Australian Critical Care 33 (2020) 244e249

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Australian Critical Care

journal homepage: www.elsevier.com/locate/aucc

Research paper

Exercise is feasible in patients receiving vasoactive medication in a

cardiac surgical intensive care unit: A prospective observational study
Jemima Boyd, BPhty, MMedRes a, b, *
Jennifer Paratz, PhD, FACP, MPhty b, c, d
Oystein Tronstad, BPhty a, e
Lawrence Caruana, BPhty a, e
James Walsh, PhD, BPhty a, b
a
Physiotherapy Department, The Prince Charles Hospital, Brisbane, Qld, 4032, Australia
b
School of Allied Health Sciences, Griffith University, Gold Coast, Qld, 4215, Australia
c
Physiotherapy Department, The Royal Brisbane and Womens' Hospital, Brisbane, Qld, 4029, Australia
d
Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, Qld, 4029, Australia
e
Critical Care Research Group, The Prince Charles Hospital, Brisbane, Qld, 4032, Australia

article information a b s t r a c t

Article history: Background: Patients may require vasoactive medication after cardiac surgery. The effect and safety
Received 24 October 2019 profile of exercise on haemodynamic parameters in these patients is unclear.
Received in revised form Objectives: The objective of this study was to measure the effect of upright positioning and low-level
26 February 2020
exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoac-
Accepted 28 February 2020
tive therapy and to determine the incidence of adverse events.
Methods: This was a prospective, single-centre, observational study conducted in an adult intensive care
Keywords:
unit of a tertiary, cardiothoracic universityeaffiliated hospital in Australia. The Flotrac-Vigileo™ system
Intensive care
Cardiac surgery
was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke vol-
Haemodynamics ume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-
Exercise normally distributed variables are presented as median [interquartile range].
Inotropes Results: There were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years.
Vasopressors Upright positioning caused significant increases (p ¼ 0.018) in the mean arterial pressure (MAP), with
MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when
back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume,
or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse
event was transient hypotension of low severity.
Conclusions: Low-level exercise in patients after cardiac surgery receiving vasoactive medication was
well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright
positioning and low-level exercise appeared safe and feasible in this patient cohort.
Crown Copyright © 2020 Published by Elsevier Ltd on behalf of Australian College of Critical Care Nurses
Ltd. All rights reserved.

1. Introduction (ICU) in Australia.1 Patients after cardiac surgery may be subject to

Postoperative management after cardiac surgery is among the
most common reasons for admission to an adult intensive care unit
* Corresponding author at: Physiotherapy Department, Cairns Hospital, Cairns,
Qld, 4870, Australia.
E-mail address: jemima.boyd@uqconnect.edu.au (J. Boyd).
haemodynamic instability as a result of hypovolemic or cardiogenic
shock and may require administration of vasoactive medication to
improve cardiac output (CO). Exercising patients in the ICU has
been shown to be safe and feasible2e8 may lead to reduced ICU and
hospital length of stay9,10 as well as improvements in health-
related quality of life after intensive care.11 Early mobilisation is
recommended as part of best evidence management for patients

