Margot Green

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.

IntroductionThe aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients.MethodsA systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients.ResultsSafety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations.ConclusionConsensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

Specific inspiratory muscle training is safe in selected patients who are ventilator-dependent: A case series

BACKGROUND Mechanical ventilation of intensive care patients results in inspiratory muscle weakness. Inspiratory muscle training may be useful, but no studies have specifically described the physiological response to training. RESEARCH QUESTIONS Is inspiratory muscle training with a threshold device safe in selected ventilator-dependent patients? Does inspiratory muscle strength increase with high-intensity inspiratory muscle training in ventilator-dependent patients? DESIGN Prospective cohort study of 10 medically stable ventilator-dependent adult patients. SETTING Tertiary adult intensive care unit. METHODS Inspiratory muscle training 5-6 days per week with a threshold device attached to the tracheostomy without supplemental oxygen. OUTCOME MEASURES Physiological response to training (heart rate, mean arterial pressure, oxygen saturation and respiratory rate), adverse events, training pressures. RESULTS No adverse events were recorded in 195 sessions studied. For each patients second training session, no significant changes in heart rate (Mean Difference 1.3 bpm, 95% CI -2.7 to 5.3), mean arterial pressure (Mean Difference -0.9 mmHg, 95% CI -6.4 to 4.6), respiratory rate (Mean Difference 1.2 bpm, 95% CI -1.1 to 3.5 bpm) or oxygen saturation (Mean Difference 1.2%, 95% CI -0.6 to 3.0) were detected Training pressures increased significantly (Mean Difference 18.6 cmH(2)O, 95% CI 11.8-25.3). CONCLUSION Threshold-based inspiratory muscle training can be delivered safely in selected ventilator-dependent patients without supplemental oxygen. Inspiratory muscle training is associated with increased muscle strength, which may assist ventilatory weaning.

Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians

Objectives To describe our experience and the practical tools we have developed to facilitate early mobilization in the intensive care unit (ICU) as a multidisciplinary team. Background Despite the evidence supporting early mobilization for improving outcomes for ICU patients, recent international point-prevalence studies reveal that few patients are mobilized in the ICU. Existing guidelines rarely address the practical issues faced by multidisciplinary ICU teams attempting to translate evidence into practice. We present a comprehensive strategy for safe mobilization utilized in our ICU, incorporating the combined skills of medical, nursing, and physiotherapy staff to achieve safe outcomes and establish a culture which prioritizes this intervention. Methods A raft of tools and strategies are described to facilitate mobilization in ICU by the multidisciplinary team. Patients without safe unsupported sitting balance and without ≥3/5 (Oxford scale) strength in the lower limbs commence phase 1 mobilization, including training of sitting balance and use of the tilt table. Phase 2 mobilization involves supported or active weight-bearing, incorporating gait harnesses if necessary. The Plan B mnemonic guides safe multidisciplinary mobilization of invasively ventilated patients and emphasizes the importance of a clearly articulated plan in delivering this valuable treatment as a team. Discussion These tools have been used over the past 5 years in a tertiary ICU with a very low incidence of adverse outcomes (<2%). The tools and strategies described are useful not only to guide practical implementation of early mobilization, but also in the creation of a unit culture where ICU staff prioritize early mobilization and collaborate daily to provide the best possible care. Conclusion These practical tools allow ICU clinicians to safely and effectively implement early mobilization in critically ill patients. A genuinely multidisciplinary approach to safe mobilization in ICU is key to its success in the long term.

Defining new barriers to mobilisation in a highly active intensive care unit – have we found the ceiling? An observational study

Background: Mobilisation of intensive care (ICU) patients attenuates ICU‐acquired weakness, but the prevalence is low (12–54%). Better understanding of barriers and enablers may inform practice. Objectives: To identify barriers to mobilisation and factors associated with successful mobilisation in our medical /surgical /trauma ICU where mobilisation is well‐established. Methods: 4‐week prospective study of frequency and intensity of mobilisation, clinical factors and barriers (extracted from electronic database). Generalized linear mixed models were used to describe associations between demographics, clinical factors and successful mobilisation. Results: 202 patients accounted for 742 patient days. Patients mobilised on 51% of patient days. Most frequent barriers were drowsiness (18%), haemodynamic/respiratory contraindications (17%), and medical orders (14%). Predictors of successful mobilisation included high Glasgow Coma Score (OR = 1.44, 95%CI=[1.29–1.60]), and male sex (OR = 2.29, 95%CI=[1.40–3.75]) but not age (OR = 1.05, 95%CI=[1.01–1.08]). Conclusions: Our major barriers (drowsiness, haemodynamic/respiratory contraindications) may be unavoidable, indicating an upper limit of feasible mobilisation therapy in ICU.