Measurement of physiologic responses to mobilisation in critically ill adults

Using Arterial Pulse and Laser Doppler Analyses to Discriminate between the Cardiovascular Effects of Different Running Levels

BACKGROUND AND AIMS

Running can induce advantageous cardiovascular effects such as improved arterial stiffness and blood-supply perfusion. However, the differences between the vascular and blood-flow perfusion conditions under different levels of endurance-running performance remains unclear. The present study aimed to assess the vascular and blood-flow perfusion conditions among 3 groups (44 male volunteers) according to the time taken to run 3 km: Level 1, Level 2, and Level 3.

METHODS

The radial blood pressure waveform (BPW), finger photoplethygraphy (PPG), and skin-surface laser-Doppler flowmetry (LDF) signals of the subjects were measured. Frequency-domain analysis was applied to BPW and PPG signals; time- and frequency-domain analyses were applied to LDF signals.

RESULTS

Pulse waveform and LDF indices differed significantly among the three groups. These could be used to evaluate the advantageous cardiovascular effects provided by long-term endurance-running training, such as vessel relaxation (pulse waveform indices), improvement in blood supply perfusion (LDF indices), and changes in cardiovascular regulation activities (pulse and LDF variability indices). Using the relative changes in pulse-effect indices, we achieved almost perfect discrimination between Level 3 and Level 2 (AUC = 0.878). Furthermore, the present pulse waveform analysis could also be used to discriminate between the Level-1 and Level-2 groups.

CONCLUSIONS

The present findings contribute to the development of a noninvasive, easy-to-use, and objective evaluation technique for the cardiovascular benefits of prolonged endurance-running training.

Barriers and facilitators of early mobilisation for intensive care unit delirium: perspectives from patients, family members and carers. A qualitative study protocol

Background/Aims

One-third of patients develop delirium following admission to an intensive care unit. Intensive care unit delirium is associated with poor patient outcomes, including long-term disability and high mortality. Early mobilisation contributes towards the prevention and reduction of intensive care unit delirium. However, the implementation of early mobilisation is infrequent. The aim of this protocol is to explore participants' experiences of the barriers to, and facilitators of, early mobilisation in the adult intensive care unit specific to people experiencing delirium.

Methods

Three moderators will carry out up to six focus groups including up to five participants in each group. Focus group discussions will be used to explore the experiences of patients, carers and family members using Microsoft Teams. Participants will be recruited from the charity ICUsteps using a purposive sampling technique.

Results

Discussions will be audio-recorded and simultaneously transcribed verbatim using the otter.ai programme. Member check approval will be sought to ensure accuracy of data. Framework analysis using a thematic methodology will identify themes in the data.

Conclusions

It is anticipated that the findings of this study will contribute towards further understanding the implementation of early mobilisation in order to improve measures for prevention and management of delirium in the adult intensive care unit.

Impact of Early Mobilization in the Intensive Care Unit on Psychological Issues

Early mobilization is an intervention protocol that can be employed in the critically ill population to effectively reduce the risks and consequences normally associated with immobility in high-acuity patients. In turn, rate and quality of recovery are improved as well as overall patient outcomes. Although there are many challenges inherent to the implementation of an early mobilization program, success of such a program is achievable through structured education of staff and diligence in its application. As a result, staff and patient experience the benefits of medical treatment that addresses a patient's immediate needs without ignoring that treatment's long-term effect.

[PROtocol-based MObilizaTION on intensive care units : Design of a cluster randomized pilot study]

BACKGROUND

Despite convincing evidence for early mobilization of patients on intensive care units (ICU), implementation in practice is limited. Protocols for early mobilization, including in- and exclusion criteria, assessments, safety criteria, and step schemes may increase the rate of implementation and mobilization.

HYPOTHESIS

Patients (population) on ICUs with a protocol for early mobilization (intervention), compared to patients on ICUs without protocol (control), will be more frequently mobilized (outcome).

METHODS

A multicenter, stepped-wedge, cluster-randomized pilot study is presented. Five ICUs will receive an adapted, interprofessional protocol for early mobilization in randomized order. Before and after implementation, mobilization of ICU patients will be evaluated by randomized monthly one-day point prevalence surveys. Primary outcome is the percentage of patients mobilized out of bed, operationalized as a score of ≥3 on the ICU Mobility Scale. Secondary outcome parameters will be presence and/or length of mechanical ventilation, delirium, stay on ICU and in hospital, barriers to early mobilization, adverse events, and process parameters as identified barriers, used strategies, and adaptions to local conditions.

