Early Active Mobilization during Mechanical Ventilation in the ICU

Early In-Bed Cycle Ergometry in Mechanically Ventilated Patients

BACKGROUND

Critical illness requiring invasive mechanical ventilation can precipitate important functional disability, contributing to multidimensional morbidity following admission to an intensive care unit (ICU). Early in-bed cycle ergometry added to usual physiotherapy may mitigate ICU-acquired physical function impairment.

METHODS

We randomly assigned 360 adult ICU patients undergoing invasive mechanical ventilation to receive 30 minutes of early in-bed Cycling + Usual physiotherapy (n=178) or Usual physiotherapy alone (n=182). The primary outcome was the Physical Function ICU Test-scored (PFIT-s) at 3 days after discharge from the ICU (the score ranges from 0 to 10, with higher scores indicating better function).

RESULTS

Cycling began within a median (interquartile range) of 2 (1 to 3) days of starting mechanical ventilation; patients received 3 (2 to 5) cycling sessions for a mean (±standard deviation) of 27.2 ± 6.6 minutes. In both groups, patients started Usual physiotherapy within 2 (2 to 4) days of mechanical ventilation and received 4 (2 to 7) Usual physiotherapy sessions. The duration of Usual physiotherapy was 23.7 ± 15.1 minutes in the Cycling + Usual physiotherapy group and 29.1 ± 13.2 minutes in the Usual physiotherapy group. No serious adverse events occurred in either group. Among survivors, the PFIT-s at 3 days after discharge from the ICU was 7.7 ± 1.7 in the Cycling + Usual physiotherapy group and 7.5 ± 1.7 in the Usual physiotherapy group (absolute difference, 0.23 points; 95% confidence interval, -0.19 to 0.65; P=0.29).

CONCLUSIONS

Among adults receiving mechanical ventilation in the ICU, adding early in-bed Cycling to usual physiotherapy did not improve physical function at 3 days after discharge from the ICU compared with Usual physiotherapy alone. Cycling did not cause any serious adverse events. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov numbers, NCT03471247 [full randomized clinical trial] and NCT02377830 [CYCLE Vanguard 46-patient internal pilot].).

The effect of an improved ICU physical environment on outcomes and post-ICU recovery-a protocol

BACKGROUND

Intensive care medicine continues to improve, with advances in technology and care provision leading to improved patient survival. However, this has not been matched by similar advances in ICU bedspace design. Environmental factors including excessive noise, suboptimal lighting, and lack of natural lights and views can adversely impact staff wellbeing and short- and long-term patient outcomes. The personal, social, and economic costs associated with this are potentially large. The ICU of the Future project was conceived to address these issues. This is a mixed-method project, aiming to improve the ICU bedspace environment and assess impact on patient outcomes. Two innovative and adaptive ICU bedspaces capable of being individualised to patients' personal and changing needs were co-designed and implemented. The aim of this study is to evaluate the effect of an improved ICU bedspace environment on patient outcomes and operational impact.

METHODS

This is a prospective multi-component, mixed methods study including a randomised controlled trial. Over a 2-year study period, the two upgraded bedspaces will serve as intervention beds, while the remaining 25 bedspaces in the study ICU function as control beds. Study components encompass (1) an objective environmental assessment; (2) a qualitative investigation of the ICU environment and its impact from the perspective of patients, families, and staff; (3) sleep investigations; (4) circadian rhythm investigations; (5) delirium measurements; (6) assessment of medium-term patient outcomes; and (7) a health economic evaluation.

DISCUSSION

Despite growing evidence of the negative impact the ICU environment can have on patient recovery, this is an area of critical care medicine that is understudied and commonly not considered when ICUs are being designed. This study will provide new information on how an improved ICU environment impact holistic patient recovery and outcomes, potentially influencing ICU design worldwide.

TRIAL REGISTRATION

ACTRN12623000541606. Registered on May 22, 2023. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385845&isReview=true .

Early Mobilization Dose Reporting in Randomized Clinical Trials With Patients Who Were Mechanically Ventilated: A Scoping Review

OBJECTIVE

The aim of this scoping review was to investigate the mobilization dose reporting in the randomized clinical trials (RCTs) of patients receiving mechanical ventilation in the intensive care unit.

METHODS

In this scoping review, RCTs published from inception to December 2022 were searched in relevant electronic databases. Trials that involved adults receiving mechanical ventilation (>48 hours) and any early mobilization modality were analyzed. Two independent authors screened, selected, and extracted data. The mobilization doses of the intervention groups (IGs) and the comparator groups (CGs) were assessed as the proportion of reported items/total applicable from the main items of the Consensus on Exercise Reporting Template (CERT).

RESULTS

Twenty-three RCTs comprising 2707 patients (1358 from IG and 1349 from CG) were included, involving studies on neuromuscular electrical stimulation (n = 7), progressive mobility (n = 6), leg cycling (n = 3), tilt table (n = 1), and multicomponent (n = 6) mobilization. The pooled reporting of CERT items was 68% (86% for IG and 50% for CG). The most reported CERT items were type of exercise (100%) and weekly frequency (100%) for IG, whereas the least reported were intensity (4%) and individualization (22%) for CG. Regardless of the group, individualization, progression, and intensity of mobilization were the least reported items. Eight IGs (35%) reported all CERT items, whereas no CGs reported all of them.

CONCLUSIONS

Deficits in mobilization dose reporting of intensive care unit RCTs were identified, especially for exercise intensity in adults receiving mechanical ventilation. One-third of IG reported all exercise dosing items, whereas no CG reported all of them. Future studies should investigate the details of optimal dosage reporting, particularly for CG.

IMPACT

The lack of dose reporting may partially explain the inconsistency in the meta-analysis results of early mobilization trials, thus limiting the interpretation for clinical practice in the intensive care unit.

Ultrasound-derived rates of muscle wasting in the intensive care unit and in the post-intensive care ward for patients with critical illness: Post hoc analysis of an international, multicentre randomised controlled trial of early rehabilitation

BACKGROUND AND AIMS

Muscle wasting results in weakness for patients with critical illness. We aim to explore ultrasound-derived rates of change in skeletal muscle in the intensive care unit (ICU) and following discharge to the post-ICU ward.

DESIGN

Post hoc analysis of a multicentre randomised controlled trial of functional-electrical stimulated cycling, recumbent cycling, and usual care delivered in intensive care.

