Early Mobilization in the Critical Care Unit: A Review of Adult and Pediatric Literature Saoirse Cameron, Ian Ball, Gediminas Cepinskas, Karen Choong, Timothy J. Doherty, Christopher G. Ellis, Claudio Martin, Tina S. Mele, Michael Sharpe, Kevin Shoemaker, Douglas D. Fraser MD, PhD PII: DOI: Reference:
S0883-9441(15)00141-0 doi: 10.1016/j.jcrc.2015.03.032 YJCRC 51794
To appear in:
Journal of Critical Care
Please cite this article as: Cameron Saoirse, Ball Ian, Cepinskas Gediminas, Choong Karen, Doherty Timothy J., Ellis Christopher G., Martin Claudio, Mele Tina S., Sharpe Michael, Shoemaker Kevin, Fraser Douglas D., Early Mobilization in the Critical Care Unit: A Review of Adult and Pediatric Literature, Journal of Critical Care (2015), doi: 10.1016/j.jcrc.2015.03.032
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Cameron et al.
Journal: Journal of Critical Care
JCRC-D-14-00856 R1
Editor-in-Chief: Dr. Philip D. Lumb
T
Article: Review
RI P
EARLY MOBILIZATION IN THE CRITICAL CARE UNIT: A REVIEW OF ADULT AND PEDIATRIC LITERATURE
SC
Saoirse Cameron,1, 2 Ian Ball,2,3 Gediminas Cepinskas,2, 4 Karen Choong,1, 5
NU
Timothy J. Doherty,1, 2, 6 Christopher G. Ellis,2, 3, 4 Claudio Martin,2, 3 Tina S. Mele,2, 7 Michael Sharpe,2, 8 Kevin Shoemaker,1, 2, 9 Douglas D. Fraser1, 2, 10
MA
1. Functional Recovery in Critically ill Children: The “Wee-Cover” Longitudinal Cohort Study 2. Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study
ED
3. Medicine, Western University, London, ON, Canada
PT
4. Medical Biophysics, Western University, London, ON, Canada 5. Pediatrics, McMaster University, Hamilton, ON, Canada
CE
6. Physical Medicine and Rehabilitation, Western University, London, ON, Canada
AC
7. Surgery, Western University, London, ON, Canada 8. Anesthesia and Perioperative Medicine, Western University, London, ON, Canada 9. Kinesiology, Western University, London, ON, Canada 10. Pediatrics, Western University, London, ON, Canada
Correspondence:
Douglas D. Fraser, MD, PhD C2-C82, Children’s Hospital, London Health Science Centre 800 Commissioners Road East, London, ON, Canada, N6A 5W9 Email: [email protected]; Tel: 51968558052; Fax: 5196858766
1
ACCEPTED MANUSCRIPT Cameron et al.
2
ABSTRACT Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated
RI P
T
into daily clinical practice. Early passive, active and combined progressive mobilizations can be safely initiated in intensive care units (ICU). Adult patients receiving early mobilization have
SC
fewer ventilator dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data is limited, but recent studies also suggest that early mobilization is achievable
NU
without increasing patient risk. In this review, we provide a current and comprehensive appraisal
MA
of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care
ED
provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient
AC
CE
specific ICU populations.
PT
outcomes will require further studies on mobilization timing and intensity, particularly within
Key Words: intensive care unit, mobility, exercise, intervention, adult, pediatric
ACCEPTED MANUSCRIPT Cameron et al.
3
Mobilization has been defined as “physical activity sufficient to elicit acute physiological effects that enhance ventilation, central and peripheral perfusion, circulation, muscle metabolism and
T
alertness and are countermeasures for venous stasis and deep vein thrombosis” [1]. A current
RI P
definition of early mobilization refers to the application of physical activity within the first two to five days of critical illness or injury [2]; however, it is important to note that some of the
SC
research published on ‘early’ mobilization is beyond this window. For example, one study
NU
defined early intervention as an activity beginning prior to ICU discharge (6.6 ± 5.5 days for sitting on bed) [3]. Delaying mobilization until the acute phase of illness has subsided may not
MA
only significantly decrease benefit, but also result in less optimal patient outcomes. The goals of this review are to (1) emphasize the practicality and effectiveness of early mobilization, and its
ED
impact on recovery from a critical illness in both adults and children, and (2) highlight the many
PT
perceived barriers to early mobilization, such as cost, health care professional views and
CE
sustainability.
AC
1. Consequences of immobility in the critically ill Typical critical care interventions that promote immobilization include the administration of analgesics and sedatives to facilitate mechanical ventilation and reduce pain, agitation, and/or anxiety [4, 5]. Immobility is associated with ICU delirium, impaired exercise capacity, ICUacquired weakness (ICU-AW) and poorer functional outcomes and quality of life [6, 7]. ICUAW is categorized by both axonal nerve degeneration and myosin loss, and is believed to be the multifactorial result of systemic inflammation, medications, electrolyte disturbances and immobility [8, 9].
ACCEPTED MANUSCRIPT Cameron et al.
