A multimodal rehabilitation program for patients with ICU acquired weakness improves ventilator weaning and discharge home

Outcome, predictors and longitudinal trajectories of subjects with critical illness polyneuropathy and myopathy (CINAMOPS): study protocol of an observational cohort study in a clinical and post-clinical setting

INTRODUCTION

Critical illness polyneuropathy and myopathy (CIP/CIM) are frequent complications in the intensive care unit (ICU) with major consequences for the progress and outcome of subjects. CIP/CIM delays the weaning process, prolongs the hospital stay and increases the mortality rate. Additionally, it may have long-term consequences beyond the hospitalisation phase with prolonged disability. Even though there is growing interest in CIP/CIM, research about the clinical and post-clinical course as well as the middle-term and long-term outcomes of subjects with CIP/CIM is scarce. A large prospective study of critically ill subjects is needed with accurate diagnosis during the acute stage and comprehensive assessment during long-term follow-up.

METHODS AND ANALYSIS

This prospective observational cohort study aims to compare the clinical and post-clinical course of chronically critically ill subjects with and without the diagnosis of CIP/CIM and to determine predictors for the middle-term and long-term outcomes of subjects with CIP/CIM. In addition, the influence of the preclinical health status and the preclinical frailty on the long-term outcome of subjects with CIP/CIM will be investigated.This single-centre study will include 250 critically ill patients who were invasively ventilated for at least 5 days at the ICU and show reduced motor strength. At five study visits at admission and discharge to neurological rehabilitation, and 12, 18 and 24 months after disease onset, a comprehensive test battery will be applied including assessments of functioning and impairment, independence, health-related quality of life, activity and participation, cognition, gait and balance, fatigue, mental health and frailty.Secondary objectives are the documentation of therapy goals, therapy content and achieved milestones during the rehabilitation, to evaluate the clinimetric properties of the Mini-BESTest in critically ill patients, and to evaluate the time course and outcome of subjects with CIP/CIM after SARS-CoV-2 infection.

ETHICS AND DISSEMINATION

The study was approved by the ethical committee of the Ludwig-Maximilians University Munich. Participants will be included in the study after having signed informed consent.Results will be published in scientific, peer-reviewed journals and at national and international conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register (DRKS00021753).

Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy

Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.

Effects of the High-Intensity Early Mobilization on Long-Term Functional Status of Patients with Mechanical Ventilation in the Intensive Care Unit

Objective

Intensive care unit (ICU)-acquired weakness often occurs in patients with invasive mechanical ventilation (IMV). Early active mobility may reduce ICU-acquired weakness, improve functional status, and reduce disability. The aim of this study was to investigate whether high-intensity early mobility improves post-ICU discharge functional status of IMV patients.

Methods

132 adult patients in the ICU who were undergoing IMV were randomly assigned into two groups with a ratio of 1 : 1, with one group received high-intensity early mobility (intervention group, IG), while the other group received conventional treatment (control group, CG). The functional status (Barthel Index (BI)), capacity of mobility (Perme score and ICU Mobility Scale (IMS)), muscle strength (Medical Research Council sum scores (MRC-SS)), mortality, complication, length of ICU stay, and duration of IMV were evaluated at ICU discharge or after 3-month of ICU discharge.

Results

The patient's functional status was improved (BI scores 90.6 ± 18.0 in IG vs. 77.7 ± 27.9 in CG; p=0.005), and capacity of mobility was increased (Perme score 17.6 ± 7.1 in IG vs. 12.2 ± 8.5 in CG, p < 0.001; IMS 4.7 ± 2.6 in IG vs. 3.0 ± 2.6 in CG, p < 0.001). The IG had a higher muscle strength and lower incidence of ICU-acquired weakness (ICUAW) than that in the CG. The incidence of mortality and delirium was also lower than CG at ICU discharge. However, there were no differences in terms of length of ICU stay, duration of IMV, ventilator-associated pneumonia, and venous thrombosis.

Conclusions

High-intensity early mobility improved the patient's functional status and increased capacity of mobility with IMV. The benefits to functional status remained after 3 month of ICU discharge. Other benefits included higher muscle strength, lower incidence of ICUAW, mortality, and delirium in IG.

