Effects of Rehabilitation Interventions on Clinical Outcomes in Critically Ill Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

We published a meta-analysis in March 2020 to assess the impact of rehabilitation in the ICU on clinical outcomes. Since then, 15 new randomized controlled trials (RCTs) have been published; we updated the meta-analysis to show how the recent studies have tipped the scale. Systematic review and meta-analysis. An update of secondary data analysis of RCTs published between January 1998 and July 2023 performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Critically ill adults. Cycling exercises or neuromuscular electrical stimulation (NMES) or protocolized physical rehabilitation (PPR) or functional electrical stimulation-assisted cycle ergometry (FESCE) compared with standard of care. Days on a mechanical ventilator, length of stay in ICU and at the hospital, and mortality. We found 15 RCTs (one on cycling, eight on NMES alone, four on PPR, and two on FESCE) into which 2116 patients were randomized. The updated meta-analysis encompasses a total of 5664 patients. The exercise interventions did not influence mortality (odds ratio, 1.00 [0.87-1.14]; n = 53 RCTs) but reduced the duration of mechanical ventilation (mean difference, -1.76 d [-2.8 to -0.8 d]; n = 46) and length of stay in ICU (-1.16 d [-2.3 to 0.0 d]; n = 45). The effects on the length of mechanical ventilation and ICU stay were only significant for the PPR subgroup by a median of -1.7 days (95% CI, -3.2 to -0.2 d) and -1.9 days (95% CI, -3.5 to -0.2 d), respectively. Notably, newly published trials provided consistent results and reduced the overall heterogeneity of these results. None of the rehabilitation intervention strategies being studied influence mortality. Both mechanical ventilation and ICU stay were shortened by PPR, this strengthens the earlier findings as all new RCTs yielded very consistent results. However, no early rehabilitation interventions in passive patients seem to have clinical benefits. Regarding long-term functional outcomes, the results remain inconclusive.

The purpose of this study was to investigate whether a combination of electrical muscle stimulation (EMS) and cycling exercise is beneficial for improving cognitive performance. Eighteen participants (7 females and 11 males) performed a Go/No-Go task before and 2min after i) cycling exercise (EX), ii) a combination of EMS and cycling (EMS + EX) and iii) a control (rest) intervention in a randomized controlled crossover design. In the EX intervention, the participants cycled an ergometer for 20min with their heart rate maintained at ∼120 beats·min-1. In the EMS + EX intervention, the participants cycled an ergometer simultaneously with EMS for 20min, with heart rate maintained at ∼120 beats·min-1. In the Control intervention, the participants remained at rest while seated on the ergometer. Cognitive performance was assessed by reaction time (RT) and accuracy. There was a significant interaction between intervention and time (p = 0.007). RT was reduced in the EX intervention (p = 0.054, matched rank biserial correlation coefficient = 0.520). In the EMS + EX intervention, RT was not altered (p = 0.243, Cohen's d = 0.285) despite no differences in heart rate between the EX and EMS + EX interventions (p = 0.551). RT was increased in the Control intervention (p = 0.038, Cohen's d = -0.529). These results indicate that combining EMS and cycling does not alter cognitive performance despite elevated heart rate, equivalent to a moderate intensity. The present findings suggest that brain activity during EMS with cycling exercise may be insufficient to improve cognitive performance when compared to exercise alone.

Acute respiratory distress syndrome (ARDS) is one of the most organ dysfunctions in sepsis. Although the development of therapeutic strategies such as protective mechanical ventilation technology has improved the mortality of ARDS patients, there is currently no effective drug for reducing the associated mortality. Our study aims to investigate the efficacy, safety, and pharmacoeconomics of sivelestat sodium in patients with septic ARDS, for providing the basis on clinical use of this drug. This was a retrospective study of 140 patients with septic ARDS. Clinical information including general conditions, mechanical ventilation time, drug cost parameters, and adverse reactions. The partial pressure of O2/fraction of inspired oxygen (PaO2/FiO2), acute physiology and chronic health evaluation score (APACHE II score) and sequential organ failure assessment (SOFA score) are for assessing the severity illness. To evaluate the efficacy of sivelestat sodium on septic ARDS patients by comparing length of mechanical ventilation and intensive care unit (ICU) hospitalization, cost of hospitalization and mortality between the two groups. There were no significant differences in the incidence of organ failure, biochemical data, blood gas analysis, acute physiology and chronic health evaluation (APACHE II score), and SOFA score between the two groups on the day of admission. The PaO2/FiO2, APACHE II score, and SOFA score of the sivelestat sodium group were significantly better than in the control group (P<0.05). The length of mechanical ventilation, length of ICU hospitalization, and cost of ICU hospitalization were all lower in the sivelestat sodium group (P<0.05). No adverse events were reported during the study period. Sivelestat sodium significantly improves the oxygenation in patients with septic ARDS, together with reducing mechanical ventilation, ICU hospitalization, and medical costs.

