Therapie & Praxis
Case reports on early mobilisation in intensive care units
Discover how interdisciplinary teams in ICUs are applying early mobilisation to accelerate recovery, reduce complications, and support critically ill patients. Explore two inspiring case reports and gain insight into practical implementation.
Tobias Giebler
Intensive care medicine and neurosurgery expert, Tübingen University Hospital
A practical excursion into early mobilisation in intensive care to disseminate scientific findings from everyday intensive care therapy.
In recent years and issues of THERAPY, the topic of early mobilisation in intensive care units has been considered many times from different angles. A systematic review with meta-analysis by Wang et al [1] – published in the International Journal of Nursing Studies in 2020 – provides a succinct summary of the effects of early mobilisation of patients requiring intensive care and confirmation of the benefits.
Results:
• 2.1 fewer ventilation days
• 2.7 fewer days in ICU
• length of hospital stay reduced by 3.7 days
• 12% more muscle power
• 13% more independent in terms of care
Included were 39 studies with a total of 3,837 patients.
The issue of safety is also a barrier for more complex intensive care patients who need to be treated with extracorporeal membrane oxygenation (ECMO). Although research suggests good feasibility with low risk [2]. Even in far less complex cases, accesses such as oral intubation can be a barrier to mobilisation from bed in clinical practice [3]. A systematic review with meta-analysis [4] shows that early mobilisation is safe to carry out. In 22,351 mobilisations, there were only 2.6% adverse events such as blood pressure changes and oxygen saturation drops. Only 0.3% entailed a consequence, such as an increase in blood pressure-raising medication. This 0.3% already includes complications with airway access. In a little over 22,000 mobilisations, there was an accidental extubation in only two cases – this corresponds to just 0.01%. This is unpleasant and possibly dramatic for the individual. In the overall picture, however, the opportunities and advantages of early mobilisation outweigh the disadvantages, which have a low probability of occurrence.
A shorter time span between knowledge and transfer to everyday clinical practice (knowledge-to-action gap) would be welcome. Unfortunately, it takes an average of 17 years for evidence in medicine to be consistently implemented in practice [5].
To stimulate the discourse and accelerate the transfer, I would like to present our implementation efforts on the following pages using practical examples. This is without any claim to achieving perfection and exhausting all possibilities.
• 2.1 fewer ventilation days
• 2.7 fewer days in ICU
• length of hospital stay reduced by 3.7 days
• 12% more muscle power
• 13% more independent in terms of care
Included were 39 studies with a total of 3,837 patients.
The issue of safety is also a barrier for more complex intensive care patients who need to be treated with extracorporeal membrane oxygenation (ECMO). Although research suggests good feasibility with low risk [2]. Even in far less complex cases, accesses such as oral intubation can be a barrier to mobilisation from bed in clinical practice [3]. A systematic review with meta-analysis [4] shows that early mobilisation is safe to carry out. In 22,351 mobilisations, there were only 2.6% adverse events such as blood pressure changes and oxygen saturation drops. Only 0.3% entailed a consequence, such as an increase in blood pressure-raising medication. This 0.3% already includes complications with airway access. In a little over 22,000 mobilisations, there was an accidental extubation in only two cases – this corresponds to just 0.01%. This is unpleasant and possibly dramatic for the individual. In the overall picture, however, the opportunities and advantages of early mobilisation outweigh the disadvantages, which have a low probability of occurrence.
A shorter time span between knowledge and transfer to everyday clinical practice (knowledge-to-action gap) would be welcome. Unfortunately, it takes an average of 17 years for evidence in medicine to be consistently implemented in practice [5].
To stimulate the discourse and accelerate the transfer, I would like to present our implementation efforts on the following pages using practical examples. This is without any claim to achieving perfection and exhausting all possibilities.
Case study 1
Ms G. was found unconscious at the bottom of her stairs after the fire and rescue service had gained entry to her flat in the early evening. A neighbour had raised the alarm. The pattern of injury and body temperature suggested that Ms G. had fallen down about 8 steps and must have been lying on the ground for quite a while before the emergency services arrived. Her body temperature was initially at 25 degrees, her heart rate had slowed down and her blood pressure was low.