Effectiveness of massage and range of motion exercises on muscle strength and intensive care unit-acquired weakness in Iranian patients with COVID-19: a randomized parallel-controlled trial

BACKGROUND

Muscle weakness is prevalent in intensive care patients. This study focused on comparing the effects of massage and range of motion (ROM) exercises on muscle strength and intensive care unit-acquired weakness (ICU-AW) among patients with coronavirus disease 2019 (COVID-19).

METHODS

This study was a randomized clinical trial that recruited patients (n=45) with COVID-19 admitted to the ICU and divided them into three groups (ROM exercises, massage, and control). We evaluated muscle strength and ICU-AW in the arms and legs using a hand dynamometer. The Medical Research Council sum score was determined before and after the intervention.

RESULTS

The study findings were that 0%, 20%, and 100% of the participants in the ROM exercises, massage, and control groups had ICU-AW on the 7th day of ICU admission. The ROM exercise group had greater muscle strength in the hands and legs than the massage and control groups, and the massage group had greater muscle strength than the control group.

CONCLUSIONS

Massage and ROM exercises could improve muscle strength and reduce ICU-AW in COVID-19 patients admitted to the ICU.

Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines

BACKGROUND

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator.

METHODS

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations.

RESULTS

Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

CONCLUSIONS

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023)

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Association between the early mobilization of mechanically ventilated patients and independence in activities of daily living at hospital discharge

Physical dysfunction after discharge from the intensive care unit (ICU) is recognized as a common complication among ICU patients. Early mobilization (EM), defined as the ability to sit on the edge of the bed within 5 days, may help improve physical dysfunction. However, the barriers to, and achievement of, EM and their impact on physical dysfunction have not been fully investigated. This study aimed to investigate the achievement of EM and barriers to it and their impact on patient outcomes in mechanically ventilated ICU patients. We conducted this multicenter retrospective cohort study by collecting data from six ICUs in Japan. Consecutive patients who were admitted to the ICU between April 2019 and March 2020, were aged ≥ 18 years, and received mechanical ventilation for > 48 h were eligible. The primary outcome was the rate of independent activities of daily living (ADL), defined as a score ≥ 70 on the Barthel index at hospital discharge. Daily changes in barriers of mobilization, including consciousness, respiratory, circulatory, medical staff factors, and device factors (catheter, drain, and dialysis), along with the clinical outcomes were investigated. The association among barriers, mobilization, and Barthel index ≥ 70 was analyzed using multivariable logistic regression analysis. During the study period, 206 patients were enrolled. EM was achieved in 116 patients (68%) on the fifth ICU day. The primary outcome revealed that achieving EM was associated with a Barthel index ≥ 70 at hospital discharge [adjusted odds ratio (AOR), 3.44; 95% confidence interval (CI), 1.70-6.96]. Device factors (AOR, 0.31; 95% CI, 0.13-0.75, respectively) were significantly associated with EM achievement. EM was associated with independent ADL at hospital discharge. Time to first mobilization and barriers to achieving mobilization can be important parameters for achieving ADL independence at discharge. Further research is required to determine the most common barriers so that they can be identified and removed.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

[Dysphagia in Tracheostomized Patients after Long-Term Mechanical Ventilation - Become Sensitive to Reduced Pharyngo-Laryngeal Sensitivity]

Independent of the type of critical illness, tracheostomized patients have a high risk of developing a dysphagia. This is potentially life-threatening as it can lead to aspiration and pneumonia. It is therefore essential to perform swallowing diagnostics by means of a bolus dyeing test and/or FEES before oral feeding. Since a physiological airflow through the larynx and adequate subglottic pressure are key components of an effective swallowing act, oralisation should be avoided as far as possible with a blocked tracheal cannula.

Muscle weakness in critically ill patients: Effects of a systematized rehabilitation nursing program

OBJECTIVE

Intensive care unit-acquired muscle weakness (ICUAW) in critically ill patients is frequent and associated with negative outcomes. Early rehabilitation is a strategy to improve outcomes. The aim was to assess the effects of a rehabilitation nursing programme at discharge from intensive care unit.

METHODS

Quasi-experimental study with the comparison between two groups: one enrolled in a systematized nursing rehabilitation program and the other with usual nursing rehabilitation care. A non-probabilistic sample, sequential, of 42 critically ill ventilated patients, 21 patients in the control group and 21 patients the intervention group (June 2017 to June 2019), in three intensive care units of one large Portuguese teaching hospital. Mann-Whitney test was performed to compare Medical Research Council Sum Score (MRC-SS) values between groups.