Transitional Percentage of Minute Volume as a Novel Predictor of Weaning from Mechanical Ventilation in Patients with Chronic Respiratory Failure

BackgroundThe present study evaluated the association between participation in a rehabilitation program during a hospital stay and 1-year survival of patients requiring at least 21 days of mechanical ventilation (prolonged mechanical ventilation [PMV]) with various respiratory diseases as their main diagnoses that led to mechanical ventilation.MethodsRetrospective data of 105 patients (71.4% male, mean age 70.1±11.3 years) who received PMV in the past 5 years were analyzed. Rehabilitation included physiotherapy, physical rehabilitation, and dysphagia treatment program that was individually provided by physiatrists.ResultsThe main diagnosis leading to mechanical ventilation was pneumonia (n=101, 96.2%) and the 1-year survival rate was 33.3% (n=35). One-year survivors had lower Acute Physiology and Chronic Health Evaluation (APACHE) II score (20.2±5.8 vs. 24.2±7.5, p=0.006) and Sequential Organ Failure Assessment score (6.7±5.6 vs. 8.5±2.7, p=0.001) on the day of intubation than non-survivors. More survivors participated in a rehabilitation program during their hospital stays (88.6% vs. 57.1%, p=0.001). The rehabilitation program was an independent factor for 1-year survival based on the Cox proportional hazard model (hazard ratio, 3.513; 95% confidence interval, 1.785 to 6.930; p<0.001) in patients with APACHE II scores ≤23 (a cutoff value based on Youden’s index).ConclusionOur study showed that participation in a rehabilitation program during hospital stay was associated with an improvement of 1-year survival of PMV patients who had less severe illness on the day of intubation.

IntroductionHand osteoarthritis (OA) is associated with pain, reduced grip strength, loss of range of motion and joint stiffness leading to impaired hand function and difficulty with daily activities. The effectiveness of different rehabilitation interventions on specific treatment goals has not yet been fully explored. The objective of this systematic review is to provide evidence based knowledge on the treatment effects of different rehabilitation interventions for specific treatment goals for hand OA.MethodsA computerized literature search of Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ISI Web of Science, the Physiotherapy Evidence Database (PEDro) and SCOPUS was performed. Studies that had an evidence level of 2b or higher and that compared a rehabilitation intervention with a control group and assessed at least one of the following outcome measures - pain, physical hand function or other measures of hand impairment - were included. The eligibility and methodological quality of trials were systematically assessed by two independent reviewers using the PEDro scale. Treatment effects were calculated using standardized mean difference and 95% confidence intervals.ResultsTen studies, of which six were of higher quality (PEDro score >6), were included. The rehabilitation techniques reviewed included three studies on exercise, two studies each on laser and heat, and one study each on splints, massage and acupuncture. One higher quality trial showed a large positive effect of 12-month use of a night splint on hand pain, function, strength and range of motion. Exercise had no effect on hand pain or function although it may be able to improve hand strength. Low level laser therapy may be useful for improving range of motion. No rehabilitation interventions were found to improve stiffness.ConclusionsThere is emerging high quality evidence to support that rehabilitation interventions can offer significant benefits to individuals with hand OA. A summary of the higher quality evidence is provided to assist with clinical decision making based on current evidence. Further high-quality research is needed concerning the effects of rehabilitation interventions on specific treatment goals for hand OA.

