Early Mobilization in the ICU: An Update

Abstract

Over the past 10 to 15 years, a culture shift in ICU care has occurred at several leading institutions across the United States. The traditional model of deep anesthesia with prolonged bedrest in mechanically ventilated patients has been replaced with a model of minimal sedation with early mobilization.1 In 2000, Kress reported a landmark study addressing sedation minimization by daily interruption of sedative infusions in mechanically ventilated patients. This study evaluated 128 adult patients who were mechanically ventilated and received continuous sedative infusion; the intervention group (who received daily sedation holidays) had a decrease in duration of mechanical ventilation of 2.4 days per patient in comparison to the control group (interruptions in sedation at the discretion of the attending physician) and a decrease in length of ICU stay by 3.5 days per patient.2 This contributed to an ICU culture change over the next decade, in which more intensive efforts to minimize sedation were made. In a follow-up study published in JAMA in 2012, daily sedation holidays were re-examined by comparing daily sedation interruption combined with a protocol based sedation strategy (designed to reduce overall sedation) to a protocol based sedation strategy alone. In this study, neither the duration of mechanical ventilation nor length of ICU stay was reduced by the addition of daily sedation interruption. The authors concluded that this likely reflected positively on the change in sedation strategy over 10 years following the initial study by Kress. Rather than the usual care of deep sedation in mechanically ventilated patients that resulted in a clinical benefit from daily sedation interruption, the more current model of global sedation minimization now negated the previous beneficial effects of daily sedation interruption.3