RESULTS

Patients undergoing the rehabilitation program had a decrease in ICUAW (at ICU discharge mean MRC-SS = 38 vs. mean MRC-SS = 42.7, p = 0.043, U = 152,5). There was a decrease in severe muscle weakness (9.5% vs. 28.6%) and significant muscle weakness (42.9% vs. 52.4%) and an increase without muscle weakness (47,6% vs. 19%).

CONCLUSIONS

The systematic rehabilitation nursing program can improve muscle strength and reduce functional disability at the time of discharge from intensive care.

A randomized controlled clinical trial of the effects of range of motion exercises and massage on muscle strength in critically ill patients

Background

Atrophy and muscle weakness is a common problem in critically ill patients admitted to the intensive care unit (ICU). Muscle weakness in severe cases can lead to tetraplegia, reduced or lost tendon reflexes, delayed weaning from mechanical ventilation, physical disability, and increased mortality. The aim of this study was to compare the effects of range of motion exercises (ROM) and massage on muscle strength of the patients admitted to ICUs.

Methods

This study was a single-blinded randomized controlled trial conducted in ICUs of Afzalipour hospital in Kerman, southeastern Iran. Ninety conscious ICU patients were randomly divided into three groups (massage, ROM exercises and control). The researcher/co-researcher massaged or did ROM exercises on the patients’ extremities once a day for seven consecutive days. Using a hand-held dynamometer, the co-researcher, rated the muscle strength before, on the fourth and seventh days of intervention at 8 p.m.

Results

The mean muscles strength of the right arm in the ROM exercise and massage groups increased by 0.63 kg, and 0.29 kg, respectively after the intervention compared with before the intervention. The muscle strength of the right arm in the control group reduced by 0.55 kg. The mean muscles strength of the left arm in the ROM exercise and massage groups increased by 0.61 kg and 0.28 kg after the intervention, respectively while it reduced by 0.56 kg in the control group. The mean muscles strength of the right leg in the ROM exercise and massage groups increased by 0.53 kg and 0.27 kg after the intervention compared with before the intervention while it reduced by 0.70 kg in the control group. The mean muscles strength of the left leg in the ROM exercise and massage groups increased by 0.54 kg and 0.26 kg after the intervention compared with before the intervention while it reduced by 0.71 kg in the control group.

Conclusion

The results of the present study showed that ROM exercises and massage were effective interventions in increasing muscle strength of the critically ill patients admitted to intensive care units.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00489-z.

Efficacy of Physiotherapy Interventions on Weaning in Mechanically Ventilated Critically Ill Patients: A Systematic Review and Meta-Analysis

Mechanical ventilation (MV) is currently considered a life-saving intervention. However, growing evidence highlighted that prolonged MV significantly affects functional outcomes and length of stay. In this scenario, controversies are still open about the optimal rehabilitation strategies for improving MV duration in ICU patients. In addition, the efficacy of physiotherapy interventions in critical ill patients without positive history of chronic respiratory conditions is still debated. Therefore, this systematic review of randomized controlled trials (RCTs) with meta-analysis aimed at characterizing the efficacy of a comprehensive physiotherapy intervention in critically ill patients. PubMed, Scopus, and Web of Science databases were systematically searched up to October 22, 2021 to identify RCTs assessing acute patients mechanical ventilated in ICU setting undergoing a rehabilitative intervention. The primary outcomes were MV duration, extubation, and weaning time. The secondary outcomes were weaning successful rate, respiratory function, ICU discharge rate and length of stay. Out of 2503 records, 12 studies were included in the present work. The meta-analysis performed in 6 RCTs showed a significant improvement in terms of MV duration (overall effect size: −3.23 days; 95% CI = −5.79, −0.67, p = 0.01; Z = 2.47) in patients treated with a comprehensive physiotherapy intervention including early mobilization, positioning, airway clearance techniques, lung expansion and respiratory muscle training. The quality assessment underlined 9 studies (75%) of good quality and 3 studies of fair quality according to the PEDro scale. In conclusion, our results provided previously unavailable data about the role of comprehensive physiotherapy intervention in improving MV duration in critical ill patients without chronic respiratory conditions. Further studies are needed to better characterize the optimal combination of rehabilitation strategies enhancing the improvements in critical ill patients without chronic respiratory disorders.

