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Albarrati A, Aldhahi MI, Almuhaid T, Alnahdi A, Alanazi AS, Alqahtani AS, Nazer RI. A Culture of Early Mobilization in Adult Intensive Care Units: Perspective and Competency of Physicians. Healthcare (Basel) 2024; 12:1300. [PMID: 38998835 PMCID: PMC11241168 DOI: 10.3390/healthcare12131300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Early mobility (EM) is vital in the intensive care unit (ICU) to counteract immobility-related effects. A multidisciplinary approach is key, as it requires precise initiation knowledge. However, physicians' understanding of EM in adult ICU settings remains unexplored. This study was conducted to investigate the knowledge and clinical competency of physicians working in adult ICUs toward EM. METHODS This cross-sectional study enrolled 236 physicians to assess their knowledge of EM. A rigorously designed survey comprising 30 questions across the demographic, theoretical, and clinical domains was employed. The criteria for knowledge and competency were aligned with the minimum passing score (70%) stipulated for physician licensure by the medical regulatory authority in Saudi Arabia. RESULTS Nearly 40% of the respondents had more than 5 years of experience. One-third of the respondents received theoretical knowledge about EM as part of their residency training, and only 4% of the respondents attended formal courses to enhance their knowledge. Almost all the respondents (95%) stated their awareness of EM benefits and its indications and contraindications and considered it safe to mobilize patients on mechanical ventilators. However, 62.3% of the respondents did not support EM for critically ill patients on mechanical ventilators until weaning. In contrast, 51.7% of respondents advised EM for agitated patients with RASS > 2. Only 113 (47.9%) physicians were competent in determining the suitability of ICU patients for EM. For critically ill patients who should be mobilized, nearly 60% of physicians refused to initiate EM. CONCLUSIONS This study underscores insufficient practical knowledge of ICU physicians about EM criteria, which leads to suboptimal decisions, particularly in complex ICU cases. These findings emphasize the need for enhanced training and education of physicians working in adult ICU settings to optimize patient care and outcomes in critical care settings.
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Affiliation(s)
- Ali Albarrati
- Rehabilitation Sciences Department, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia
| | - Monira I Aldhahi
- Department of Rehabilitation Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Turki Almuhaid
- Prince Mohammed Bin Abdulaziz Hospital, Ministry of Health, Riyadh 14214, Saudi Arabia
| | - Ali Alnahdi
- Rehabilitation Sciences Department, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia
| | - Ahmed S Alanazi
- Department of Physical Therapy, College of Medical Rehabilitation Sciences, Taibah University, Medina 42353, Saudi Arabia
| | - Abdulfattah S Alqahtani
- Rehabilitation Sciences Department, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia
| | - Rakan I Nazer
- Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh 11421, Saudi Arabia
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Wi S, Shin HI, Hyun SE, Sung KS, Lee WH. Feasibility and safety of in-bed cycling/stepping in critically ill patients: A study protocol for a pilot randomized controlled clinical trial. PLoS One 2024; 19:e0301368. [PMID: 38728323 PMCID: PMC11086822 DOI: 10.1371/journal.pone.0301368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness (ICU-AW) is one of the most common complications of post-ICU syndrome. It is the leading cause of gait disturbance, decreased activities of daily living, and poor health-related quality of life. The early rehabilitation of critically ill patients can reduce the ICU-AW. We designed a protocol to investigate the feasibility and safety of conventional rehabilitation with additional in-bed cycling/stepping in critically ill patients. METHODS The study is designed as a single-center, single-blind, pilot, randomized, parallel-group study. After the screening, participants are randomly allocated to two groups, stratified by mechanical ventilation status. The intervention group will be provided with exercises of in-bed cycling/stepping according to the level of consciousness, motor power, and function in addition to conventional rehabilitation. In contrast, the control group will be provided with only conventional rehabilitation. The length of intervention is from ICU admission to discharge, and interventions will be conducted for 20 minutes, a maximum of three sessions per day. RESULTS The outcomes are the number and percentage of completed in-bed cycling/stepping sessions, the duration and percentage of in-bed cycling/stepping sessions, and the number of cessations of in-bed cycling/stepping sessions, the interval from ICU admission to the first session of in-bed cycling/stepping, the number and percentage of completed conventional rehabilitation sessions, the duration and percentage of conventional rehabilitation sessions, the number of cessations of conventional rehabilitation sessions, the number of adverse events, level of consciousness, functional mobility, muscle strength, activities of daily living, and quality of life. DISCUSSION This study is a pilot clinical trial to investigate the feasibility and safety of conventional rehabilitation with additional in-bed cycling/stepping in critically ill patients. If the expected results are achieved in this study, the methods of ICU rehabilitation will be enriched. TRIAL REGISTRATION clinicialtrials.gov, Clinical Trials Registration #NCT05868070.
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Affiliation(s)
- Soohyun Wi
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sung Eun Hyun
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kwan-Sik Sung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Woo Hyung Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
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Woodbridge HR, McCarthy CJ, Jones M, Willis M, Antcliffe DB, Alexander CM, Gordon AC. Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study. Crit Care 2024; 28:144. [PMID: 38689372 PMCID: PMC11061934 DOI: 10.1186/s13054-024-04919-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/17/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs. METHODS A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two. RESULTS Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions. CONCLUSIONS The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).