https://doi.org/10.1016/j.aucc.2020.02.004
1036-7314/Crown Copyright © 2020 Published by Elsevier Ltd on behalf of Australian College of Critical Care Nurses Ltd. All rights reserved.
 J. Boyd et al. / Australian Critical Care 33 (2020) 244e249
after cardiac surgery.12e14 However, the safety profile of exercising
patients who are receiving vasoactive medication is unclear, with
limited evidence available to guide practice for clinicians. Interna-
tional consensus guidelines acknowledge that this is a “grey area”,
and further research is required into this.15
Recent studies16e18 found that mobilising ICU patients who
were receiving vasoactive medication had a low risk for an adverse
event, suggesting that vasoactive medication should not be
considered an absolute contraindication to mobilisation. To our
knowledge, there is no literature regarding the effect of exercise in
ICU patients receiving vasoactive medication on more specific
haemodynamic parameters such as CO, cardiac index (CI), and
stroke volume (SV). Traditionally these parameters are obtained
through invasive techniques such as the thermodilution method or
a pulmonary artery catheter. More recently, the Flotrac-Vigileo™
system (Edwards Lifesciences, Irvine, CA, USA) is a minimally
invasive instrument that can monitor these specific haemodynamic
measurements.
The aims of this study were to determine the effect of low-level
exercise in upright positioning on haemodynamic measurements,
namely CO, CI, heart rate (HR), SV, and mean arterial pressure
(MAP), of adult patients requiring vasoactive medication after car-
diac surgery. An additional aim was to determine any incidence of
adverse events associated with mobilising these patients. We
hypothesised that upright positioning and low-level exercise in this
patient cohort may be safe with a low incidence of adverse events.
2. Method
2.1. Design
This was a prospective, single-centre, observational study con-
ducted in a specialist tertiary, university-affiliated cardiothoracic
ICU hospital in Australia. The institution's Human Research Ethics
Committee approved this study with patient or next of kin written
informed consent (HREC 17/QPCH/31).
2.2. Recruitment
Informed consent was obtained from participants preopera-
tively. From August 2017 to May 2018, potential participants were
screened postoperatively in the ICU on weekdays to confirm that
they met the eligibility criteria (i.e., required vasoactive support).
Patients were eligible for inclusion if they were older than 18 years,
undergoing elective open-heart surgery, and postoperatively were
receiving low, moderate, or high levels of vasoactive support as
described in Table 1. A final convenience sample was recruited,
consisting of 20 participants, reflecting the availability of the
single-use haemodynamic monitoring equipment (the Flotrac-
Vigileo™) and researcher and clinical staff availability.
After surgery, consented patients were screened against the
secondary exclusion criteria, which are given in supplementary
appendix 1.
Table 1
Classification of vasoactive medication dosages for this study.
Vasoactive medication Low (mcg/kg/min)
Dopamine <3
Dobutamine <3
Adrenaline <0.05
Noradrenaline <0.05
Vasopressin 0.01
Levosimendan 0.05
Milrinone 0e0.15
245
Participants were classified into the low-, moderate-, or high-
dose category as follows:
2.3. Measures
Demographic information was collected, including age, sex, type
of surgery, length of surgery, length of time on bypass, dosage of
Category Criteria
Low dose One vasoactive medication at a low dose.
Moderate One vasoactive medication at a moderate dose, or two vasoactive
dose medications at a low dose.
High dose - At least one vasoactive medication at a high dose.
- Two vasoactive medications with at least one greater than low
dose.
- Greater than two vasoactive medications regardless of dose.
vasoactive medications, and preoperative level of function. Preop-
erative level of function was ascertained by asking patients
whether they could walk greater than 100 m and if they used a
walking aid.
2.4. Flotrac-Vigileo™ system
Specific haemodynamic measurements were obtained using
the Flotrac-Vigileo system (4th generation), which was attached
to the patient by the treating nurse. The Flotrac-Vigileo™ sys-
tem is a single-use, minimally invasive system that can
continuously derive detailed haemodynamic parameters. It at-
taches to the patient's arterial line (radial access in this study)
and analyses the arterial waveform with inputted demographic
patient data. The Flotrac-Vigileo™ has been shown to reliably
measure CO19,20 and has significant correlation with haemody-
namic measurements derived from the highly invasive thermo-
dilution technique in patients after cardiac surgery.19 Cardiac
output, CI, and SV measurements were obtained from this sys-
tem. These parameters were measured before the upright po-
sitions when they were in supine, after 1 min of adopting each
subsequent upright position, and 5 min after the participant had
returned to supine.
HR, rhythm, arterial systolic and diastolic blood pressure (BP),
MAP, respiratory rate, and SpO2 were obtained from the partici-
pant's bedside monitor (Phillips, Amsterdam, Netherlands) after
moving into each different position. Clinical indicators of adequate
tissue perfusion were noted before commencing upright posi-
tioning with the participant. These indicators are listed in
supplementary appendix 2.
2.5. Adverse events
Adverse events were classified as changes in BP or HR greater or
less than 20% of resting values or a decrease in SpO2 or CO greater
