[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]

Robot-assisted early mobilization for intensive care unit patients: Feasibility and first-time clinical use

BACKGROUND

Early mobilization is only carried out to a limited extent in the intensive care unit. To address this issue, the robotic assistance system VEMOTION® was developed to facilitate (early) mobilization measures more easily. This paper describes the first integration of robotic assistance systems in acute clinical intensive care units.

OBJECTIVE

Feasibility test of robotic assistance in early mobilization of intensive care patients in routine clinical practice.

SETTING

Two intensive care units guided by anesthesiology at a German university hospital.

PARTICIPANTS

Patients who underwent elective surgery with postoperative treatment in the intensive care unit and had an estimated ventilation time over 48 h.

METHODS

Participants underwent robot-assisted mobilization, scheduled for twenty-minute sessions twice a day, ten times or one week, conducted by nursing staff under actual operational conditions on the units. No randomization or blinding took place. We assessed data regarding feasible cutoff points (in brackets): the possibility of enrollment (x ≥ 50 %), duration (pre- and post-setup (x ≤ 25 min), therapy duration (x = 20 min), and intervention-related parameters (number of mobilizing professionals (x ≤ 2), intensity of training, events that led to adverse events, errors or discontinuation). Mobilizing professionals rated each mobilization regarding their physical stress (x ≤ 3) and feasibility (x ≥ 4) on a 7 Point Likert Scale. An estimated sample size of at least twenty patients was calculated. We analyzed the data descriptively.

RESULTS

Within 6 months, we screened thirty-two patients for enrollment. 23 patients were included in the study and 16 underwent mobilization using robotic assistance, 7 dropped out (enrollment eligibility = 69 %). On average, 1.9 nurses were involved per therapy unit. Participants received 5.6 robot-assisted mobilizations in mean. Pre- and post-setup had a mean duration of 18 min, therapy a mean of 21 min. The robot-assisted mobilization was started after a median of 18 h after admission to the intensive care unit. We documented two adverse events (pain), twelve errors in handling, and seven unexpected events that led to interruptions or discontinuation. No serious adverse events occurred. The mobilizing nurses rated their physical stress as low (mean 2.0 ± 1.3) and the intervention as feasible (mean 5.3 ± 1.6).

CONCLUSIONS

Robot-assisted mobilization was feasible, but specific safety measures should be implemented to prevent errors. Robotic-assisted mobilization requires process adjustments and consideration of unit staffing levels, as the intervention does not save staff resources or time.

REGISTRATION

clinicaltrials.org TRN: NCT05071248; Date: 2021/10/08; URL https://clinicaltrials.gov/ct2/show/NCT05071248.

TWEETABLE ABSTRACT

Robot-assisted early mobilization in intensive care patients is feasible and no adverse event occurred.

[Therapeutic healthcare professional staffing requirements in intensive care units]

BACKGROUND

Therapeutic healthcare professionals in the multiprofessional intensive care unit (ICU) team are important for early mobilization, dysphagia therapy, and psychosocial care of critically ill patients.

OBJECTIVE

Despite the high relevance of therapeutic healthcare professions for care in ICUs, there are no recommendations on the specific staffing of therapists in ICUs.

RESULTS

Considering the main areas of activity of the individual professional groups and based on productivity time, a requirements analysis for staffing ICUs of different care levels with physiotherapists, occupational therapists, speech therapists, and psychologists was performed. For every 10 beds in the highest care level (LoC3), 1.28 full-time equivalent (FTE) physiotherapists, 0.91 FTE occupational therapists and speech therapists, and 0.80 FTE psychologists should be employed.

CONCLUSION

In order to implement multiprofessional patient treatment and support for relatives in the ICU, it is essential to employ a proportionate number of therapeutic healthcare professionals.

Barriers and facilitators in the implementation of mobilization robots in hospitals from the perspective of clinical experts and developers

BACKGROUND

Early mobilization can help reduce severe side effects such as muscle atrophy that occur during hospitalization. However, due to time and staff shortages in intensive and critical care as well as safety risks for patients, it is often difficult to adhere to the recommended therapy time of twenty minutes twice a day. New robotic technologies might be one approach to achieve early mobilization effectively for patients and also relieve users from physical effort. Nevertheless, currently there is a lack of knowledge regarding the factors that are important for integrating of these technologies into complex treatment settings like intensive care units or rehabilitation units.

METHODS

European experts from science, technical development and end-users of robotic systems (n = 13) were interviewed using a semi-structured interview guideline to identify barriers and facilitating factors for the integration of robotic systems into daily clinical practice. They were asked about structural, personnel and environmental factors that had an impact on integration and how they had solved challenges. A latent content analysis was performed regarding the COREQ criteria.