Intubated and completely immobilised, the patient arrived at the hospital by helicopter in the late afternoon.
Ms G. was found unconscious at the bottom of her stairs after the fire and rescue service had gained entry to her flat in the early evening. A neighbour had raised the alarm. The pattern of injury and body temperature suggested that Ms G. had fallen down about 8 steps and must have been lying on the ground for quite a while before the emergency services arrived. Her body temperature was initially at 25 degrees, her heart rate had slowed down and her blood pressure was low.
Intubated and completely immobilised, the patient arrived at the hospital by helicopter in the late afternoon.
Findings from the trauma room:
• minor trauma from “long lie”
• head laceration
• multiple rib fractures on the right, bilateral pleural effusion, bibasilar atelectasis
• minor trauma from “long lie”
• head laceration
• multiple rib fractures on the right, bilateral pleural effusion, bibasilar atelectasis
Preliminary findings:
• hypertension
• decompensation with shortness of breath associated with pleural effusions
• multiple bilateral thoracocentesis. Effusions of unclear cause with chronic inflammation
• medicated and regularly monitored
Admission to intensive care occurred in the late evening. The patient was intubated and required circulatory support medication..
• hypertension
• decompensation with shortness of breath associated with pleural effusions
• multiple bilateral thoracocentesis. Effusions of unclear cause with chronic inflammation
• medicated and regularly monitored
Admission to intensive care occurred in the late evening. The patient was intubated and required circulatory support medication..
Early mobilisation:
In the morning around 8:30 am, the patient was back to normal temperature, but still needed circulatory support medication, was still intubated and required assisted ventilation. Stimulation.
In the morning around 8:30 am, the patient was back to normal temperature, but still needed circulatory support medication, was still intubated and required assisted ventilation. Stimulation.
A shorter time span between knowledge and transfer to everyday clinical practice (knowledge-to-action gap) would be welcome.
The patient responded in an untargeted way to loud and clear speech in combination with tactile stimulation. In the interdisciplinary team, consisting of doctors, nursing staff and therapists, no contraindications for early mobilisation were determined. The daily goal was activation and mobilisation as far as possible from the bed. If possible, the patient was to be activated and her vigilance promoted to such an extent that extubation, the removal of the breathing tube, could become a possibility.
The following measures were carried out in the first early mobilisation unit:
• speaking to the patient, personal introduction and explaining the situation and goals of the therapy session;
• activating, body-oriented movement of the extremities;
• promoting vigilance by jointly washing the face using a cold flannel and wiping the mouth with a damp swab.
• speaking to the patient, personal introduction and explaining the situation and goals of the therapy session;
• activating, body-oriented movement of the extremities;
• promoting vigilance by jointly washing the face using a cold flannel and wiping the mouth with a damp swab.
Ms G. became more alert during these measures and followed individual prompts – it became increasingly possible to communicate with her using head movements and she answered simple questions.
After activation, the patient was placed at the edge of the bed with the support of the nursing staff and a physiotherapist. In addition to further activation measures, communication with Ms G. was further intensified. The aim was for Ms G. to feel well cared for, protected and safe, in addition to the cognitive stimulation. Building on this, exercises were completed to improve sitting stability. After a few minutes, Ms G. required only minimal support to sit. It was clear from her behaviour that she was in pain. In addition to the respiratory pain from the rib fractures, she reported pain throughout her body, presumably from the fall. A painkiller was administered – also as a basis for the next step, respiratory therapy.
The focus now turned towards respiratory therapy – the aim being to open the areas of atelectasis (collapsed lung areas) and optimally prepare the patient for extubation. This released secretions from the lungs, which could then be coughed up and suctioned. Ms G. was then transferred back to bed and placed in the cardiac chair position. With improved alertness, protective reflexes and respiratory gases, the patient was extubated a short time later.
