ArticlesEarly, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial
Introduction
More than 5·7 million patients in the USA, and more than 2 million patients in Germany are treated annually in intensive care units, of which about one-third are admitted to these wards after an elective or emergency surgical procedure. Muscle weakness is as common as arterial hypotension in the surgical intensive care unit (SICU),1, 2, 3 and is predictive of adverse outcomes in critically ill patients.4, 5, 6, 7
Intensive care unit-acquired muscle weakness, a term describing several pathological entities with similar clinical features,3, 8 can be aggravated by immobilisation,3, 9, 10, 11 which is often prescribed in patients in the SICU as a by-product of a well established safety culture.12, 13 Mobilisation is often neglected, delayed, or done with subjective provider-specific efforts,14 due to scarcity of knowledge and available evidence. Because tools to measure the effect of early, goal-directed mobilisation therapy in the SICU were not available, as a first step our team created the SICU optimal mobilisation score (SOMS), a numerical rating scale ranging from 0 (no mobilisation) to 4 (ambulation), which describes patients’ mobilisation capacity. We validated SOMS in English, German, and Italian, as the basis to achieve early, goal-directed mobilisation therapy in the SICU.14, 15, 16, 17, 18
In this study we tested if early, goal-directed mobilisation, using a strict mobilisation algorithm combined with facilitated inter-professional communication, in critically ill SICU patients leads to improved mobility during SICU admission, decreased length of stay on the SICU, and increased functional independence at hospital discharge.
Section snippets
Study design
This trial was an international, multicentre, randomised controlled, clinical trial in SICUs of five university hospitals in Austria (Landeskrankenhaus Salzburg [Salzburg]), Germany (Klinikum rechts der Isar der Technischen Universität München [Munich]), and the USA (Beth Israel Deaconess Medical Center [Boston, MA], Massachusetts General Hospital [Boston, MA], and University of Massachusetts Medical Center [Worcester, MA]). The research protocol was approved by all participating centres’
Results
From July 1, 2011, to Nov 4, 2015, we randomly assigned 200 eligible adult patients to receive either standard treatment (96 [48%] patients; control group) or early, goal-directed mobilisation therapy (104 [52%] patients; intervention group; Figure 1, Figure 2). Seven (7%) patients in the intervention group were not included in the per-protocol population. Four patients voluntarily withdrew consent and three patients were not eligible (due to treatment plan being changed to comfort care) after
Discussion
Early, goal-directed mobilisation therapy in the SICU increased patients’ mobility level, decreased the length of stay in the SICU and hospital, and improved functional independence at hospital discharge.
Despite reports on the effectiveness of early mobilisation in medical ICU patients,30, 38, 39 early mobilisation during the first 3 days after admission to an ICU40 is not typically implemented in surgical patients.12, 13 Reasons as to why mobilisation is not used in patients in the SICU
References (57)
- et al.
Early mobilization in critically ill patients: patients‘ mobilization level depends on health care provider's profession
PM R
(2011) - et al.
The German validation study of the surgical intensive care unit optimal mobility score
J Crit Care
(2016) - et al.
The Surgical Optimal Mobility Score predicts mortality and length of stay in an Italian population of medical, surgical, and neurologic intensive care unit patients
J Crit Care
(2015) - et al.
The complexities of ICU discharge
Chest
(2015) - et al.
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
Lancet
(2009) - et al.
Optimally weighted, fixed sequence and gatekeeper multiple testing procedures
J Stat Plan Inference
(2001) - et al.
Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project
Arch Phys Med Rehabil
(2010) - et al.
The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review
Surgery
(2016) Physiotherapy in intensive care: an updated systematic review
Chest
(2013)- et al.
Preventing delirium in the intensive care unit
Crit Care Clin
(2013)
Supply-demand mismatch transients in susceptible peri-infarct hot zones explain the origins of spreading injury depolarizations
Neuron
Acquired muscle weakness in the surgical intensive care unit: nosology, epidemiology, diagnosis, and prevention
Anesthesiology
Clinical review: intensive care unit acquired weakness
Crit Care
The sick and the weak: neuropathies/myopathies in the critically ill
Physiol Rev
One-year outcomes in survivors of the acute respiratory distress syndrome
N Engl J Med
Functional disability 5 years after acute respiratory distress syndrome
N Engl J Med
Can sarcopenia quantified by ultrasound of the rectus femoris muscle predict adverse outcome of surgical intensive care unit patients as well as frailty? A prospective, observational cohort study
Ann Surg
Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues
Clin Nutr
ICU-acquired weakness and recovery from critical illness
N Engl J Med
Acute skeletal muscle wasting in critical illness
JAMA
Systemic inflammatory response syndrome increases immobility-induced neuromuscular weakness
Crit Care Med
Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans
N Engl J Med
Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study
Crit Care
Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany
Crit Care Med
The surgical intensive care unit optimal mobility score predicts mortality and length of stay
Crit Care Med
Surgical Intensive Care Unit Optimal Mobilisation Score (SOMS) trial: a protocol for an international, multicentre, randomised controlled trial focused on goal-directed early mobilisation of surgical ICU patients
BMJ Open
Functional evaluation: the Barthel Index
Md State Med J
Physical therapy utilization in intensive care units: results from a national survey
Crit Care Med
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Members of the International Early SOMS-guided Mobilization Research Initiative listed at the end of the Article