Mobilisation in the ICU

Reviewed and revised 15 August 2015

OVERVIEW

  • The effects of critical illness, and the therapies instituted, can have effects that persist long after ICU discharge
  • These effects include profound and prolonged neuromuscular dysfunction
  • ICU-acquired weakness (ICUAW) is common (up to 60% in some studies) and begins in the first few days of critical illness
  • It is plausible that early mobilisation (exercising patients while they are still receiving mechanical ventilation) may protect against ICUAW and limit longterm meuromuscular dysfunction
  • Provision of physiotherapy is standard care in Australasian ICUs,
  • Other deleterious consequences of immobility may also be attenuated by mobilising patients in the ICU

PHYSIOLOGY

Benefits of positioning upright from supine

  • ↑ Lung volumes
  • ↑ Lung compliance
  • ↓ Airway closure
  • ↑ PaO2
  • ↓ Work of breathing
  • ↑ Mobilisation of secretions

Benefits of mobilisation

  • ↑ Ventilation
  • ↑ V/Q matching
  • ↑ Recruitment of lung units
  • ↑ Surfactant production/distribution
  • ↑ Mobilisation of secretions
  • ↑ Cardiopulmonary fitness and exercise capacity

DISADVANTAGES

  • injury and falls risk
  • haemodynamic instability
  • neurological instability (e.g. acute agitation and pain)
  • respiratory instability (e.g. desaturation, ventilator asynchrony)
  • Increased metabolic demand, VO2 and VCO2
  • risk of disconnection/ dislodging lines and tubes and subsequent complications (e.g. endotracheal tubes, ECMO lines, vascaths, central lines, IDCs)
  • early mobilisation causes harm in medical stroke patients (AVERT study)
  • cost due to increased staffing and physiotherapy time demands

BARRIERS TO MOBILSIATION

These are commonly perceived barriers (they are not absolute and can often be overcome!):

  • endotracheal intubation and mechanical ventilation
  • ECMO
  • femoral lines
  • sedation
  • delirium
  • staffing levels
  • need for a multi-disciplinary team approach
  • respiratory stability
  • haemodynamic stability

Barriers to early mobilisation are likely cultural (to individual ICUs) rather than specifically related to patient factors

EARLY MOBILISATION

  • Early mobilisation refers to exercising patients while they are still receiving mechanical ventilation
  • The precise timing, combination of interventions and their intensities (‘step up as tolerated’ versus ‘step down when tiring’) varies between studies and clinical settings
  • Interventions commonly include:
    • passive range of motion exercises
    • sitting
    • transfer to chair
    • standing
    • ambulation
    • bicycle ergometry

EVIDENCE CONCERNING EARLY MOBILISATION

High level evidence supporting the use of early mobilisation in intensive care patients is currently lacking. Notable studies include the following:

Morris et al, 2008

  • single center trial in USA, n = 165
  • nonrandomized block allocation
  • medical ICU patients enrolled <48h after intubation
  • 80% of the mobilization group had at least one physical therapy session compared with only 47% in the usual care group (P < .001)
  • The mobilization group was out of bed faster (8.5 days vs 13.7 days; P < .001) and had fewer hospital days (14.9 vs 17.2; P = .05)
  • Noadverse events or unintentional removal of medical devices during  mobilization sessions

 Burtin et al, 2009

  • RCT early exercise using a bedside bicycle ergometer in patients with expected prolonged stays (>7 more days) in medical and surgical ICUs
  • intervention arm involved a cycling exercise session 5 days per week using a bedside cycle ergometer (passive and/or active cycling)
  • intervention patients at hospital discharge had better:
    • 6-min walk distance (196 m vs 143 m, P < .05)
    • 36-item Short Form Health Survey physical function scores  (21 vs 15, P < .05)
    • quadriceps forcep (2.37 N/kg vs 2.03 N/kg, P < .05)
  • no serious adverse events — sessions stopped early in only 16/425 sessions (e.g. desaturation, high or low BP)
  • not truly “early mobilisation” as the actual number of ICU days before enrolment in the study was 14 (intervention group) vs 10 (control group), P < .05!

Schweikert et al, 2009

  • small RCT in 2 centers in the USA
  • medical ICU patients with <72h mechanical ventilation (average 1.5days) who were previously functionally independent
  • intervention group underwent a progressive physical and occupational therapy regimen focused on mobilization and achievement of occupational tasks
  • intervention group had improved outcomes:
    • functional recovery at hospital discharge (59% vs 35%, P = .02)
    • discharge directly home after hospitalization (43% vs 24%, P= .06)
    • ICU delirium days were reduced by 50% (2.0 days vs 4.0 days, P = .03) in spite of no differences in sedatives administered
    • higher maximal walking distances while in the hospital (33.4 vs 0 m, P = .004)
    • more ventilator-free days (23.5 days vs 21.1 days; P = .05)
  • adverse events were  rare (e.g. 0.8% had device removal, 6% had >5% desaturation, etc)
  • standard care was “no physiotherapy” until after extubation; thus this study lacks external validity to the Australasian ICU setting