During the second early mobilisation (on the same day), Ms G. was awake and followed simple prompts. She was not oriented in all spheres but remained friendly and approachable. With support, she was mobilised to the edge of the bed once again and performed the first exercises with a breathing trainer. She then stood in front of the bed with support on both sides. After a short break sitting down, she was able to walk the first 20 metres on the high walking frame with a lot of support. To do this, she only needed 3 litres of oxygen administered through a nasal cannula. Afterwards, Ms G. remained sitting mobilised in a wheelchair. This is beneficial in this situation for both lung function and cognition.
Ms G. was then transferred to a normal ward on the same day.
After activation, the patient was placed at the edge of the bed with the support of the nursing staff and a physiotherapist. In addition to further activation measures, communication with Ms G. was further intensified. The aim was for Ms G. to feel well cared for, protected and safe, in addition to the cognitive stimulation. Building on this, exercises were completed to improve sitting stability. After a few minutes, Ms G. required only minimal support to sit. It was clear from her behaviour that she was in pain. In addition to the respiratory pain from the rib fractures, she reported pain throughout her body, presumably from the fall. A painkiller was administered – also as a basis for the next step, respiratory therapy.
The focus now turned towards respiratory therapy – the aim being to open the areas of atelectasis (collapsed lung areas) and optimally prepare the patient for extubation. This released secretions from the lungs, which could then be coughed up and suctioned. Ms G. was then transferred back to bed and placed in the cardiac chair position. With improved alertness, protective reflexes and respiratory gases, the patient was extubated a short time later.
During the second early mobilisation (on the same day), Ms G. was awake and followed simple prompts. She was not oriented in all spheres but remained friendly and approachable. With support, she was mobilised to the edge of the bed once again and performed the first exercises with a breathing trainer. She then stood in front of the bed with support on both sides. After a short break sitting down, she was able to walk the first 20 metres on the high walking frame with a lot of support. To do this, she only needed 3 litres of oxygen administered through a nasal cannula. Afterwards, Ms G. remained sitting mobilised in a wheelchair. This is beneficial in this situation for both lung function and cognition.
Ms G. was then transferred to a normal ward on the same day.
Case study 2
Mr H. is 19 years old and had been ill for 12 days. At first with a headache, then from the second day onwards with a fever and increasing listlessness, as well as a cough. Further deterioration of his general condition led to hospitalisation. The initial therapy with oxygen and non-invasive ventilation (NIV) with a mask was no longer sufficient, so intubation (insertion of a breathing tube) was indicated. Progressive lung failure occurred even under intensified mechanical ventilation. Contact was made with an ECMO centre and the subsequent implantation of an ECMO by specialists. Mr H. was then admitted to the intensive care unit for further therapy.
Mr H. is 19 years old and had been ill for 12 days. At first with a headache, then from the second day onwards with a fever and increasing listlessness, as well as a cough. Further deterioration of his general condition led to hospitalisation. The initial therapy with oxygen and non-invasive ventilation (NIV) with a mask was no longer sufficient, so intubation (insertion of a breathing tube) was indicated. Progressive lung failure occurred even under intensified mechanical ventilation. Contact was made with an ECMO centre and the subsequent implantation of an ECMO by specialists. Mr H. was then admitted to the intensive care unit for further therapy.
