- Journal club critique
- Open Access
Early mobilization improves functional outcomes in critically ill patients
© BioMed Central Ltd 2010
- Published: 24 September 2010
Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCalliste KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009; 373(9678): 1874-1882. PubMed PMID: 19446324. This is available on http://www.pubmed.gov.
Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilization secondary to sedation might potentiate these problems.
To assess efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care.
Open label randomized clinical trial.
Study was conducted at two university hospitals on patients receiving sedation and mechanical ventilation. Subjects were those who received mechanical ventilation for < 72 hrs, were functionally independent prior to hospitalization, and were expected to continue for at least 24 hrs after enrollment.
104 mechanically ventilated patients in the ICU.
Patients were randomized to receive either early exercise and mobilization (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n = 49) or daily interruption of sedation with therapy as ordered by the primary care team (control; n = 55). Therapists who undertook patient assessments were blinded to treatment assignment.
The primary endpoint was the number of patients returning to independent functional status at hospital discharge defined as the ability to perform six activities of daily living and the ability to walk independently. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay.
The return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p = 0.02; odds ratio 2.7 [95% CI 1.2-6.1]). Patients in the intervention group had shorter duration of delirium (median 2.0 days, IQR 0.0-6.0 vs 4.0 days, 2.0-8.0; p = 0.02), and more ventilator-free days (23.5 days, 7.4-25.6 vs 21.1 days, 0.0-23.8; p = 0.05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony.
A strategy for whole-body rehabilitation consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care.
Schweickert and colleagues should be commended for showing us that the early administration of PT and OT in critical illness is safe, effective, and improves overall functional independence. It is unclear, however, whether these findings can be extrapolated across all spectrums of critically ill patients and a larger multicenter trial would be helpful in answering some of these questions. Even in the absence of such evidence, it would seem prudent do our best to minimize sedation and to initiate PT/OT as early as possible.
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