METHOD

Participants underwent ultrasound assessment of rectus femoris at ICU admission, weekly in the ICU, upon awakening, ICU discharge, and hospital discharge. The primary outcome was rate of change in rectus femoris cross-sectional area (ΔRFCSA) in mm2/day in the ICU (enrolment to ICU discharge) and in the post-ICU ward (ICU discharge to hospital discharge). Secondary outcomes included rate of change in echo intensity (ΔEI), standard deviation of echo intensity (ΔEISD), and the intervention effect on ultrasound measures. Echo intensity is a quantitative assessment of muscle quality. Elevated echo intensity may indicate fluid infiltration, adipose tissue, and reduced muscle quality.

RESULTS

154 participants were included (mean age: 58 ± 15 years, 34% female). Rectus femoris cross-sectional area declined in the ICU (-4 mm2/day [95% confidence interval {CI}: -9 to 1]) and declined further in the ward (-9 mm2/day [95% CI: -14 to -3]) with a mean difference between ICU and ward of -5 mm2/day ([95% CI: -2, to 11]; p = 0.1396). There was a nonsignificant difference in ΔEI between in-ICU and the post-ICU ward of 1.2 ([95% CI: -0.1 to 2.6]; p = 0.0755), a statistically significant difference in ΔEISD between in-ICU and in the post-ICU ward of 1.0 ([95% CI, 0.5 to 1.5]; p = 0.0003), and no difference in rate of change in rectus femoris cross-sectional area between groups in intensive care (p = 0.411) or at hospital discharge (p = 0.1309).

CONCLUSIONS

Muscle wasting occurs in critical illness throughout the hospital admission. The average rate of loss in muscle cross-sectional area does not slow after ICU discharge, even with active rehabilitation.

Physical Rehabilitation and Mobilization in Patients Receiving Extracorporeal Life Support: A Systematic Review

OBJECTIVES

We planned to synthesize evidence examining the potential efficacy and safety of performing physical rehabilitation and/or mobilization (PR&M) in adult patients receiving extracorporeal life support (ECLS).

DATA SOURCES

We included any study that compared PR&M to no PR&M or among different PR&M strategies in adult patients receiving any ECLS for any indication and any cannulation. We searched seven electronic databases with no language limitations.

STUDY SELECTION AND DATA EXTRACTION

Two reviewers, independently and in duplicate, screened all citations for eligibility. We used the Cochrane Risk of Bias 2 and Cochrane Risk Of Bias In Non-randomized Studies of Interventions tools to assess individual study risk of bias. Although we had planned for meta-analysis, this was not possible due to insufficient data, so we used narrative and tabular data summaries for presenting results. We assessed the overall certainty of the evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation framework.

DATA SYNTHESIS

We included 17 studies that enrolled 996 patients. Most studies examined venovenous extracorporeal membrane oxygenation (ECMO) and/or venoarterial ECMO as a bridge to recovery in the ICU. We found an uncertain effect of high-intensity/active PR&M on mortality, duration of mechanical ventilation, ICU length of stay, hospital length of stay, or quality of life compared with low-intensity/passive PR&M in patients receiving ECLS (very low certainty due to very serious imprecision). There was similarly an uncertain effect on safety events including clinically important bleeding, spontaneous intracerebral hemorrhage, limb ischemia, accidental decannulation, or ECLS circuit dysfunction (very low certainty due to very serious risk of bias and imprecision).

CONCLUSIONS

Based on the currently available summary of evidence, there is an uncertain effect of high-intensity/active PR&M on patient important outcomes or safety in patients receiving ECLS. Despite indirect data from other populations suggesting potential benefit of high-intensity PR&M in the ICU; further high-quality randomized trials evaluating the benefits and risks of physical therapy and/or mobilization in this population are needed.

Early Mobilization Using a Mobile Patient Lift in the ICU: A Randomized Controlled Trial

OBJECTIVES

To ascertain whether a mobile patient lift facilitates early mobilization in ventilated ICU patients.

DESIGN

A single-center, open-label, randomized controlled trial.

SETTING

An academic ICU in Tokyo.

PATIENTS

Eighty patients were admitted to ICU and expected ventilation for at least 48 hours.

INTERVENTIONS

In the intervention group, in addition to the rehabilitation protocol received by the control group, patients were assisted in sitting, standing, transfers, and walking using the mobile patient lift.

MEASUREMENTS AND MAIN RESULTS

The intervention group predominantly stood faster than the control group (1.0 vs. 3.0 d, p < 0.01). The Intervention group also had significantly higher Functional Status Score-ICU scores at ICU discharge. However, the Medical Research Council score and Barthel index at discharge, length of ICU stay, and number of ventilator-free days did not differ between the two groups.

CONCLUSIONS

The use of mobile patient lifts facilitates the earlier standing of patients on ventilators. This may contribute to patients improved physical function in the ICU.

TRIAL REGISTRATION

The study protocol was registered with the University Hospital Medical Information Network (UMIN) under the registration number UMIN000044965. Registered July 30, 2021.

Association between changes in disease severity and physical function after surviving a critical illness: A multicentre retrospective observational study

BACKGROUND

Whilst disease severity can significantly impact functional outcomes, the ability to predict the scale of this impact has not been consistent.

AIM

We aimed to investigate whether changes in disease severity within the first 48 h of ICU admission are more strongly associated with physical dysfunction than a single-time assessment of disease severity at ICU admission.

METHODS

A multicentre retrospective study in seven tertiary ICUs in Japan, including all consecutive adult ICU patients (>48 h ICU stay) between September 2019 and February 2020. The primary outcome was physical function defined as the Barthel Index, which is an ordinal scale (0-100: larger indicates better function) to measure physical independence and performance. The association between Barthel Index score at hospital discharge and the Sequential Organ Failure Assessment (SOFA) scores, measured at ICU admission, the highest recorded score within 48 h of ICU admission, and the level of change between these two timepoints were investigated in multivariable analysis.

