THE JOURNAL OF PEDIATRICS • www.jpeds.
com
Early Mobility in the Pediatric Intensive Care Unit: Can We Move On?
“It means a great deal. . .to be put on their own feet in a short
time, rather than be confined to bed, having their weak backs and
general debility increase rather than disappear after the opera-
tion which was to cure them.”—Dr Emil Ries,
JAMA 18991 See related article, p •••
T
he concept of early mobilization is not
new—it was introduced more than a century ago. An
editorial in JAMA written 4 decades after Dr Ries’s first
report discussed the benefits of “early rising” after surgery, in-
cluding the “a more rapid return to normal strength and ac-
tivity and a better outlook and morale in the patient”.2 As early
as 1944, a controlled clinical trial to test the effectiveness of
early mobilization after major surgery found less surgical and
organ-specific complications in the group that sat in a chair
and walked on the day after surgery compared with bedrest
for 10-15 days.3,4 Early rising after major surgery became a
popular dialogue in the 1940s, with “the evil sequelae” and
“abuse” of bedrest being commonly discussed and
documented,5,6 and even an entire conference dedicated to the
topic.7
In the intensive care unit (ICU), however, a primary focus
on resuscitation and maintaining physiologic stability propa-
gated the notion that bedrest could minimize metabolic demand
and facilitate healing and recovery. That approach, com-
pounded by the use of continuous sedative infusions and neu-
romuscular blockade to ensure patient safety and amnesia, led
to an ICU culture of immobility. In 1998, Petty compared his
rounds in the ICU with those at the start of his career in 1964
and was troubled by the patients who were “sedated and lying
without motion, appearing to be dead, except for the moni-
tors that tell me otherwise.”8
Fast-forward 20 years and the pendulum is still swinging.
There is burgeoning research on the impact of early mobili-
zation in critically ill adults, including strategies for decreas-
ing the risk of postintensive care syndrome.9,10 Although
awareness about the benefits of early mobilization has in-
creased, so too has the knowledge that optimizing mobility re-
quires modifying our approach to other aspects of care, including
choice of sedation, sleep hygiene, and recognition of delirium.11,12 ture surrounding the topic of acute rehabilitation in chil-
As such, the Society of Critical Care Medicine (SCCM) has forged
an “ICU Liberation” Collaborative, of which the core is the
“ABCDEF” bundle.13 This multifaceted approach to improv-
ing outcomes in survivors of critical illness incorporates these
important elements into routine ICU care: “A,” Assessment of
pain; “B,” Both spontaneous awakening and breathing trials;
“C,” Choice of sedation and analgesia; “D,” Delirium moni-
toring and management; “E,” Early mobility and exercise; and
“F,” Family engagement. Of specific interest to us in pediatrics,
ICU Intensive care unit
PICU Pediatric intensive care unit
SCCM Society of Critical Care Medicine
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EDITORIALS
10% of the 76 ICUs participating in the SCCM Collaborative
were pediatric intensive care units (PICUs).
In this volume of The Journal, Cuello-Garcia et al report their
systematic review of early mobilization in
critically ill children.14 After screening 1199
abstracts, the authors identified 11 studies and
1 clinical practice guideline focused on early mobilization in
the PICU setting. The studies encompassed 2 pilot random-
ized controlled trials, with the remaining studies encompass-
ing prospective studies, before–after studies, and retrospective
cohort studies. The authors divided the review into 3 catego-
ries: (1) definition; (2) safety and feasibility; and (3) efficacy.
With regard to defining early mobility, they found there was
marked variability in the definition of both the terms “early”
and “mobilization.” Contraindications to mobilization across
studies often included cardiorespiratory instability; however,
the threshold for what constituted “instability” was not con-
sistently defined. Eleven of the studies demonstrated the
common theme that early mobilization was safe with no in-
crease in adverse events and was feasible when the appropri-
ate resources and support from the care team were available.
Across the board, the implementation of early-mobilization
programs led to an increase in the frequency of rehabilita-
tion consults and reduced time to mobilization. However, the
authors report that efficacy outcomes, including duration of
mechanical ventilation, length of stay, and morbidities, were
most often chosen as secondary endpoints and that the cer-
tainty of this evidence was low. The authors conclude that
current evidence suggests interdisciplinary collaboration to in-
crease mobilization is feasible. However, they state the chal-
lenges of ongoing patient, family, and resource barriers in
combination and a lack of efficacy outcomes as areas of needed
attention.
