariate and logistic regression models, we analyzed time first mobilized and 90-day modified Rankin scale (mRS). RESULTS : Median time first mobilized was 9 hours from administration of alteplase. For every hour delay in mobilization, the odds of being slightly or moderately disabled (mRS, 2-3) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .004), and the odds of being severely disabled or dead (mRS, 4-6) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .02). In addition, for every hour delay in mobilization, 24-hour National Institutes of Health Stroke Scale increased by 1.8%. DISCUSSION: Our results support that the PEMS protocol is safe, and possibly beneficial, for acute ischemic stroke patients treated with intravenous alteplase. Our protocol differs from other very early mobility protocols because it does not prescribe a "dose" of activity. Instead, each patient was mobilized to his/her individual highest degree as soon as it was safe to do so.

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

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

Early detection and assessment of intensive care unit-acquired weakness: a comprehensive review

Intensive care unit-acquired weakness (ICU-AW) is a serious complication in critically ill patients. Therefore, timely and accurate diagnosis and monitoring of ICU-AW are crucial for effectively preventing its associated morbidity and mortality. This article provides a comprehensive review of ICU-AW, focusing on the different methods used for its diagnosis and monitoring. Additionally, it highlights the role of bedside ultrasound in muscle assessment and early detection of ICU-AW. Furthermore, the article explores potential strategies for preventing ICU-AW. Healthcare providers who manage critically ill patients utilize diagnostic approaches such as physical exams, imaging, and assessment tools to identify ICU-AW. However, each method has its own limitations. The diagnosis of ICU-AW needs improvement due to the lack of a consensus on the appropriate approach for its detection. Nevertheless, bedside ultrasound has proven to be the most reliable and cost-effective tool for muscle assessment in the ICU. Combining the Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score assessment, and ultrasound can be a convenient approach for the early detection of ICU-AW. This approach can facilitate timely intervention and prevent catastrophic consequences. However, further studies are needed to strengthen the evidence.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Responsiveness of Critically Ill Adults With Multimorbidity to Rehabilitation Interventions: A Patient-Level Meta-Analysis Using Individual Pooled Data From Four Randomized Trials

OBJECTIVE

To explore if patient characteristics (pre-existing comorbidity, age, sex, and illness severity) modify the effect of physical rehabilitation (intervention vs control) for the coprimary outcomes health-related quality of life (HRQoL) and objective physical performance using pooled individual patient data from randomized controlled trials (RCTs).

DATA SOURCES

Data of individual patients from four critical care physical rehabilitation RCTs.

STUDY SELECTION

Eligible trials were identified from a published systematic review.

DATA EXTRACTION

Data sharing agreements were executed permitting transfer of anonymized data of individual patients from four trials to form one large, combined dataset. The pooled trial data were analyzed with linear mixed models fitted with fixed effects for treatment group, time, and trial.

DATA SYNTHESIS

Four trials contributed data resulting in a combined total of 810 patients (intervention n = 403, control n = 407). After receiving trial rehabilitation interventions, patients with two or more comorbidities had HRQoL scores that were significantly higher and exceeded the minimal important difference at 3 and 6 months compared with the similarly comorbid control group (based on the Physical Component Summary score (Wald test p = 0.041). Patients with one or no comorbidities who received intervention had no HRQoL outcome differences at 3 and 6 months when compared with similarly comorbid control patients. No patient characteristic modified the physical performance outcome in patients who received physical rehabilitation.

CONCLUSIONS

The identification of a target group with two or more comorbidities who derived benefits from the trial interventions is an important finding and provides direction for future investigations into the effect of rehabilitation. The multimorbid post-ICU population may be a select population for future prospective investigations into the effect of physical rehabilitation.

Activin A level is associated with physical function in critically ill patients

BACKGROUND

Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels.

OBJECTIVES

The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital.

METHODS

Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU.

RESULTS

High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures.

CONCLUSIONS

Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness.

STUDY REGISTRATION

ACTRN12615000047594.

Identifying Comorbid Subtypes of Patients With Acute Respiratory Failure

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical impact of rehabilitation and ICU diary on critically ill patients: A systematic review and meta‐analysis

Background

Various physical and mental sequelae reduce the quality of life (QOL) of intensive care unit (ICU) patients. Current guidelines recommend multi‐angular approaches to prevent these sequelae. Some studies have demonstrated the clinical effectiveness of rehabilitation or the ICU diary against these sequelae, whereas others have not.

