Wake up, get up and get out

Shorter length of stay in the ICU and hospital, more independent at discharge – early mobilisation in the ICU improves outcomes and is also safe, and feasible.

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Muscle loss begins within the first 72 hours of bed rest

It has been known for many years that (still often) prescribed bed rest has little benefit for many diseases. On the contrary, it can be harmful and prolong the patients’ recovery time. Muscle loss begins within the first 72 hours of bed rest, reducing muscle power by 16% in ten days in healthy older adults. In combination with a critical illness, such as sepsis, this muscle loss is even higher. For example, after seven days of mechanical ventilation, 24 to 77% of patients already suffer from generalised muscle weakness, called ICUAW (Intensive Care Unit Acquired Weakness).

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Diagnostic criteria of ICUAW

ICUAW is a diagnosis of exclusion; except for the critical illness itself, no determinable cause can be found. It describes clinically diagnosed, new-onset, diffuse muscle weakness, with affected ICU patients by definition scoring less than 48 on the Medical Research Council sum score.

1. Generalised muscle weakness following the onset of critical illness
2. Diffuse weakness (involvement of distal and proximal muscles), symmetrical, flaccid and generally without cranial nerve involvement
3. MRC sum score <48, or respective mean value of the tested muscles <4 at at least two different times (>24 hours apart)
4. Dependence on mechanical ventilation
5. Exclusion of possible other diagnoses

For diagnosis, at least points 1, 2, 3 or 4 + 5 must be fulfilled. The Medical Research Council (MRC) sum score evaluates muscle power in three muscle groups of all four extremities. Each muscle group is assigned a score between 0 and 5 (M0 = no muscle activity, M5 = normal power), which corresponds to a maximum score of 60.

Overcome the vicious circle

To overcome the vicious circle between immobility, ventilation and sedation and to reduce post- intensive care syndrome, the evidence-based, interdisciplinary ABCDE concept is recommended (Awakening, Breathing, Coordination, Delirium monitoring, Exercise/Early Mobilisation).

Protocols are used to check and adjust the need for ventilation and sedation on a daily basis. Daily screening is intended to prevent an acute state of confusion (delirium) and immobility is reduced by early mobilisation, daily activities and movement exercises.

Early mobilization is safe and feasible

Potential barriers to early mobilisation include the fear of inadvertently removing a vital catheter or causing a deterioration in vital signs in an already unstable patient. However, there is increasingly positive evidence of the safety of early mobilisation.

Early mobilisation pyramid with successive interventions building on one another

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The basis of early mobilisation in the intensive care unit is movement therapy. Nowadays, various new aids enrich the early rehabilitation of critically ill patients. A motor-assisted bed bicycle ergometer enables moderate endurance training even for sedated or ICUAW patients. An electric standing table facilitates the mobilisation of a critically ill patient to a standing position and video games can promote motivation, as well as endurance and balance for critically ill patients.

Physiotherapists play an essential role in this often survival-focused setting, as they can evaluate and treat functional impairments while still in the ICU, in accordance with the available evidence and the motto: “Wake up, get up and get out of the ICU as soon as possible!”.

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Early mobilisation improves outcome

Not only is the early mobilisation of critically ill patients in intensive care units safe, but it has also been proven to improve the outcome. An early mobilisation concept in a medical intensive care unit therefore leads to a significantly shorter stay in the intensive care unit and hospital. Additional bed-bicycle training in the intensive care unit improved walking distance, measured with the 6-minute walking test, as well as subjective physical functioning in the 36-item short form survey (SF-36) upon discharge from hospital.

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Early Mobilisation Matters

This article is part of THERA-Trainer's "Early Mobilisation Matters" campaign. Information and resources on #ICU early mobilisation can be found here: https://lp.thera-trainer.com/early-mobilization

Author of the full article: Sabrina Grossenbacher-Eggmann, PT MSc, works as a therapy expert at the Ins- titute for Physiotherapy at Inselspital, the University Hospital of Bern, Switzerland. She is the specialist in charge of the interdisciplinary category I intensive care unit (entire spectrum of intensive care medicine, with the exception of severe burns) and the initiator of a study on training in the intensive care unit.

?? Read the full article here.