RESULTS

A total of 199 patients were included. Median SOFA score at ICU admission and the highest recorded score within the first 48 h were 6 (interquartile range: 5-10) and 8 (interquartile range: 6-11), respectively. A quarter of patients had a Barthel Index score of 60 or less at hospital discharge. The highest SOFA score within 48 h of ICU admission and the level of change in SOFA scores between ICU admission and the highest recorded score within 48 h were significantly associated with lower Barthel Index scores at hospital discharge. No significant association was identified with regard to Barthel Index scores and SOFA score at ICU admission. An increase in SOFA score of 1 or more within the first 48 h of ICU admission was the threshold to predict a Barthel Index score of 60 or less at hospital discharge. Larger changes in SOFA scores over the first 48 h of ICU admission were also significantly associated with smaller changes in Barthel Index scores from ICU discharge to hospital discharge.

CONCLUSIONS

The level of change in SOFA score between ICU admission and the highest recorded score within the first 48 h of ICU stay can more accurately predict the presence of physical dysfunction at hospital discharge than a single-time assessment of disease severity at ICU admission. The larger worsening in SOFA potentially indicates lower recovery after a critical illness.

Early Mobility Index and Patient Outcomes: A Retrospective Study in Multiple Intensive Care Units

BACKGROUND

Early mobility interventions in intensive care units (ICUs) are safe and improve outcomes in subsets of critically ill adults. However, implementation varies, and the optimal mobility dose remains unclear.

OBJECTIVE

To test for associations between daily dose of out-of-bed mobility and patient outcomes in different ICUs.

METHODS

In this retrospective cohort study of electronic records from 7 adult ICUs in an academic quarternary hospital, multivariable linear regression was used to examine the effects of out-of-bed events per mobility-eligible day on mechanical ventilation duration and length of ICU and hospital stays.

RESULTS

In total, 8609 adults hospitalized in ICUs from 2015 through 2018 were included. Patients were mobilized out of bed on 46.5% of ICU days and were eligible for mobility interventions on a median (IQR) of 2.0 (1-3) of 2.7 (2-9) ICU days. Median (IQR) out-of-bed events per mobility-eligible day were 0.5 (0-1.2) among all patients. For every unit increase in out-of-bed events per mobility-eligible day before extubation, mechanical ventilation duration decreased by 10% (adjusted coefficient [95% CI], -0.10 [-0.18 to -0.01]). Daily mobility increased ICU stays by 4% (adjusted coefficient [95% CI], 0.04 [0.03-0.06]) and decreased hospital stays by 5% (adjusted coefficient [95% CI], -0.05 [-0.07 to -0.03]). Effect sizes differed among ICUs.

CONCLUSIONS

More daily out-of-bed mobility for ICU patients was associated with shorter mechanical ventilation duration and hospital stays, suggesting a dose-response relationship between daily mobility and patient outcomes. However, relationships differed across ICU subpopulations.

Recovery Trajectories in Children Requiring 3 or More Days of Invasive Ventilation

OBJECTIVES

To characterize health-related quality of life (HRQL) and functional recovery trajectories and risk factors for prolonged impairments among critically ill children receiving greater than or equal to 3 days of invasive ventilation.

DESIGN

Prospective cohort study.

SETTING

Quaternary children's hospital PICU.

PATIENTS

Children without a preexisting tracheostomy who received greater than or equal to 3 days of invasive ventilation, survived hospitalization, and completed greater than or equal to 1 postdischarge data collection.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We evaluated 144 children measuring HRQL using proxy-report Pediatric Quality of Life Inventory and functional status using the Functional Status Scale (FSS) reflecting preillness baseline, PICU and hospital discharge, and 1, 3, 6, and 12 months after hospital discharge. They had a median age of 5.3 years (interquartile range, 1.1-13.0 yr), 58 (40%) were female, 45 (31%) had a complex chronic condition, and 110 (76%) had normal preillness FSS scores. Respiratory failure etiologies included lung disease ( n = 49; 34%), neurologic failure ( n = 23; 16%), and septic shock ( n = 22; 15%). At 1-month postdischarge, 68 of 122 (56%) reported worsened HRQL and 35 (29%) had a new functional impairment compared with preillness baseline. This improved at 3 months to 54 (46%) and 24 (20%), respectively, and remained stable through the remaining 9 months of follow-up. We used interaction forests to evaluate relative variable importance including pairwise interactions and found that therapy consultation within 3 days of intubation was associated with better HRQL recovery in older patients and those with better preillness physical HRQL. During the postdischarge year, 76 patients (53%) had an emergency department visit or hospitalization, and 62 (43%) newly received physical, occupational, or speech therapy.

CONCLUSIONS

Impairments in HRQL and functional status as well as health resource use were common among children with acute respiratory failure. Early therapy consultation was a modifiable characteristic associated with shorter duration of worsened HRQL in older patients.

Association of active mobilisation variables with adverse events and mortality in patients requiring mechanical ventilation in the intensive care unit: a systematic review and meta-analysis

BACKGROUND

Mobilisation during critical illness is now included in multiple clinical practice guidelines. However, a large, randomised trial and systematic review have recently identified an increased probability of adverse events and mortality in patients who received early active mobilisation in the intensive care unit (ICU). We aimed to determine the effects of mobilisation compared with usual care on adverse events and mortality in an acute ICU setting. In subgroup analyses, we specifically aimed to investigate possible sources of harm, including the timing and duration of mobilisation achieved, ventilation status, and admission diagnosis.

METHODS

In this systematic review with frequentist and Bayesian analyses, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, SCOPUS, Web of Science, and PEDro electronic databases, as well as clinical trial registries (ICTRP and ClinicalTrials.gov), from inception to March 16, 2023, without language restrictions. Eligible studies were randomised controlled trials that examined active mobilisation compared with either no mobilisation or mobilisation commencing later, or at a lower frequency or intensity, in adults who were critically ill during or after a period of mechanical ventilation in an acute ICU setting. Two authors independently screened reports, extracted data, and assessed the risk of bias using the Cochrane risk-of-bias tool (version 1). The primary outcome was the number of adverse events that occurred during the implementation of mobilisation, with the effect of mobilisation on mortality being the secondary outcome. Risk ratios (RRs) with 95% CIs were calculated in R (version 4.0.3) using random-effects modelling, with Bayesian analysis completed to calculate the probability of treatment harm (ie, RR >1). Subgroup analyses were completed to investigate the association of various factors of mobilisation on adverse events and mortality: duration of mobilisation (longer [≥20 min per day] vs shorter [<20 min per day]), timing of commencement (early [≤72 h from ICU admission] vs late [>72 h from ICU admission]), ventilation status at commencement (all patients mechanically ventilated vs all patients extubated), and ICU admission diagnosis (surgical vs medical). This study was registered with PROSPERO, CRD42022369272.