Aim

The aims of the present study were to establish whether rehabilitation or the ICU diary was useful for reducing the severity of anxiety, depression, and post‐traumatic stress disorder (PTSD) in ICU patients. We also investigated whether these interventions improved the QOL of these patients.

Study design

We conducted a systematic review and meta‐analysis of relevant randomized controlled trials published between January 1, 1985, and October 19, 2022, with the following search engines: PubMed, CHINAHL, all Ovid journals, and CENTRAL. The hospital anxiety and depression scale (HADS), the short‐form health survey (SF‐36), the EuroQol 5‐dimensions, 5‐levels (EQ‐5D‐5L), and the Impact of Event Scale‐Revised (IES‐R) were used as outcome measures. The quality of evidence across all studies was independently assessed using Review Manager software (v.5.4).

Results

We included 12 rehabilitation studies and five ICU diary studies. Rehabilitation had no significant effects on HADS‐anxiety, HADS‐depression, or EQ‐5D‐5L, but significantly improved the physical component summary (PCS) [MD = 3.31, 95%CI (1.33 to 5.28), p = .001] and mental component summary (MCS) [MD = 4.31, 95%CI: (1.48 to 7.14), p = .003] of the SF‐36. The ICU diary significantly ameliorated HADS‐anxiety [MD = 0.96, 95%CI: (0.21 to 1.71), p = .01], but did not affect HADS‐depression, the IES‐R, or the PCS or MCS of the SF‐36.

Conclusions

The present study showed that rehabilitation initiated after discharge from the ICU effectively improved SF‐36 scores. The ICU diary ameliorated HADS‐anxiety. Neither rehabilitation nor the ICU diary attenuated HADS‐depression or IES‐R in this setting. Rehabilitation and the ICU diary partially improved the long‐term prognosis of ICU patients.

Relevance to clinical practice

The present study provides evidence for the beneficial effects of rehabilitation and the ICU diary for ICU patients. Rehabilitation alone does not ameliorate anxiety, depression, or PTSD symptoms, but may improve QOL. The ICU diary only appeared to ameliorate anxiety.

Structured Mobilization for Critically Ill Patients: A Pragmatic Cluster-randomized Trial

Rationale: Small trials and professional recommendations support mobilization interventions to improve recovery among critically ill patients, but their real-world effectiveness is unknown. Objective: To evaluate a low-cost, multifaceted mobilization intervention. Methods: We conducted a stepped-wedge cluster-randomized trial across 12 ICUs with diverse case mixes. The primary and secondary samples included patients mechanically ventilated for ⩾48 hours who were ambulatory before admission, and all patients with ICU stays ⩾48 hours, respectively. The mobilization intervention included 1) designation and posting of daily mobilization goals; 2) interprofessional closed-loop communication coordinated by each ICU's facilitator; and 3) performance feedback. Measurements and Main Results: From March 4, 2019 through March 15, 2020, 848 and 1,069 patients were enrolled in the usual care and intervention phases in the primary sample, respectively. The intervention did not increase the primary outcome, patient's maximal Intensive Care Mobility Scale (range, 0-10) score within 48 hours before ICU discharge (estimated mean difference, 0.16; 95% confidence interval, -0.31 to 0.63; P = 0.51). More patients in the intervention (37.2%) than usual care (30.7%) groups achieved the prespecified secondary outcome of ability to stand before ICU discharge (odds ratio, 1.48; 95% confidence interval, 1.02 to 2.15; P = 0.04). Similar results were observed among the 7,115 patients in the secondary sample. The percentage of days on which patients received physical therapy mediated 90.1% of the intervention effect on standing. ICU mortality (31.5% vs. 29.0%), falls (0.7% vs. 0.4%), and unplanned extubations (2.0% vs. 1.8%) were similar between groups (all P > 0.3). Conclusions: A low-cost, multifaceted mobilization intervention did not improve overall mobility but improved patients' odds of standing and was safe. Clinical trial registered with www.clinicaltrials.gov (NCT03863470).

Critical Care Cycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients

INTRODUCTION

In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults.

METHODS AND ANALYSIS

We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups.

ETHICS AND DISSEMINATION

Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).

