Early Mobilization in Mechanically Ventilated ICU Patients
Early Mobilization in Mechanically Ventilated ICU Patients
A total of 192 patients met the inclusion criteria with no exclusions (Figure 1). There were 117 (61%) males and the overall mean age was 58.0 ± 15.8 years; 57 patients (30%) had no co-morbidities while overall there was a low functional co-morbidity index of 1 (interquartile range (IQR) 1 to 2). The mean Acute Physiology and Chronic Health Evaluation II score was 19.1 ± 7.6, which was higher than the overall Acute Physiology and Chronic Health Evaluation II score for the ICUs during this time period (mean 15.5 ± 5.6). Baseline patient characteristics are presented in Table 1. Patients were admitted to tertiary centres (n = 95, 49%), metropolitan centres (n = 9, 46%) and rural centres (n = 8, 4%).
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Figure 1.
Flow of patients through the study.
The use of vasopressors (n = 127, 66%) and deep sedation (n = 124, 64%) were common. The main reported barriers in patients who did not receive early mobilisation were intubation and sedation (Table 2). The median (IQR) duration of ICU length of stay was 11 (6 to 17) days. Nine patients (5%) were readmitted to the ICU after discharge. Overall ICU mortality was 36/192 (18.8%) and 90-day mortality was 26.6% (51/192) (Table 3). Of the 147 patients who survived to hospital discharge, 80 (54%) were discharged from hospital to home, 35 (24%) were discharged to another acute hospital and 32 (22%) were discharged to a rehabilitation centre.
Of our cohort, 122 (63.5%) patients did not receive early mobilisation. We collected information during 1,288 patient–physiotherapy interactions while patients were mechanically ventilated (Figure 2). No early mobilisation occurred in 1,079 (84%) of these episodes. The first physiotherapy sessions occurred early in the ICU stay (median 2 days from ICU admission, IQR 2 to 4 days) as the patients could be seen for respiratory physiotherapy or for early mobilisation.
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Figure 2.
Flow of included patients through the study from days 1 to 14. Data for the number of patients invasively ventilated and mobilising (active), invasively ventilated and inactive, dead, extubated or discharged from the ICU.
Of the 70 patients (36.5%) who received early mobilisation during mechanical ventilation, the median (IQR) time from ICU admission to early mobilisation was 5 (3 to 8) days and the median (IQR) number of active mobilisation episodes per patient was 2 (1 to 4). There was no difference in any baseline variables between patients who were mobilised compared with patients who were not mobilised. There were 209 recorded episodes of early mobilisation. Among these episodes, the maximum levels of mobilisation were exercise in bed (n = 94, 45%), passively transferred to sitting (n = 52, 25%), sitting over the edge of the bed (dangling, n = 22, 11%), standing at the bedside (n = 11, 5%), transferring from bed to chair through standing (n = 4, 2%) or walking (n = 26, 12%) (Figure 3). One-quarter of these patients were mobilised by day 3 and one-third by day 4. No mechanically ventilated patients were walking before day 7. All patients who were mobilised out of bed and stood had a Richmond Agitation and Sedation Scale score of –1 to +1, while some patients were able to sit over the edge of the bed with a Richmond Agitation and Sedation Scale score of between –2 and +2.
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Figure 3.
Maximum level of activity in invasively ventilated patients for days 1 to 14. Measured using the ICU mobility scale, where 0 = no activity, 1 = exercises in bed, 2 = passively moved to the chair, 4 = sitting on the edge of the bed, 5 = standing, 6 = transferring from bed to chair through standing, 7 = marching on the spot, 8 = walking with assistance of two people, 9 = walking with assistance of one person and 10 = walking independently.
There were no serious adverse events reported during mobilisation, although early cessation of mobilisation as a result of cardiovascular or respiratory instability occurred in 0.4% (six of the 1,288) physiotherapy–patient interactions. None of these required medical intervention.