BackgroundChronic obstructive pulmonary disease (COPD) represents a significant reason for mortality and morbidity worldwide that induces a high socioeconomic burden, with exacerbations necessitating mechanical ventilation representing a major aspect of illness management. Many patients with COPD frequently presented with troubles in the liberation from mechanical ventilation. The aim of the current study was to verify the validity of the weaning categorization that is classified according to the difficulty and length of the weaning procedure in mechanically ventilated patients with COPD and its effect on the different clinical and mortality outcome variables.Patients and methodsA total of 102 patients with COPD who achieved the weaning criteria were classified according to the length and difficulty of weaning procedure into simple weaning group (n=60, 58.8%) and nonsimple weaning group (which include difficult and prolonged weaning categories) (n=42, 42.2%). The outcome measures are the length of mechanical ventilation, the duration of ICU stay, and lastly the mortality rate.ResultsRegarding baseline data recorded at admission, no significant difference between both weaning groups was found apart from Acute Physiology and Chronic Health Evaluation score II. The nonsimple weaning group had considerably higher duration of invasive mechanical ventilation, length of ICU stays, and lastly the mortality rate, in comparison with the simple weaning group.ConclusionWeaning categorization according to the length and the difficulty of the weaning procedure may be used as a suitable predictor of outcome in severe COPD exacerbation with the requirement for invasive mechanical ventilation.

The primary aim of this study was to investigate the functional, physiological and subjective responses to NMES exercise in cancer patients. Participants with a cancer diagnosis, currently undergoing treatment, and an had an Eastern Cooperative Oncology Group (ECOG) performance status (ECOG) of 1 and 2 were recommended to participate by their oncologist. Following a 2-week, no-NMES control period, each participant was asked to undertake a concurrent NMES exercise intervention over a 4-week period. Functional muscle strength [30 s sit-to-stand (30STS)], mobility [timed up and go (TUG)], exercise capacity [6-min walk test (6MWT)] and health related quality of life (HR-QoL) were assessed at baseline 1 (BL1), 2-week post control (BL2) and post 4-week NMES exercise intervention (POST). Physiological and subjective responses to LF-NMES were assessed during a 10-stage incremental session, recorded at BL2 and POST. Fourteen participants [mean age: 62 years (10)] completed the intervention. No adverse events were reported. 30STS (+ 2.4 reps, p = .007), and 6MWT (+ 44.3 m, p = .028) significantly improved after the intervention. No changes in TUG or HR-QoL were observed at POST. Concurrent NMES exercise may be an effective exercise intervention for augmenting physical function in participants with cancer and moderate and poor functional status. Implications for cancer survivors: By allowing participants to achieve therapeutic levels of exercise, concurrent NMES may be an effective supportive intervention in cancer rehabilitation.

Osteoarthritis year in review: rehabilitation

Background Mechanical ventilation is typically required for ICU patients as part of their care. This recommends the use of analgesia and sedation in a balanced strategy to alter patients’ comfort and assist synchronization with mechanical ventilation while avoiding the downsides of excessive sedation. Objective The aim of the study was to compare between deep sedation and light sedation, analgesia, and no sedation strategies and their effects on the length of mechanical ventilation, and their effects on patients’ prognosis. Patients and methods This cohort prospective pilot study was conducted at the medical respiratory ICU at Ain Shams University Hospital in Cairo, Egypt, on 54 patients separated into four groups according to the type of sedation and analgesia suited for each patient’s severity condition. Results In this study, 54 mechanically ventilated patients in respiratory ICU were recruited. The patients were divided into group 1: no sedation or analgesia, group 2: analgesia only, group 3: light sedation, and group 4: deep sedation. There was a significant difference in Acute Physiology and Chronic Health Evaluation score and severity%, although the Acute Physiology and Chronic Health Evaluation score and severity % were the highest in group 1 (25.53, 55.11%) and group 4 (23.40, 47.68%), but the prognosis was poorer in group 4 and was affected by deep sedation (100% death rate) than that in group 1 (60.0%). The average infusion rate of fentanyl and the total dose were significantly different between groups, the highest being in the deep sedation group. ICU length of stay was nonsignificant between groups but it was lower in group 4 (median: 9 days) than other groups. The average rate of dormicum infusion in the deep sedation group was 5 µg, while there was no daily vacation period; so, it can be explained that higher doses of sedation and analgesia in group 4 affected their prognosis to be poorer than other groups. Delirium occurred in 80% of group 4 patients, but only in 6.7% of subgroups, indicating a highly significant difference. Complications either metabolic, cardiac, or hematologic in the postextubation period were higher in group 4 (60%), than in group 1 (47.7%), group 2 (40%), and group 3 (15%). Conclusion Light sedation and analgesia strategies with daily sedation interruption would have a better survival outcome and cause fewer issues in patients, who were on mechanical ventilation than a heavy sedation approach.