FINDINGS

After title and abstract screening of 14 440 studies and review of 466 full texts, 67 trials with 7004 participants met inclusion criteria, with 59 trials contributing to the meta-analysis. Of the 67 included studies, 15 (22%) did not mention adverse events and 13 (19%) reported no adverse events occurring across the trial period. Overall, we found no effect of mobilisation compared with usual care on the occurrence of adverse events (RR 1·09 [95% CI 0·69-1·74], p=0·71; I2 91%; 32 731 events, 20 studies; very low certainty), with a 2·96% occurrence rate (693 events in 23 395 intervention sessions; 25 studies). Mobilisation did not have any effect on mortality (RR 0·98 [95% CI 0·87-1·12], p=0·81; I2 0%; n=6218, 58 studies; moderate certainty). Subgroup analysis was hindered by the large amount of data that could not be allocated and analysed, making the results hypothesis generating only.

INTERPRETATION

Implementation of mobilisation in the ICU was associated with a less than 3% chance of an adverse event occurring and was not found to increase adverse events or mortality overall, providing reassurance for clinicians about the safety of performing this intervention. Subgroup analyses did not clearly identify any specific variable of mobilisation implementation that increased harm.

FUNDING

None.

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

BACKGROUND

Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.

METHODS

A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.

RESULTS

Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions.

CONCLUSIONS

The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

Effects of robotic-assisted early mobilization versus conventional mobilization in intensive care unit patients: prospective interventional cohort study with retrospective control group analysis

BACKGROUND

Approximately one in three survivors of critical illness suffers from intensive-care-unit-acquired weakness, which increases mortality and impairs quality of life. By counteracting immobilization, a known risk factor, active mobilization may mitigate its negative effects on patients. In this single-center trial, the effect of robotic-assisted early mobilization in the intensive care unit (ICU) on patients' outcomes was investigated.

METHODS

We enrolled 16 adults scheduled for lung transplantation to receive 20 min of robotic-assisted mobilization and verticalization twice daily during their first week in the ICU (intervention group: IG). A control group (CG) of 13 conventionally mobilized patients after lung transplantation was recruited retrospectively. Outcome measures included the duration of mechanical ventilation, length of ICU stay, muscle parameters evaluated by ultrasound, and quality of life after three months.

RESULTS

During the first week in the ICU, the intervention group received a median of 6 (interquartile range 3-8) robotic-assisted sessions of early mobilization and verticalization. There were no statistically significant differences in the duration of mechanical ventilation (IG: median 126 vs. CG: 78 h), length of ICU stay, muscle parameters evaluated by ultrasound, and quality of life after three months between the IG and CG.

CONCLUSION

In this study, robotic-assisted mobilization was successfully implemented in the ICU setting. No significant differences in patients' outcomes were observed between conventional and robotic-assisted mobilization. However, randomized and larger studies are necessary to validate the adequacy of robotic mobilization in other cohorts.

TRIAL REGISTRATION

This single-center interventional trial was registered in clinicaltrials.gov as NCT05071248 on 27/08/2021.

Physical and Cognitive Impairment in Acute Respiratory Failure

Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.

Anticipating ICU discharge and long-term follow-up

PURPOSE OF REVIEW

This review aims to summarize recent literature findings on long-term outcomes following critical illness and to highlight potential strategies for preventing and managing health deterioration in survivors of critical care.

RECENT FINDINGS

A substantial number of critical care survivors experience new or exacerbated impairments in their physical, cognitive or mental health, commonly named as postintensive care syndrome (PICS). Furthermore, those who survive critical illness often face an elevated risk of adverse outcomes in the months following their hospital stay, including infections, cardiovascular events, rehospitalizations and increased mortality. These findings underscore the need for effective prevention and management of long-term health deterioration in the critical care setting. While robust evidence from well designed randomized clinical trials is limited, potential interventions encompass sedation limitation, early mobilization, delirium prevention and family presence during intensive care unit (ICU) stay, as well as multicomponent transition programs (from ICU to ward, and from hospital to home) and specialized posthospital discharge follow-up.

SUMMARY

In this review, we offer a concise overview of recent insights into the long-term outcomes of critical care survivors and advancements in the prevention and management of health deterioration after critical illness.

Rehabilitation for adult patients undergoing extracorporeal membrane oxygenation

BACKGROUND AND PURPOSE

Current information on the latest rehabilitative practices is limited, with previous reviews only covering data up to October 2021, and some considering only patients on awake ECMO or with COVID-19. This review aims to present a concise overview of the latest findings on rehabilitation and highlight emerging trends for patients undergoing ECMO support.

METHODS

This integrative review was conducted by searching the National Library of Medicine - PubMed database. Two different search strings "extracorporeal membrane oxygenation" AND "rehabilitation" and "extracorporeal membrane oxygenation" AND "physiotherapy" were used to search the published literature. Articles that did not describe rehabilitation techniques, editorials, conference proceedings, letters to editor, reviews and research protocols were excluded. Studies conducted on pediatric populations were also excluded. The search process was completed in December 2023.

RESULTS

Thirteen articles were included in the final analysis. Eight hundred and thirty-nine patients aged between 27 and 63 years were included; 428 were men (51%). In 31% of the included studies, patients had COVID-19; nevertheless, rehabilitative activities did not differ from non-COVID-19 patients. In most studies, rehabilitation commenced within the first 48-96 h and consisted of progressive exercise and out-of-bed activities such as sitting, standing and walking.

CONCLUSION

Current practice focuses on rehabilitative protocols that incorporate exercise routines with progressive intensity, greater emphasis on out-of-bed activities, and a multidisciplinary approach to patient mobilization.

Critical illness-associated limb and diaphragmatic weakness

PURPOSE OF REVIEW

In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW).

RECENT FINDINGS

In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW.

SUMMARY

This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.

Mobilisation during mechanical ventilation: A qualitative study exploring the practice of conscious patients, nurses and physiotherapists in intensive care unit

AIM

To explore the practice of mobilisation of conscious and mechanically ventilated patients and the interaction between patients, nurses and physiotherapists.

BACKGROUND

Long-term consequences of critical illness can be reduced by mobilisation starting in Intensive Care Units, but implementation in clinical practice is presently sparse.

DESIGN

A qualitative study with a phenomenological-hermeneutic approach.

