Cover story


Early rehabilitation

Training critically ill patients in intensive care units begins early

 
For faster regeneration in intensive care units, it is essential that critically ill patients are mobilised as soon as possible. The current guideline on “Positioning therapy and early mobilisation for the prophylaxis or therapy of pulmonary dysfunctions” of the German Society of Anaesthesiology and Intensive Care Medicine [1] recommends that patient mobilisation should begin within the first three days after admission to the intensive care unit and should be carried out twice a day for at least 20 minutes using an algorithm.

Text: Tobias Giebler

Why is it essential for therapy to start quickly?

Immobility, the result of a lack of early mobilisation, has plenty of negative effects on the body. For the cardiovascular system, it means that the resting heart rate increases, the vascular system loses the ability to react adequately to changes in position (orthostatic hypotension) and the risk of developing thrombosis also increases. The musculoskeletal system quickly starts to atrophy. In addition to muscle atrophy, the bones also lose stability, the joint cartilage is under-supplied and the capsular ligaments shrink. The consequences are long-term restricted movement and painful changes in the joints. In terms of the lungs, immobility means reduced ventilation, usually in the lowest areas. The consequences can be a blockage of the secretory duct, the formation of atelectasis and dystelectasis, and ultimately the development of pneumonia. The central nervous system also atrophies if it is not required. Psychological stress also occurs; the incidence of depression, fear, anxiety disorders and delirium increases. PTSD (post-traumatic stress disorder) is often a late complication. Immobility also has negative effects on other organ systems such as the metabolism, the endocrine system, the kidneys and the gastrointestinal tract.

Evidence-based effects are reductions in: 

  • Delirium, a neuro-psychiatric syndrome with states of confusion affecting 80% of intubated patients. In addition, one-year mortality per day of delirium increases by 10% [6]
  • ICUAW (Intensive care unit acquired weakness), a neuromuscular organ failure with muscle weakness extending to plegia and a mortality of up to 60% [6]
  • Ventilation time [6]
  • ICU length of stay [5]
  • Mortality [5]

In addition, the long-term outcome and retention of motor skills and functional strength can be improved. This creates the option for patients to return to an independent and autonomous life. [6]

At the cellular level, pro-inflammatory cytokines are inhibited when anti-inflammatory messengers are simultaneously activated (e.g. IL 10). Glucose uptake into muscle cells is also facilitated. [6]

According to Morris [5], a study with 330 patients who were intubated for more than 24 hours compared to standard therapy showed the following effect of protocol-supported early mobilisation during the daily sedation breaks:

Concerns about patient safety are repeatedly raised as arguments against early mobilisation. However, a systematic review with meta-analysis [7] showed that early mobilisation is safe to carry out. In 23,000 mobilisations, there were only 2.6% adverse events such as decreased oxygen saturation, of which only 0.3% resulted in an increase in blood pressure increasing medication.

Early mobilisation guideline

The risk from early mobilisation can therefore be considered negligible, but in any case the opportunities outweigh the risks. So how can it be implemented?The ABCDEF bundle [4] is an evidence-based guide for clinicians with the aim of specifying organisational changes conducive to improved recovery and outcomes for intensive care patients. It explicitly refers to mobilisation. The letters stand for the following:

A    = Assess, prevent, and manage pain
B    = Both spontaneous awakening & breathing trials
C    = Choice of medication management
D    = Delirium
E    = Early mobilisation & exercise
F    = Family engagement and empowerment

The main focus here is early mobilisation. It quickly becomes clear, however, that all other points cannot be excluded. For example, an optimal pain and ventilation situation is essential for mobilisation and often has to be adjusted during the process. Within this broader approach, it also becomes clear that early mobilisation is an interdisciplinary task.

It requires close consultation, a shared will and goal, as well as interdisciplinary evaluation, in order to successfully support the critically ill patient in an optimal way. The patient is also part of the treatment team and should be involved in this process as soon as vigilance allows.

A systematic approach to planning mobilisation is recommended [1]. This is where checklists are used, rather like in the aviation industry. Cancellation criteria are defined at the same time and the current mobilisation stage is determined from the checklist evaluation. 

In terms of practical implementation with the patient, early mobilisation [1] is subdivided into three groups:

  1. Passive mobilisation
  2. Active-assisted mobilisation
  3. Active mobilisation

Determining which subgroup the patient should be assigned to is done through the evaluation process in preparation for mobilisation. Vigilance and the checklist result are critical here. The stage can then be expressed in the ICU Mobility Scale [6]. A practical example: A post-operative cardiac patient who is responsive and with no exclusion criteria for early mobilisation is assigned to active-assisted mobilisation and an ICU Mobility Scale of > 3 (at least sitting over edge of bed).

The Borg Scale, for example, is suitable for controlling exertion and breathing effort [8]. A value of 4 – 7 BS is a proven target range.