Optimal timing of introducing mobilization therapy for ICU patients with sepsis

Background

For patients admitted to the intensive care unit (ICU) with sepsis, mobilization therapy during ICU stay can improve their outcomes during and after the ICU stay. However, little is known about the optimal timing of introducing mobilization therapy.

Methods

This is a retrospective cohort study using data from a tertiary medical center in Japan during 2013–2017. We included patients aged ≥ 18 years who were admitted to the ICU with sepsis based on the Sepsis-3 criteria. We defined early mobilization (EM) as the rehabilitation at the level of sitting on the edge of the bed or more within the first 3 days of the patients’ ICU stay. Patients were divided into the EM and non-EM groups. The primary outcomes were in-hospital mortality and ambulatory dependence at hospital discharge. We estimated the effects of EM by stabilized inverse probability weighting (sIPW). We then tested alternative definitions of EM by changing the cutoff in days to mobilization by 1-day increments from 2 to 7 days to investigate the optimal timing of mobilization.

Results

Our study sample consisted of a total of 296 septic patients, including 96 patients in the EM group and 200 patients in the non-EM group. In the sIPW model, the adjusted OR for in-hospital mortality in the EM group compared to the non-EM group was 0.22 [95% CI 0.06–0.88], and the adjusted OR for ambulatory dependence at the hospital discharge was 0.24 [95% CI 0.09–0.61]. When alternative definitions of EM were tested, patients who achieved mobilization within the first 2–4 days of their ICU stays had better outcomes.

Conclusions

Achieving mobilization within the first 3 days of ICU stay was significantly associated with better outcomes. Patients with sepsis might benefit most from achieving mobilization within 2–4 days. Further studies are warranted to validate the findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00613-8.

Handgrip strength cutoff value predicting successful extubation in mechanically ventilated patients

Background

Handgrip strength (HGS) is an alternative tool to evaluate respiratory muscle function. HGS cutoff value indicating extubation success or failure has not been investigated. This study aimed to determine HGS cutoff value to predict successful extubation.

Methods

A prospective study was conducted. Patients requiring intubated mechanical ventilation with intubation ≥ 48 hours in medical wards were recruited. HGS test was performed at 10 minutes before and 30 minutes after spontaneous breathing trial (SBT). Rapid shallow breathing index (RSBI) was measured at 10 minutes before SBT.

Results

Ninety-three patients (58% men) were included. Mean age was 71.6 ± 15.2 years. Weaning failure rate was 6.5%. The area under the ROC curve of 0.84 for the best HGS cutoff value at 10 minutes before SBT was 12.7 kg, with 75.9% sensitivity and 83.3% specificity (P = 0.005). The best HSG cutoff value at 30 minutes after SBT was 14.9 kg, with the area under the ROC curve of 0.82, with 58.6% sensitivity and 83.3% specificity (P = 0.009). The best RSBI cutoff value was 43.5 breaths/min/L, with the area under the ROC curve of 0.46, 33.3% sensitivity and 66.6% specificity (P = 0.737).

Conclusions

HGS may be a predictive tool to guide extubation with better sensitivity and specificity than RSBI. A prospective study is needed to verify HGS test as adjunctive to RSBI in ventilator weaning protocol.

Early rehabilitation nursing in ICU promotes rehabilitation of patients with respiratory failure treated with invasive mechanical ventilation

OBJECTIVE

This paper aimed at exploring the application value of early rehabilitation nursing (ERN) in intensive care unit (ICU) for nursing patients with respiratory failure (RF) treated with invasive mechanical ventilation (IMV).

METHODS

Admitted to the ICU of our hospital from January 2019 to June 2020, 172 RF patients that was treated with IMV were selected as the research objects. Those in the general group (n=80) received routine nursing in ICU, whereas those in the recovery group (n=92) received ERN on the basis of the general group. The recovery of their vital signs, blood gas functions and pulmonary functions was monitored. Their treatment time in ICU, mechanical ventilation time (MVT), total hospitalization time (THT) and incidence of complications were recorded. Their negative emotions, quality of life (QOL) and nursing satisfaction were assessed.