RESULTS

We found relevant factors regarding the development, introduction, and routine of the robotic system. In this context, costs, process adjustments, a lack of exemptions, and a lack of support from the manufacturers/developers were identified as challenges. Easy handling, joint decision making between the end-users and the decision makers in the hospital, an accurate process design and the joint development of the robotic system of end-users and technical experts were found to be facilitating factors.

CONCLUSION

The integration and preparation for the integration of robotic assistance systems into the inpatient setting is a complex intervention that involves many parties. This study provides evidence for hospitals or manufacturers to simplify the planning of integrations for permanent use.

TRIAL REGISTRATION

DRKS-ID: DRKS00023848; registered 10/12/2020.

[Robotic-assisted mobilization for an effective mobilization in a COVID-19 patient with ECMO treatment]

An effective (early) mobilization in COVID-19 intensive care patients with ECMO treatment is very important. Sedation, extracorporeal procedures with the danger of circuit malfunction, large lumen ECMO cannulas with a risk of dislocation and a very severe neuromuscular weakness are factors that could deem mobilization beyond stage 1 of the ICU mobility score (IMS) in some cases difficult or impossible; however, early mobilization is a key point of the ABCDEF bundle to counteract pulmonary complications, neuromuscular dysfunction and enable recovery. The case of a 53-year-old, previously healthy and active male patient with a severe and complicated course of COVID-19 and pronounced ICU-acquired weakness is described. While receiving ECMO the patient could be mobilized using a robotic system. Due to severe and rapidly progressing pulmonary fibrosis, additional low-dose methylprednisolone therapy (Meduri protocol) was implemented. Under this multimodal treatment the patient was successfully weaned from the ventilator and decannulated. Robotic assisted mobilization has the potential to be a novel and safe therapeutic option for a customized and highly effective mobilization in ECMO patients.

[Robotic-assisted mobilization for an effective mobilization in a COVID-19 patient with ECMO treatment]

An effective (early) mobilization in COVID-19 intensive care patients with ECMO treatment is very important. Sedation, extracorporeal procedures with the danger of circuit malfunction, large lumen ECMO cannulas with a risk of dislocation and a very severe neuromuscular weakness are factors that could deem mobilization beyond stage 1 of the ICU mobility score (IMS) in some cases difficult or impossible; however, early mobilization is a key point of the ABCDEF bundle to counteract pulmonary complications, neuromuscular dysfunction and enable recovery. The case of a 53-year-old, previously healthy and active male patient with a severe and complicated course of COVID-19 and pronounced ICU-acquired weakness is described. While receiving ECMO the patient could be mobilized using a robotic system. Due to severe and rapidly progressing pulmonary fibrosis, additional low-dose methylprednisolone therapy (Meduri protocol) was implemented. Under this multimodal treatment the patient was successfully weaned from the ventilator and decannulated. Robotic-assisted mobilization has the potential to be a novel and safe therapeutic option for a customized and highly effective mobilization in ECMO patients.

Robot-assisted early mobilization of intensive care patients: a feasibility study protocol

Background

Early mobilization positively influences the outcome of critically ill patients, yet in clinical practice, the implementation is sometimes challenging. In this study, an adaptive robotic assistance system will be used for early mobilization in intensive care units. The study aims to evaluate the experience of the mobilizing professionals and the general feasibility of implementing robotic assistance for mobilization in intensive care as well as the effects on patient outcomes as a secondary outcome.

Methods

The study is single-centric, prospective, and interventional and follows a longitudinal study design. To evaluate the feasibility of robotic-assisted early mobilization, the number of patients included, the number of performed VEM (very early mobilization) sessions, and the number and type of adverse events will be collected. The behavior and experience of mobilizing professionals will be evaluated using standardized observations (n > 90) and episodic interviews (n > 36) before implementation, shortly after, and in routine. Patient outcomes such as duration of mechanical ventilation, loss of muscle mass, and physical activity will be measured and compared with a historical patient population. Approximately 30 patients will be included.

Discussion

The study will provide information about patient outcomes, feasibility, and the experience of mobilizing professionals. It will show whether robotic systems can increase the early mobilization frequency of critically ill patients. Within ICU structures, early mobilization as therapy could become more of a focus. Effects on the mobilizing professionals such as increased motivation, physical relief, or stress will be evaluated. In addition, this study will focus on whether current structures allow following the recommendation of mobilizing patients twice a day for at least 20 min.