Association Between Knee Extension Strength and Functional Capacity After Intensive Care Unit Discharge: A 6-Mo Prospective Cohort Study

INTRODUCTION

Assessing functional improvement after intensive care unit discharge is particularly challenging. The aim of this study was to measure the association between (1) changes in knee extension muscle strength or quadriceps femoris and rectus femoris muscle thickness and (2) changes in functionality/function-related measurements in post-intensive care unit patients.

METHODS

This prospective cohort study included adult patients without previous disability, consecutively selected after intensive care unit discharge. Some parameters, such as Short-Form 36, 6-min walking test, 1-min sit-to-stand, and Short Physical Performance Battery, were measured at baseline and 3 and 6 mos after discharge. Correlations were assessed and regression models were built to assess the association between evolution in knee extension strength or muscle thickness and evolution in functional tests.

RESULTS

Thirty patients completed the follow-up. Moderate correlation was found between knee extension strength change and Short-Form 36 physical functioning (correlation coefficient [ ρ ] = 0.53), 6-min walking test ( ρ = 0.38), 1-min sit-to-stand ( ρ = 0.52), and Short Physical Performance Battery ( ρ = 0.38). Baseline values and changes in knee extension strength moderately predicted evolution in Short-Form 36 physical functioning ( r2 = 0.32, P = 0.006). Changes in muscle thickness were overall not associated with changes in functional variables.

CONCLUSION

Changes in knee extension muscle strength may inform on functional progression over time after intensive care unit discharge, although confirmatory studies are needed.

Feasibility of mobilisation in ICU: a multi-centre point prevalence study of mobility practices in the UK

BACKGROUND

Early mobilisation in critical care is recommended within clinical guidance; however, mobilisation prevalence across the UK is unknown. The study aimed to determine the proportion of patients mobilised out of bed within 48-72 h, to describe their physiological status, and to compare this to published consensus safety recommendations for out-of-bed activity.

METHODS

A UK cross-sectional, multi-centre, observational study of adult critical care mobility practices was conducted. Demographic, physiological and organ support data, mobility level, and rationale for not mobilising out of bed, were collected for all patients on 3rd March 2022. Patients were categorised as: Group 1-mobilised ICU Mobility Scale (IMS) ≥ 3; Group 2-not-mobilised IMS < 3 with physiological reasons; or Group 3-not-mobilised IMS < 3 with non-physiological barriers to mobilisation. Rationale for the decision to not mobilise was collected qualitatively. Regression analysis was used to compare the physiological parameters of Group 1 (mobilised) versus Group 2 (not-mobilised with physiological reasons). Patients were stratified as 'low-risk', 'potential-risk' or 'high-risk' using published risk of adverse event ratings.

RESULTS

Data were collected for 960 patients across 84 UK critical care units. Of these 393 (41%) mobilised, 416 (43%) were not-mobilised due to physiological reasons and 151 (16%) were not mobilised with non-physiological reasons. A total of 371 patients had been admitted for ≤ 3 days, of whom 180 (48%) were mobilised, 140 (38%) were not mobilised with physiological reasons, and 51 (14%) were not mobilised with non-physiological reasons. Of the 809 without non-physiological barriers to mobilisation, 367 (45%) had a low risk of adverse event rating and 120 (15%) a potential risk, of whom 309 (84%) and 78 (65%) mobilised, respectively. Mobility was associated with a Richmond Agitation-Sedation Scale of - 1 to + 1, lower doses of vasoactive agents, a lower inspired oxygen requirement.

CONCLUSION

Although only 40% of patients mobilised out of bed, 89% of those defined 'low-risk' did so. There is significant overlap in physiological parameters for mobilisation versus non-mobilisation groups, suggesting a comprehensive physiological assessment is vital in decision making rather than relying on arbitrary time points.

CLINICAL TRIALS REGISTRATION

NCT05281705 Registered March 16, 2022. Retrospectively registered.

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.

Post-intensive care syndrome (PICS): recent updates

An increasing number of patients are surviving critical illness, but some experience new or worsening long-lasting impairments in physical, cognitive and/or mental health, commonly known as post-intensive care syndrome (PICS). The need to better understand and improve PICS has resulted in a growing body of literature exploring its various facets. This narrative review will focus on recent studies evaluating various aspects of PICS, including co-occurrence of specific impairments, subtypes/phenotypes, risk factors/mechanisms, and interventions. In addition, we highlight new aspects of PICS, including long-term fatigue, pain, and unemployment.