METHODS

Participant observations in three Intensive Care Units involved twelve conscious mechanically ventilated patients, thirty-one nurses and four physiotherapists. Additionally seven semi-structured patient interviews, respectively at the ward and after discharge and two focus group interviews with healthcare professionals were conducted. The data analysis was inspired by Ricoeur's interpretation theory. The study adhered to the COREQ checklist.

FINDINGS

Healthcare professionals performed a balance of support and guidance to promote mobilisation practice. The complexity of ICU mobilisation required a flexible mobility plan. Furthermore, interaction with feedback and humour was found to be 'a leverage' for patient's motivation to partake in mobilisation. The practice of mobilisation found patients striving to cope and healthcare professionals promoting a 'balanced standing by' and negotiating the flexible mobility plan to support mobilisation.

CONCLUSION

The study revealed a need to clarify interprofessional communication to align expectations towards mobilisation of conscious and mechanically ventilated patients.

RELEVANCE TO CLINICAL PRACTICE

The study demonstrated the important role of healthcare professionals to perform a stepwise and 'balanced standing by' in adequately supporting and challenging the mobilisation of mechanically ventilated patients. Furthermore, a synergy can arise when nurses and physiotherapists use supplementary feedback and humour, and cooperate based on a flexible situation-specific mobility plan in intensive care.

Effects of structured protocolized physical therapy on the duration of mechanical ventilation in patients with prolonged weaning

PURPOSE

20% of patients with mechanical ventilation (MV) have a prolonged, complex weaning process, often experiencing a condition of ICU-acquired weakness (ICUAW), with a severe decrease in muscle function and restricted long-term prognosis. We aimed to analyze a protocolized, systematic approach of physiotherapy in prolonged weaning patients and hypothesized that the duration of weaning from MV would be shortened.

METHODS

ICU patients with prolonged weaning were included before (group 1) and after (group 2) introduction of a quality control measure of a structured and protocolized physiotherapy program. Primary endpoint was the tested dynamometric handgrip strength and the Surgical Intensive Care Unit Optimal Mobilization Score (SOMS). Secondary endpoints were weaning success rate, ventilator-free days, hospital mortality, the prevalence of ICUAW, infections and delirium.

RESULTS

106 patients were included. Both the SOMS and the handgrip test were significantly improved after introducing the program. Despite no differences in weaning success rates at discharge, the total length of MV was significantly shorter in group 2, which also had lower prevalence of infection and higher probability of survival.

CONCLUSIONS

Protocolized, systematic physiotherapy resulted in an improvement of the clinical outcome in patients with prolonged weaning. Results were objectifiable with the SOMS and the handgrip test.

Deep Machine Learning Might Aid in Combating Intensive Care Unit-Acquired Weakness

Secondary muscle weakness in critically ill patients like intensive care unit (ICU)-associated weakness is frequently noted in patients with prolonged mechanical ventilation and ICU stay. It can be a result of critical illness, myopathy, or neuropathy. Although ICU-acquired weakness (ICU-AW) has been known for a while, there is still no effective treatment for it. Therefore, prevention of ICU-AW becomes the utmost priority, and knowing the risk factors is crucial. Nevertheless, the pathophysiology and the attributing causes are complex for ICU-AW, and proper delineation and formulation of a preventive strategy from such vast, multifaceted data are challenging. Artificial intelligence has recently helped healthcare professionals understand and analyze such intricate data through deep machine learning. Hence, using such a strategy also helps in knowing the risk factors and their weight as contributors, applying them in formulating a preventive path for ICU-AW worth trials.

The impact of critical illness on patients' physical function and recovery: An explanatory mixed-methods analysis

OBJECTIVES

To determine how the perception of physical function 6-months following critical illness compares to objectively measured function, and to identify key concerns for patients during recovery from critical illness.

RESEARCH METHODOLOGY AND DESIGN

A nested convergent parallel mixed methods study assessed physical function during a home visit 6-months following critical illness, with semi-structured interviews conducted at the same time.

SETTING

Participants were recruited from two hospitals at one healthcare network in Melbourne, Australia from September 2017 to October 2018 with follow-up data completed in April 2019.

MAIN OUTCOME MEASURES

Physical function was assessed through four objective outcomes: the functional independence measure, six-minute walk test, functional reach test, and grip strength. Semi structured interviews focused on participants function, memories of the intensive care and hospital stay, assistance required on discharge, ongoing limitations, and the recovery process.

FINDINGS

Although many participants (12/20, 60%) stated they had recovered from their critical illness, 14 (70%) had function below expected population norms. Decreased function on returning home was commonly reported, although eleven participants were described as independent and safe for discharge from hospital-based staff. The importance of family and social networks to facilitate discharge was highlighted, however participants often described wanting more support and issues accessing services. The effect of critical illness on the financial well-being of the family network was confirmed, with difficulties accessing financial support identified.

CONCLUSION

Survivors of critical illness perceived a better functional state than measured, but many report new limitations 6-months after critical illness. Family and friends play a crucial role in facilitating transition home and providing financial support.

IMPLICATIONS FOR CLINICAL PRACTICE

Implementation of specific discharge liaison personnel to provide education, support and assist the transition from hospital-based care to home, particularly in those without stable social supports, may improve the recovery process for survivors of critical illness.

Early Mobilization and Rehabilitation of Critically-Ill Patients

Post-intensive care unit (ICU) syndrome may occur after ICU treatment and includes ICU-acquired weakness (ICU-AW), cognitive decline, and mental problems. ICU-AW is muscle weakness in patients treated in the ICU and is affected by the period of mechanical ventilation. Diaphragmatic weakness may also occur because of respiratory muscle unloading using mechanical ventilators. ICU-AW is an independent predictor of mortality and is associated with longer duration of mechanical ventilation and hospital stay. Diaphragm weakness is also associated with poor outcomes. Therefore, pulmonary rehabilitation with early mobilization and respiratory muscle training is necessary in the ICU after appropriate patient screening and evaluation and can improve ICU-related muscle weakness and functional deterioration.

