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Sedation and Mobility
Changing 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
• 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 unemployed
5 years after ICU discharge
- 100 % had ongoing physical limitations (subnormal
scores on 6-minute walk tests)
- mental component scores had returned to a
• What we routinely do in ICU ?
Liberal use of sedatives, analgesics and at times
muscle relaxants with resultant active
• The changing paradigm !!!!
Minimal sedation to intermittent sedation + early
Bailey et al. Early activity is feasible and safe in
respiratory 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 )
Responsive to verbal stimuli, Fio2 <60 % or PEEP < 10
No vasopressors or ionotropes or orthostatic hypotension
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 .
• 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
• 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-2009
First prospective randomized trial.
• 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 sedative
interruption, daily SBT, early enteral nutrition, and tight
glucose control were offered in both.
Primary end point - Return to functional independence
1) the ability to perform ADLs i.e. bathing,dressing, eating,
grooming, transfer from bed to chair, toileting) and
2) the ability to walk independently @ hospital discharge.
Intervention group- activities possible
In bed mobility - 76%, Sitting in a chair - 33%
Standing- 33%, Ambulation - 15%
Primary end point met 59 % 35 % 0.02
Discharge to home rather than
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
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
• 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
• The burden of neuromuscular weakness and
cognitive impairment is on the rise with better ICU
• 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