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Affiliation(s)
- Huw R Woodbridge
- Imperial College Healthcare NHS Trust, London, UK.
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | | | | | | | - David B Antcliffe
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Caroline M Alexander
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Anthony C Gordon
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey. Burns 2023; 49:42-54. [PMID: 36202684 DOI: 10.1016/j.burns.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 01/06/2023]
Abstract
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.
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Borges LF, Fraga Righetti R, de Souza Francisco D, Pereira Yamaguti W, Barros CFD. Hemodynamic impact of early mobilization in critical patients receiving vasoactive drugs: A prospective cohort study. PLoS One 2022; 17:e0279269. [PMID: 36538515 PMCID: PMC9767358 DOI: 10.1371/journal.pone.0279269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Vasoactive drugs are one of the most common patient-related barriers to early mobilization. Little is known about the hemodynamic effects of early mobilization on patients receiving vasoactive drugs. This study aims to observe and describe the impact of mobilization on the vital signs of critical patients receiving vasoactive drugs as well as the occurrence of adverse events. METHODS This is a cohort study performed in an Intensive Care Unit with patients receiving vasoactive drugs. All patients, either mobilized or non-mobilized, had their clinical data such as vital signs [heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation], type and dosage of the vasoactive drug, and respiratory support collected at rest. For mobilized patients, the vital signs were also collected after mobilization, and so was the highest level of mobility achieved and the occurrence of adverse events. The criteria involved in the decision of mobilizing the patients were registered. RESULTS 53 patients were included in this study and 222 physiotherapy sessions were monitored. In most of the sessions (n = 150, 67.6%), patients were mobilized despite the use of vasoactive drugs. There was a statistically significant increase in heart rate and respiratory rate after mobilization when compared to rest (p<0.05). Only two (1.3%) out of 150 mobilizations presented an adverse event. Most of the time, non-mobilizations were justified by the existence of a clinical contraindication (n = 61, 84.7%). CONCLUSIONS The alterations observed in the vital signs of mobilized patients may have reflected physiological adjustments of patients' cardiovascular and respiratory systems to the increase in physical demand imposed by the early mobilization. The adverse events were rare, not serious, and reversed through actions such as a minimal increase of the vasoactive drug dosage.
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Lindholz M, Schellenberg CM, Grunow JJ, Kagerbauer S, Milnik A, Zickler D, Angermair S, Reißhauer A, Witzenrath M, Menk M, Boie S, Balzer F, Schaller SJ. Mobilisation of critically ill patients receiving norepinephrine: a retrospective cohort study. Crit Care 2022; 26:362. [PMID: 36434724 PMCID: PMC9700948 DOI: 10.1186/s13054-022-04245-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/15/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Mobilisation and exercise intervention in general are safe and feasible in critically ill patients. For patients requiring catecholamines, however, doses of norepinephrine safe for mobilisation in the intensive care unit (ICU) are not defined. This study aimed to describe mobilisation practice in our hospital and identify doses of norepinephrine that allowed a safe mobilisation. METHODS We conducted a retrospective single-centre cohort study of 16 ICUs at a university hospital in Germany with patients admitted between March 2018 and November 2021. Data were collected from our patient data management system. We analysed the effect of norepinephrine on level (ICU Mobility Scale) and frequency (units per day) of mobilisation, early mobilisation (within 72 h of ICU admission), mortality, and rate of adverse events. Data were extracted from free-text mobilisation entries using supervised machine learning (support vector machine). Statistical analyses were done using (generalised) linear (mixed-effect) models, as well as chi-square tests and ANOVAs. RESULTS A total of 12,462 patients were analysed in this study. They received a total of 59,415 mobilisation units. Of these patients, 842 (6.8%) received mobilisation under continuous norepinephrine administration. Norepinephrine administration was negatively associated with the frequency of mobilisation (adjusted difference -0.07 mobilisations per day; 95% CI - 0.09, - 0.05; p ≤ 0.001) and early mobilisation (adjusted OR 0.83; 95% CI 0.76, 0.90; p ≤ 0.001), while a higher norepinephrine dose corresponded to a lower chance to be mobilised out-of-bed (adjusted OR 0.01; 95% CI 0.00, 0.04; p ≤ 0.001). Mobilisation with norepinephrine did not significantly affect mortality (p > 0.1). Higher compared to lower doses of norepinephrine did not lead to a significant increase in adverse events in our practice (p > 0.1). We identified that mobilisation was safe with up to 0.20 µg/kg/min norepinephrine for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation. CONCLUSIONS Mobilisation with norepinephrine can be done safely when considering the status of the patient and safety guidelines. We demonstrated that safe mobilisation was possible with norepinephrine doses up to 0.20 µg/kg/min for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation.
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Affiliation(s)
- Maximilian Lindholz
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Clara M Schellenberg
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Julius J Grunow
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Simone Kagerbauer
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
| | - Annette Milnik
- Division of Molecular Neuroscience, University of Basel, Basel, Switzerland
| | - Daniel Zickler
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Stefan Angermair
- Department of Anesthesiology and Operative Intensive Care Medicine (CBF), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Anett Reißhauer
- Department of Physical Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Sebastian Boie
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Stefan J Schaller
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany.
- Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany.
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