Early Mobility Among ICU Patients May Reduce Later Disability

Key Point

Encouraging ICU patients to get out of bed as soon as possible may help them avoid deconditioning and inflammatory dysfunction.

CHICAGO—Getting ICU patients who are conscious and cooperative up and moving is a better, safer strategy than keeping them in bed, said researchers reporting at the American College of Chest Physicians’ 2007 Annual International Scientific Assembly. They suggested that activities such as carefully assisted walking not only prevent deconditioning but also may reduce inflammation.

This session, jointly sponsored by the American Association of Critical-Care Nurses and the American College of Chest Physicians, was chaired by Peter E. Morris, MD, of Wake Forest University in Winston-Salem. The presenters were Chris Winkelman, PhD, RN, CCRN, of the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, and Ramona Hopkins, RN, PhD, from the Department of Critical Care Medicine, Pulmonary Critical Care Division of LDS Hospital in Salt Lake City, and Chair of the Department of Psychology at Brigham Young University in Provo, Utah.

Dr. Morris noted that there is a gap in research regarding mobility and loss of function inside the ICU setting. Although regular mobility may help prevent deep venous thromboses, pulmonary emboli, and skin ulcers—as well as muscle atrophy and joint contractures—data are scarce, he said.

“A new ICU paradigm links deconditioning and inflammation to impairments in physical function. Keeping patients immobile certainly will cause muscle atrophy, but also most of our ICU patients have a systemic inflammation that could possibly produce a second injury. These two together can cause the functional complications,” Dr. Morris commented.

REDUCED INFLAMMATION

Dr. Winkelman reported on three pilot studies of mobility in ICU patients.

“My theory is that there is an inflammatory dysfunction that can be reset when patients have some mobility therapy,” she said. “Low intensity physical activity has a positive influence on cytokine dysfunction, promoting a recovery phase.”

The first study included 20 patients with prolonged critical illness who had received mechanical ventilation for an average of 10 days. The researchers were surprised to find that even hemodynamically stable ICU patients engaged in very little activity—mainly turning (usually for hygiene purposes), with occasional chair-sitting. Whenever patients did engage in activity, the researchers immediately performed serum blood tests.

Following activity, patients experienced a reduction in proinflammatory cytokines such as interleukin 6 (IL-6) and an increase in anti-inflammatory cytokines such as IL-10.

BARRIERS TO MOBILITY

Dr. Winkelman’s group conducted a second study to determine why so many ICU patients with a length of stay beyond 10 days and who were currently hemodynamically stable received continuous bed rest. Bed rest was not associated with age, illness severity on admission, or whether patients had do-not-resuscitate codes.

“The most common reason was a decreased level of consciousness, reported by their nurses. The other reason for not getting them out of bed was the patients’ weakness. So they stay in bed, which makes them weaker,” Dr. Winkelman said.

In addition, mechanical ventilation was perceived as a barrier to patient activity by unit staff, who were worried about unintentional extubation.
The third study involved 17 patients in a trial of early mobilization.

“Our goal was to get people out of bed by day 3,” Dr. Winkelman said. All patients had COPD, and all were mobilized on day 2 or 3 of ICU or step-down admission, regardless of whether or not they were intubated.

By the second day of mobility therapy, most patients were able to tolerate about 20 minutes of activity. The researchers combined active and passive range of motion and, for patients who initially were reluctant to get out of bed, helped them progress from sitting at the edge of bed, to standing, to non–weight-bearing transfer to a chair.

“After consulting with the intensivist MD and nurse, we were able to motivate a lot of patients to participate in activity by looking them in the eye and saying firmly, ‘You’re getting out of bed today,’” Dr. Winkelman said.

Activity produced some change in patients’ IL-6 or IL-10 levels and did not promote a proinflammatory profile. Dr. Winkelman noted that her team encountered resistance from residents who thought that the ICU patients were too sick for mobility and needed bed rest, despite the absence of hemodynamic instability, heart-rate or rhythm variability, or alterations in oxygen saturation with routine care.

“Some of the staff were amazed to see our patients in the hallway walking. They would say, ‘You are walking, Mrs. Smith?’ and Mrs. Smith would be nodding and smiling,” Dr. Winkelman said.

TESTING A NEW PROTOCOL

The research team Dr. Hopkins worked with also documented benefits of early mobility. She noted that at present, 50% of ICU patients are unable to return to work after hospitalization due to fatigue, weakness, cognitive problems, and poor functional status.

Her group conducted a two-year outcome study of 104 patients discharged from ICUs. “At hospital discharge, ICU patients typically have extremely low physical function. Even two years after ICU discharge, there is considerable improvement in physical function but not up to the level of healthy persons, particularly in what patients are able to do in their daily lives,” Dr. Hopkins said.

The study tested an intervention activity protocol provided by a team of nurses, respiratory therapists, and physical therapists in the respiratory ICU. Eligible patients were able to follow commands and cooperate, had no catecholamine drips or orthostasis, and had reasonable oxygen saturation. If patients were intubated, oxygen flow was increased before activity. Oxygen saturation was monitored during activity. The researchers also carefully monitored adverse effects, such as falling to knees, oxygen desaturation, extubation, or changes in blood pressure. The treatment goal was for the patients to be able to walk farther than 100 feet by the time they were discharged from the ICU.

“Being able to walk 100 feet will usually get you to your bathroom and to your kitchen,” Dr. Hopkins said. “In our study, the majority of our patients—almost 70%—were ambulating 100 feet or more, with the average distance ambulated close to 200 feet.”

Fewer than 1% of the activity sessions resulted in an adverse event. Adverse events included five falls to the knees without injury (because the team was in place to support the patient and enable a controlled fall), four episodes of systolic blood pressure dropping to below 90 mm Hg, three episodes of oxygen saturation decreasing to below 80%, one increase in systolic blood pressure, and one small bowel feeding tube removal. “We had no extubations and no complications that required additional therapy, cost, or longer length of hospital stay,” Dr. Hopkins said.

In conclusion, Dr. Morris described a project at his institution—the ICU Early Mobility Project—which produced similar results, with 1.4 days less ICU time and three days shorter overall hospital stay among patients who received the intervention compared with patients who did not.           

—Janis Kelly

Suggested Reading
Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin. 2007;23(1):81-96.
Morris PE. Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin. 2007;23(1):
1-20.
Winkelman C. Inactivity and inflammation in the critically ill patient. Crit Care Clin. 2007;23(1):21-34.
Winkelman C, Higgins PA, Chen YJ, Levine AD. Cytokines in chronically critically ill patients after activity and rest. Biol Res Nurs. 2007;8(4):261-271.

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