LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.
Dr. Russell R. Miller III
Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.
The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).
Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.
In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.
Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.
Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.
The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.
Dr. Miller said that he had no disclosures relevant to this topic.