Meeting the needs of patients' family members becomes an essential part of responsibilities of intensive care unit physicians. The aim of this study was to evaluate the satisfaction of patients' family members using the Arabic version of the Society of Critical Care Medicine's Family Needs Assessment questionnaire and to assess the predictors of family satisfaction using the classification and regression tree method. The authors conducted a prospective study. This study was conducted at a 12-bed medical intensive care unit in Morocco. Family representatives (n = 194) of consecutive patients with a length of stay >48 hrs were included in the study. Intervention was the Society of Critical Care Medicine's Family Needs Assessment questionnaire. Demographic data for relatives included age, gender, relationship with patients, education level, and intensive care unit commuting time. Clinical data for patients included age, gender, diagnoses, intensive care unit length of stay, Acute Physiology and Chronic Health Evaluation, MacCabe index, Therapeutic Interventioning Scoring System, and mechanical ventilation. The Arabic version of the Society of Critical Care Medicine's Family Needs Assessment questionnaire was administered between the third and fifth days after admission. Of family representatives, 81% declared being satisfied with information provided by physicians, 27% would like more information about the diagnosis, 30% about prognosis, and 45% about treatment. In univariate analysis, family satisfaction (small Society of Critical Care Medicine's Family Needs Assessment questionnaire score) increased with a lower family education level (p = .005), when the information was given by a senior physician (p = .014), and when the Society of Critical Care Medicine's Family Needs Assessment questionnaire was administered by an investigator (p = .002). Multivariate analysis (classification and regression tree) showed that the education level was the predominant factor contributing to the Society of Critical Care Medicine's Family Needs Assessment questionnaire score. Society of Critical Care Medicine's Family Needs Assessment questionnaire increased (greater satisfaction) with a higher education level. Other factors of great satisfaction included the senior physician providing the information, and Acute Physiology and Chronic Health Evaluation <15. Satisfaction of intensive care unit patients' families in a Moroccan sample using the classification and regression tree was dependent on relatives' education level, communication presented by senior caregiver, and low Acute Physiology and Chronic Health Evaluation score. These data underline cultural specificities of the study and suggest that caregivers should develop structured communication programs considering satisfaction predictors.

Ambulation of patients with acute respiratory failure may be unnecessarily limited in the acute intensive care setting. We hypothesized that ambulation of patients with acute respiratory failure would increase with transfer to an intensive care unit where activity is a key component of patient care. Pre-post cohort study of respiratory failure patients. Adult intensive care units at LDS Hospital. Respiratory failure patients requiring >4 days of mechanical ventilation who were transferred from other LDS Hospital intensive care units to the respiratory intensive care unit. We prospectively applied an early activity protocol to all consecutive respiratory failure patients transferred to the respiratory intensive care unit. We studied 104 respiratory failure patients who required mechanical ventilation for >4 days. Transferring a patient to the respiratory intensive care unit substantially increased the probability of ambulation (p < .0001). After 2 days in the respiratory intensive care unit, the number of patients ambulating had increased three-fold compared with pretransfer rates. Female gender (p = .019), the absence of sedatives (p = .009), and lower Acute Physiology and Chronic Health Evaluation II scores (p = .017) also predicted an increased probability of ambulation. Improvements in ambulation with transfer to the respiratory intensive care unit remained significant after adjustment for Acute Physiology and Chronic Health Evaluation II scores and other covariates. Transfer of acute respiratory failure patients to the respiratory intensive care unit substantially improved ambulation, independent of the underlying pathophysiology. The intensive care environment may contribute unnecessary immobilization throughout the course of acute respiratory failure. Sedatives, even given intermittently, substantially reduce the likelihood of ambulation. Controlled studies are needed to determine whether intensive care unit immobilization contributes to long-term neuromuscular dysfunction or whether early intensive care unit activity improves outcomes.

