Early mobilisation in Intensive Care Units for seriously diseased patients with COVID-19

According to the recommendation of the guideline “Positioning therapy and early mobilization for the prophylaxis or therapy of pulmonary dysfunctions” of the German Society for Anaesthesia and Intensive Care Medicine [1], every patient for whom no exclusion criteria apply should be mobilized algorithm-supported twice daily for 20 minutes each within the first 72 hours after admission to the intensive care unit. The aim is to counteract the negative effects of immobility [1], such as neuromuscular and skeletal atrophy, psychological stress, deconditioning of the cardiovascular system and the respiratory system. An estimated 5% of infected patients become severely ill and often present with a respiratory disease with massive oxygenation disturbance up to respiratory global insufficiency, ARDS (Acute Respiratory Distress Syndrome) [3]. In general, studies show that ARDS has a massive physical and psychological impact on the long-term outcome of patients [4]. Functional limitations such as reduced walking distance and the increased occurrence of depression, anxiety and post-traumatic stress disorder are noted [4]. A permanent cognitive deficit is often the result [4].  In the acute stage, the incidence of delirium is significantly increased [5]. Delir is a neuropsychiatric syndrome with acute confusion, which in itself is a life-threatening condition with significantly increased mortality [5], [6]. Furthermore, ARDS is one of the three decisive risk factors (sepsis and multiorgan dysfunction) [7] for the development of ICUAW (intensive care unit acquired weakness), a neuromuscular organ failure. This results in muscle weakness up to plegia and high mortality [6]. It is precisely these complications that early mobilisation with its evidence-based effects can have a positive influence on [6], [7], [8]. This is most evident in long-term outcome through functional independence in the sense of an independent life [9]. Early mobilisation can also reduce the length of stay in intensive care units [10].  Early mobilisation should therefore not be neglected, especially at the present time when intensive care beds and specialist staff are a scarce resource.

In practice, this means that patients with a pronounced oxygenation disorder (possibly also with extracorporeal membrane oxygenation, ECMO) are regularly placed in the prone position for 16-24 hours to recruit the dorso-basal sections [3]. Once the patients have been turned back and are able to make contact, early mobilisation is started after systematic evaluation in an interdisciplinary team and if no contraindications or exclusion criteria for early mobilisation have been determined. After an activation of the cardiovascular system adapted to the situation, the assisted mobilization into the sitting position begins. This is precisely where the Mobilizer Medior from Reha & Medi can be of assistance. With the Mobilizer, mobilization into the sitting and standing position is possible with low cardiopulmonary resources of the patient. After transfer with the rollboard to the Mobilizer Medior, the patient can be gently and effortlessly raised, positioned in a position that makes breathing easier and supported as needed. With the table attached to the armrests, the upper extremity can be positioned in a breath-relieving position. If necessary, the patient can be stimulated with a vibration under the sole of the foot. It is not unusual for the patient’s vigilance to improve during this process. Initial everyday activities such as independent facial care promote the patient’s own activity. Even with exudative consolidation, a good possibility for secretolysis and expectoration is shown in a sitting position. Early mobilisation is in itself and under optimal circumstances a complex interdisciplinary team task. Even if a lot is demanded of us in this pandemic phase with high patient numbers and complex infection control measures, early mobilisation is a decisive component in the recovery of the patient for a successful return to an independent life!

 

Tobias Giebler, physiotherapist at the University Hospital Tübingen in the field of intensive care medicine

Sources:

  • Bein T, Bischoff M, Brückner U et al. (2015). S2e-Leitlinie: „Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen“, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).
  • Word Health Organisation, (2020) Coronavirus disease 2019 (COVID- 19) Situation 46.
  • Krenek B, Mayerhofer S, Nessizius S, (2020) Leitlinie für Physiotherapie bei COVID-19.
  • Sensen B, Braune S, de Heer G, Bein T, Kluge S. (2017) Life after ARDS.
  • Hsieh SJ, Soto GJ, Hope AA, Ponea A, Gong MN. (2015) The association between acute respiratory distress syndrome, delirium, and in-hospital mortality in intensive care unit patients.
  • Nessizius S, Rottensteiner C, Nydahl P (2017). Frührehabilitation in der Intensivmedizin – Interprofessionelles Management, S. 90-174.
  • Senger, Frank Joachim Erbguth, (2017) Critical-illness-Myopathie und -Polyneuropathie
  • Ponfick M, BöslK, Lüdemann-Podubecka J, Neumann G, Pohl M, Nowak D, Gdynia H.-J. (2014) Erworbene Muskelschwäche des kritisch Kranken.
  • Schweickert WD, Pohlman MC, Pohlman AS et al. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
  • Morris PE, Goad A, Thompson C et al. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

Further literature:

  • Physiotherapeutische Management für COVID 19 im Akutkrankenhaus, Thomas et al (2020)
  • Physiotherapie bei PatientInnen Mit COVID-19, Physio Deutschland (2020)