Early Mobilization in the Intensive Care Unit: A Systematic Guide

Globally people recover from critical illnesses and get discharged from an ICU setup, however, it has been noticed that patients develop weakness, probably credited to their prolonged period of immobilization. Post intensive care syndrome was the term used that describes the worsening of physical, mental, and cognitive problems. Early mobilization of critically ill patients is a safe option with additional benefits of improving functional outcomes. The term mobilization in the Intensive care unit is referred to as physical activity performed to the intensity that can bring about physiological changes. Early mobilization is the application of physical activity as early as the 2nd to 5th day after the onset of critical illness or injury.

Early Mobilization in ICU

Why Early Mobilization

Long term ICU care is always associated with complications in a high proportion of ICU survivors. Prolonged periods of immobility have often been associated with physical deconditioning, fatigue, loss of function and decreased quality of life have also been observed.[1] A systematic review and meta-analysis suggest early rehabilitation in the ICU reduces the incidence of developing Intensive care unit-acquired weakness (ICUAW). Another cross-sectional survey suggests patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%) are the most common barriers to early mobilization. Also, the study infers a significant positive relationship between the type of ventilation and out-of-bed patient mobilization.

According to a retrospective cohort study in survivors of a prolonged ICU-stay, the ability to ambulate was related with a higher possibility of being discharged. Thus, emphasizing the importance of mobility training in long-term acute care hospitals.

Below is a gist of the system-wise complications of prolonged immobility.

In Respiratory system, it causes retention of secretions, reduced respiratory excursion, pneumonia, and atelectasis.
Cardiovascular complications include orthostatic hypertension, deep vein thrombosis, hypovolemia, and embolization.
Gastrointestinal complications include decreased motility, constipation, ileus.
Musculoskeletal complications include muscle shortening, weakness, and wasting which would, in turn, cause functional denervation, joint contractures, bone demineralization, and heterotrophic ossification.
Neurological system is affected by polyneuropathies due to reduced microcirculation at the nerve.
Endocrine system-related complications include Hyperglycemia with insulin resistance and catabolism.
Integumentary system, it can cause pressure ulcers.
Psychology of the person is affected causing depression and delirium.

Physiological Effects

There is an improved ventilation/perfusion matching, better lung compliance, mucociliary clearance, reduced work of breathing in upright positions. Movement of the lower limbs mainly the ankle prevented stasis of blood and hence prevents Deep vein thrombosis as well as pulmonary embolus formation.

Prescription of Early Mobilization

To assist in the clinical decision-making process, you can follow the steps below:

Step 1: Identifying the contributing factors towards oxygen transport deficits

Understanding the pathophysiology of the condition or disease
Extrinsic factors that affect patient care
Intrinsic factors related to the patient
Relative immobility

Step 2: Determining the specific need for mobilization and subsequently the form of mobilization or exercise that will address the oxygen transport deficiency.

Step 3: Matching the selected mobilization technique or exercise type to the patient’s oxygen-carrying capacity.

Step 4: Set the dosage, i.e. the intensity to match the safe limits of oxygen transport of the patient.

Step 5: Combining body positions with these maneuvers

Thoracic mobility exercises
ROM exercises (Active, passive and active-assisted)
Coordinating breathing control with body movements
Coughing, supported by self or others

Step 6: Use oxygen transport and its indices to monitor the dosage of mobilization, not a fixed duration of time.

Step 7: Repeat this mobilization as frequently and safely as the beneficial effects are tolerated by the subject or patient.

Step 8: The intensity of the mobilization stimulus can be increased as long as the patient capacity permits the effects of the mobilization stressor, keeping the oxygen transport as the benchmark, constantly monitoring vitals.

Early Mobilization Intervention

The frequency of early mobilization can be conducted every day of the week or five days a week. Although active techniques are preferred more than passive and attribute more to the prevention of complications, these are some of the listed techniques that come under the scope of early mobilization: