Passive motion of the lower extremities in sedated and ventilated patients in the ICU - a systematic review of early effects and replicability of Interventions

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

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATION FOR CLINICAL PRACTICE

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

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

Background

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

Methods

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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