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Mobilizing Patients in the Intensive Care Unit: Improving Neuromuscular Weakness and Physical Function Early mobilization of patients in the hospital and the intensive care unit has a strong historical precedent. In more recent times, deep sedation and bed rest have been part of routine in medical care for many mechanically ventilated patients. A growing body of literature demonstrates that survivors of severe critical illness commonly have significant and prolonged neuromuscular complications that impair their physical function and quality of life after hospital discharge. Bed rest, and its associated mechanisms, may play an important role in the pathogenesis of neuromuscular weakness in critically ill patients. A new approach for managing mechanically ventilated patients includes reducing deep sedation and increasing rehabilitation therapy and mobilization soon after admission to the intensive care unit. Emerging research in this field provides preliminary evidence supporting the safety, feasibility, and potential benefits of early mobilization in critical care medicine. Abstract Dale M. Needham, MD, PhD JAMA, October 8, 2008 – Volume 300, No. 14 Phenomenon Given the high prevalence of deep sedation and best rest for mechanically ventilated patients in the ICU, neuromuscular weakness is often recognized late when there is a difficulty liberating a patient from mechanical ventilation, or once a patient has been discharged to the ward and caregivers recognize the patient’s inability to perform simple activities of daily living. With critical illness myopathy: Weakness may be proximal, with decreased or absent reflexes, and no sensory deficits. Critical illness polyneuropathy and myopathy commonly coexist giving rise to a complex clinical presentation. Testing will reveal abnormalities that may otherwise be undetected by clinical examination. However, the functional significance of these abnormalities and the value of routine testing in clinical practice remain controversial. Among patients with chronic pulmonary conditions or long term mechanical ventilation, prior studies have demonstrated these important points: 1) rehabilitation therapy helps patients regain their ability to ambulate and conduct activities of daily living 2) higher-intensity rehabilitation may lead to greater benefit Purpose One of the first published report is an uncontrolled study of routine multidisciplinary, twice daily, rehabilitation therapy in the ICU provided to 103 mechanically ventilated patients. This is research demonstrated that activity, including sitting and ambulation, is feasible and safe in mechanically ventilated patients with an endotracheal tube. This study demonstrated benefit with 69% of these ICU patients ambulating more than 100ft by ICU discharge with a mean distance walked of 212 ft. Similar findings regarding safety and feasibility also have been described by others, including a subsequent larger study that compared early mobility with a usual care control group, which also found that early mobility patients were out of bed early (5 vs. 11 days; P <.001) with a shorter length of stay in the ICU (5.5 vs. 6.9 days; P =.03) and the hospital (11.2 vs. 14.5 days; P =.006). Minimizing sedation and changing ICU culture to focus on recovery and rehabilitation issues are key success factors for early mobilization in the ICU. Despite these positive findings, this existing evidence is still preliminary without the support of any large, multicenter, randomized controlled trials to comprehensively evaluate safety, short and long term benefits. Evidence Testable Hypothesis An ICU care strategy that includes an early focus on improving patient recovery and subsequent outcomes, aspects of physical medicine and rehabilitation are introduced within days of admission. This approach includes minimization of heavy sedation aiming for target sedation levels that permit greater wakefulness. Clear presence of a need to further examine the efficacy of early mobilization of ICU patients. As a case-presentation, it does its job as establishing a preliminary rationale for future research focusing on randomized controlled clinical trials directed at the short and long term benefits of early mobilization in the ICU. The author clearly suggests the physical therapists vital role in the patient’s ICU stay-duration, immediate function after discharge, as well as quality of life after long term discharge. Assessing the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation. Importance/Conclusion Early mobilization of critically ill patients has a historical precedent, more recently, bed rest and deep sedation have become routine part of medical care for many mechanically ventilated patients. Preliminary investigations implementing decreased sedation, increased mobilization and rehabilitation soon after admission provide encouraging results regarding safety, feasibility, and potential benefits to provide a new foundation for new research and re-evaluation of current medical practice. Summary Surviving acute illness = Long-term