Diagnoses:
• severe ARDS (lung failure) with septic shock associated with:
• pneumococcal pneumonia (bacterial pneumonia)
• influenza A detection (flu)
• ventilation requirement
• VV ECMO (veno-venous ECMO = pure lung replacement)
• prone therapy
• pleural empyema on the right (collection of pus in the pleural space)
• surgical therapy: VATS (video-assisted thoracoscopic surgery = minimally invasive surgery in the thorax) on the right, pleurolysis, haematoma evacuation
• repeat VATS for haematothorax (blood in the thoracic cavity)
• severe ARDS (lung failure) with septic shock associated with:
• pneumococcal pneumonia (bacterial pneumonia)
• influenza A detection (flu)
• ventilation requirement
• VV ECMO (veno-venous ECMO = pure lung replacement)
• prone therapy
• pleural empyema on the right (collection of pus in the pleural space)
• surgical therapy: VATS (video-assisted thoracoscopic surgery = minimally invasive surgery in the thorax) on the right, pleurolysis, haematoma evacuation
• repeat VATS for haematothorax (blood in the thoracic cavity)
As the disease progressed:
• acute renal failure requiring dialysis
Secondary diagnoses:
• prior Covid-19 infection with only minor impairment of general condition
• acute renal failure requiring dialysis
Secondary diagnoses:
• prior Covid-19 infection with only minor impairment of general condition
Early mobilisation:
Due to the pronounced lung failure, Mr H. was initially placed in the prone position but could be mobilised. In the morning around 8:30 am at the interdisciplinary meeting, the patient was still in the prone position. A minimally invasive video-assisted surgery (VATS) to relieve the purulent collection in the area of the right lung was planned for that day. An initial early mobilisation in bed from prone position with a focus on respiratory therapy was arranged and carried out.
At the interdisciplinary early consultation on the following day, there were no contraindications for mobilisation of the patient. The goal was that the patient should be able to stand in front of the bed and take his first steps on the spot by the end of the week. Remaining prone for 16 hours and a sedation interruption were planned to allow mobilisation to the edge of the bed. In order to be able to provide Mr H. with optimal psychological support in his situation, his mother was brought in for mobilisation. As a trusted person, his mother was able to provide practical support for this strenuous process. Mr H. was awake on the breathing tube at the time of early mobilisation and communicated by making small movements with his head. He seemed oriented and motivated. The situation and therapy goals were clarified and agreed together with his mother. The patient cooperated well with the preparatory assistive movement of the extremities. He was also able to spontaneously support the transfer to the edge of the bed. Mr H. seemed tense and frightened in view of the overall situation and the number of staff in attendance. At this time, an intensive care nurse, a doctor, the patient’s mother and two physiotherapists were in the room to facilitate mobilisation under ventilation, ECMO and dialysis therapy.
Mr H. needed to be stabilised in his seat. He was supported in straightening up, and respiratory therapy measures were carried out. Massive amounts of secretions were loosened, coughed up and suctioned. The transfer back to bed took place after a few minutes – Mr H. needed to cough a lot and this affected the ECMO therapy. The patient was also exhausted. A short time later, he was placed in the prone position again to optimise the situation of his lungs.
The following day, the aim was to mobilise the patient to the edge of the bed. In addition to respiratory therapy, the patient’s independence in terms of movement transitions and sitting stability was to be enhanced – this was the outcome of the early consultation.
Unfortunately, Mr H. was not awake during the sedation interruption and was – even after intensive stimulation with cold stimuli – so lacking in awareness that mobilisation was not possible.
Due to the pronounced lung failure, Mr H. was initially placed in the prone position but could be mobilised. In the morning around 8:30 am at the interdisciplinary meeting, the patient was still in the prone position. A minimally invasive video-assisted surgery (VATS) to relieve the purulent collection in the area of the right lung was planned for that day. An initial early mobilisation in bed from prone position with a focus on respiratory therapy was arranged and carried out.
At the interdisciplinary early consultation on the following day, there were no contraindications for mobilisation of the patient. The goal was that the patient should be able to stand in front of the bed and take his first steps on the spot by the end of the week. Remaining prone for 16 hours and a sedation interruption were planned to allow mobilisation to the edge of the bed. In order to be able to provide Mr H. with optimal psychological support in his situation, his mother was brought in for mobilisation. As a trusted person, his mother was able to provide practical support for this strenuous process. Mr H. was awake on the breathing tube at the time of early mobilisation and communicated by making small movements with his head. He seemed oriented and motivated. The situation and therapy goals were clarified and agreed together with his mother. The patient cooperated well with the preparatory assistive movement of the extremities. He was also able to spontaneously support the transfer to the edge of the bed. Mr H. seemed tense and frightened in view of the overall situation and the number of staff in attendance. At this time, an intensive care nurse, a doctor, the patient’s mother and two physiotherapists were in the room to facilitate mobilisation under ventilation, ECMO and dialysis therapy.