Trial registration

ClinicalTrials.gov, NCT05071248. Date: 2021/10/21

[Specific treatment of acute lung failure]

Wegen der hohen Heterogenität und Dynamik des Krankheitsverlaufes stellt die Behandlung des akuten Lungenversagens Intensivmediziner vor außerordentliche Herausforderungen. Nachdem die aktuelle Definition, Pathophysiologie und die Differenzialdiagnosen in der vorliegenden Zeitschrift bereits dargestellt wurden, werden im Folgenden Möglichkeiten der spezifischen und individualisierten Therapie behandelt. Die Beatmungstherapie mit Limitierung der Tidalvolumina und Druckamplitude zeigt einen Vorteil hinsichtlich der Letalität, ist aber aufgrund der vielfältigen Ätiologie des akuten Lungenversagens im Kontext mit den unterschiedlichen Gegebenheiten individuell anzupassen. In den letzten Jahren wurde die Bedeutung der Bauchlage, der möglichst frühzeitigen Spontanatmung und der Frühmobilisation für den positiven Krankheitsverlauf erkannt. Eine individualisierte Therapie sollte die Besonderheiten des Patienten und den spezifischen Krankheitsverlauf berücksichtigen.

[What is evidence-based in the treatment of sepsis?]

BACKGROUND

The term sepsis was redefined in 2016 as a life-threatening organ dysfunction caused by an inadequate host response to an infection. The German S3 guidelines for the treatment of sepsis were published in 2018.

OBJECTIVE

What is evidence-based in the treatment of patients with sepsis?

MATERIAL AND METHODS

Discussion of the S3 guidelines and inclusion of study results after 2018.

RESULTS

The cornerstones for the treatment of sepsis continue to consist of early hemodynamic stabilization, anti-infection treatment and organ support procedures. Supportive and extracorporeal treatments are controversially discussed and continue to be intensively investigated.

CONCLUSION

Despite an improved understanding of the pathophysiology, there is still no effective causal sepsis treatment, i.e. directed against the pathological host reaction. The treatment of patients with sepsis is therefore still based on the basic principles of correction of volume deficits, anti-infective agents, source control and organ support, including the symptomatic treatment of vasoplegia with catecholamines.

Hintergrundtext zu Empfehlungen der DGPRM zu Struktur und Ausstattung von Akutkrankenhäusern bezüglich Physikalisch-medizinischer/Rehabilitativer Maßnahmen in Intensivmedizin und Intermediate Care

Wissenschaftlicher Hintergrund, Erläuterungen, Definitionen von Begriffen, Literaturangaben und Empfehlungen zur Empfehlungen der Deutschen Gesellschaft für Physikalische und Rehabilitative Medizin (DGPRM) zu Struktur und Ausstattung von Akutkrankenhäusern bezüglich Physikalisch-medizinischer/Rehabilitativer Maßnahmen in der Intensivmedizin und Intermediate Care. Konkrete Problemfelder und mögliche Maßnahmen werden erläutert. Sowohl für personelle Schlüssel als auch Therapiefrequenz und Dauer jeweils werden konkrete Empfehlungen benannt.

Mechanical Ventilation and Extracorporeal Membrane Oxygena tion in Acute Respiratory Insufficiency

BACKGROUND

Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, ac- companying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care).

METHODS

This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus.

RESULTS

Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-in- vasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone posi- tioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate).

CONCLUSION

Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early sponta- neous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.

[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

[Extreme obesity-particular aspect of invasive and noninvasive ventilation]

The obesity rate is increasing worldwide and the percentage of obese patients in the intensive care unit (ICU) is rising concomitantly. Ventilatory support strategies in obese patients must take into account the altered pathophysiological conditions. Unfortunately, prospective randomized multicenter trials on this subject are lacking. Therefore, current strategies are based on the individual experiences of ICU physicians and single-center studies. Noninvasive ventilation (NIV) in critically ill patients with acute respiratory failure and obesity hypoventilation syndrome (OHS) is an efficient treatment option and should be provided as early as possible is an effort to avoid intubation. Patient positioning is also crucial: half-sitting positions (>45°) improve lung compliance and functional residual capacity in patients with respiratory failure. Transpulmonary pressure measurements or the Acute Respiratory Distress Syndrome (ARDS) Network tables may help to adjust the optimal positive end-expiratory pressure (PEEP). The tidal volume should be adapted to the ideal and not the actual bodyweight (V_t = 6 ml/kg of ideal bodyweight) to avoid lung damage and (additional) right ventricular stress. Under particular conditions, inspiratory pressures >30 cmH₂O may be tolerated for a limited duration. Early tracheostomy combined with termination/reduction of sedation and relaxation is controversy discussed in the literature as a therapeutic option during invasive ventilation of morbidly obese patients. However, data on early tracheotomy in obese respiratory failure patients are rare and this should be regarded as an individual treatment attempt only. In cases of refractory lung failure, venovenous extracorporeal membrane oxygenation (vv-ECMO) is an option despite anatomic changes in morbid obesity.