Focal points of passive mobilisation

  • Passive movement in functional patterns
  • Promotion of sensory perception with various stimuli and senses (thermal, mechanical, acoustic, vestibular)
  • Respiratory therapy in various positions; secretolysis if present, thoracic mobilisation, improvement of ventilation in poorly ventilated areas
  • Bed bicycle passive

Focal points of active-assisted mobilisation

  • Promoting the beginning of independent activity and using therapeutically
  • Assistive movement – if possible, with meaningful actions, e.g. bringing small sticks with water to the mouth
  • Developing movement transitions, using the patient’s potential
  • Mobilisation in the assisted seat
  • Developing core stability, a prerequisite for all higher starting positions.
  • Verticalisation, initiation of standing
  • Promotion of sensory perception and cognitive training
  • Respiratory therapy

Focal points of active mobilisation

  • Resistive exercises – according to personal preferences (fun as motivation)
  • Practising active movement transitions --> Independence
  • Bed bicycle active
  • Standing and gait training
  • Any form of handling can be used --> Training aspect

Bed Cycling

According to guideline [1], the bed bicycle should be used in all stages of mobilisation, because it combines many positive effects for the patient. Mobility is maintained and promoted, the cardiovascular system is stimulated, oxidative stress can be reduced and the lymphatic system is stimulated. In a study by Burtin [2], standard mobilisation was compared with standard mobilisation and 20 minutes of bed bicycle daily. The 6-minute walk test at discharge showed a clear difference in the patients’ walking ability: 143 m vs. 196 m, so the walking distance could be increased by 37%. This method of early mobilisation can be used as a good supplement, for example for a second training session a day, as the time required for installation is minimal.

The patient in focus

In summary, early mobilisation is a challenging team task that requires a high level of motivation of all involved and aims to enable the patient to return to an independent life. Only when all the disciplines involved evaluate and plan together and have a common goal can this task be optimally solved. This requires a systematic approach, good planning and consistent, attentive implementation. Here, the focus must be on the patient, they must always feel safe, well looked after and involved. The surrounding atmosphere plays a decisive role, especially for patients who are not yet fully oriented. The patient needs clear, short instructions. Since processing is usually slowed down, the time for reaction must be created.

Last but not least, the provision of personnel and technical aids is crucial. If it is possible to perform the most essential tasks, such as medication administration and monitoring with intervention, early mobilisation as an additional task may not be reasonable for intensive care staff. Well planned and cleverly introduced, early mobilisation can also be positively received. The time of mobilisation can be connected, for example, with personal hygiene or the positioning of the critically ill patient. This is an immediate relief of work for the nursing staff.

However, even the most resourceful staff cannot replace missing aids such as bed bicycles, suitable mobilisation chairs and transfer possibilities.

The topic of early mobilisation has developed considerably in recent years, but still offers much more potential. The data situation regarding the positive aspects of early mobilisation is clear, it saves considerable resources in everyday hospital life over the long term and, above all, enables each individual patient to lead an independent life in the long term. In the interests of economic efficiency and patient well-being, it would therefore be welcome if the topic were taken seriously and the technical equipment improved with appropriate aids.
 

At a glance - Summarised

  1. Critically ill patients should be mo­bilised promptly – if possible within the first three days. Bed bicycles can be useful aids and make work easier for therapists.
  2. Early mobilisation, even in intensive care units, has many positive effects – among others, it reduces ventilation time, length of stay in intensive care units and mortality rates. The probability of returning to an independent life increases.
  3. A lack of exercise leads to a higher resting pulse and an increased risk of thrombosis and has negative effects on bone stability and metabolism. Overall, immobility can lead to movement restrictions in the long term.
     

Literature

[1] Bein T, Bischoff M, Brückner U et al. (2015). S2e-Leitlinie: „Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen“, Deutsche Gesell­schaft für Anästhesiologie und Intensivmedizin (DGAI).

[2] Burtin C, Clerckx B, Robbeets C et al. (2009). Early exercise in critically ill patients enhances short-term functional recovery.

[3] Hodgson C, Needham D, Bailey M et al. (2014). ICU Mobility Scale.

[4] Marra A, Ely EW, Pandharipande PP, Patel MB (2018). The ABCDEF Bundle in Critical Care.

[5] Morris PE, Goad A, Thompson C et al. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

[6] Nessizius S, Rottensteiner C, Nydahl P (2017). Frührehabilitation in der Intensivmedizin – Interprofessionelles Management, S. 90-174.

[7] Nydahl P, Sricharoenchai T, Chandra S, Kundt FS, Huang M, Fischill M, Needham DM (2017). Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis.

[8] Schefer M (2008). Wie anstrengend ist das für Sie?

[9] Schweickert WD, Pohlman MC, Pohlman AS et al. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.

Author



Tobias Giebler
graduated as a physiotherapist at the University Hospital of Freiburg in 2013. Due to his several years of working as a paramedic in the emergency services, he already brought knowledge in dealing with ICU patients into his physiotherapeutic training.

He has been working on the topic of early mobilisation in intensive care units at the University Hospital of Tübingen for 6 years.