A critical care specialist at Johns Hopkins who has
reviewed recent studies of intensive care
unit patients and data from The Johns Hopkins Hospital
concludes that the routine use of deep
sedation and bed rest in ICU patients may be causing
unnecessary and long-term physical impairment
and poor quality of life after hospital discharge.
"The benefits of getting hospitalized patients out of
bed and moving were understood during
World War II with battlefield injuries," said Dale Needham,
assistant professor in the
Division of Pulmonary and Critical Care Medicine and
in the Department of
Physical Medicine and Rehabilitation at
the Johns Hopkins School of Medicine. "My review shows it
may be time to go back to the future. It's
becoming clear that the safety and benefits of early
mobilization are real and that it's better to get
moving sooner rather than later."
In a report published in the Oct. 8 issue of
Journal of the American Medical Association,
Needham says that routinely keeping ICU patients deeply
sedated and on bed rest can lead to muscle
weakness and that it's probably best to get patients up and
moving shortly after admission to an ICU.
The conclusions are based on Needham's review of
recent studies and experience at The Johns
Hopkins Hospital, where a new physical medicine and
rehabilitation program has been developed for
ICU patients.
Systematic review by Needham and colleagues found that
across 24 studies focused on ICU
patients with sepsis, prolonged mechanical ventilation and
multiple organ failure, 46 percent of 1,421
patients had neuromuscular dysfunction that was associated
with extended use of mechanical
ventilation and longer stays in the ICU. Other studies
reviewed showed that early physical medicine
and rehabilitation therapy while patients are on life
support in the ICU can safely allow patients to get
out of bed and walk more quickly, resulting in shorter time
on a ventilator and a shorter stay in the
ICU.
According to Needham, early mobilization of
hospitalized patients was introduced in World War
II as a means of getting injured soldiers quickly back to
the battlefield. This practice was popularized
by related editorials at that time, such as one titled "The
Evil Sequelae of Complete Bed Rest." Even
during the early years after creation of ICUs, patients
were frequently awake and out of bed. Over
time, however, technology and other factors led to the more
routine use of deep sedation and bed
rest. Needham, in his review, cited numerous studies
highlighting the physical harm of lengthy bed
rest, such as loss of muscle strength and changes in heart
function.
The cause of muscle weakness after an ICU stay are
complicated, he said, but experimental
studies do show that even healthy people experience a 4
percent to 5 percent loss of muscle strength
for each week of bed rest and require a prolonged recovery
period. "Although there are many causes
of muscle weakness, getting ICU patients up and moving does
help modify the negative effects of bed
rest," he said.
In the JAMA report, Needham offered an example of the
benefits of early mobility in the case
of a 56-year-old man with severe lung disease admitted to
Johns Hopkins with new kidney failure. The
patient, who had a two-month stay in the medical ICU, was
almost immediately put on a program of
walking laps around the ICU, accompanied by ICU and
rehabilitation staff, while on a ventilator with a
breathing tube in his mouth. Seven months later, after
further rehabilitation in a special facility, the
patient reported that his muscle strength and physical
function continued to improve.
Needham cautions that despite this evidence for early
mobilization, additional research is
needed to more fully understand the best methods for doing
it, and the short-term and long-term
benefits.
Funding support for Needham was provided by the
National Institute of Health and the
Canadian Institutes of Health Research.