Mr H. needed to be stabilised in his seat. He was supported in straightening up, and respiratory therapy measures were carried out. Massive amounts of secretions were loosened, coughed up and suctioned. The transfer back to bed took place after a few minutes – Mr H. needed to cough a lot and this affected the ECMO therapy. The patient was also exhausted. A short time later, he was placed in the prone position again to optimise the situation of his lungs.
The following day, the aim was to mobilise the patient to the edge of the bed. In addition to respiratory therapy, the patient’s independence in terms of movement transitions and sitting stability was to be enhanced – this was the outcome of the early consultation.
Unfortunately, Mr H. was not awake during the sedation interruption and was – even after intensive stimulation with cold stimuli – so lacking in awareness that mobilisation was not possible.
In the interdisciplinary team, consisting of doctors, nursing staff and therapists, no contraindications for early mobilisation were determined.
Following a further interdisciplinary consultation, an early mobilisation in bed took place. With the goal remaining unchanged and after a prolonged wake-up phase, the situation the next day was as follows. Mr H. was awake but not oriented. He didn’t know where he was or what was happening. He was greatly troubled by the breathing tube and tried to pull at it when he was not distracted. Here, too, his mother had a calming effect. She once again provided support during mobilisation. His lung situation had already improved somewhat in the meantime.
Mr H. was mobilised at the edge of the bed with the support of nursing and physiotherapy staff. Exercises were carried out to improve spatial perception. As a consequence, Mr H. regained a feeling for gravity.
Support in the seat could be reduced. Furthermore, attempts were made to support Mr H. in his orientation and to explain his current situation to him. His mother was not only an enormous help but also the main communicator. The last step was breathing therapy, along with the application of a hot towel roll. After about 15 minutes of sitting on the edge of the bed, Mr H. was exhausted and the mobilisation was stopped.
Mr H. was mobilised at the edge of the bed with the support of nursing and physiotherapy staff. Exercises were carried out to improve spatial perception. As a consequence, Mr H. regained a feeling for gravity.
Support in the seat could be reduced. Furthermore, attempts were made to support Mr H. in his orientation and to explain his current situation to him. His mother was not only an enormous help but also the main communicator. The last step was breathing therapy, along with the application of a hot towel roll. After about 15 minutes of sitting on the edge of the bed, Mr H. was exhausted and the mobilisation was stopped.
As treatment progressed, this was supplemented by regular training with the bed bike to optimally support muscle development and strength in terms of standing and walking ability.
Mr H. was regularly mobilised into a sitting position over the following days, with the same objective. His lung situation increasingly improved. He was still kept in the prone position for at least 16 hours and mobilised during the sedation interruptions. Mr H. was increasingly oriented and motivated during therapy. He quickly regained skills such as turning independently to the side position, transferring to the edge of the bed and sitting freely. Mr H was able to write down the things he wanted to say, allowing for communication. Tolerance of the breathing tube remained difficult. The stress for Mr H. and his mother was enormous – during a joint round it was decided to bring in the psychosocial service in a support role. In addition, the second therapy session was often used to promote relaxation by means of a hot towel roll, among other things – usually in combination with breathing therapy. By day 8, the lung situation had improved to such an extent that the lung could fully take over gaseous exchange once again and the ECMO was explanted. The following day, another minimally invasive operation had to be performed on the thorax. Blood had accumulated in the thorax after the operation.
