1) Early mobilization of critically ill patients in the ICU can reduce ICU-acquired weakness, improve functional recovery during hospitalization, and reduce hospital length of stay. However, many ICUs are still conservative in mobilizing mechanically ventilated patients. 2) A study found that combining daily interruption of sedation with physical and occupational therapy led to more patients returning to independent function at discharge and fewer ICU delirium days compared to interruption of sedation alone. 3) While early mobilization studies have shown it to be safe, some physicians still report patient safety as a barrier; interdisciplinary communication and leadership may help reduce avoidable barriers to early mobilization.

1. DR.SHIKHA PANWAR
HOD,
CRITICAL CARE MEDICINE,
SARVODAYA
HOSPITAL ,FARIDABAD
MOBILIZATION
OF VENTILATED PATIENT IN ICU

2. MORTALITY
MORBIDITY
 Mortality from critical illnesshasdeclined, the numberof
ICUsurvivorsisgrowing but persistent morbidity ison
rise.
Why ???
 >50% patients experience neuromuscularweakness
that may be severeand prolonged.

4. CONCLUSION:Survivors of the acute respiratory distress syndrome have
persistent functional disability one year after discharge from the intensive care
unit. Most patients have extrapulmonary conditions, with muscle wasting and
weakness being most prominent

5.  Intensive care unit-acquired weakness
(ICUAW) is a clinical diagnosis of weakness
that is classified into three component
conditions:
1. Critical illness polyneuropathy(CIP),
2. Critical illness myopathy (CIM),
3. Critical illness neuromyopathy(CINM).
 CIP and CIM frequently co-exist (CINM) and when
present separately cannot be reliably distinguished
clinically.
 Approximately 46% of the patients with severe sepsis,
multiple organ failure, or prolonged mechanical
ventilation will develop ICUAW.
ICU ACCQUIRED
WEEKNESS

7. ICU acquired weakness
 Independent risk factor are increased duration of
mechanical ventilation, increased weaning duration,
increased duration of ICU and hospital lengths of
stay, and increased hospital mortality.
 Approximately 45% of those patients diagnosed with
ICUAW will die within their hospital admission with a
further 20% dying within the first year after ICU
discharge.
 Complete functional recovery however only occurs
in∼68% of the patients, with persistent severe

8. WHAT IS EARLY
MOBILISATION?
 EMistheintensification and early application (within the
first 2 to 5 daysof critical illness)of thephysicaltherapy
that isadministered to critically ill patients.
 EMmayalsoincludeadditional specificmobilization-
enhancinginterventionssuch asactive mobilization of
patients requiring mechanicalventilation and theuseof novel
techniquessuch ascycleergometry and transcutaneous
electrical musclestimulation(TEMS).

9. Benefits of early mobilization
ReducedICU-acquiredweakness,
 Improvedfunctionalrecoverywithin hospital,
 Improvedwalking distanceat hospitaldischarge.
 Reducedhospitallengthof stay.

10. Theyidentified survivorsof acuterespiratory failure who
then
required subsequent hospitalization.
Acohortof acuterespiratory failure survivors,who
participated inanearly ICU-mobility program, was
assessedto determineif variables from theindex
hospitalization predict hospital readmissionor death,
within12 monthsof hospital discharge.
Methods—Hospitaldatabase and responsesto letters mailed
to 280 ARFsurvivors.Univariate predictor variables shown
to be associatedwith hospital readmissionor death (p<0.1)

11. Results—Of the 280 survivors,132 (47%) had at least one
readmission or died within the first year, 126 (45%) were not
readmitted, and 22 (8%) were lost to follow-up.
Tracheostomy[OR 4.02(CI 1.72, 9.40)], female gender
[OR1.94 (CI1.13, 3.32)], a higher Charlson Comorbidity
Index assessedupon index hospitalization discharge [OR
1.15 (CI1.01, 1.31)], and lack of early ICUmobility
therapy [OR1.77 CI(1.04, 3.01)] predicted readmission or
death in the first year post-Index hospitalization.
Conclusions—Tracheostomy,female gender, higher Charlson
Comorbidity Index and lack of early ICUmobility were associated

12. Assessedthe efficacy of combining daily interruption of sedation
with physical and occupational therapy onfunctional outcomesin
patients receiving mechanical ventilation in intensive care.
<72 hoursof mechanicalventilation
Functionally independent at baseline
Early exercise and mobilisation during periods of daily interruption
of sedation (intervention; n=49) or to daily interruption of sedation
with therapy asordered by the primary care team (control; n=55).
The primary endpoint-the numberof patients returning to
independent functional statusat hospital discharge-was defined as
the ability to perform six activities of daily living and the ability to
walk independently.