Moderate (mcg/kg/min) High (mcg/kg/min)
3e10 >10
3e10 >10
0.05e0.2 >0.2
0.05e0.2 >0.2
0.01e0.03 >0.03
0.05e0.2 >0.2
0.15e0.5 >0.5
246 J. Boyd et al. / Australian Critical Care 33 (2020) 244e249
than 10% of that required stopping intervention. Full detail sur-
rounding classification of adverse events can be found in
supplementary appendix 3.
2.6. Protocol
Haemodynamic measurements were recorded after 1 min of the
participant adopting progressively more upright positions and ex-
ercise. The participant began in supine. The order of positional
changes is illustrated in Fig. 1. One-minute-per-position time
period was used to standardise the amount of time each participant
spent in each position and to allow time for stabilisation of hae-
modynamic measurements.
The principal investigator, a physiotherapist, directed and
assisted the movement changes with the participant. The treating
nurse adjusted the arterial transducer to ensure it remained at the
phlebostatic axis with each change in position, and another
investigator documented the haemodynamic measurements. If a
participant could not adopt one of the positions because of reasons
such as pain, nausea, or shortness of breath, then they were
regressed through the procedure sequence to a more supportive
position that was tolerated by the participant. Decisions to progress
and regress a participant through the positioning protocol based
were made by the principal investigator based on the clinical
assessment of patient symptoms and physiological observations.
2.7. Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics for
Windows, Version 24.0 (Armonk, NY: IBM Corp). Participants were
categorised into low, moderate, or high level of vasoactive medi-
cation dose as per Table 1. Tests for normality were conducted, and
appropriate statistical analysis methods were used based on the
outcome of these tests. Normally distributed variables are pre-
sented as n (%) and mean (standard deviation), and non-normally
distributed variables are presented as median [interquartile range]
or as a range.
A one-way repeated-measures analysis of variance was used to
identify significant changes in normally distributed haemodynamic
variables that occurred with upright positioning. Normally
distributed haemodynamic variables included CO, CI, HR, and MAP.
The Friedman test was used to identify significant changes in the
non-normally distributed haemodynamic variable of SV. Initially,
we planned to investigate the relationship between vasoactive
medication type/dosage and incidence of adverse events; however,
owing to the low number of adverse events, the results are pre-
sented descriptively.
3. Results
Data were collected from 20 study participants. The screening,
consent, and data collection process are illustrated in Fig. 2. Base-
line characteristics are described in Table 2.
Fig. 1. Order of positional changes.
3.1. Vasoactive medication details
As per study criteria, six (30%) participants were classified as
receiving low dose, 13 (65%) as moderate dose, and one (5%) as high
dose of vasoactive medication at the time of data collection. This is
detailed in Table 3.
All participants were receiving dopamine. Overall, the mean
dose received amongst the group was 3.89 [1.12] mcg/kg/min.
In the low category, the mean dose of dopamine was 2.56 [0.32]
mcg/kg/min. The mean dose of dopamine in the moderate category
was 4.22 [0.78] mcg/kg/min. One participant was categorised in the
high-dose group due to the number of vasoactive medications
administered; dopamine was administered at 5.00 mcg/kg/min.
Nine participants (45%) were being weaned from their medication
in ranges varying from 0.5 ml to 4 ml every 1e6 h.
3.2. Indicators of tissue perfusion
Lactate levels ranged from less than 1.0 to greater than
2.0 mmol/h. Nine (45%) participants had a lactate level ranging
between 1.0 and 2.0 mmol/h, 6 (30%) had a lactate level of less than
1.0 mmol/h, and 5 (25%) greater than 2.0 mmol/h. The mean FiO2
requirement was 0.32 (0.05). Bowel sounds were present in 19
(95%) participants before the intervention, and 16 (80%) had warm
hands and feet. Average urine output per hour varied amongst the
participants, ranging from less than 60 to greater than 200 ml/h;
however, 15 (75%) had an average urine output of less than 100 ml/
h. All participants had a Glasgow Coma Scale of 15 before
commencing the exercise interventions.
3.3. Haemodynamic changes
There was a statistically significant increase in MAP during ex-
ercise (p ¼ 0.018), with MAP readings increasing from baseline
(supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when
back in supine. Further details of the changes in MAP amongst the
group are reported in supplementary appendix 4. There were no
clinically significant changes to CO (p ¼ 0.628), CI (p ¼ 0.390), HR
(p ¼ 0.050), or SV (p ¼ 0.146) during exercise. It was noted that in
individual cases, larger than expected increases CO were observed.
These changes did not necessitate stopping data collection, and the
participants were asymptomatic. These individual cases are
detailed in Table 4. Supplementary appendix 4 provides a summary
of mean and median haemodynamic measurements amongst the
group in each position.
3.4. Adverse events
One adverse event occurred. This event was categorised as an
alteration in BP greater than 20% of resting values, which necessi-
tated stopping intervention as they were symptomatic. This
occurred while the participant was standing. Haemodynamic pa-
rameters and symptoms returned to baseline upon sitting back
 J. Boyd et al. / Australian Critical Care 33 (2020) 244e249 247

Fig. 2. Patient flow chart.

down on the bed, and this participant did not require an increase in
vasoactive medication.
Table 2
Baseline participant characteristics.

Characteristic n ¼ 20
4. Discussion

Sex, n (%)
This study investigated the effects of positional changes and
Male, n (%) 16 (80)
Female, n (%) 4 (20) low-level exercise in cardiac surgical patients receiving vasoactive
Age (years), mean [SD] 65.90 [10.60] medication. We found statistically significant increases in MAP
Height (cm), mean [SD] 173.30 [8.30] with exercise. In our study, the increase in MAP did not lead to
Weight (kg), mean [SD] 84.70 [24.70]
immediate down titration of medication. No clinically significant
Self-reported preoperative level of function, n (%)
>100 m independently, n (%) 17 (85) increases in CO, SV, or HR were observed. We had one documented
<100 m independently, n (%) 3 (15) adverse event relating to an episode of hypotension that was
Gait aid (4 wheeled-walker or walking stick), n (%) 2 (10) considered transient and of low severity. Our findings add to the
No gait aid, n (%) 18 (90) limited available literature pertaining to the safety and haemody-
Surgery details namic effects of exercising patients receiving vasoactive
Surgery type, n (%) medication.
Coronary artery bypass surgery, n (%) 11 (55) We observed statistically significant increases in MAP with ex-
Valve replacement or repair, n (%) 7 (35) ercise, which mirrors findings from Medrinal et al.21 In their study,
Coronary artery bypass surgery þ valve replacement/repair, n 1 (5) MAP increased significantly during supine cycling in general ICU
(%)
Aortic root replacement, n (%) 1 (5)
patients (main diagnoses include pneumonia, drug overdose, intra-
Day after surgery, n (%) abdominal sepsis, and cardiac failure) receiving vasoactive medi-
1, n (%) 15 (75) cation. Although their subjects were supine, the results highlight
2, n (%) 2 (10) the impact the muscle pump from leg activity may have in main-
3, n (%) 2 (10)
taining and increasing MAP. Previous studies looking at the effect of
4, n (%) 1 (5)
Mechanical ventilation time (mins), mean [SD] 619.30 upright positioning in ICU patients (medical, surgical, and trauma)
[342.08] who were not receiving vasoactive medication5,22 also found sig-
Cardiopulmonary bypass time (mins), mean [SD] 83.89 [41.95] nificant increases in arterial pressure readings. We observed only
Cross-clamp time (mins), mean [SD] 57.68 [30.71] one adverse event in our study. This low rate of adverse events
SD, standard deviation. mirrors findings from previous studies looking at exercise with
248 J. Boyd et al. / Australian Critical Care 33 (2020) 244e249

Table 3
Vasoactive medication details.

Participant Dose classification Vasoactive medication and dosage (mcg/kg/min)

Dopamine Adrenaline Noradrenaline Vasopressin

1 Moderate 4.91
2 High 5.00 0.09 0.05 0.02
3 Moderate 5.00
4 Low 2.50
5 Moderate 5.00
6 Moderate 5.00 0.02
7 Moderate 5.00
8 Moderate 4.88
9 Low 2.50
10 Moderate 5.00 0.02
11 Low 2.99
12 Low 2.86
13 Moderate 3.00
14 Low 2.50
15 Moderate 5.00
16 Moderate 3.00
17 Low 2.00
18 Moderate 3.50
19 Moderate 3.70
20 Moderate 4.50 0.02

