High dose early mobilization raised mortality risk in ventilated patients with diabetes
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Key takeaways:
- High dose early mobilization is not recommended for those with diabetes in the ICU.
- A larger proportion of ventilated patients with vs. without diabetes died by day 180.
SAN DIEGO — High dose early mobilization vs. usual care mobilization for ventilated patients negatively impacted those with diabetes, according to a presentation at the American Thoracic Society International Conference.
“In patients with diabetes, high dose early mobilization was associated with increased risk of mortality compared to usual care, even after adjustment for other potential confounders,” 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, said during her presentation.
As Healio previously reported, adults receiving mechanical ventilation who underwent early active mobilization — consisting of sedation minimization and daily physiotherapy — at a higher dose than usual did not survive significantly longer than patients with standard mobilization in the international, multicenter, randomized, controlled TEAM trial.
Researchers from this trial also observed that an increase in early active mobilization was linked to more adverse events in the patient population compared with those receiving an ICU’s usual care.
Using data from the TEAM trial, Hodgson and colleagues conducted a secondary analysis by splitting up the population based on pre-existing diabetes (n = 159 with; n = 582 without) to find out if this characteristic changed the outcomes observed in the initial trial.
Similar to the main trial, 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.
Among those with diabetes, 87 patients (mean age, 66.2 years; 31% women) underwent early mobilization and 72 patients (mean age, 64.7 years; 30.6% women) received usual care mobilization.
Among those without diabetes, 284 patients (mean age, 61.4 years; 35.6% women) underwent early mobilization and 298 (mean age, 61.1 years; 41.6% women) received usual care mobilization.
“Patients with diabetes were not the same as patients without diabetes,” Hodgson said. “There were baseline differences, including they were older, they were more likely to be frail, they were more often on vasopressors and they had a higher severity of illness.”
For daily duration of active mobilization, both high dose early mobilization groups had longer times vs. the usual care mobilization groups. However, between those with vs. without diabetes, researchers observed more daily minutes of active mobilization among those without this disease (19 minutes vs. 15 minutes).
By day 180, the median number of days alive and out of the hospital was significantly lower among those with vs. without diabetes (124 days vs. 147 days; P = .013) in an analysis adjusted for several potential confounders (age, sex, APACHE II, ICU admission type, congestive heart failure and sepsis).
Mortality at day 180 also significantly differed between the two groups in this adjusted analysis, with a greater proportion of deaths in the group with vs. without diabetes (30% vs. 18%; P = .044).
Among those with diabetes, researchers found that the risk for 180-day mortality rose with high dose early mobilization (adjusted HR = 2.92; 95% CI, 1.52-5.62). In contrast, high dose early mobilization did not impact mortality risk among those without diabetes.
“High dose mobilization clearly harms patients with diabetes, and the effect is the opposite in patients with usual care mobilization,” Hodgson said.
She additionally noted that the reason for the difference in mortality between the diabetes groups could not have been adverse events for renal failure or other organ failures since these did not differ among those with vs. without diabetes.
Researchers observed elevated probabilities for several adverse events 5 days after randomization with high dose early mobilization in a subset of patients with diabetes (n = 71). These events included severe hypotension (94%), hypotension (83%), use of noradrenaline (81%), severe hyperglycemia (77%), severe bradycardia (71%), severe tachycardia (69%) and hypoglycemia (68%).
Lastly, Hodgson highlighted that cardiogenic shock, multiple organ failure, mesenteric ischemia and cardiac arrest were causes of death for those with diabetes receiving high dose early mobilization but not for those with diabetes receiving usual care mobilization.
“Close monitoring, an individualized treatment plan and usual care rehabilitation is recommended until we have further evidence of benefit or harm,” Hodgson said.