complications/weakness is a frequent complication and is associated with major disability and protracted rehabilitation. Delirium during ICU in patients undergoing ventilation is associated with higher mortality rates, and longer length of stay. Focused on level of independence at time of discharge as a primary end-point, primarily focusing on complete functional independence. Exercises depended on the responsiveness of patients due to sedation, such as unresponsive patients in the intervention group went through PROM in all limbs and once patient interaction was achieved, sessions began with AAROM and AROM in supine position. If exercises were tolerated, treatment advanced to bed mobility activities, including transferring to upright sitting then to balance activities followed by ADLs and activities that encouraged increased functional independence. Bed rest results in: – Changes in muscle fibers, inflammatory markers, and metabolic parameters, disuse atrophy occurs in skeletal muscle. Moreover, – Myosin isoforms alters from slow to fast twitch, metabolism changes from fatty acids to glucose, and protein synthesis is decreased. Muscle activity also may play an anti- inflammatory –mediated diseases of critical illness, such as adult respiratory distress syndrome and sepsis.. John P. Kress MD; Clinical trials of early mobilization of critically ill patients; Crit Care Med 2009 Vol. 37, No. 10(supp) Schweickert, Pohlman, Pohlman; Early physical and occupational therapy in mechanically ventilated, critically ill patients: a RCT; Lancet 2009; 373: 1874-82 Theory A systematic review was referenced that evaluated 24 eligible studies focusing on ICU patients with sepsis, multi-organ failure, or prolonged mechanical ventilation. Neuromuscular dysfunction was identified in 655 of 1421 (46%) of these patients and was associated with prolonged mechanical ventilation and length of ICU/hospital stay. In a landmark study conducted by Herridge et al.: o Average loss of 18% body weight in the ICU o Median 6-minute walk distance of survivors was only 66% of predicted at 1 year after ICU discharge. o The limitations were attributed to ICU acquired morbidities such as global muscle wasting and weakness, foot drop, joint immobility, and dyspnea. Bed rest alone, is an important etiology with experimental studies demonstrating that healthy, well-nourished individuals experience a 4% to 5% loss of muscle strength for each week of bed rest. After only 5 days of bed rest: o Healthy individuals developed insulin resistance and microvascular dysfunction. Other system effects relevant to ICU patients: fluid losses contributing to postural hypotension and tachycardia, decreased stroke volume, cardiac output, and decreased peak oxygen uptake, all of which have been observed in healthy volunteers undergoing bed rest. Even in these healthy volunteers, there is a prolonged recovery period required after cessation of bed rest before return to baseline status. % of 104 patients returned to independent functional status at time of discharge. Intervention: 59% compared to Control: 35% Intervention group: shorter duration of delirium, more ventilator- free days during the 28-day follow up period than the controls. This RCT supported incorporating whole-body rehabilitation resulting in: Better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared to standard care. States the importance of early interventional rehabilitation in increasing functional independence and quality of life at and after discharge supporting the implementation of mobilization for critically ill, ICU patients. 1 year after recovering from acute RDS, every patient reported poor function which was attributed to loss of muscle bulk, proximal muscle weakness, and fatigue. 50% of patients in this cohort were employed 1 year after recovery and the reported reasons for continued unemployment included persistent fatigue, weakness, and poor functional status (such as large joint immobility, etc.). Early mobilization after physiologic stabilization in the ICU might lead to patients accomplishing ambulation by the time of ICU discharge. 103 patients that underwent 1449 activity events which concluded with a total of 593 of the activity events occurred in intubated patients receiving wide ranges of Fio2. Findings: 83% of patients that survived to hospital discharge had a median ambulation distance of > 200 feet. Ultimately, early mobilization is vital to maintaining, or increasing, physical function in patients admitted to ICU. All articles express the need for early interventional, skilled mobilization and rehabilitation for patients admitted to the intensive care unit. Recent research has given support to this theory by incorporating a strategy for whole-body rehabilitation resulting in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days. Shift to more frequent sedation interruption, all research is relatively preliminary and suggests a need for physical therapists to further establish advanced clinical trials aimed at the safety and feasibility of early mobilization, even for mechanically ventilated patients.