13.  More patients returned to
independent function at time of
discharge (59% vs30%, p=0.02)
 ReducedICUdelirium days in
intervention group(median 2 days
vs4, p=0.03)
No difference in ICUor hospital LOS
More ventilator-free days (23.5 days,
during the 28-day follow-up period
than did controls
.

14. Are we doing enough mobility???
None of these patients
were mechanically
ventilated
Berneyetal., CritCare Resusc

15. Nydahlet al., CritCareMed 2013
Are we doing enough mobility???

16. P
A
TIENTSAFETY
TEAMCONFLICTS
ORGANISATIONAL
Barriers ….

17. Organizational factors
Lack offunding
Timeconstraints
Lackof equipmentandresources
Lack ofstaffing
Busycaseloads

18. Lackof planning andcoordination
Lackof communication
Riskand extra work for mobility providers
Inexperienced staff
Lackof leadership
Poorworkculture
Team factors

19. Early
mobilization
barriers
Patient
factors
Patient
refusal
Pain
Low
GCS
Delirious
patient
Sedated
patient
Unstable
patient

20. 42% of physicians in Washington survey report
“patient safety” as a barrier to mobilization
Jolley et al., BMCAnesthesiology, 2014
42% of physiciansin Washingtonsurveyreport “patient safety” asa barrier to
mobilization
Providers still worry about harm

21. Study No. of
patient
s
Inclusions Activity Primary outcomenkey
findings
Baileyand
colleague
s
,2007
Prospect
ive,
observati
onal,
103
patients
Acuterespiratory
failure
with MV >4 days
Sit on edgeofbed, sit
onchair and
ambulate
Early activity events:1,449
(53% ambulate).
Adverseevents:<1% (fall
to the knees with
noinjury, SBP>200 or<90
mmHgand
desaturation <80%)
Thomsenand
colleagues
104 Acuterespiratory
failure
with MV >4 days
Early activity protocol;
PROM,SOEOB,
transfer to chair, walk
Ambulation (increased
probability P<0.0001)
Morris and
colleagues
Prosspe
cti ve,
Cohort
165
Medical patients
with
acute respiratory
failure
requiring MV
4 levelsof activity:
PROM,active resisted
exerciseand sitting,
SOEOB,and transfer to
chair
Overall, noserious adverse
medical
consequences

22. Study No. of
patients
Activity Primary outcomes and
key findings
BurtinC2009 Prospective
RCT
90 enrolled;
67 completed)
(36 control;
31 treatment
group)
Bothgroupsreceived:
Upper extremity and lower
extremity PTand functional
training.
Treatmentgroup:Additional
cycling sessionx 20 minutes
total, daily
425 total exercise
sessions
desaturation <90% or
HTn
◊ Achillestendon rupture
(x1)
◊ cardiorespiratory
instability
(x2)
Schweickert WD.
200920
Prospective
RCT
(N=104; all
patients
completed
study)
7 days/ week
Treatmentgroup: Progressive
UE/ L
EPT
.;Trunk control/
balance
activities
Functionaltraining including
ADL’s
498 PT/ OT sessions:
1%desaturation<80%
1 radial artery removed
PT/OTdiscontinued
during 19 sessions(4%)
for perceived patient
ventilator
asynchrony

23. L E T S M O V E

29. MoveT
oImprove
Early Mobilization: ICU
Mobility Protocol:Non-ICU
Sedation Delirium
Multidisciplinary
Approach
Ventilator Weaning
Sedation Vacation
(RASS,SAS)
(ICDSC,CAM-ICU)
CAM-ICU= ConfusionAssessmentMethod for theICU;ICDSC=
IntensiveCare DeliriumScreening Checklist; RASS= Richmond
Agitation-Sedation Scale; SAS= Sedation-Agitation Scale
Early mobility

32. Training Upright Positions and Weight
Bearing with the Right Equipment

33. Slings
Cycleergometer
Tilt table

34. Mobility beds andchairs

36. Thecurrent evidence suggeststhat early mobilization is
safe and feasible and mayimprove functional recovery at
hospital discharge; however ICUsare still very conservative
in mobilizing mechanically ventilated patients, with some
potentially avoidable barriers.
Interdisciplinary communication and a clinical lead or
champion may reduce barriers to earlymobilization
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