[Above and beyond BMI : Alternative methods of measuring body fat and muscle mass in critically ill patients and their clinical significance]

Obesity leads to better survival in critically ill patients. Although there are several studies confirming this thesis, the "obesity paradox" is still surprising from the clinician's perspective. One explanation for the "obesity paradox" is the fact that the body mass index (BMI), which is used in almost all clinical evaluations to determine weight categories, is not an appropriate measure of fat and skeletal muscle mass and its distribution in critically ill patients. In addition, height and weight are frequently estimated rather than measured. Central obesity has been identified in many disorders as an independent risk factor for an unfavourable outcome. The first clues are to be found in intensive care. Along with obesity, an individual's entire muscle mass is a variable that has an influence on outcome. Central obesity can be measured relatively easily with an abdominal calliper, but the calculation of muscle mass is more complex. A valid and detailed measurement of this can be obtained using computed tomography (CT) images, acquired during routine care. For future clinical observation or interventional studies, single cross-sectional CT is a more sophisticated tool for measuring patients' anthropometry than a measuring tape and callipers. Patients with sarcopenic obesity, for example, who may be at a particular risk, can only be identified using imaging procedures such as single cross-sectional CT. Thus, BMI should take a back seat as an anthropometric tool, both in the clinic and in research.

Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada

OBJECTIVE

Early mobilization is safe, feasible, and associated with better outcomes in patients with critical illness. However, barriers to mobilization in clinical practice still exist. The objective of this study was to assess the knowledge and practice patterns of intensive care unit (ICU) clinicians, as well as the barriers and facilitators to early mobilization.

DESIGN

Cross-sectional survey.

SETTING

Intensive care units of 3 university-affiliated hospitals in Montreal, Canada.

PARTICIPANTS

One hundred and thirty-eight ICU clinicians, including nurses, physicians, respiratory therapists, and physiotherapists.

INTERVENTIONS

None.

MEASUREMENTS

Perceived barriers, facilitators, knowledge, and practice patterns of early mobilization were assessed using a previously validated mobility survey tool.

MAIN RESULTS

The overall response rate was 50.0% (138 of 274). Early mobilization was not perceived as a top priority in 49% of respondents. Results showed that clinicians were not fully aware of the benefits of early mobilization as per the current literature. About 58% of clinicians did not feel well trained and informed to mobilize mechanically ventilated patients. Perceptions on patient-level barriers varied with clinicians' professional training, but there was a high degree of interprofessional and intraprofessional disagreement on the permissible maximal level activity in different scenarios of critically ill patients.

CONCLUSIONS

Our survey shows limited awareness, among our respondents, of the clinical benefits of early mobilization and high level of disagreement on the permissible maximal level of activity in the critically ill patients. Future studies should evaluate the role of knowledge translation in modifying these barriers and improving early mobilization.

Pneumologie

Die Pneumologie und Beatmungsmedizin gehört zur Basis der Intensivmedizin. Die Abklärung der Dyspnoe, das Management des Asthma bronchiale, der akuten COPD-Exazerbation und des akuten Lungenversagens (ARDS) bilden die Säulen dieses Kapitels. Im Rahmen der bettseitigen Abklärung der Dyspnoe gewinnt die Lungen- bzw. Thoraxsonographie zunehmend an Bedeutung.

[Algorithms for early mobilization in intensive care units]

Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one's own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient's awareness, pain, anxiety, stress, delirium and family's presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.

[Positioning therapy and early mobilization in intensive care units : Findings from the current 2015 guidelines]

The 2007 guidelines "Positioning for prophylaxis and therapy of pulmonary disorders" were completely revised in 2015 on behalf of the German Society of Anaesthesiology and Intensive Care Medicine. With regard to practical and scientific relevance, early mobilization of patients in critical care has been included in the guidelines for the first time. Furthermore, the recommendations for prone positioning have been updated, based on current evidence in medicine and nursing. In addition, recommendations regarding unsuitable positions that may actually harm patients were made. As such, the flat supine position should only be used in cases of urgent medical or nursing needs. This underlines the importance of a moderately elevated head of bed position (20(o)-45(o)) in mechanically ventilated patients.