Mobilizing Progress: A Comprehensive Review of the Efficacy of Early Mobilization Therapy in the Intensive Care Unit

Early mobilization therapy has emerged as a crucial aspect of intensive care unit (ICU) management, aiming to counteract the detrimental effects of prolonged immobility in critically ill patients. This comprehensive review examines the efficacy of early mobilization therapy in the ICU setting, synthesizing evidence from clinical trials, meta-analyses, and guidelines. Key findings indicate that early mobilization is associated with numerous benefits, including reduced muscle weakness, a shorter duration of mechanical ventilation, decreased ICU and hospital length of stay, and improved functional outcomes. However, safety concerns, staffing limitations, and patient-specific considerations pose significant barriers to widespread adoption. Despite these challenges, early mobilization is important for improving ICU patient outcomes. This review underscores the critical need for continued research and implementation efforts to optimize early mobilization protocols, address remaining challenges, and expand access to this beneficial therapy. By working collaboratively to overcome barriers and prioritize early mobilization, healthcare providers can enhance the quality of care and improve outcomes for critically ill patients in the ICU.

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.

Should New Data on Rehabilitation Interventions in Critically Ill Patients Change Clinical Practice? Updated Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

We published a meta-analysis in March 2020 to assess the impact of rehabilitation in the ICU on clinical outcomes. Since then, 15 new randomized controlled trials (RCTs) have been published; we updated the meta-analysis to show how the recent studies have tipped the scale.

DESIGN

Systematic review and meta-analysis.

SETTING

An update of secondary data analysis of RCTs published between January 1998 and July 2023 performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

PATIENTS

Critically ill adults.

INTERVENTIONS

Cycling exercises or neuromuscular electrical stimulation (NMES) or protocolized physical rehabilitation (PPR) or functional electrical stimulation-assisted cycle ergometry (FESCE) compared with standard of care.

MEASUREMENTS AND MAIN RESULTS

Days on a mechanical ventilator, length of stay in ICU and at the hospital, and mortality. We found 15 RCTs (one on cycling, eight on NMES alone, four on PPR, and two on FESCE) into which 2116 patients were randomized. The updated meta-analysis encompasses a total of 5664 patients. The exercise interventions did not influence mortality (odds ratio, 1.00 [0.87-1.14]; n = 53 RCTs) but reduced the duration of mechanical ventilation (mean difference, -1.76 d [-2.8 to -0.8 d]; n = 46) and length of stay in ICU (-1.16 d [-2.3 to 0.0 d]; n = 45). The effects on the length of mechanical ventilation and ICU stay were only significant for the PPR subgroup by a median of -1.7 days (95% CI, -3.2 to -0.2 d) and -1.9 days (95% CI, -3.5 to -0.2 d), respectively. Notably, newly published trials provided consistent results and reduced the overall heterogeneity of these results.

CONCLUSIONS

None of the rehabilitation intervention strategies being studied influence mortality. Both mechanical ventilation and ICU stay were shortened by PPR, this strengthens the earlier findings as all new RCTs yielded very consistent results. However, no early rehabilitation interventions in passive patients seem to have clinical benefits. Regarding long-term functional outcomes, the results remain inconclusive.

Persistent inflammation, immunosuppression, and catabolism syndrome (PICS): a review of definitions, potential therapies, and research priorities

Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) is a clinical endotype of chronic critical illness. PICS consists of a self-perpetuating cycle of ongoing organ dysfunction, inflammation, and catabolism resulting in sarcopenia, immunosuppression leading to recurrent infections, metabolic derangements, and changes in bone marrow function. There is heterogeneity regarding the definition of PICS. Currently, there are no licensed treatments specifically for PICS. However, findings can be extrapolated from studies in other conditions with similar features to repurpose drugs, and in animal models. Drugs that can restore immune homeostasis by stimulating lymphocyte production could have potential efficacy. Another treatment could be modifying myeloid-derived suppressor cell (MDSC) activation after day 14 when they are immunosuppressive. Drugs such as interleukin (IL)-1 and IL-6 receptor antagonists might reduce persistent inflammation, although they need to be given at specific time points to avoid adverse effects. Antioxidants could treat the oxidative stress caused by mitochondrial dysfunction in PICS. Possible anti-catabolic agents include testosterone, oxandrolone, IGF-1 (insulin-like growth factor-1), bortezomib, and MURF1 (muscle RING-finger protein-1) inhibitors. Nutritional support strategies that could slow PICS progression include ketogenic feeding and probiotics. The field would benefit from a consensus definition of PICS using biologically based cut-off values. Future research should focus on expanding knowledge on underlying pathophysiological mechanisms of PICS to identify and validate other potential endotypes of chronic critical illness and subsequent treatable traits. There is unlikely to be a universal treatment for PICS, and a multimodal, timely, and personalised therapeutic strategy will be needed to improve outcomes for this growing cohort of patients.

ERS International Congress 2023: highlights from the Respiratory Intensive Care Assembly

Early career members of Assembly 2 (Respiratory Intensive Care) attended the 2023 European Respiratory Society International Congress in Milan, Italy. The conference covered acute and chronic respiratory failure. Sessions of interest to our assembly members and to those interested in respiratory critical care are summarised in this article and include the latest updates in respiratory intensive care, in particular acute respiratory distress syndrome and mechanical ventilation.

Rehabilitation in the intensive care unit: How amount of physical and occupational therapy affects patients' function and hospital length of stay

BACKGROUND

Patients in the intensive care unit (ICU) often experience extended periods of immobility. Following hospital discharge, many face impaired mobility and never return to their baseline function. Although the benefits of physical and occupational rehabilitation are well established in non-ICU patients, a paucity of work describes effective practices to alleviate ICU-related declines in mobility.

OBJECTIVE

To assess how rehabilitation with physical and occupational therapy (PT-OT) during ICU stays affects patients' mobility, self-care, and length of hospital stay.

DESIGN

Retrospective cohort study.

SETTING

Inpatient ICU.

PARTICIPANTS

A total of 6628 adult patients who received physical rehabilitation across multiple sites (Arizona, Florida, Minnesota, and Wisconsin) of a single institution between January 2018 and December 2021.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Descriptive statistics, linear regression models, and gradient boosting machine methods were used to determine the relationship between the amount of PT-OT received and outcomes of hospital length of stay (LOS), Activity Measure for Post-Acute Care Daily Activity and Basic Mobility scores.