RESULTS

After intervention, the body temperature, the respiratory rate and the heart rate in the recovery group were lower than those in the general group (P<0.05). The arterial partial pressure of oxygen (PaO₂) and blood oxygen saturation (SpO₂) were remarkably higher in the recovery group, while the arterial partial pressure of carbon dioxide (PaCO₂) was remarkably lower (P<0.05). One-second forced expiratory volume (FEV₁), FEV₁/forced vital capacity (FVC) and FEV₁% were remarkably higher in the recovery group (P<0.05). The treatment time in ICU, the MVT and the THT were remarkably shorter in the recovery group (P<0.05). During intervention, the total incidence of complications was lower in the recovery group (P<0.05). While after intervention, the scores of the Self-rating Anxiety Scale (SAS), the Self-rating Depression Scale (SDS) and the St. George's Respiratory Questionnaire (SGRQ; symptom, activity, impact) were lower in the recovery group, but the nursing satisfaction was remarkably higher (P<0.05).

CONCLUSION

During the treatment of RF patients with IMV, ERN can promote their recovery, reduce the incidence of complications, relieve their negative emotions, and improve their QOL and nursing satisfaction. So, this nursing model is worthy of clinical application.

The Effect of High Protein and Mobility-Based Rehabilitation on Clinical Outcomes in Survivors of Critical Illness

BACKGROUND

Protein supplementation and mobility-based rehabilitation programs (MRP) individually improve functional outcomes in survivors of critical illness. We hypothesized that combining MRP therapy with high protein supplementation is associated with greater weaning success from prolonged mechanical ventilation (PMV) and increased discharge home in this population.

METHODS

We conducted a retrospective analysis assessing the effects of an MRP on a cohort of survivors of critical illness. All received usual care (UC) rehabilitation. The MRP group received 3 additional MRP sessions each week for a maximum of 8 weeks. Subjects were prescribed nutrition and classified as receiving high protein (HPRO) or low protein (LPRO), based on a recommended 1.0 g/kg/d, and then the subjects were categorized into 4 groups: MRP+HPRO, MRP+LPRO, UC+HPRO, and UC+LPRO.

RESULTS

A total of 32 subjects were enrolled. The MRP+HPRO group had greater weaning success (90% vs 38%, P = .045) and a higher rate of discharge home (70% vs 13%, P = .037) compared to UC+LPRO group. The MRP+HPRO group had a higher, nonsignificant rate of discharge home compared to the MRP+LPRO (70% vs 20%, P = .10).

CONCLUSIONS

Combining high protein with mobility-based rehabilitation was associated with increased rates of discharge home and ventilator weaning success in survivors of critical illness. Further studies are needed to evaluate the role of combined exercise and nutrition interventions in this population.

Neuromuscular Electrical Stimulation and High-Protein Supplementation After Subarachnoid Hemorrhage: A Single-Center Phase 2 Randomized Clinical Trial

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (SAH) survivors live with long-term residual physical and cognitive disability. We studied whether neuromuscular electrical stimulation (NMES) and high-protein supplementation (HPRO) in the first 2 weeks after SAH could preserve neuromotor and cognitive function as compared to standard of care (SOC) for nutrition and mobilization.

METHODS

SAH subjects with a Hunt Hess (HH) grade > 1,modified Fisher score > 1 and BMI < 40 kg/m² were randomly assigned to SOC or NMES + HPRO. NMES was delivered to bilateral quadricep muscles daily during two 30-min sessions along with HPRO (goal:1.8 g/kg/day) between post-bleed day (PBD) 0 and 14. Primary endpoint was atrophy in the quadricep muscle as measured by the percentage difference in the cross-sectional area from baseline to PBD14 on CT scan. All subjects underwent serial assessments of physical (short performance physical battery, SPPB) cognitive (Montreal Cognitive Assessment Scale, MoCA) and global functional recovery (modified Rankin Scale, mRS) at PBD 14, 42, and 90.

RESULTS

Twenty-five patients (SOC = 13, NMES + HPRO = 12) enrolled between December 2017 and January 2019 with no between-group differences in baseline characteristics (58 years old, 68% women, 50% HH > 3). Median duration of interventions was 12 days (range 9-14) with completion of 98% of NMES sessions and 83% of goal HPRO, and no reported serious adverse events. There was no difference in caloric intake between groups, but HPRO + NMES group received more protein (1.5 ± 0.5 g/kg/d v 0.9 ± 0.4 g/kg/d, P < 0.01). Muscle atrophy was less in NMES + HPRO than the SOC group (6.5 ± 4.1% vs 12.5 ± 6.4%, P 0.01). Higher atrophy was correlated with lower daily protein intake (ρ = - 0.45, P = 0.03) and lower nitrogen balance (ρ = 0.47, P  = 0.02); and worse 3 month SPPB (ρ = -  0.31, P = 0.1) and mRS (ρ = 0.4, P  = 0.04). NMES + HPRO patients had a better median [25%,75] SPPB (12[10, 12] v. 9 [4, 12], P = 0.01) and mRS (1[0,2] v.2[1, 3], P = 0.04) than SOC at PBD 90.