Neurological complications of sepsis

PURPOSE OF REVIEW

Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a leading cause of hospital and ICU admission. The central and peripheral nervous system may be the first organ system to show signs of dysfunction, leading to clinical manifestations such as sepsis-associated encephalopathy (SAE) with delirium or coma and ICU-acquired weakness (ICUAW). In the current review, we want to highlight developing insights into the epidemiology, diagnosis, prognosis, and treatment of patients with SAE and ICUAW.

RECENT FINDINGS

The diagnosis of neurological complications of sepsis remains clinical, although the use of electroencephalography and electromyography can support the diagnosis, especially in noncollaborative patients, and can help in defining disease severity. Moreover, recent studies suggest new insights into the long-term effects associated with SAE and ICUAW, highlighting the need for effective prevention and treatment.

SUMMARY

In this manuscript, we provide an overview of recent insights and developments in the prevention, diagnosis, and treatment of patients with SAE and ICUAW.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Nutritional status of patients with COVID-19 one year post-ICU stay: a prospective observational study

Objective

Patients discharged from the Intensive Care Unit (ICU) often suffer from physical complaints and poor nutritional intake, which negatively affect nutritional status (NS). Our aim was to describe NS of patients with COVID-19 one year post-ICU stay.

Research Methods & Procedures

Observational study of adult patients with COVID-19 one year post-ICU. NS assessment (nutrient balance, body composition and physical status) was performed. Nutritional intake and nutrition-related complaints were examined. Nutritional requirements were determined with indirect calorimetry and body composition with bio-electrical impedance. Fat-free mass index (FFMI) and fat mass index (FMI) were calculated. Physical status was determined with handgrip strength (HGS), 6-minute walk test, and 1-minute sit to stand test (1MSTST). Descriptive statistics and paired sample t-tests were used for analysis.

Results

We included 48 patients (73% male; median age 60 years [IQR 52;65]). Median weight loss during ICU stay was 13%. One year post-ICU 12% weight was regained. Median BMI was 26 kg/m² and 23% was obese (BMI>30 kg/m² and high FMI). Of the patients, 50% had high FMI and 19% had low FFMI. Median reported nutritional intake was 90% of measured resting energy expenditure. Nutrition-related complaints were seen in 16%. Percentages of normal values reached in physical tests were 92% of HGS, 95% of 6 minute walking distance and 79% of 1MSTST.

Conclusion(s)

Despite almost fully regained weight and good physical recovery in adult patients one year post-ICU stay, NS remained impaired due to elevated FMI, even though reported nutritional intake was below the estimated requirements.

The Effect of Mobilization at 6 Months after Critical Illness - Meta-Analysis

BACKGROUND: The comparative efficacy and safety of early active mobilization compared with usual care regarding long-term outcomes for adult critically ill survivors remain uncertain. METHODS: We systematically reviewed randomized clinical trials comparing early active mobilization versus usual care in critically ill adults. The primary outcome was days alive and out of hospital to day 180 after pooling data using random effects modeling. We also performed a Bayesian meta-analysis to describe the treatment effect in probability terms. Secondary outcomes were mortality, physical function, strength, health-related quality of life at 6 months, and adverse events. RESULTS: Fifteen trials from 11 countries were included with data from 2703 participants. From six trials (1121 participants) reporting the primary outcome, the pooled mean difference was an increase of 4.28 days alive and out of hospital to day 180 in those patients who received early active mobilization (95% confidence interval, −4.46 to 13.03; I2=41%). Using Bayesian analyses with vague priors, the probability that the intervention increased days alive and out of hospital was 75.1%. In survivors, there was a 95.1% probability that the intervention improved physical function measured through a patient-reported outcome measure at 6 months (standardized mean difference, 0.2; 95% confidence interval, 0.09 to 0.32; I2=0%). Although no treatment effect was identified on any other secondary outcome, there was a 66.4% possibility of increased adverse events with the implementation of early active mobilization and a 72.2% chance it increased 6-month mortality. CONCLUSIONS: Use of early active mobilization for critically ill adults did not significantly affect days alive and out of hospital to day 180. Early active mobilization was associated with improved physical function in survivors at 6 months; however, the possibility that it might increase mortality and adverse events needs to be considered when interpreting this finding. (PROSPERO number, CRD42022309650.)