Sedation and MobilityChanging the Paradigm

John P. Kress, MD Critical Care Clinics 29, Jan -2013

• Intensivists prioritise their attention to maintenance of homeostasis compatible with survival in Critically ill patients .

• Cardiovascular, pulmonary, renal , hematological system traditionally have received the highest priority.

• Most trials in critically ill have focused on short-term end points pertaining with those organ system.

• We have got support systems and even option of organ transplant for stabilising them.

• But only few intensivists foresee physical deconditioning (critical illness neuromyopathy) or cognitive impairment as a complication while handling a critically ill patient.

“Problem statement ”Herridge MS et al. One-year and five year outcomes in survivors of the ARDS. N Engl J Med 2003;2008

Of the 109 ARDS survivors (median age 45 years) 1 year after ICU discharge - 100 % patients reported loss of muscle bulk, proximal muscle

weakness, and fatigue - 50% were unemployed5 years after ICU discharge - 100 % had ongoing physical limitations (subnormal scores

on 6-minute walk tests) - mental component scores had returned to a low-normal level

• What we routinely do in ICU ?Liberal use of sedatives, analgesics and at times muscle relaxants with resultant active immobilisation

• The changing paradigm !!!!Minimal sedation to intermittent sedation + early aggressive mobilisation

Bailey et al. Early activity is feasible and safe inrespiratory failure patients (Crit Care Med 2007)100 patients sat at the edge of bed, moved out to a chair, stood, marched at a spot and even walked, all while still intubated (mechanically ventilated or on SBT )

Prerequisites- Responsive to verbal stimuli, Fio2 <60 % or PEEP < 10No vasopressors or ionotropes or orthostatic hypotension

Results- Of 1500 exercise events performed, 40 % done while still ventilated, with rare adverse events noted.

Morris et al, Early ICU mobility in ARDS (Crit Care Med 2008)First prospective comparative study of Early mobilization Vs Usual care in ICU patients.A total of 330 patients were studied. Each group had one physical activity session daily, difference being the timing of initiating mobilisation .

Results –

• The early mobilization group was out of bed 5 days sooner • Had a lesser hospital stay by 2 days (both statistically significant)• Adverse events did not occur during any activity sessions. • Control patients who did not receive early mobilization had a

significantly higher likelihood of death or readmission to the hospital at 1 year (odds ratio, 1.77 [95% , CI- 1.04–3.01])

Burtin C et al, Early exercise in critically ill patients enhances

short-term functional recovery. Crit Care Med 2009

In SICU patients, bicycle ergometer was attached to foot

end of patients and pedals strapped to the feet.

Active movements when awake, passive if asleep.

• Patients divided as cases and controls.• 84% of cases were intubated and mechanically

ventilated • Strength and functional assessments were

substantially better in the intervention group at the time of hospital discharge.

• The 6-minute walk distance was greater (196 vs 143 m,P<.05), • SF-36 physical function score was better (21 vs 15, P<.05)• The cycling sessions were well tolerated, with

only rare adverse events reported

Schweickert WD et al. Early physical & occupational therapy in mechanically ventilated, critically ill patients:a RCT. Lancet-2009First prospective randomized trial.Methodology – • n= 104 , MICU patients• 58 % were with ARDS, patients included irrespective of MODS

• Should have a short period of mechanical ventilation (< 72 hrs)• Should be functionally independent before their ICU admission• Randomly assigned as to cases and control• Cases - underwent a progressive physical and occupational

therapy regimen focused on mobilization and achievement of occupational tasks like Activities of Daily iving [ADL]

• Controls - usual care, no physical therapy until after they were extubated and shiftable from the ICU.

Only difference in mgt was “Early mobilisation” Other evidence-based strategies like daily sedativeinterruption, daily SBT, early enteral nutrition, and tight glucose control were offered in both.

Primary end point - Return to functional independence1) the ability to perform ADLs i.e. bathing,dressing, eating, grooming, transfer from bed to chair, toileting) and2) the ability to walk independently @ hospital discharge.

Intervention group- activities possible In bed mobility - 76%, Sitting in a chair - 33%Standing- 33%, Ambulation - 15%

Outcomes Intervetion group

Control group

P value

Primary end point met 59 % 35 % 0.02

Discharge to home rather than rehab centre

43 % 24% 0.06

Duration of mechanical ventilation(in days )

3.4 6.1 0.02

Ventilator-free days 23.5 21.1 0.05

Maximal walking distances (in metres)

33.4 0 0.004

Numbers of ADLs performed 6 4 0.06

ICU delerium days 2 4 0.03

• No difference in amount of sedatives• No adverse events• Premature discontinuation – in 4 % cases only.

Needham DM et al. Early physical medicine & Rehabilitation

for patients with acute respiratory failure: a quality improvement

project. Arch Phys Med Rehabil 2010

Medical ICU patients additionally received interactive video

games, such as boxing, bowling, and balance board, as part of

physical therapy.• Length of ICU stay decreased by an average of 2.1 days and • Length of hospital stay decreased by 3.1 days• Better return to functional independence

To conclude • The burden of neuromuscular weakness and

cognitive impairment is on the rise with better ICU survival.

• Uninterrupted liberal sedation without active mobilisation is the major cause for same in critically ill patients in longer run.

• Early mobilization of mechanically ventilated patients is feasible, safe, and carries the potential for tremendous benefit for such set of patients

• To allow widespread use of such a care model, continued focus on minimization of sedation must occur.

Thank You