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a r t i c l e i n f o a b s t r a c t
Keywords: Introduction: The use of sedation and analgesia protocols, daily interruption of sedation, and early mobilization
Early mobilization (EM) have been shown to decrease duration of mechanical ventilation and hospital length of stay (LOS).
Neurologic injury Methods: A retrospective chart review was conducted during a 6-month premobilization (pre-EM) and 6-month
Neurosurgery postmobilization (post-EM) period. Patients older than 18 years who were admitted to the neurosciences inten-
Critical care
sive care unit (ICU) and mechanically ventilated for at least 24 hours without documentation of withdrawal of life
Sedation
Analgesia
support or brain death were included.
Results: Thirty-one pre-EM and 37 post-EM patients were included. Baseline demographics were similar with the
exception of more ischemic stroke patients in the pre-EM group (P b .05). In the pre-EM and post-EM groups,
patients received similar cumulative doses of propofol, dexmedetomidine, and benzodiazepines but higher
median (interquartile range) doses of opioids (50.0 [13.8-165.0] vs 173.3 [41.2-463.2] μg of fentanyl equivalents
[P b .05]) in the post-EM group. Neurosciences ICU LOS was 10 (6-19) and 13 (8-18) days, respectively (P = .188).
Conclusions: After implementation of an EM program, an increase in opioid use and no significant change in other
sedatives were observed. Despite an increase in the amount of physical therapy and occupational therapy provided
to patients, there was no change in hospital and ICU LOS or duration of mechanical ventilation.
© 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcrc.2014.12.003
0883-9441/© 2014 Elsevier Inc. All rights reserved.
R. Witcher et al. / Journal of Critical Care 30 (2015) 344–347 345
significantly, as did the rates of hospital-acquired infection and 2.3. Data collection
ventilator-associated pneumonia. Investigators did not detect a
difference in falls or inadvertent line disconnections between the 2 Demographic and clinical data were collected from the electronic
periods, and ultimately, the authors concluded that EM in neurologi- medical record, including age, sex, weight, medical history, NICU admit-
cally injured patients was safe and effective in decreasing hospital ting diagnosis, admission GCS score, and hospital and ICU LOS. The use
LOS and hospital-acquired infections. of therapeutic hypothermia, presence of vasopressors on admission,
Currently, the impact of an EM program on analgesia and sedation and presence of a brain tissue oxygen monitor or external ventricular
patterns has not been evaluated in a neurocritically ill population. drain were also collected. Daily cumulative doses of analgesic and seda-
Progressive practices including EM are not universally applied to tive agents were collected as well as the requirement of mechanical
neurocritically ill patients due to fear of serious or sentinel adverse ventilation and use of antipsychotic agents. The number of PT and OT
events given some of the unique characteristics of this patient popula- sessions administered was collected from the electronic medical record,
tion. However, subpopulations in the neurosciences ICU (NICU) may including pre-PT/OT and post-PT/OT pain scores and intensity of activi-
benefit from practices of EM despite their neurologic injury. This study ties. Discharge disposition was also collected and recorded as to home,
sought to examine the effect of an EM protocol on sedation practices to home with a health aide, or to a rehabilitation facility.
of critically ill, mechanically ventilated patients in the NICU.
2.4. Outcomes
2. Patients and methods The primary outcome was the cumulative daily amount of analgesics
and sedatives used in the NICU before and after the implementation of
We hypothesized that there would be a decrease in sedative and an- an EM program. The secondary outcomes included number of PT and
algesic use as well as a decrease in duration of mechanical ventilation OT sessions before and after implementation of an EM protocol, change
and a decrease in hospital and ICU LOS after the implementation of an in pain after PT/OT sessions, a description of the intensity of activity dur-
EM program. ing PT/OT, use of antipsychotics, duration of mechanical ventilation, ICU
and hospital LOS, and discharge disposition.
Our institution initiated an EM program beginning in January 2013 The statistical analyses were conducted using Minitab software
in an 11-bed NICU at a large, urban, academic medical center. At the (version 16; Minitab, Inc, State College, PA) and SPSS Statistics (version
time of this study, there was no formalized protocol for sedation prac- 21; IBM, Armonk, NY). Discrete variables were expressed as percent-
tices in this ICU, but Richmond Assessment for Sedation Scale scores ages, and continuous variables were expressed as median and inter-
were monitored routinely and a clinical pharmacist was available dur- quartile range, except when noted as mean and 95% confidence
ing weekdays to assess sedation for all patients. A dedicated team of interval. For comparison between pre-EM and post-EM groups, χ 2 or
physical and occupational therapists assessed each patient in the NICU 2-sided t test was used for all categorical data, and Mann-Whitney U,
daily for eligibility for mobilization using specific predefined criteria. Pa- for all continuous variables' medians and interquartile ranges. P b .05
tients were considered ineligible for sedation interruption if they were was considered statistically significant.