After just over a week, the agreed early mobilisation goal finally came into focus: Mr H. was ready to be mobilised to the standing position. The breathing tube was still the biggest hurdle. Nevertheless, the goal was achievable. In the presence of his mother, Mr H. managed to stand in front of the bed three times. His knees were still unstable, but the first attempts to stand were successful. First steps on the spot were possible with support. Mr H. repeatedly gave a “thumbs up” sign and was pleased with his success. In addition, as treatment progressed, Mr H. received regular training with the bed bike to optimally support muscle development and strength in terms of standing and walking ability. In the days that followed, there was sustained improvement in his lung situation. Mr H. was extubated and verbal communication was finally possible. Mr H. stood in front of the bed and could be transferred to the wheelchair by taking steps. A milestone had been reached.
The following day, Mr H. was transferred to a normal ward.
After just over a week, the agreed early mobilisation goal finally came into focus: Mr H. was ready to be mobilised to the standing position. The breathing tube was still the biggest hurdle. Nevertheless, the goal was achievable. In the presence of his mother, Mr H. managed to stand in front of the bed three times. His knees were still unstable, but the first attempts to stand were successful. First steps on the spot were possible with support. Mr H. repeatedly gave a “thumbs up” sign and was pleased with his success. In addition, as treatment progressed, Mr H. received regular training with the bed bike to optimally support muscle development and strength in terms of standing and walking ability. In the days that followed, there was sustained improvement in his lung situation. Mr H. was extubated and verbal communication was finally possible. Mr H. stood in front of the bed and could be transferred to the wheelchair by taking steps. A milestone had been reached.
The following day, Mr H. was transferred to a normal ward.
Conclusion and outlook
The case studies show that, in the context of early mobilisation in intensive care, adaptations to support each patient on an individual basis are essential. In the interdisciplinary team, the relevant therapy concept must be firmly integrated into everyday practice and its importance must also be considered beyond the boundaries of physiotherapy. Only through close interdisciplinary cooperation with a focus on patient well-being and great commitment from all sides is successful implementation possible. If the transfer from knowledge to action is successful, sustainable added value can be created, above all for patients, but also for clinics and the healthcare system.
The case studies show that, in the context of early mobilisation in intensive care, adaptations to support each patient on an individual basis are essential. In the interdisciplinary team, the relevant therapy concept must be firmly integrated into everyday practice and its importance must also be considered beyond the boundaries of physiotherapy. Only through close interdisciplinary cooperation with a focus on patient well-being and great commitment from all sides is successful implementation possible. If the transfer from knowledge to action is successful, sustainable added value can be created, above all for patients, but also for clinics and the healthcare system.
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THERAPY 2023-III
THERAPY Magazine
Tobias Giebler
Intensive care medicine and neurosurgery expert, Tübingen University Hospital
Tobias Giebler graduated as a physiotherapist at the University Hospital of Freiburg
in 2013. Due to his several years of working as a paramedic in the emergency services,
he already brought knowledge in dealing with patients in the intensive care unit into
his physiotherapeutic training. He has been working intensively on the topic of early
mobilisation for 9 years. He works at the Tübingen University Hospital in the Therapy
Centre and has been the deputy area expert for intensive care medicine and neurosurgery
since 2023.
References:
- Wang J, Ren D, Liu Y et al (2020). Effects of early mobilization on the prognosis of critically ill patients: A systematic review and meta-analysis; DOI: 10.1016/j.ijnurstu.2020.103708
- Baasner A, Koeppen M, Rosenberger P, (2022) Blutungsrisiko im Kanülenbereich bei physiotherapeutischer Mobilisation unter extrakorporaler Membranoxygenierung- Eine retrospektive Analyse bei Patient*innenmit akutem Lungenversagen; https://doi.org/10.1007/s00063-022-00965-x
- Morris Z, Wooding S, Grant J, (2011) The answer is 17 years, what is the question: understanding time lags in translational research; https://doi.org/10.1258/jrsm.2011.110180
- Nydahl P, Sricharoenchai T, Chandra S, et al. (2017). Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis; https://doi.org/10.1513/AnnalsATS.201611-843SR
- Nydahl P, Hermes C, Schuchhardt D et al. (2014),.Frühmobilisierung in Deutschland ; DOI: 10.1055/s-0034-1395432