Background:Hypoalbuminemia is associated with fluid overload, the development of acute respiratory distress syndrome, and mortality. The co-administration of albumin and diuretics for the treatment of patients with hypoalbuminemia is expected to increase urine output, without hemodynamic instability, and improve pulmonary function; however, these effects have not been systematically investigated. Here, we aimed to clarify the benefits of the co-administration of albumin and diuretics in mechanically ventilated patients.Methods:We searched for randomized, placebo-controlled trials that investigated the effects of the co-administration of albumin and diuretics compared with placebo and diuretics, in mechanically ventilated patients with hypoalbuminemia. We searched these trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, and EMBASE databases. Primary outcomes were hypotensive events after the intervention, all-cause mortality, and the length of mechanical ventilation. Secondary outcomes were improvement in the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (P/F ratio) at 24 hours, total urine output (mL/d), and the clinical requirement of renal replacement therapy (RRT).Results:From the 1574 records identified, we selected 3 studies for quantitative analysis. The results of albumin administration were as follows: hypotensive events (risk ratio [RR] −1.05 [95% confidence interval {CI}: 0.15–0.81]), all-cause mortality (RR 1.0 [95% CI: 0.45–2.23]), the length of mechanical ventilation in days (mean difference −1.05 [95% CI: −3.35 to 1.26]), and improvement in P/F ratio (RR 2.83 [95% CI: 1.42–5.67]). None of the randomized controlled trials reported the total urine output, and one reported that no participants required RRT. Adverse events were not reported during the trials. The certainty of evidence was low (in the hypotensive events after the intervention and all-cause mortality) to moderate (in the length of mechanical ventilation in days, improvement of P/F ratio, clinical requirement of RRT, and adverse events).Conclusions:Although this treatment combination reduced the number of days for which mechanical ventilation was required, it did not reduce the all-cause mortality at 30 days. In conclusion, the co-administration of albumin and diuretics may reduce hypotensive events and improve the P/F ratio at 24 hours.

IntroductionIn the past two decades, healthcare adopted industrial strategies for process measurement and control. In the industry model, care is taken to avoid minimal deviations from a standard. In healthcare there is scarce data to support that a similar strategy can lead to better outcomes. Briefly, when compliance is high, further attempts to improve uptake of a process are seldom made. Our intensive care unit (ICU) improved the compliance with minimizing sedation from a high baseline of 80.4% (95% CI: 66.9 to 90.2) to 96.2% (95% CI: 95.2 to 97.0) 12 months after a quality improvement initiative. We sought to measure whether this minute improvement in compliance led to a reduction in duration of mechanical ventilation.MethodsWe collected data on compliance with the process during 12 months. A trained data collector abstracted data from charts every other day. Our database contains data for length of mechanical ventilation, mortality, type of admission, and acute physiology and chronic health evaluation (APACHE) II scores for the 12 months before and after the process improvement.To control for secular trends we used an interrupted-time series with adjustment for auto-correlation. We calculated the expected length of mechanical ventilation on each month by the end of the intervention period, and calculated the fitted value for the post-intervention months.ResultsWe included 1556 patients. There was an immediate effect of the intervention (regression coefficient = -0.129, P value < 0.001) and the secular trend was a determinant of length of mechanical ventilation (regression coefficient = 0.010, P value = 0.004). The trend post-intervention was not significant (regression coefficient = 0.004, P value = 0.380).The relative change in the length of mechanical ventilation was 14.5% (IQR 13.8% to 15.8%) and the total expected decrease in mechanical ventilation days was 502.7 days (95% CI 300.9 to 729.1) over one year.ConclusionsIn a system already working at high levels of compliance, outcomes can still be improved. Our intervention was successful in reducing the length of mechanical ventilation. ICUs should have a process of quality assurance in place to provide constant monitoring of key quality of care processes and correct deviations from the proposed standard.

Forward This document aims to summarize the current literature guiding the use of red cell transfusion in critically ill patients and provides recommendations to support clinicians in their day-to-day practice. Critically ill patients differ in their age, diagnosis, co-morbidities, and severity of illness. These factors influence their tolerance of anaemia and alter the risk to benefit ratio of transfusion. The optimal management for an individual may not fall clearly within our recommendations and each decision requires a synthesis of the available evidence and the clinical judgment of the treating physician. This guideline relates to the use of red cells to manage anaemia during critical illness when major haemorrhage is not present. A previous British Committee for Standards in Haematology (BCSH) guideline has been published on massive haemorrhage (Stainsby et al, 2006), but this is a rapidly changing field. We recommend readers consult recent guidelines specifically addressing the management of major haemorrhage for evidence-based guidance. A subsequent BCSH guideline will specifically cover the use of plasma components in critically ill patients.