Physiotherapists measured MRC-SS in a subset of 94 (60%) of the 156 ICU survivors. The baseline demographics of these patients were similar to the entire cohort (Table 1). In the patients with MRC-SS measured at ICU discharge, the MRC-SS score (mean ± standard deviation) was 43.3 ± 12.5 and 49 (52%) of the patients had ICUAW (defined as MRC-SS <48/60) at ICU discharge. There was no difference between patients with ICUAW and patients without ICUAW for age, Acute Physiology and Chronic Health Evaluation II score or functional co-morbidity index.
A higher MRC-SS score was associated with those patients who mobilised early while mechanically ventilated (50.0 ± 11.2 vs. 42.0 ± 10.8, P = 0.003) and those patients who were discharged home compared with all other patients discharged alive to other acute hospitals, rehabilitation or chronic care facilities (48.9 ± 10.3 vs. 37.8 ± 11.6, P <0.0001). The MRC-SS in patients who survived to day 90 was higher than those who survived to ICU discharge but who had died by day 90 (44.9 ± 11.4 vs. 28.9 ± 13.2, P <0.0001). Similarly, patients who survived to ICU discharge and were diagnosed with ICUAW by MRC-SS score demonstrated decreased survival to day 90 (Figure 4).
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Figure 4.
Survival to day 90 in patients who survived to ICU discharge and were diagnosed with ICU-acquired weakness compared with patients without ICU-acquired weakness. ICUAW, ICU-acquired weakness.
Of the entire cohort, 141 (73%) patients survived to day 90, and 120 (62%) patients survived to 6 months and responded to our telephone interview. Three patients died between day 90 and 6-month follow-up, while 18 patients (9%) were lost to follow-up. Of the 120 patients contacted at 6 months, 38% reported moderate–severe problems with usual care activities, 39% reported moderate–severe problems with anxiety and depression, 40% reported moderate–severe problems with mobility and 41% of patients reported moderate–severe problems with pain at 6 months based on the EuroQoL standardised health outcome tool (Table 4). Finally, 77 patients were working prior to ICU admission (Table 4). Only 29 (38%) of these patients had returned to work and only 25 (32%) had returned to work in their previous work role and hours.
Results
Patient Characteristics
A total of 192 patients met the inclusion criteria with no exclusions (Figure 1). There were 117 (61%) males and the overall mean age was 58.0 ± 15.8 years; 57 patients (30%) had no co-morbidities while overall there was a low functional co-morbidity index of 1 (interquartile range (IQR) 1 to 2). The mean Acute Physiology and Chronic Health Evaluation II score was 19.1 ± 7.6, which was higher than the overall Acute Physiology and Chronic Health Evaluation II score for the ICUs during this time period (mean 15.5 ± 5.6). Baseline patient characteristics are presented in Table 1. Patients were admitted to tertiary centres (n = 95, 49%), metropolitan centres (n = 9, 46%) and rural centres (n = 8, 4%).
(Enlarge Image)
Figure 1.
Flow of patients through the study.
The use of vasopressors (n = 127, 66%) and deep sedation (n = 124, 64%) were common. The main reported barriers in patients who did not receive early mobilisation were intubation and sedation (Table 2). The median (IQR) duration of ICU length of stay was 11 (6 to 17) days. Nine patients (5%) were readmitted to the ICU after discharge. Overall ICU mortality was 36/192 (18.8%) and 90-day mortality was 26.6% (51/192) (Table 3). Of the 147 patients who survived to hospital discharge, 80 (54%) were discharged from hospital to home, 35 (24%) were discharged to another acute hospital and 32 (22%) were discharged to a rehabilitation centre.
Mobilisation Activities
Of our cohort, 122 (63.5%) patients did not receive early mobilisation. We collected information during 1,288 patient–physiotherapy interactions while patients were mechanically ventilated (Figure 2). No early mobilisation occurred in 1,079 (84%) of these episodes. The first physiotherapy sessions occurred early in the ICU stay (median 2 days from ICU admission, IQR 2 to 4 days) as the patients could be seen for respiratory physiotherapy or for early mobilisation.
(Enlarge Image)
Figure 2.
Flow of included patients through the study from days 1 to 14. Data for the number of patients invasively ventilated and mobilising (active), invasively ventilated and inactive, dead, extubated or discharged from the ICU.
