Early mobilization in ICU may not reduce mortality or hospital stay: NEJM

Melbourne: A trial presented at the LIVES 2022 meeting of the European Society of Intensive Care Medicine in Paris and published in the New England Journal of Medicine showed that getting patients moving as much as possible while they were on mechanical ventilation in the intensive care unit (ICU) did not increase their likelihood of survival or help them go home faster.

Due to rapid muscle loss and other factors, ICU-acquired weakness affects about 40% of patients and is linked to a higher risk of death, a longer stay in the hospital, and a slower recovery, according to the researchers. Due to the inconsistent findings of earlier studies on early mobilization, guidelines only suggested mobilization without recommending a specific time or regimen.

"The next phase of early-mobilization research in critically ill patients must concentrate on figuring out which patients can benefit most from early mobilization, setting up the right comparison group, assessing outcomes that are achievable and notify clinical practice, and determining the appropriate type, timing, intensity, coordination, and duration of therapy, "the authors implored.

The TEAM trial was proposed to assess various early mobilization "doses."

In order to do this, they divided up 750 adult patients in the ICU who were receiving invasive mechanical ventilation into groups and randomly assigned them to receive either increased early mobilization (sedation minimization and daily PT) or standard care (the level of mobilization that was normally provided in each ICU). The number of days the patients were still alive and out of the hospital 180 days following randomization was the main outcome.

Hodgson and colleagues noted that "both the intensity and length of mobilization in the control groups in our meta-analysis varied substantially, a characteristic that made it challenging to make comparisons throughout the trials."

The results, however, were consistent with three more recent randomized controlled trials, which demonstrated that routine rehabilitation therapy in the critical care unit did not result in a shorter hospital stay or any benefit for physical function.

Key findings of the trial:

• In the early-mobilization group, patients spent an average of 143 days alive and out of the hospital, compared to 145 days in the usual-care group (absolute difference, 2.0 days; 95% confidence interval [CI], 10 to 6; P=0.62).
• The two groups' respective mean (SD) daily active mobilization durations were 20.8±14.6 minutes and 8.8±9.0 minutes (difference: 12.0 minutes per day; 95% CI: 10.4 to 13.6).
• With a median interval of 3 days and 5 days, respectively, 77% of patients in each group were able to stand (difference, 2 days; 95% CI, 3.4 to 0.6).
• By day 180, 19.5% of patients receiving normal treatment and 22.5% of those receiving early mobilization had passed away (odds ratio, 1.15; 95% CI, 0.81 to 1.65).
• Life quality, daily living activities, impairment, cognitive function, and psychological function were comparable between the two groups of survivors.
• 7 patients in the early mobilization group and one patient receiving standard care both had serious adverse effects.
• Arrhythmias, changes in blood pressure, and desaturation were reported as unfavorable events in 34 of 371 patients (9.2%) in the early mobilization group and in 15 of 370 patients (4.1%) in the usual care group (P=0.005).

The authors concluded that early active mobilization among individuals receiving mechanical ventilation in the ICU did not result in noticeably better survival rates and discharge from the hospital as did the standard level of mobilization in the ICU. A rise in unfavorable events was linked to the intervention.

REFERENCE

The TEAM Study Investigators and the ANZICS Clinical Trials Group "Early active mobilization during mechanical ventilation in the ICU" N Engl J Med 2022; DOI: 10.1056/NEJMoa2209083.