Cuello-Garcia et al are to be congratulated for synthesiz-
ing the available data on an important and timely area in pe-
diatric critical care. Particularly helpful is the comprehensive
listing of excluded studies in the supplemental content, which
provides the reader with an overview of the breadth of litera-
dren. The authors have included 4 abstracts in the 11 studies
discussed, which highlights the limited amount of evidence
available to meet the author’s criteria for inclusion. It is also
notable that 5 of the 11 included studies were conducted by
the senior author of the systematic review, suggesting that at
the present time, research in PICU early mobilization is still
in its infancy, with a small pool of engaged investigators.
However, that pool is growing, with new publications focused
The authors declare no conflicts of interest.
0022-3476/$ - see front matter. © 2018 Elsevier Inc. All rights reserved.
https://doi.org10.1016/j.jpeds.2018.08.058
THE JOURNAL OF PEDIATRICS • www.jpeds.com
on quality-improvement initiatives and establishment of
medical criteria for PICU mobilization.15,16
It is important to point out that this is not the first system-
atic review conducted on pediatric acute rehabilitation—in fact,
it is the third in 4 years.17,18 The take-home from all of these
reviews has been consistent—it’s time to study the out-
comes. Early mobilization in the PICU is safe and feasible when
approached systematically. However, we still don’t know how
it changes the short- and long-term trajectory of pediatric sur-
vivors of critical illness. This aspect is critically important, given
the current landscape of pediatric critical care, where de-
creased mortality has been exchanged for increased short- and
long-term morbidities.19 We also have not determined the
optimal timing, dose, or duration of rehabilitation interven-
tions in critically ill children. How much is too much? Or too
often? Is there a threshold where the risk–benefit actually weighs
heavier toward risk?
There are few places in the hospital that rival the hetero-
geneity of the PICU, where the same nurse may be assigned
to care for a 1-month-old cardiac surgery patient and a 17-
year-old patient with diabetic ketoacidosis during the same shift.
That same variability poses unique challenges for
transdisciplinary rehabilitation research, including the need for
both age- and size-specific equipment and standard pediat-
ric tools for evaluating functional outcomes across the age and
developmental spectrum. Indeed, a lack of efficacy data makes
it difficult to overcome the inertia of PICU immobility culture.
However, the promising effects of early mobilization in adults
should be the impetus for large-scale pediatric studies evalu-
ating not only its efficacy but the mechanisms by which early
mobilization makes a difference. The opportunities for dis-
covery as a pediatric critical care community are expansive.
Data on the baseline acute rehabilitation practices in PICUs
internationally will likely illuminate specific areas for tar-
geted research.20 Building on the ABCDEF bundle, we are learn-
ing that optimizing sedation, integrating sleep promotion, and
preventing delirium go hand in hand with creating healing en-
vironments for infants and children too,21-23 and the SCCM
Pediatric Collaborative data are forthcoming. We are investi-
gating ICU-acquired weakness in children and modalities for
monitoring and diagnosis,24-26 and have established the PICU
framework for postintensive care syndrome.27
It is crucial to establish the safety and feasibility of early mo-
bilization in the PICU setting. Now we need to focus not on
the “if” but instead sharpen our focus on the “how” and “why.”
How should we approach it? Why does it work? Why should
we do it? How does it improve outcomes?
It’s time to move on. ■
Tracie Walker, MD
Department of Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Medicine
Charlotte R. Bloomberg Children’s Center
Baltimore, Maryland
Sapna R. Kudchadkar, MD, PhD
Department of Anesthesiology and Critical Care Medicine
EDI 5.5.0 DTD ■ YMPD10245_proof ■ September 27, 2018
Volume ■■ • ■■ 2018
Department of Pediatrics
Department of Physical Medicine and Rehabilitation
Johns Hopkins University School of Medicine
Charlotte R. Bloomberg Children’s Center
Baltimore, Maryland
Reprint requests: Sapna R. Kudchadkar, MD, PhD, 1800 Orleans Street, Suite
6336, Baltimore, MD 21287. E-mail: sapna@jhmi.edu
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