CONCLUSIONS

NMES + HPRO appears to be feasible and safe acutely after SAH and may reduce acute quadriceps muscle wasting with a lasting benefit on recovery after SAH.

Ambulatory Status Is Associated With Successful Discharge Home in Survivors of Critical Illness

BACKGROUND

Survivors of prolonged ICU admissions are bedridden and immobilized for an extended period of time. These patients often are discharged to long-term acute care hospitals (LTACHs) for continued medical care and rehabilitation. Early ambulation has been associated with improved functional outcomes and lower readmission rates in hospitalized patients. The aim of this study was to determine the association between ambulatory status and discharge disposition in survivors of prolonged ICU stays who were admitted to an LTACH.

METHODS

We performed a retrospective cohort study of 285 survivors of prolonged ICU stays who were admitted to a university-affiliated LTACH facility from 2010 to 2013. Outcomes of interest included comparing the relationship between ambulatory status and disposition status (ie, home vs acute rehabilitation facility, nursing home, readmission to an ICU, or death).

RESULTS

The mean age of our cohort was 59.0 ± 15.3 y, with 129 (45%) males, 148 (52%) African-American, 123 (43%) white, and 14 (5%) of subjects other races. Most of these subjects were transferred from a medical ICU (68%). The median ICU and LTACH lengths of stay were 25.5 (13-38.8) d and 34.0 (14-64) d, respectively. Thirty-eight (13.3%) subjects were discharged home, 25 (8.7%) to an acute rehabilitation facility, 70 (24.6%) to a nursing home, 139 (48.8%) were readmitted to an ICU, and 13 (4.6%) died. Of 285 total subjects, 74 (26%) ambulated during physical therapy, while 211 (74%) subjects never ambulated. Of those who ambulated, 24 (32.4%) went home, whereas 14 of 211 (6.6%) subjects who did not ambulate went home (P < .001).

CONCLUSIONS

The ability to ambulate was associated with a greater likelihood of being discharged home in survivors of prolonged ICU stays who were admitted to an LTACH. These results suggest that mobility training for survivors of prolonged ICU stays in LTACH facilities should be strongly emphasized to improve their likelihood of being discharged home.

Support needs and health-related quality of life of family caregivers of patients requiring prolonged mechanical ventilation and admission to a specialised weaning centre: A qualitative longitudinal interview study

OBJECTIVES

Family caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre.

RESEARCH METHODOLOGY/DESIGN

A longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis.

SETTING

A 6-bed specialised weaning centre in Toronto, Canada.

FINDINGS

Eighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight.

CONCLUSIONS

Deficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed.

Utility of Plasma GDF-15 for Diagnosis and Prognosis Assessment of ICU-Acquired Weakness in Mechanically Ventilated Patients: Prospective Observational Study

Objective

To identify the clinical correlations between plasma growth differentiation factor-15 (GDF-15), skeletal muscle function, and acute muscle wasting in ICU patients with mechanical ventilation. In addition, to investigate its diagnostic value for ICU-acquired weakness (ICU-AW) and its predictive value for 90-day survival in mechanically ventilated patients.

Methods

95 patients with acute respiratory failure, who required mechanical ventilation therapy, were randomly selected among hospitalized patients from June 2017 to January 2019. The plasma GDF-15 level was detected by ELISA, the rectus femoris cross-sectional area (RFcsa) was measured by ultrasound, and the patient's muscle strength was assessed using the British Medical Research Council (MRC) muscle strength score on day 1, day 4, and day 7. Patients were divided into an ICU-AW group and a non-ICU-AW group according to their MRC-score on the 7th day. The differences in plasma GDF-15 level, MRC-score, and RFcsa between the two groups were compared on the 1st, 4th, and 7th day after being admitted to the ICU. Then, the correlations between plasma GDF-15 level, RFcsa loss, and MRC-score on day 7 were investigated. The receiver operating characteristic curve (ROC) was used to analyze the plasma GDF-15 level, RFcsa loss, and % decrease in RFcsa on the 7th day to the diagnosis of ICU-AW in mechanically ventilated patients. Moreover, the predictive value of GDF-15 on the 90-day survival status of patients was assessed using patient survival curves.