EXPECTED RESULTS

Exploratory evaluation of study feasibility and estimation of effect sizes as the basis for a future explanatory study.

Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis

BACKGROUND

Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation.

OBJECTIVES

To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation.

DATA SOURCES

Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events.

DATA EXTRACTION

Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy).

SYNTHESIS

Heterogeneity was assessed by I² statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions.

CONCLUSIONS

Patient mobilization and physical rehabilitation in the ICU appears safe, with a low incidence of potential safety events, and only rare events having any consequences for patient management. Heterogeneity in the definition of safety events across studies emphasizes the importance of implementing existing consensus-based definitions.

Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial. However, implementation of early mobility as part of routine clinical care can be challenging. The objective of this review is to identify barriers to early mobilization and discuss strategies to overcome such barriers. Based on a literature search, we synthesize data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were patient-related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%) process-related barriers. These barriers varied across ICUs and within disciplines, depending on the ICU patient population, setting, attitude, and ICU culture. To overcome the identified barriers, over 70 strategies were reported and are synthesized in this review, including: implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and involvement of physician champions. Systematic efforts to change ICU culture to prioritize early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.

[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.

Complications related to early mobilization of mechanically ventilated patients on Intensive Care Units

AIMS AND OBJECTIVES

To compare international literature on the detection of complications associated with early mobilization of mechanically ventilated patients in intensive care units (ICUs).

BACKGROUND

Early mobilization of mechanically ventilated ICU patients is considered to be a more beneficial approach to treatment in intensive care; however, it remains unclear how safe this approach is and what complications to expect.

SEARCH STRATEGIES

A systematic literature research in English and German was conducted in June 2013 in the databases Pubmed, CINAHL, Cochrane library and MedPilot without limiting by year of publication. References of the included studies were screened and supplemented by manual search.

INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria were studies about mechanically ventilated adult patients on ICU, who were mobilized and reported complications. Excluded were studies that (a) did not differentiate between non-ventilated and ventilated patients, (b) did not report complications and (c) focused on in-bed mobilization.

CONCLUSIONS

Of 952 titles, 16 articles fit the criteria including 3 reviews and 13 clinical trials. The percentage of complications in clinical trials ranged between 0% and 16%. In total, 453 patients were mobilized 3613 times (up to walking with ventilation) with a complication mean rate of 3·9% (n = 144) using the inherent safety limits. No fall, cardiac arrest, or death was reported. Most complications were pulmonary, followed by haemodynamic ones. Serious complications that led to further consequences were observed in 0·3% (n = 10) of all mobilizations. The clinical studies have been carried out in trained, interdisciplinary teams with most of them using adapted algorithms for safety.

RELEVANCE TO CLINICAL PRACTICE

Despite a low complication rate, a frame for safety during early mobilization including team training and adapted criteria is recommended.

Lymphomatoid granulomatosis with spinal involvement after childhood acute lymphoblastic leukemia

Lymphomatoid granulomatosis (LYG) is a lymphoproliferative disease involving the lungs most frequently; however, it may also involve the kidneys, skin and especially the central nervous system. Unique initial presentation of spinal involvement is extremely rare and epidural lesion of thoracic spine has not been reported. The prognosis for LYG has been reported to be poor, and there currently exists no satisfactory established treatment protocol. The purpose of this study is to report a case of successful treatment with surgery and rituximab combination therapy in thoracic spinal LYG.

Idiopathic lumbosacral spinal chronic subdural hematoma

Reports of spontaneous spinal chronic subdural hematoma (SDH) are extremely rare. In the limited cases reported, the origin, symptoms and treatments are diversely revealed. Therefore accurate diagnoses and proper treatments are difficult to determine. We report a 74-year-old male presented with severe low back pain and both buttocks pain. Magnetic resonance imaging showed a diffuse subdural infiltrating mass compress nerve roots at the level of L2-S2. Emergency operation for decompression and excision of mass revealed spinal chronic SDH. His pain was subsided after the operation. We report a rare case of idiopathic lumbosacral spinal chronic SDH and discuss various causes and treatments.