Limited Mobility to the Bed Reduces the Chances of Discharge and Increases the Chances of Death in the ICU

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

BACKGROUND

While early mobilization is commonly implemented in intensive care unit treatment guidelines to improve functional outcome, the characterization of the optimal individual dosage (frequency, level or duration) remains unclear. The aim of this study was to demonstrate that artificial intelligence-based clustering of a large ICU cohort can provide individualized mobilization recommendations that have a positive impact on the likelihood of being discharged home.

METHODS

This study is an analysis of a prospective observational database of two interdisciplinary intensive care units in Munich, Germany. Dosage of mobilization is determined by sessions per day, mean duration, early mobilization as well as average and maximum level achieved. A k-means cluster analysis was conducted including collected parameters at ICU admission to generate clinically definable clusters.

RESULTS

Between April 2017 and May 2019, 948 patients were included. Four different clusters were identified, comprising "Young Trauma," "Severely ill & Frail," "Old non-frail" and "Middle-aged" patients. Early mobilization (< 72 h) was the most important factor to be discharged home in "Young Trauma" patients (OR_adj 10.0 [2.8 to 44.0], p < 0.001). In the cluster of "Middle-aged" patients, the likelihood to be discharged home increased with each mobilization level, to a maximum 24-fold increased likelihood for ambulating (OR_adj 24.0 [7.4 to 86.1], p < 0.001). The likelihood increased significantly when standing or ambulating was achieved in the older, non-frail cluster (OR_adj 4.7 [1.2 to 23.2], p = 0.035 and OR_adj 8.1 [1.8 to 45.8], p = 0.010).

CONCLUSIONS

An artificial intelligence-based learning approach was able to divide a heterogeneous critical care cohort into four clusters, which differed significantly in their clinical characteristics and in their mobilization parameters. Depending on the cluster, different mobilization strategies supported the likelihood of being discharged home enabling an individualized and resource-optimized mobilization approach.

TRIAL REGISTRATION

Clinical Trials NCT03666286, retrospectively registered 04 September 2018.

Evaluation of therapy in traumatic elderly falls to return autonomy and functional status

Background

Traumatic falls among the elderly (≥ 65 years old) are the leading cause of injury, morbidity and mortality are increasing with rising medical costs.

Methods

This is a retrospective medical record review of elderly mechanical fall patients (288 patients) admitted to an American College of Surgeons level II trauma center from January 2016 to January 2021. Demographics and comorbidities were determined, and physical/occupational therapy used to predict subsequent fall readmissions.

Results

Out of 288 patients, 243 received therapy with 45 readmissions for subsequent falls. Age (P = .016), body mass index (P = .035), previous falls (P = .003), walker/cane use (P = .039), and dementia (P = .038) were predictive of readmission. Therapy was shown to benefit patients, but deferred therapy sessions were shown to be associated with prolonged hospitalization.

Conclusion

Directed therapy may improve functionality and return autonomy to elderly mechanical fall patients admitted to trauma services.

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Elderly fall patient evaluation after falls can predict need for therapy.

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Directed therapy can benefit and potentially prevent recurrence of falls.

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Deferrals of therapy are associated with prolonged hospital stays.

Therapeutic Potential of Electromyostimulation (EMS) in Critically Ill Patients—A Systematic Review

Ample evidence exists that intensive care unit (ICU) treatment and invasive ventilation induce a transient or permanent decline in muscle mass and function. The functional deficit is often called ICU-acquired weakness with critical illness polyneuropathy (CIP) and/or myopathy (CIM) being the major underlying causes. Histopathological studies in ICU patients indicate loss of myosin filaments, muscle fiber necrosis, atrophy of both muscle fiber types as well as axonal degeneration. Besides medical prevention of risk factors such as sepsis, hyperglycemia and pneumonia, treatment is limited to early passive and active mobilization and one third of CIP/CIM patients discharged from ICU never regain their pre-hospitalization constitution. Electromyostimulation [EMS, also termed neuromuscular electrical stimulation (NMES)] is known to improve strength and function of healthy and already atrophied muscle, and may increase muscle blood flow and induce angiogenesis as well as beneficial systemic vascular adaptations. This systematic review aimed to investigate evidence from randomized controlled trails (RCTs) on the efficacy of EMS to improve the condition of critically ill patients treated on ICU. A systematic search of the literature was conducted using PubMed (Medline), CENTRAL (including Embase and CINAHL), and Google Scholar. Out of 1,917 identified records, 26 articles (1,312 patients) fulfilled the eligibility criteria of investigating at least one functional measure including muscle function, functional independence, or weaning outcomes using a RCT design in critically ill ICU patients. A qualitative approach was used, and results were structured by 1) stimulated muscles/muscle area (quadriceps muscle only; two to four leg muscle groups; legs and arms; chest and abdomen) and 2) treatment duration (≤10 days, >10 days). Stimulation parameters (impulse frequency, pulse width, intensity, duty cycle) were also collected and the net EMS treatment time was calculated. A high grade of heterogeneity between studies was detected with major cofactors being the analyzed patient group and selected outcome variable. The overall efficacy of EMS was inconclusive and neither treatment duration, stimulation site or net EMS treatment time had clear effects on study outcomes. Based on our findings, we provide practical recommendations and suggestions for future studies investigating the therapeutic efficacy of EMS in critically ill patients.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021262287].