Results

Based on whether the 7th day MRC-score was <48, 50 cases were included in the ICU-AW group and 45 cases in the non-ICU-AW group. The length of mechanical ventilation, ICU length of stay, and hospital length of stay were significantly longer in the ICU-AW group than in the non-ICU-AW group (all P < 0.05), while the other baseline indicators were not statistically significant between the two groups. As the treatment time increased, the plasma GDF-15 level was significantly increased, the ICU-AW group demonstrated a significant decreasing trend in the MRC-score and RFcsa, while no significant changes were found in the non-ICU-AW group. In the ICU-AW group, the plasma GDF-15 level was significantly higher than that in the non-ICU-AW group, while the RFcsa and the MRC-score were significantly lower than those in the non-ICU-AW group (GDF-15 (pg/ml): 2542.44 ± 629.38 vs. 1542.86 ± 502.86; RFcsa (cm²): 2.04 ± 0.64 vs. 2.34 ± 0.61; MRC-score: 41.22 ± 3.42 vs. 51.42 ± 2.72, all P < 0.05), while the other baseline indicators were not statistically significant between the two groups. As the treatment time increased, the plasma GDF-15 level was significantly increased, the ICU-AW group demonstrated a significant decreasing trend in the MRC-score and RFcsa, while no significant changes were found in the non-ICU-AW group. In the ICU-AW group, the plasma GDF-15 level was significantly higher than that in the non-ICU-AW group, while the RFcsa and the MRC-score were significantly lower than those in the non-ICU-AW group (GDF-15 (pg/ml): 2542.44 ± 629.38 vs. 1542.86 ± 502.86; RFcsa (cm²): 2.04 ± 0.64 vs. 2.34 ± 0.61; MRC-score: 41.22 ± 3.42 vs. 51.42 ± 2.72, all r = −0.60), while it was significantly positively correlated with the RFcsa loss (r = −0.60), while it was significantly positively correlated with the RFcsa loss (r = −0.60), while it was significantly positively correlated with the RFcsa loss (r = −0.60), while it was significantly positively correlated with the RFcsa loss (P < 0.05), while the other baseline indicators were not statistically significant between the two groups. As the treatment time increased, the plasma GDF-15 level was significantly increased, the ICU-AW group demonstrated a significant decreasing trend in the MRC-score and RFcsa, while no significant changes were found in the non-ICU-AW group. In the ICU-AW group, the plasma GDF-15 level was significantly higher than that in the non-ICU-AW group, while the RFcsa and the MRC-score were significantly lower than those in the non-ICU-AW group (GDF-15 (pg/ml): 2542.44 ± 629.38 vs. 1542.86 ± 502.86; RFcsa (cm²): 2.04 ± 0.64 vs. 2.34 ± 0.61; MRC-score: 41.22 ± 3.42 vs. 51.42 ± 2.72, all P < 0.05), while the other baseline indicators were not statistically significant between the two groups. As the treatment time increased, the plasma GDF-15 level was significantly increased, the ICU-AW group demonstrated a significant decreasing trend in the MRC-score and RFcsa, while no significant changes were found in the non-ICU-AW group. In the ICU-AW group, the plasma GDF-15 level was significantly higher than that in the non-ICU-AW group, while the RFcsa and the MRC-score were significantly lower than those in the non-ICU-AW group (GDF-15 (pg/ml): 2542.44 ± 629.38 vs. 1542.86 ± 502.86; RFcsa (cm²): 2.04 ± 0.64 vs. 2.34 ± 0.61; MRC-score: 41.22 ± 3.42 vs. 51.42 ± 2.72, all P < 0.05), while the other baseline indicators were not statistically significant between the two groups. As the treatment time increased, the plasma GDF-15 level was significantly increased, the ICU-AW group demonstrated a significant decreasing trend in the MRC-score and RFcsa, while no significant changes were found in the non-ICU-AW group. In the ICU-AW group, the plasma GDF-15 level was significantly higher than that in the non-ICU-AW group, while the RFcsa and the MRC-score were significantly lower than those in the non-ICU-AW group (GDF-15 (pg/ml): 2542.44 ± 629.38 vs. 1542.86 ± 502.86; RFcsa (cm²): 2.04 ± 0.64 vs. 2.34 ± 0.61; MRC-score: 41.22 ± 3.42 vs. 51.42 ± 2.72, all

Conclusion

The plasma GDF-15 concentration level was significantly associated with skeletal muscle function and muscle wasting on day 7 in ICU patients with mechanical ventilation. Therefore, it can be concluded that the plasma GDF-15 level on the 7th day has a high diagnostic yield for ICU-acquired muscle weakness, and it can predict the 90-day survival status of ICU mechanically ventilated patients.

Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study

PURPOSE

Gait independence is one of the most important factors related to returning home from the hospital for patients treated in the intensive care unit (ICU), but the factors affecting gait independence have not been clarified. This study aimed to determine the factors affecting gait independence at hospital discharge using a standardized early mobilization protocol that was shared by participating hospitals.

MATERIALS AND METHODS

Patients who entered the ICU from January 2017 to March 2018 were screened. The exclusion criteria were mechanical ventilation < 48 hours, age < 18, loss of gait independence before hospitalization, being treated for neurological issues, unrecoverable disease, unavailability of continuous data, and death during ICU stay. Basic attributes, such as age, ICU length of stay, information on early mobilization while in the ICU, Medical Research Council (MRC) sum-score at ICU discharge, incidence of ICU-acquired weakness (ICU-AW) and delirium, and the degree of gait independence at hospital discharge, were collected. Gait independence was determined using a mobility scale of the Barthel Index, and the factors that impaired gait independence at hospital discharge were investigated using a Cox proportional hazard regression analysis.

RESULTS

One hundred thirty-two patients were analyzed. In the univariate analysis, age, APACHE II score, duration of mechanical ventilation, ICU length of stay, incidence of delirium, and MRC sum-score at ICU discharge were extracted as significant. In the multivariate analysis, age (p = 0.014), MRC sum-score < 48 (p = 0.021), and delirium at discharge from ICU (p < 0.0001) were extracted as significant variables.

CONCLUSIONS

We found that age and incidence of ICU-AW and delirium were significantly related to impaired gait independence at hospital discharge.

Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis

BACKGROUND

Physical therapy can prevent functional impairments and improve the quality of life of patients after hospital discharge. However, the effect of early mobilization on patients with a critical illness remains unclear. This study was performed to assess the evidence available regarding the effect of early mobilization on critically ill patients in the intensive care unit (ICU).

METHODS

Electronic databases were searched from their inception to March 21, 2019. Randomized controlled trials (RCTs) comprising critically ill patients who received early mobilization were included. The methodological quality and risk of bias of each eligible trial were assessed using the Cochrane Collaboration tool. Data were extracted using a standard collection form each included study, and processed using the Mantel-Haenszel (M-H) or inverse-variance (I-V) test in the STATA v12.0 statistical software.

RESULTS

A total of 1,898 records were screened. Twenty-three RCTs comprising 2,308 critically ill patients were ultimately included. Early mobilization decreased the incidence of ICU-acquired weakness (ICU-AW) at hospital discharge (three studies, 190 patients, relative risk (RR): 0.60, 95% confidence interval (CI) [0.40, 0.90]; p = 0.013, I2 = 0.0%), increased the number of patients who were able to stand (one study, 50 patients, 90% vs. 62%, p = 0.02), increased the number of ventilator-free days (six studies, 745 patients, standardized mean difference (SMD): 0.17, 95% CI [0.02, 0.31]; p = 0.023, I2 = 35.5%) during hospitalization, increased the distance the patient was able to walk unassisted (one study, 104 patients, 33.4 (0-91.4) meters vs. 0 (0-30.4) meters, p = 0.004) at hospital discharge, and increased the discharged-to-home rate (seven studies, 793 patients, RR: 1.16, 95% CI [1.00, 1.34]; p = 0.046). The mortality (28-day, ICU and hospital) and adverse event rates were moderately increased by early mobilization, but the differences were statistically non-significant. However, due to the substantial heterogeneity among the included studies, and the low quality of the evidence, the results of this study should be interpreted with caution. Publication bias was not identified.

CONCLUSIONS

Early mobilization appears to decrease the incidence of ICU-AW, improve the functional capacity, and increase the number of ventilator-free days and the discharged-to-home rate for patients with a critical illness in the ICU setting.

Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities

Background

Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature.

Methods

Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies.

Results

Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation.

Conclusions

This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.