Early Active Mobilization during Mechanical Ventilation in the ICU

Hodgson, Carol; Bailey, Michael; Bellomo, Rinaldo; Brickell, Kathy; Broadley, Tessa; Buhr, Heidi; Gabbe, Belinda; Gould, Doug W; Harrold, Megan; Higgins, Alisa; Hurford, Sally; Iwashyna, Theodore J.; Neto, Ary Serpa; Nichol, Alistair; Presneill, Jeffrey; Schaller, Stefan J.; Sivasuthan, Janani; Tipping, Claire J; Webb, Steven A R; Young, Paul

doi:10.1056/nejmoa2209083

Cited by 180 publications

(83 citation statements)

References 42 publications

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“…However, in the recently published TEAM trial increasing active early mobilization did not result in significantly reduced hospital length of stay or mortality compared to usual ICU mobilization. In addition, the rate of adverse events was increased in the intervention group [ 6 ]. This raises the question which patients benefit most from early mobilization and how to determine the appropriate type, timing, intensity, coordination and duration of therapy [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

et al. 2023

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Background While early mobilization is commonly implemented in intensive care unit treatment guidelines to improve functional outcome, the characterization of the optimal individual dosage (frequency, level or duration) remains unclear. The aim of this study was to demonstrate that artificial intelligence-based clustering of a large ICU cohort can provide individualized mobilization recommendations that have a positive impact on the likelihood of being discharged home. Methods This study is an analysis of a prospective observational database of two interdisciplinary intensive care units in Munich, Germany. Dosage of mobilization is determined by sessions per day, mean duration, early mobilization as well as average and maximum level achieved. A k-means cluster analysis was conducted including collected parameters at ICU admission to generate clinically definable clusters. Results Between April 2017 and May 2019, 948 patients were included. Four different clusters were identified, comprising “Young Trauma,” “Severely ill & Frail,” “Old non-frail” and “Middle-aged” patients. Early mobilization (< 72 h) was the most important factor to be discharged home in “Young Trauma” patients (ORadj 10.0 [2.8 to 44.0], p < 0.001). In the cluster of “Middle-aged” patients, the likelihood to be discharged home increased with each mobilization level, to a maximum 24-fold increased likelihood for ambulating (ORadj 24.0 [7.4 to 86.1], p < 0.001). The likelihood increased significantly when standing or ambulating was achieved in the older, non-frail cluster (ORadj 4.7 [1.2 to 23.2], p = 0.035 and ORadj 8.1 [1.8 to 45.8], p = 0.010). Conclusions An artificial intelligence-based learning approach was able to divide a heterogeneous critical care cohort into four clusters, which differed significantly in their clinical characteristics and in their mobilization parameters. Depending on the cluster, different mobilization strategies supported the likelihood of being discharged home enabling an individualized and resource-optimized mobilization approach. Trial Registration: Clinical Trials NCT03666286, retrospectively registered 04 September 2018.

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Section: Introductionmentioning

confidence: 99%

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

et al. 2023

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“…hypotension) [ 13 ]. In our larger cohort, we recorded one severe adverse event; which is low compared to the largest available randomised data available on active forms of mobilisation only [ 11 ]. Other than that, we mainly found transient physiological changes (mainly hypotension).…”

Section: Discussionmentioning

confidence: 99%

“…The delay in initiation of mobilisation and the reduced frequency of mobilisation is not surprising, with hemodynamic instability being one of the main barriers to the mobilisation of critically ill patients [ 5 , 11 , 14 ]. Higher norepinephrine dosages were associated with decreased mobilisation level for patients who received a continuous norepinephrine application.…”

Section: Discussionmentioning

confidence: 99%

“…Although the assistance is mostly carried out by one person, we took a conservative approach and assigned an IMS of 7 in those cases. The highest achieved IMS level of one mobilisation session was used as described [ 11 , 22 ].…”

Section: Methodsmentioning

confidence: 99%

“…Vasopressors are an indicator of hemodynamic instability [ 3 ] and are perceived as a barrier to starting early mobilisation [ 5 , 6 ], resulting in less mobilisation [ 4 ]. While sufficient mobilisation of patients is a crucial step in rehabilitation in the intensive care unit (ICU) [ 6 – 10 ], too much mobilisation, especially active forms, inherits the potential of harm [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

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Mobilisation of critically ill patients receiving norepinephrine: a retrospective cohort study

et al. 2022

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Background Mobilisation and exercise intervention in general are safe and feasible in critically ill patients. For patients requiring catecholamines, however, doses of norepinephrine safe for mobilisation in the intensive care unit (ICU) are not defined. This study aimed to describe mobilisation practice in our hospital and identify doses of norepinephrine that allowed a safe mobilisation. Methods We conducted a retrospective single-centre cohort study of 16 ICUs at a university hospital in Germany with patients admitted between March 2018 and November 2021. Data were collected from our patient data management system. We analysed the effect of norepinephrine on level (ICU Mobility Scale) and frequency (units per day) of mobilisation, early mobilisation (within 72 h of ICU admission), mortality, and rate of adverse events. Data were extracted from free-text mobilisation entries using supervised machine learning (support vector machine). Statistical analyses were done using (generalised) linear (mixed-effect) models, as well as chi-square tests and ANOVAs. Results A total of 12,462 patients were analysed in this study. They received a total of 59,415 mobilisation units. Of these patients, 842 (6.8%) received mobilisation under continuous norepinephrine administration. Norepinephrine administration was negatively associated with the frequency of mobilisation (adjusted difference -0.07 mobilisations per day; 95% CI − 0.09, − 0.05; p ≤ 0.001) and early mobilisation (adjusted OR 0.83; 95% CI 0.76, 0.90; p ≤ 0.001), while a higher norepinephrine dose corresponded to a lower chance to be mobilised out-of-bed (adjusted OR 0.01; 95% CI 0.00, 0.04; p ≤ 0.001). Mobilisation with norepinephrine did not significantly affect mortality (p > 0.1). Higher compared to lower doses of norepinephrine did not lead to a significant increase in adverse events in our practice (p > 0.1). We identified that mobilisation was safe with up to 0.20 µg/kg/min norepinephrine for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0–1) mobilisation. Conclusions Mobilisation with norepinephrine can be done safely when considering the status of the patient and safety guidelines. We demonstrated that safe mobilisation was possible with norepinephrine doses up to 0.20 µg/kg/min for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0–1) mobilisation.

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Stakeholder Perspectives on Minimum Clinically Important Difference and Noninferiority Margin for Hospital-Free Days to Assess Interventions

et al. 2023

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Early Active Mobilization during Mechanical Ventilation in the ICU

Cited by 180 publications

References 42 publications

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU

Mobilisation of critically ill patients receiving norepinephrine: a retrospective cohort study

Stakeholder Perspectives on Minimum Clinically Important Difference and Noninferiority Margin for Hospital-Free Days to Assess Interventions

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