ICU-acquired weakness is the acute onset of neuromuscular and functional impairment in critically ill patients.([FOOTNOTE=Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Reducing iatrogenic risks: ICU-acquired delirium and weakness—crossing the quality chasm. Chest. 2010;138(5):1224–1233. doi: 10.1378/chest.10-0466],[ANCHOR=],[LINK=]) Up to 80 percent of ICU patients can develop some form of it,([FOOTNOTE=Jolley SE, Bunnell AE, Hough CL. ICU-acquired weakness. Chest. 2016;150(5):1129–1140. doi: 10.1016/j.chest.2016.03.045],[ANCHOR=],[LINK=]) and it can persist after discharge, sometimes for years.([FOOTNOTE=Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19:274. doi: 10.1186/s13054-015-0993-7],[ANCHOR=],[LINK=])
Early mobility programs can:
ICU-acquired delirium, which can affect the sickest ICU populations, remains poorly understood.([FOOTNOTE=Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306–1316. doi: 10.1056/NEJMoa1301372],[ANCHOR=],[LINK=]) And the length of a patient’s delirium directly correlates with his or her ability or inability to perform activities of daily living.([FOOTNOTE=Brummel NE, Jackson JC, Pandharipande PP, et al. Delirium in the intensive care unit and subsequent long-term disability among survivors of mechanical ventilation. Crit Care Med. 2014;42(2):369–377. doi: 10.1097/CCM.0b013e3182a645bd],[ANCHOR=],[LINK=])
Early mobility, in concert with customized sedation regimens, may reduce delirium and increase functional outcomes at ICU discharge — and beyond.3,9,([FOOTNOTE=Cameron S, Ball I, Cepinskas G, et al. Early mobilization in the critical care unit: a review of adult and pediatric literature. J Crit Care. 2015;30(4):664–672. doi: 10.1016/j.jcrc.2015.03.032],[ANCHOR=],[LINK=])
Dr. Wischmeyer of Duke University gives an overview of the challenges associated with early mobility, and the importance of implementing protocols.
Early mobility — combined with reduced sedation and spontaneous awakening and breathing trials as part of the ABCDEF bundle — can be safely administered to ventilated patients.([FOOTNOTE=Raoof, S, Baumann MH. Ventilator-associated events: the new definition. Am J Crit Care. 2014;23(1):7–9. doi: 10.4037/ajcc2014469.],[ANCHOR=],[LINK=]) And early mobility is associated with fewer days on a ventilator.3,([FOOTNOTE=Balas MC, EE Vasilevskis, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle. Crit Care Med. 2014;42(5):1024–1036. doi: 10.1097/CCM.0000000000000129],[ANCHOR=],[LINK=])
Ventilator-associated events, such as ventilator-associated pneumonia([FOOTNOTE=Hunter, JD. Ventilator associated pneumonia. BMJ. 2012;344:e3325. doi: 10.1136/bmj.e3325.],[ANCHOR=],[LINK=]) and pulmonary embolism,([FOOTNOTE=Stevens, JP, Silva G, Gillis J, et al. Automated surveillance for ventilator-associated events. Chest. 2014;146(6):1612–1618. doi: 10.1378/chest.13-2255],[ANCHOR=],[LINK=]) correlate with longer ICU stays and greater chance of death.14
Cognitive impairment refers to a persistent loss of brain function following a critical illness. Between one- and two-thirds of mechanically ventilated patients suffer from some level of cognitive impairment, with loss of function comparable to traumatic brain injury or even mild Alzheimer’s disease.([FOOTNOTE=Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513–1520. doi: 10.1097/CCM.0b013e3181e47be1],[ANCHOR=],[LINK=])
Length of delirium has been associated with poorer cognition scores one year post-lCU.10 The reduction in delirium afforded by early mobility treatments lays a foundation for better outcomes that last beyond discharge from the ICU.
Early mobility is part of a comprehensive set of strategies to improve patient outcomes in the ICU. Called the ABCDEF bundle, it comprises the following protocols:
The ABCDEF bundle is associated with shorter ICU and hospital length of stays, less delirium, shorter time on the ventilator, and higher hospital survival rates.18