Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease — both of which could be related to the immobilisation caused by sedation. An Article published Online First and in an upcoming edition of The Lancet has found that interrupting sedation in the earliest days of treatment to give critically ill patients physical and occupational therapy leads to better outcomes than standard care.
In this randomised controlled trial, Dr John Kress (University of Chicago, USA) and colleagues analysed sedated adults in the ICU who had been on mechanical ventilation for less than 72 h, and were expected to continue for at least 24 h. Patients were assigned to the early exercise and mobilisation* (49 patients-intervention group) or standard care of daily interruption of sedation and therapy at the discretion of the ICU team (55 patients—control group). The study calculated the proportion of patients from each group that had independent functional status (IFS) at hospital discharge — defined as ability to do six tasks of daily living** and walk unaided.
The researchers found that 59% of patients in the intervention group achieved IFS, compared with 35% in the control group. Intervention patients also suffered from ICU delirium*** only half as long (2.0 days) as did control patients (4.0 days). Intervention patients also had more ventilator free days while in ICU in the 28 day follow-up (23.5 days vs 21.1 days for control).
The authors conclude: "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."
They add: "This study highlights the robust outcomes that can be achieved with the coordinated efforts of multiple disciplines dedicated to the survival and mental and physical recovery of critically ill patients receiving mechanical ventilation."
In an accompanying Comment, Dr Stephan M Jakob and Dr Jukka Takala, University Hospital, Switzerland, say: "Exercise should have a central role in the treatment of critically ill patients... Although physiotherapy is commonly administered to patients in intensive care during recovery from critical illness in the USA, the frequency and type of physiotherapy greatly varies between the type of hospital and clinical scenarios."
Dr John P. Kress, University of Chicago, USA T) please complete telephone number T) +1 773-702-6790 E) jkress@medicine.bsd.uchicago
Dr Stephan M Jakob and Dr Jukka Takala, University Hospital, Switzerland T) +41 31 632 4144 E) stephan.jakob@insel.ch
For full Article and Comment see: http://press.thelancet.com/icutherapy.pdf
Notes to editors: *For full details of therapy provided, see p2 full paper 'procedures'
**six activities of daily living: bathing, dressing, eating, grooming, transferring from bed to chair, using the toilet.
***ICU delirium is an acute change in mental status with inattention and altered consciousness
Journal
The Lancet