4
Immobility associated muscle loss begins within 48 hours of critical illness onset or injury [10] and is greatest during the first two to three weeks of an ICU stay[11]. Up to a 40% loss in muscle
T
strength can occur within the first week of immobilization with a daily rate of strength loss
RI P
between 1.0-5.5% [6, 12]. A 10.3-13.9% decrease in cross sectional measurements of the rectus femoris muscle has been observed within the first ICU week and is positively correlated with
SC
elevated C-reactive protein levels and organ dysfunction severity [13, 14]. Diaphragmatic
NU
atrophy due to ventilator induced diaphragm inactivity during positive pressure ventilation is positively correlated with the severity of limb weakness (maximal inspiratory pressure rho =
MA
0.35, p=0.001; maximal expiratory pressure rho = 0.49, p
S0883-9441(15)00141-0 doi: 10.1016/j.jcrc.2015.03.032 YJCRC 51794
To appear in:
Journal of Critical Care
Please cite this article as: Cameron Saoirse, Ball Ian, Cepinskas Gediminas, Choong Karen, Doherty Timothy J., Ellis Christopher G., Martin Claudio, Mele Tina S., Sharpe Michael, Shoemaker Kevin, Fraser Douglas D., Early Mobilization in the Critical Care Unit: A Review of Adult and Pediatric Literature, Journal of Critical Care (2015), doi: 10.1016/j.jcrc.2015.03.032
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Cameron et al.
Journal: Journal of Critical Care
JCRC-D-14-00856 R1
Editor-in-Chief: Dr. Philip D. Lumb
T
Article: Review
RI P
EARLY MOBILIZATION IN THE CRITICAL CARE UNIT: A REVIEW OF ADULT AND PEDIATRIC LITERATURE
SC
Saoirse Cameron,1, 2 Ian Ball,2,3 Gediminas Cepinskas,2, 4 Karen Choong,1, 5
NU
Timothy J. Doherty,1, 2, 6 Christopher G. Ellis,2, 3, 4 Claudio Martin,2, 3 Tina S. Mele,2, 7 Michael Sharpe,2, 8 Kevin Shoemaker,1, 2, 9 Douglas D. Fraser1, 2, 10
MA
1. Functional Recovery in Critically ill Children: The “Wee-Cover” Longitudinal Cohort Study 2. Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study
ED
3. Medicine, Western University, London, ON, Canada
PT
4. Medical Biophysics, Western University, London, ON, Canada 5. Pediatrics, McMaster University, Hamilton, ON, Canada
CE
6. Physical Medicine and Rehabilitation, Western University, London, ON, Canada
AC
7. Surgery, Western University, London, ON, Canada 8. Anesthesia and Perioperative Medicine, Western University, London, ON, Canada 9. Kinesiology, Western University, London, ON, Canada 10. Pediatrics, Western University, London, ON, Canada
Correspondence:
Douglas D. Fraser, MD, PhD C2-C82, Children’s Hospital, London Health Science Centre 800 Commissioners Road East, London, ON, Canada, N6A 5W9 Email: [email protected]; Tel: 51968558052; Fax: 5196858766
1
ACCEPTED MANUSCRIPT Cameron et al.
2
ABSTRACT Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated
RI P
T
into daily clinical practice. Early passive, active and combined progressive mobilizations can be safely initiated in intensive care units (ICU). Adult patients receiving early mobilization have
SC
fewer ventilator dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data is limited, but recent studies also suggest that early mobilization is achievable
NU
without increasing patient risk. In this review, we provide a current and comprehensive appraisal
MA
of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care
ED
provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient
AC
CE
specific ICU populations.
PT
outcomes will require further studies on mobilization timing and intensity, particularly within
Key Words: intensive care unit, mobility, exercise, intervention, adult, pediatric
ACCEPTED MANUSCRIPT Cameron et al.
3
Mobilization has been defined as “physical activity sufficient to elicit acute physiological effects that enhance ventilation, central and peripheral perfusion, circulation, muscle metabolism and
T
alertness and are countermeasures for venous stasis and deep vein thrombosis” [1]. A current
RI P
definition of early mobilization refers to the application of physical activity within the first two to five days of critical illness or injury [2]; however, it is important to note that some of the
SC
research published on ‘early’ mobilization is beyond this window. For example, one study
NU
defined early intervention as an activity beginning prior to ICU discharge (6.6 ± 5.5 days for sitting on bed) [3]. Delaying mobilization until the acute phase of illness has subsided may not
MA
only significantly decrease benefit, but also result in less optimal patient outcomes. The goals of this review are to (1) emphasize the practicality and effectiveness of early mobilization, and its
ED
impact on recovery from a critical illness in both adults and children, and (2) highlight the many
PT
perceived barriers to early mobilization, such as cost, health care professional views and
CE
sustainability.
AC
1. Consequences of immobility in the critically ill Typical critical care interventions that promote immobilization include the administration of analgesics and sedatives to facilitate mechanical ventilation and reduce pain, agitation, and/or anxiety [4, 5]. Immobility is associated with ICU delirium, impaired exercise capacity, ICUacquired weakness (ICU-AW) and poorer functional outcomes and quality of life [6, 7]. ICUAW is categorized by both axonal nerve degeneration and myosin loss, and is believed to be the multifactorial result of systemic inflammation, medications, electrolyte disturbances and immobility [8, 9].
ACCEPTED MANUSCRIPT Cameron et al.
4
Immobility associated muscle loss begins within 48 hours of critical illness onset or injury [10] and is greatest during the first two to three weeks of an ICU stay[11]. Up to a 40% loss in muscle
T
strength can occur within the first week of immobilization with a daily rate of strength loss
RI P
between 1.0-5.5% [6, 12]. A 10.3-13.9% decrease in cross sectional measurements of the rectus femoris muscle has been observed within the first ICU week and is positively correlated with
SC
elevated C-reactive protein levels and organ dysfunction severity [13, 14]. Diaphragmatic
NU
atrophy due to ventilator induced diaphragm inactivity during positive pressure ventilation is positively correlated with the severity of limb weakness (maximal inspiratory pressure rho =
MA
0.35, p=0.001; maximal expiratory pressure rho = 0.49, p