Denehy et al, 2014

  • small SCRCT in Australia
  • early mobilisation was commenced 5 days after ICU admission
  • Outcome was not improved compared with standard care at ICU discharge, hospital discharge or 3, 6 or 12 months
  • Note that standard care included physical therapy in mechanically ventilated patients, and the treatment group received additional physical therapy, perhpas explaining the lack of benefit compared to the Schweikert et al, 2009 study

TEAM Study, 2015

  • multi-centre observational study in Australia and New Zealand
  • included ICU patients mechanically ventilated within 48 hours of ICU admission, expected to be be mechanically ventilated for >72 hours
  • no early mobilisation occurred in 84% of physiotherapy sessions
  • more than 50% of patients were discharged from ICU with ICUAW
  • median time of 5 days to early mobilisation and a median number of two early mobilisation sessions per patient
  • mobilisation was safe with no serious adverse events and only a small number of sessions ceased early as a result of physiological changes
  • less than one-third of patients had returned to their previous work at 6 months and 40% of patients were still reporting significant pain and reduced health-related quality of life
  • patients with higher strength scores at ICU discharge were more likely to survive to 90 days
  • a pilot study by the TEAM investigators of early mobilisation as an intervention has been completed and will hopefully be published soon

AVERT Study, 2015

  • parallel-group, single-blind, MCRCT
  • n= 2104 at 56 acute stroke units in five countries
  • Patients (aged ≥18 years) with ischaemic or haemorrhagic stroke, first or recurrent, who met physiological criteria were randomly assigned (1:1), via a web-based computer generated block randomisation procedure (block size of six),
  • usual stroke-unit care alone or very early mobilisation in addition to usual care
  • primary outcome was a favourable outcome 3 months after stroke, defined as a modified Rankin Scale score of 0–2
    • This was WORSE in the early mobilisation group had WORSE outcomes: 46% vs 50%; adjusted OR 0·73, 95% CI 0·59–0·90; p=0·004)
    • no mortality difference
    • no difference in non-fatal serious adverse event
    • no reduction in immobility-related complications
  • Note that AVERT focussed on stroke patients and did not specifically study ICU patients or the critically ill, limiting its generalisiability
  • This study is important as it suggests that early mobilisation can be harmful – at least in certain patient subgroups – and the finding was unexpected by many given the early mobilisation was previously recommended in many stroke centers

Issues

  • current evidence is conflicting
  • “are the weak dying, or the dying weak?” (associations do not imply causation)
  • in settings where physiotherapy is widely available, early mobilisation per se may or may not offer additional benefits
  • some patient subgroups (e.g. stroke) may be harmed by early immobilisation
  • the following are unknown regarding early mobilisation: which intervention? timing of intervention? dosage?

AN APPROACH

  • Standard physiotherapy practice should be continued in Australasia
  • Early mobilisation is unlikely to be harmful, except in certain subgroups, and may be beneficial. It should be further studied the setting of randomised controlled trials.

References and links

LITFL

Journal articles

  • AVERT Trial Collaboration group, Bernhardt J, Langhorne P, Lindley RI, et al. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet. 2015 Jul 4;386(9988):46-55. doi: 10.1016/S0140-6736(15)60690-0. Epub 2015 Apr 16. Erratum in: Lancet. 2015 Jul 4;386(9988):30. [PubMed]
  • Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139–45. doi: 10.1097/01.CCM.0000251130.69568.87. [PubMed]
  • Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37:2499–505. doi: 10.1097/CCM.0b013e3181a38937. [PubMed]
  • Clemmer TP. Why the reluctance to meaningfully mobilize ventilated patients? ‘The answer my friend is blowin’ in the wind’ Crit Care Med. 2014;42:1308–9. [PubMed]
  • Denehy L, Skinner EH, Edbrooke L, Haines K, Warrillow S, Hawthorne G, et al. Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months follow up. Crit Care. 2013;17:R156. [PMC free article]
  • Hodgson CL, Berney S, Harrold M, Saxena M, Bellomo R. Clinical review: Early patient mobilization in the ICU. Crit Care. 2013;17:207. doi: 10.1186/cc11820. [PMC free article] [PubMed]
  • Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238–43. doi: 10.1097/CCM.0b013e318180b90e. [PubMed]
  • Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.Lancet. 2009;373:1874–82. doi: 10.1016/S0140-6736(09)60658-9. [PubMed]
  • Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest. 2013;144:825–47. doi: 10.1378/chest.12-2930. [PubMed]
  • TEAM Study Investigators, Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care. 2015 Feb 26;19:81. doi: 10.1186/s13054-015-0765-4.[PubMed] [PMC free article]
  • Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedside review: mobilizing patients in the intensive care unit–from pathophysiology to clinical trials. Crit Care. 2009;13:(4)216. [pubmed] [PMC free article]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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