Higher dose of early active mobilization appears ineffective, ‘potentially harmful’
Click Here to Manage Email Alerts
Patients receiving mechanical ventilation who underwent early active mobilization at a higher dose than usual did not survive significantly longer than patients with standard mobilization, according to study results.
Further, the results — published in The New England Journal of Medicine in conjunction with the European Society of Intensive Care Medicine LIVES 2022 Annual Congress, held Oct. 22 to 26 in Paris — showed an increase in early active mobilization was linked to more adverse events in the patient population compared with those receiving the ICU’s usual care, according to researchers.
“Our study suggests that very early exercise of patients on life support is ineffective, compared to mobilization as a part of usual care and can cause adverse events,” Carol L. Hodgson, PhD, FACP, FAHMS, head of the division of clinical trials and cohort studies at the school of public health and preventive medicine at Monash University, told Healio. “These findings are important because they will ultimately prevent patients receiving additional treatment that does not benefit them and may cause harm.”
In an international, multicenter, randomized, controlled trial, Hodgson and colleagues evaluated 750 adults receiving invasive mechanical ventilation in 49 ICUs from Feb. 27, 2018, to Nov. 19, 2021, to observe whether an increase in early mobilization — consisting of sedation minimization and daily physiotherapy — improved survival and outcomes compared with the standard care normally given in each ICU.
Days alive and discharged from the hospital at day 180 served as the study’s primary endpoint, with death by day 180 as the secondary endpoint.
Of the total cohort, 371 patients (mean age, 60.5 ± 14.8 years; 34.5% women) underwent early mobilization, and 370 patients (mean age, 59.5 ± 15.2 years; 39.5% women) received the usual care of the ICU.
For mean daily duration of active mobilization, researchers observed more than double the dose in the early mobilization group, with a 12-minute (95% CI, 10.4-13.6) difference between those receiving early mobilization (20.8 ± 14.6 minutes) and those receiving usual care (8.8 ± 9 minutes).
According to researchers, the median number of days alive and out of the hospital differed by only 2 days (95% CI, –10 to 6) between groups, at 143 days (interquartile range [IQR], 21-161) in the early mobilization group compared with 145 days (IQR, 51-164) in the usual care group.
Researchers also found a small difference when observing the median interval it took for a total of 77% of patients in each group to stand. For patients in the early mobilization group, it took a median interval of 3 days, and for those in the usual care group, it took 5 days (difference, –2 days; 95% CI, –3.4 to –0.6).
At the end of the study period, researchers observed that 22.5% of patients receiving early mobilization died compared with 19.5% of patients receiving usual care (OR = 1.15; 95% CI, 0.81-1.65).
Additionally, more patients receiving early mobilization experienced serious adverse events — including arrhythmias, desaturation and a cerebrovascular accident — than those in the usual care group (n = 7 vs. 1). Researchers further found that 34 patients (9.2%) receiving early mobilization experienced adverse events related to mobilization, such as arrhythmias, altered blood pressure and desaturation, compared with 15 patients (4.1%) receiving usual care (P = .005).
“The notion that exercising patients soon after starting life support might prevent development of muscle weakness was very appealing, but previous clinical trials evaluating this strategy were small and inconclusive,” Hodgson told Healio. “We were surprised to find that the increased dose of exercise compared with usual care was not just ineffective but also potentially harmful.
“Our study suggests there is a dose response with early mobilization, and this needs to be understood more carefully in future trials,” Hodgson added.
This study by Hodgson and colleagues adds to the literature indicating that benefits of early mobilization in this patient population requires more research, according to an accompanying editorial by Marc Moss, MD, professor of medicine in the division of pulmonary sciences and critical care medicine at the University of Colorado School of Medicine.
“The next stage of early-mobilization research in critically ill patients should focus on identifying which patients receive the most benefit from early mobilization, implementing the appropriate comparison group, examining outcomes that are attainable and inform clinical practice, and determining the appropriate type, timing, intensity, coordination, and duration of therapy,” Moss wrote. “Ultimately, these studies should lend more clarity to the role of early mobilization in critically ill patients.”
Reference:
For more information:
Carol L. Hodgson, PhD, FACP, FAHMS, can be reached at carol.hodgson@monash.edu.