RESULTS

The 6628 patients who met inclusion criteria received an average (median) of 23 (range: 1-89) minutes of PT-OT per day. Regression analyses showed each additional 10 minutes of PT-OT per day was associated with a 1.0% (95% confidence interval [CI]: 0.41-1.66, p < .001) higher final Basic Mobility score, a 1.8% (95% CI: 1.30%-2.34%, p < .001) higher final Daily Activity score, and a 1.2-day (95% CI: -1.28 to -1.09, p < .001) lower hospital LOS. One-dimensional partial dependence plots revealed an exponential decrease in predicted LOS as minutes of PT-OT received increased.

CONCLUSION

Higher rehabilitation minutes provided to patients in the ICU may reduce the LOS and improve patients' functional outcomes at discharge. The benefits of rehabilitation increased with increasing amounts of time of therapy received.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Current Concepts in Early Mobilization of Critically Ill Patients Within the Context of Neurologic Pathology

Neurocritical patients (NCPs) in the intensive care unit (ICU) rapidly progress to respiratory and peripheral muscle dysfunctions, which significantly impact morbidity and death. Early mobilization in NCPs to decrease the incidence of ICU-acquired weakness has been showing rapid growth, although pertinent literature is still scarce. With this review, we summarize and discuss current concepts in early mobilization of critically ill patients within the context of neurologic pathology in NCPs. A narrative synthesis of literature was undertaken trying to answer the following questions: How do the respiratory and musculoskeletal systems in NCPs behave? Which metabolic biomarkers influence physiological responses in NCPs? Which considerations should be taken when prescribing exercises in neurocritically ill patients? The present review detected safety, feasibility, and beneficial response for early mobilization in NCPs, given successes in other critically ill populations and many smaller intervention trials in neurocritical care. However, precautions should be taken to elect the patient for early care, as well as monitoring signs that indicate interruption for intervention, as worse outcomes were associated with very early mobilization in acute stroke trials.

Physical and respiratory therapy in the critically ill patient with obesity: a narrative review

Obesity has become increasingly prevalent in the intensive care unit, presenting a significant challenge for healthcare systems and professionals, including rehabilitation teams. Caring for critically ill patients with obesity involves addressing complex issues. Despite the well-established and safe practice of early mobilization during critical illness, in rehabilitation matters, the diverse clinical disturbances and scenarios within the obese patient population necessitate a comprehensive understanding. This includes recognizing the importance of metabolic support, both non-invasive and invasive ventilatory support, and their weaning processes as essential prerequisites. Physiotherapists, working collaboratively with a multidisciplinary team, play a crucial role in ensuring proper assessment and functional rehabilitation in the critical care setting. This review aims to provide critical insights into the key management and rehabilitation principles for obese patients in the intensive care unit.

Early mobilisation within 72 hours after admission of critically ill patients in the intensive care unit: A systematic review with network meta-analysis

INTRODUCTION

Early mobilisation within 72 hours of intensive care unit admission counteracts complications caused by critical illness. The effect of different interventions on intensive care unit length of stay and other outcomes is unclear. We aimed to investigate the effectiveness of various early mobilisation interventions within 72 hours of admission to the intensive care unit on length of stay and other outcomes.

METHODS

A systematic review and (network) meta-analysis examining the effect of early mobilisation on length of stay in the intensive care unit and other outcomes, conducting searches in four databases. Randomised controlled trials were included from inception to 10/08/2022. Early mobilisation was defined as interventions that initiates and/or supports passive/active range-of-motion exercises within 72 hours of admission. In multi-arm studies, interventions used in other studies were declared as early intervention and were included in subgroup meta-analysis. Risk-of-bias was assessed using RoB2.

RESULTS

Of 29,680 studies screened, 18 studies with 1923 patients (three high, eleven some, four low risk-of-bias) and seven discriminable interventions of early mobilisation met inclusion criteria. Early mobilisation alone (WMD 0.78 days, 95 %CI [-1.38;-0.18], 11 studies, n = 1124) and early mobilisation with early nutrition (WMD -1.19 days, 95 %CI [-2.34;-0.03], 1 study, n = 100) were able to significantly shorten length of stay. Early mobilisation alone could also substantially shorten hospital length of stay (WMD -1.05 days, 95 %CI [-1.74;-0.36], 8 studies, n = 977). This effect in hospital length of stay was furthermore seen in the early intervention group compared with standard care (WMD -1.71 days, 95 %CI [-2.99;-0.43], 14 studies, n = 1587). Also, functionality and quality of life could significantly be improved by an early start of mobilisation.

CONCLUSION

In the network meta-analysis, early mobilisation alone and early mobilisation with early nutrition demonstrated a significant effect on intensive care length of stay. Early mobilisation could also reduce hospital length of stay and positively influence functionality and quality of life.

IMPLICATION FOR CLINICAL PRACTICE

Early mobilisation and early mobilisation with early nutrition seemed to be beneficial compared to other interventions like cycling on intensive care length of stay.

Extracorporeal Life Support Organization Registry International Report 2022: 100,000 Survivors

The Extracorporeal Life Support Organization (ELSO) maintains the world's largest extracorporeal membrane oxygenation (ECMO) registry by volume, center participation, and international scope. This 2022 ELSO Registry Report describes the program characteristics of ECMO centers, processes of ECMO care, and reported outcomes. Neonates (0-28 days), children (29 days-17 years), and adults (≥18 years) supported with ECMO from 2009 through 2022 and reported to the ELSO Registry were included. This report describes adjunctive therapies, support modes, treatments, complications, and survival outcomes. Data are presented descriptively as counts and percent or median and interquartile range (IQR) by year, group, or level. Missing values were excluded before calculating descriptive statistics. Complications are reported per 1,000 ECMO hours. From 2009 to 2022, 154,568 ECMO runs were entered into the ELSO Registry. Seven hundred and eighty centers submitted data during this time (557 in 2022). Since 2009, the median annual number of adult ECMO runs per center per year increased from 4 to 15, whereas for pediatric and neonatal runs, the rate decreased from 12 to 7. Over 50% of patients were transferred to the reporting ECMO center; 20% of these patients were transported with ECMO. The use of prone positioning before respiratory ECMO increased from 15% (2019) to 44% (2021) for adults during the coronavirus disease-2019 (COVID-19) pandemic. Survival to hospital discharge was greatest at 68.5% for neonatal respiratory support and lowest at 29.5% for ECPR delivered to adults. By 2022, the Registry had enrolled its 200,000th ECMO patient and 100,000th patient discharged alive. Since its inception, the ELSO Registry has helped centers measure and compare outcomes across its member centers and strategies of care. Continued growth and development of the Registry will aim to bolster its utility to patients and centers.

