Oct. 16, 2008 A critical care specialist at Johns Hopkins who has reviewed recent studies of intensive care unit (ICU) 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," says Dale Needham, M.D., Ph.D., assistant professor in the Division of Pulmonary and Critical Care Medicine and Department of Physical Medicine and Rehabilitation at the Johns Hopkins University 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 (JAMA), 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 medical intensive care unit.
A 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 Needham 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 for these critically ill patients.
Needham also based his comments on experience with patients at The Johns Hopkins Hospital medical intensive care unit, where a new physical medicine and rehabilitation program has been developed for ICU patients.
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 in ICUs. 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 says, 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 says.
In the JAMA report, Needham offered one 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 with accompanying 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.
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