patients receiving vasoactive medication.5,16e18 The majority of
these adverse events were described as hypotension that led to
transient effects of low severity, similar to our study.
The safety of mobilising patients receiving vasoactive medica-
tion remains a point of contention among the ICU community,15
with limited understanding about the safety and haemodynamic
effects of doing so. Our study demonstrated that low-intensity
exercise, such as marching on the spot for 1 min, led to increases in
MAP and no lasting adverse effects. By successfully demonstrating
that low-level exercise was safe in this cohort, clinicians may
consider a more timely commencement of mobility in patients
receiving vasoactive medication.
A normal response to exercise is an increase in CO that is ach-
ieved by increasing HR and SV.23 We observed no clinically signif-
icant changes to CO, CI, HR, or SV with exercise. However, changes
in CO were observed with individual participants that we consid-
ered clinically significant, as shown in Table 3. Our findings may
suggest an inadequacy of cardiac contractility during exercise early
after cardiac surgery and could be due to many reasons. Poor
contractility of the heart can occur after surgery owing to
myocardial ischaemia during cross-clamping or cardioplegia-
induced myocardial dysfunction.24 There is a possibility that
some participants had sustained myocardial injury as a result of
surgery and/or had pre-existing myocardial injury. It is important
to note that our study had participants perform exercise at a low
level of intensity, which may not have been intense enough to elicit
changes in CO, HR, or SV.
Other institutions may have varied patient cohorts and different
requirements for, and dosages of, vasoactive medication from this
study. However, we believe that our study's findings are clinically
applicable to patients receiving vasoactive medication after cardiac
surgery. All of the participants in the present study were receiving
dopamine, which is reflective of the unit practice and patient
cohort.
A limitation of the study is the small sample size. However, the
results could be used to power future studies in this field. Accuracy
of the Flotrac-Vigileo™ readings depends on the patency of the
arterial waveform, and therefore, readings may be inaccurate if
there is an unreliable trace before calibration or if the patient's
upper limbs are moving. Variability in application and calibration of
the device with changes in patient body position are other potential
sources of error. In our study, to potentially alleviate this issue, we
standardised our protocol and ensured that the treating nurse was
responsible for calibration of the device and positioning of the
arterial line at the phlebostatic axis throughout all positional
changes. Another consideration is that the calculation of data out-
puts is furthermore dependent on accurate input data such as
actual rather than estimated height and weight. In addition, we did
not account for pain or sedation medications that may have had an
impact on blood pressure.
In this study, participants were mobilised on the spot for a
maximum of 1 min. This may not accurately represent the intensity
to which most patients in the ICU are usually mobilised. However,
we thought it likely that the frailest of our participants would
tolerate at least 1 min in each position. In our clinical experience,
5 min in an upright position may be the maximum that some pa-
tients, particularly those that may be haemodynamically compro-
mised, may tolerate on day 1 after cardiac surgery. However,
although our participants were exercised for a short period of time
at a low level of intensity, our study provides information that has
not existed before. Our standardised exercise protocol may be used
in future studies of this nature. To our knowledge, there have been

Table 4
Examples of large CO changes at an individual level.

Subject number Vasoactive medication details (mcg/kg/min) Cardiac output (L/min)

Baseline (supine) High sitting SOEOB Standing MOS SOEOB Supine 1 min

5 Dopamine 5.00 (moderate dose) 6.4 6.9 8.2 7.3 11.6 9.6 9.2
11 Dopamine 2.99 (low dose) 8.7 4.9 6.5 8.4 7.3 7.2 6.2
17 Dopamine 2.00 (low dose) 6.5 6.4 7.5 4.9 5.4 3.3 3.3

SOEOB, sit on edge of bed.

 J. Boyd et al. / Australian Critical Care 33 (2020) 244e249
no other studies published that look at the specific haemodynamic
effects of exercise in patients receiving vasoactive medications after
cardiac surgery.
5. Conclusion
Statistically significant increases in MAP occurred during low-
level exercise in upright positioning in patients who were receiving
vasoactive medication after cardiac surgery. There were no clini-
cally significant changes to CO, CI, HR, and SV. The incidence of
adverse events was low. The findings from this study adds to the
small body of literature regarding haemodynamic responses to
upright positioning and low-intensity exercise in patients receiving
vasoactive medication. Further research into this area is needed to
continue building on understanding the safety profile of exercising
ICU patients receiving vasoactive support.
Conflict of interest
None.
CRediT authorship contribution statement
Jemima Boyd: Conceptualization, Data curation, Formal anal-
ysis, Funding acquisition, Investigation, Methodology, Project
administration, Resources, Software, Supervision, Validation,
Writing - original draft, Writing - review & editing. Jennifer Paratz:
Conceptualization, Data curation, Formal analysis, Investigation,
Methodology, Project administration, Resources, Supervision,
Validation, Writing - original draft, Writing - review & editing.
Oystein Tronstad: Conceptualization, Data curation, Formal anal-
ysis, Investigation, Methodology, Project administration, Resources,
Supervision, Validation, Writing - original draft, Writing - review &
editing. Lawrence Caruana: Conceptualization, Data curation,
Formal analysis, Investigation, Methodology, Project administra-
tion, Resources, Supervision, Validation, Writing - original draft,
Writing - review & editing. James Walsh: Conceptualization, Data
curation, Formal analysis, Investigation, Methodology, Project
administration, Resources, Supervision, Validation, Writing - orig-
inal draft, Writing - review & editing.
Acknowledgements
This work was supported by the Prince Charles Hospital Foun-
dation by an equipment grant used to purchase the consumables
necessary for this study (grant number SEQ2016-06). Edwards-
Lifesciences kindly loaned a Vigileo™ monitor to the investi-
gating team for the duration of this study.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.aucc.2020.02.004.
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