Does the level of mobility on ICU discharge impact post-ICU outcomes? A retrospective analysis

PURPOSE

Mobilisation is a common intervention in Intensive Care (ICU). However, few studies have explored the relationship between mobility levels and outcomes. This study assessed the association of the level of mobility on ICU discharge with discharge destination from the hospital and hospital length of stay.

MATERIALS AND METHODS

A retrospective analysis of data from 522 patients admitted to a single UK general ICU who were ventilated for ≥5 days was performed. The level of mobility was assessed using the Manchester Mobility Score (MMS). Multivariable regression analysed demographic and clinical variables for the independence of association with discharge destination and hospital length of stay.

RESULTS

MMS ≥5 on ICU discharge was independently associated with discharge destination and hospital LOS (p < 0.001). Patients achieving MMS ≥5 on ICU discharge were more likely to be discharged home (OR 3.86 95% CI 2.1 to 6.9, p < 0.001), and had an 11.8 day shorter hospital LOS (95% CI -17.6 to -6.1, p < 0.001).

CONCLUSIONS

The ability to step transfer to a chair (MMS ≥5) before ICU discharge was independently associated with discharge to usual residence and hospital LOS, irrespective of preadmission morbidity. Increasing the level of patient mobility at ICU discharge should be a key focus of rehabilitation interventions.

Early mobilization of patients with subarachnoid haemorrhage: a national survey of french intensive care units

OBJECTIVE

To describe French intensive care unit practices regarding the mobilization of patients with subarachnoid haemorrhage.

DESIGN

A cross-sectional nationwide survey study.

SUBJECTS

Intensivists and physiotherapists or nurses from French intensive care units managing patients with subarachnoid haemorrhage.

METHODS

An online questionnaire survey was distributed through the Neurocritical Care and Neuro Anesthesiology French Speaking Society.

RESULTS

The response rate was 89%. Of these, 90% did not have a mobilization protocol for patients with subarachnoid haemorrhage. Sixteen percent of departments prohibited all forms of motor physiotherapy for a predefined period. Nineteen percent systematically prohibited out-of-bed mobilization, regardless of the severity of subarachnoid haemorrhage and in the absence of any complication, for a predefined period. The main factors that would delay or interrupt physiotherapy prescription were intracranial hypertension (79%), currently treated vasospasm (59%), and suspicion of vasospasm (44%). Ninety-one percent of the centres identified at least one complication that could be associated with standing upright. These mainly included decreased cerebral perfusion (71%), dislodged external ventricular or lumbar derivations (68%), and haemodynamic instability (65%).

CONCLUSION

Mobilization of patients with subarachnoid haemorrhage is heterogeneous among French neuro-intensive care units and several barriers preclude improvement of mobilization practices. Interventional studies assessing mobilization practices, as well as education and training of staff, are crucial to ensure the proper management of patients with subarachnoid haemorrhage and to improve outcomes.

Unraveling the causes of sarcopenia: Roles of neuromuscular junction impairment and mitochondrial dysfunction

Sarcopenia is a systemic skeletal muscle disease characterized by a decline in skeletal muscle mass and function. Originally defined as an age-associated condition, sarcopenia presently also encompasses muscular atrophy due to various pathological factors, such as intensive care unit-acquired weakness, inactivity, and malnutrition. The exact pathogenesis of sarcopenia is still unknown; herein, we review the pathological roles of the neuromuscular junction and mitochondria in this condition. Sarcopenia is caused by complex and interdependent pathophysiological mechanisms, including aging, neuromuscular junction impairment, mitochondrial dysfunction, insulin resistance, lipotoxicity, endocrine factors, oxidative stress, and inflammation. Among these, neuromuscular junction instability and mitochondrial dysfunction are particularly significant. Dysfunction in neuromuscular junction can lead to muscle weakness or paralysis. Mitochondria, which are plentiful in neurons and muscle fibers, play an important role in neuromuscular junction transmission. Therefore, impairments in both mitochondria and neuromuscular junction may be one of the key pathophysiological mechanisms leading to sarcopenia. Moreover, this article explores the structural and functional alterations in the neuromuscular junction and mitochondria in sarcopenia, suggesting that a deeper understanding of these changes could provide valuable insights for the prevention or treatment of sarcopenia.

A group concept mapping and ethnographic study of intensive care rehabilitation culture

BACKGROUND

Early physical activity and physical rehabilitation are advocated in the critical care unit for patients recovering from critical illness. Despite this, there are still many factors associated with implementation of early physical rehabilitation into routine critical care and practice. One such factor that has been consistently identified is unit culture, yet there is little understanding of how or why the culture of a critical care unit impacts on implementation of early rehabilitation.

AIM

To develop a detailed understanding of the cultural barriers and enablers to the promotion and implementation of physical activity and early mobilization in National Health Service (NHS) critical care units in the United Kingdom (UK).

STUDY DESIGN

A mixed-methods, two-phase study incorporating online group concept mapping (GCM) and ethnography. GCM will be conducted to provide a multistakeholder co-authored conceptual framework of rehabilitation culture. Ethnographic observations and interviews will be conducted of culture and behaviours in relation to the implementation and promotion of early physical activity and rehabilitation in two NHS critical care units in the North East of England.

RESULTS

The results of the Group Concept Mapping and ethnographic observations and interviews will be triangulated to develop a contextual framework of rehabilitation culture in critical care.

RELEVANCE TO CLINICAL PRACTICE

This study will provide a detailed understanding of barriers and facilitators in relation to providing a positive rehabilitation culture in the critical care unit.

Intensive care unit-acquired weakness: Recent insights

Intensive care unit-acquired weakness (ICU-AW) is a common complication in critically ill patients and is associated with a variety of adverse outcomes. These include the need for prolonged mechanical ventilation and ICU stay; higher ICU, in-hospital, and 1-year mortality; and increased in-hospital costs. ICU-AW is associated with multiple risk factors including age, underlying disease, severity of illness, organ failure, sepsis, immobilization, receipt of mechanical ventilation, and other factors related to critical care. The pathological mechanism of ICU-AW remains unclear and may be considerably varied. This review aimed to evaluate recent insights into ICU-AW from several aspects including risk factors, pathophysiology, diagnosis, and treatment strategies; this provides new perspectives for future research.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.