Of the 70 patients (36.5%) who received early mobilisation during mechanical ventilation, the median (IQR) time from ICU admission to early mobilisation was 5 (3 to 8) days and the median (IQR) number of active mobilisation episodes per patient was 2 (1 to 4). There was no difference in any baseline variables between patients who were mobilised compared with patients who were not mobilised. There were 209 recorded episodes of early mobilisation. Among these episodes, the maximum levels of mobilisation were exercise in bed (n = 94, 45%), passively transferred to sitting (n = 52, 25%), sitting over the edge of the bed (dangling, n = 22, 11%), standing at the bedside (n = 11, 5%), transferring from bed to chair through standing (n = 4, 2%) or walking (n = 26, 12%) (Figure 3). One-quarter of these patients were mobilised by day 3 and one-third by day 4. No mechanically ventilated patients were walking before day 7. All patients who were mobilised out of bed and stood had a Richmond Agitation and Sedation Scale score of –1 to +1, while some patients were able to sit over the edge of the bed with a Richmond Agitation and Sedation Scale score of between –2 and +2.
(Enlarge Image)
Figure 3.
Maximum level of activity in invasively ventilated patients for days 1 to 14. Measured using the ICU mobility scale, where 0 = no activity, 1 = exercises in bed, 2 = passively moved to the chair, 4 = sitting on the edge of the bed, 5 = standing, 6 = transferring from bed to chair through standing, 7 = marching on the spot, 8 = walking with assistance of two people, 9 = walking with assistance of one person and 10 = walking independently.
There were no serious adverse events reported during mobilisation, although early cessation of mobilisation as a result of cardiovascular or respiratory instability occurred in 0.4% (six of the 1,288) physiotherapy–patient interactions. None of these required medical intervention.
Muscle Strength at ICU Discharge
Physiotherapists measured MRC-SS in a subset of 94 (60%) of the 156 ICU survivors. The baseline demographics of these patients were similar to the entire cohort (Table 1). In the patients with MRC-SS measured at ICU discharge, the MRC-SS score (mean ± standard deviation) was 43.3 ± 12.5 and 49 (52%) of the patients had ICUAW (defined as MRC-SS <48/60) at ICU discharge. There was no difference between patients with ICUAW and patients without ICUAW for age, Acute Physiology and Chronic Health Evaluation II score or functional co-morbidity index.
A higher MRC-SS score was associated with those patients who mobilised early while mechanically ventilated (50.0 ± 11.2 vs. 42.0 ± 10.8, P = 0.003) and those patients who were discharged home compared with all other patients discharged alive to other acute hospitals, rehabilitation or chronic care facilities (48.9 ± 10.3 vs. 37.8 ± 11.6, P <0.0001). The MRC-SS in patients who survived to day 90 was higher than those who survived to ICU discharge but who had died by day 90 (44.9 ± 11.4 vs. 28.9 ± 13.2, P <0.0001). Similarly, patients who survived to ICU discharge and were diagnosed with ICUAW by MRC-SS score demonstrated decreased survival to day 90 (Figure 4).
(Enlarge Image)
Figure 4.
Survival to day 90 in patients who survived to ICU discharge and were diagnosed with ICU-acquired weakness compared with patients without ICU-acquired weakness. ICUAW, ICU-acquired weakness.
Six-month Outcomes
Of the entire cohort, 141 (73%) patients survived to day 90, and 120 (62%) patients survived to 6 months and responded to our telephone interview. Three patients died between day 90 and 6-month follow-up, while 18 patients (9%) were lost to follow-up. Of the 120 patients contacted at 6 months, 38% reported moderate–severe problems with usual care activities, 39% reported moderate–severe problems with anxiety and depression, 40% reported moderate–severe problems with mobility and 41% of patients reported moderate–severe problems with pain at 6 months based on the EuroQoL standardised health outcome tool (Table 4). Finally, 77 patients were working prior to ICU admission (Table 4). Only 29 (38%) of these patients had returned to work and only 25 (32%) had returned to work in their previous work role and hours.
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