Clinical trials of early mobilization of critically ill patients

Clinical trials of early mobilization of critically ill patients
John P. Kress, MD
Intensive care unit-acquired weakness is a common complication of critical illness leading to severe functional impairment in many intensive care unit survivors. Critically ill patients who require mechanical ventilation are routinely immobilized for prolonged time periods. This immobilization is exacerbated byfrequent administration of sedative agents. Recently, several investigators have described the feasibility and potential benefits of mobilizing mechanically ventilated intensive care unit patients. Such an intervention requires a multidisciplinary team approach to patient care, involving nursing, physical therapy, occupational therapy, and respiratory therapy practitioners. Recent studies of earlymobilization of mechanically ventilated intensive care unit patients have noted this intervention to be safe and associated with improved functional outcomes in this extremely ill patient cohort. Such outcomes include high percentages of patients able to ambulate on intensive care unit and hospital discharge and shortened hospital length of stay. With preliminary studies demonstrating remarkablefeasibility and successes, further prospective studies of early mobilization are needed to evaluate this intervention. (Crit Care Med 2009; 37[Suppl.]:S442–S447) KEY WORDS: mechanical ventilation; clinical protocols; physical therapy; occupational therapy; mobilization; ICU-acquired weakness; critical illness myopathy; muscle atrophy; intensive care unit; neuropathy; sedation

ritically illpatients frequently present with an extreme derangement of physiologic homeostasis, leading intensive care unit (ICU) care to focus on recovery from acute organ system failure. Those organ systems whose failure threatens survival (e.g., cardiovascular, pulmonary, renal) accordingly receive greatest attention in the ICU. Patients requiring mechanical ventilation are among the most challenging in thisregard. In the midst of ICU care, with its focus on resuscitation and survival, there is customarily little early attention toward neuromuscular function. However, recent work on outcomes in ICU survivors has recognized that these patients suffer profound and persistent impairments in physical function, with recovery that is typically slow and incomplete (1–5). In 109 patients studied 1 yr afterrecovering from acute respiratory distress syndrome, Herridge and colleagues noted that every patient reported poor function, which was attributed to loss of muscle bulk, proximal

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From the Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL. The author has not disclosed any potential conflicts of interest. For information regarding this article,E-mail: jkress@medicine.bsd.uchicago.edu Copyright © 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3181b6f9c0

muscle weakness, and fatigue (1). Only half of the patients in this cohort were employed 1 yr after recovery, and the reported reasons for continued unemployment included persistent fatigue, weakness, and poor functional status(e.g., footdrop and large joint immobility). De Jonghe and colleagues described a 25% prevalence of ICU-acquired weakness in a cohort of 95 patients receiving mechanical ventilation (6). The study described independent predictors of ICU-acquired weakness, which included duration of mechanical ventilation, days of multiple system organ failure, corticosteroid administration, and female gender. Asclinical recovery from critical illness and respiratory failure describes severe physical deconditioning accompanied by weight loss, profound weakness, and functional impairment (1, 2, 7, 8), a growing body of literature recounts neuropathies and myopathies described categorically as “ICU-acquired weakness” (9). Although the mechanisms are poorly understood (10), preliminary evidence suggests that...