Early Rehabilitation in the Intensive Care Unit: Preventing Impairment of Physical and Mental Health

Abstract

Survivors of critical illness often experience new or worsening impairments in physical, cognitive and/or mental health, referred to as post-intensive care syndrome (PICS). Such impairments can be long-lasting and negatively impact survivors’ quality of life. Early rehabilitation in the intensive care unit (ICU), while patients remain on life-support therapies, may reduce the complications associated with PICS. This article addresses evidence-based rehabilitation interventions to reduce the physical and mental health impairments associated with PICS. Implementation of effective early rehabilitation interventions targeting physical impairments requires consideration of 5 factors: barriers, benefits, feasibility, safety, and resources. Mental health impairments may be addressed by the following interventions: ICU diaries, early in-ICU psychological intervention, and post-ICU coping skills training. In both cases, a multidisciplinary team-based approach is paramount to the successful incorporation of early rehabilitation into routine practice in the ICU.

The Role of Early Mobilization in the Intensive Care

“…Approximately 15-35% of patients admitted to an Intensive Care Unit will develop myopathy and about 50% to 70% of patients with sepsis, multiorganic dysfunction or prolonged mechanical ventilation will have neuromuscular dysfunction [9]. Critical illness patient mechanically ventilated for more than 7 days have increased mortality risk (48-84% versus 19-56% comparing to no mechanically ventilated patients) [10]. Intensive care-associated myopathy is an acute myopathy defined by the loss of myosin filaments and atrophy of muscle fibers, especially type II, resulting in a more evident deficit of muscle strength at the proximal level [2].…”

“…Thus, the etiology is multifactorial and several risk factors have been described, such as: The severity and duration of the systemic inflammatory response syndrome, high score in the Acute Physiologic Assessment and Chronic Health Evaluation, sepsis, multiorgan dysfunction, hyperglycemia, hypoalbuminemia, immobility, parenteral nutrition, corticoids, duration of the hospitalization, female gender and age [11]. Diagnosis is based in clinical presentation and may be confirmed by electrophysiology studies [10]. It is fundamental the clinical suspection to other differential diagnosis, such as: Stroke, epidural abscess, Guillain Barre Syndrome, other neuropathies, rabdomiolisis, pharmacological iatrogenia (neurotoxicity, cortisol myopathy) [7,8,10].…”

“…Diagnosis is based in clinical presentation and may be confirmed by electrophysiology studies [10]. It is fundamental the clinical suspection to other differential diagnosis, such as: Stroke, epidural abscess, Guillain Barre Syndrome, other neuropathies, rabdomiolisis, pharmacological iatrogenia (neurotoxicity, cortisol myopathy) [7,8,10].…”

The Surgical Optimal Mobility Score predicts mortality and length of stay in an Italian population of medical, surgical, and neurologic intensive care unit patients

“…Early mobilization during the intensive care unit (ICU) stay has been advocated to mitigate the effects of muscle weakness [1][2][3][4][5]. Early rehabilitation includes a spectrum of interventions ranging from passive motion exercises to ambulation and to the use of novel technologies such as cycle-ergometry and transcutaneous electrical muscle stimulation [6].…”

“…Although not free of risks [3,5,7], its safety profile is reported to be good with low rates of complications even in patients who are traditionally not mobilized, such as those with femoral vein or artery catheters [8][9][10]. Different strategies have been proposed to modify potential barriers to early mobilization, such as changing vascular catheter location, careful scheduling of procedures, and improved sedation management [11,12].…”