being managed for status epilepticus, treated with paralytics, diagnosed
with acute respiratory distress syndrome/hypoxemia, displayed evi- 3. Results
dence of intracranial herniation, or had partial pressure of brain tissue
oxygen less than 15 mm Hg or intracranial pressure greater than A total of 180 patients were screened for inclusion, of which 112
20 mm Hg. Patients who completed a sedation interruption were subse- were not included (55 mechanically ventilated b24 hours or in NICU
quently assessed for eligibility for mobilization. Patients ineligible for b24 hours, 30 documentation of withdrawal of life support or brain
EM included those with any contraindication for sedation interruption, death, 14 mechanically ventilated outside the NICU, and 13 intubated
Glasgow Coma Scale (GCS) score less than or equal to 8 or coma off se- or received a tracheostomy outside the NICU), resulting in 68 patients
dation, locked in syndrome, clinically symptomatic vasospasm, unstable included in this analysis: 31 in the pre-EM group and 37 in the post-
spine despite brace, cerebrospinal fluid leak, subdural hematoma evac- EM group. Baseline demographics are listed in Table 1. The median
uation within previous 24 hours, unsecured ruptured aneurysm, or age was 61 years; most common admission diagnoses were acute ische-
alteplase administration within previous 24 hours. The physical and oc- mic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage;
cupational therapists rounded with the charge nurse daily and deter- and median admission GCS score was 7 in the pre-EM group and 8 in
mined appropriate therapies for each patient. Interventions included the post-EM group. There were statistically significantly more patients
passive range of motion, active range of motion, bed-level activities in- being treated for acute ischemic stroke in the pre-EM group (22.6% vs
cluding sitting and leg dangling, and standing and ambulation. In coor- 5.4%, P = .049); however, all other characteristics were statistically sim-
dination with the primary team, physical therapy (PT) and occupational ilar between groups. There was no statistical difference in the number of
therapy (OT) sessions were then prescribed and administered by the patients requiring vasopressor therapy on admission to the NICU or use
team of therapists. Although pain was assessed before therapy was ad- of neuromuscular blocking agents, therapeutic hypothermia, external
ministered, pretreatment with analgesics was not a routine component ventricular drains, or brain tissue oxygen monitors during NICU stay.
of this program. There was a statistically significant increase in the cumulative opioid
dose during ICU stay in the pre-EM vs post-EM groups (50.0 μg/d [13.8-
165.0] vs 173 μg/d [41.2-463.2], P = .012). The cumulative doses of
2.2. Patients benzodiazepines, propofol, and dexmedetomidine were not statistically
different between the 2 periods (Table 2). Statistically, more patients
This was a retrospective chart review of patients who were admitted received analgesic or sedative infusions after the implementation of
to the NICU from January to June 2012 (pre-EM) and January to June EM (80.6% vs 97.3%, P = .041).
2013 (post-EM), 18 years or older, and intubated in the NICU and me- After the implementation of EM, there was a statistically significant
chanically ventilated for at least 24 hours. Included patients could not increase in the mean number (95% confidence interval) of PT sessions
have documentation of withdrawal of life support or brain death. per patient (2.1 [1.6-2.7] vs 4.2 [3.6-4.9], P b .001) and OT sessions per
346 R. Witcher et al. / Journal of Critical Care 30 (2015) 344–347
Table 1 Table 3
Baseline characteristics Description of PT and OT sessions
Table 2
Cumulative analgesic and sedative use
Pre-EM Post-EM P
Schweickert et al [9] evaluated the impact of an EM protocol with collected in this analysis. In addition, nurses in this institution were edu-
goal-directed sedation on return to independent functional status in cated on recognition and management of inpatient pain control after the
mechanically ventilated critically ill patients. Patients' sedation was implementation of the EM program, which may have increased identifica-
interrupted daily, and subjects were randomized to receive early tion and subsequent treatment of pain in the post-EM period.
exercise and mobilization during sedation holidays or to PT and OT as On a fundamental level, the population included in this evaluation is
prescribed by providers. The authors found that when mechanically heterogeneous by nature despite being limited to neurologic and neuro-
ventilated patients were mobilized earlier in their ICU stays, they surgical illnesses, as demonstrated by the myriad admitting diagnoses.
experienced more ventilator-free days and a shorter duration of deliri- These conditions are managed very differently, both medically and sur-
um. There was no statistical difference in the duration of sedative or gically. Although the only statistically significant difference in admitting
analgesic agent use or in the amount of propofol, opioids, or benzodiaz- diagnoses was acute ischemic stroke, there are several large trends that
epines between groups. Notably, there were no unplanned extubations, may reach significance with a larger patient population. Given that the
falls, or significant decreases in blood pressure, which is consistent neurocritically ill population is diverse, future research should aim to
with previous studies demonstrating the feasibility and safety of mobi- evaluate the effects of EM on patients with specific neurologic injuries
lization [6,9,12]. Similar to other trials, this population was exclusively to identify those who may experience maximal benefit from EM. Future
medically ill [8]. investigations should not only continue to focus on changes in analgesia
There are many unique characteristics of the neurocritically ill and sedation patterns but also address neuropsychiatric illness, func-
population that must be taken into account when considering sedation tional outcomes, and adverse events experienced with EM.
and mobilization practices [12,13]. Within this population, it is difficult
to determine if the patient's primary neurologic process rather than 5. Conclusion
iatrogenic causes or the clinical setting is precipitating agitation or dis-
comfort. Neurologically injured patients may also be instrumented Implementation of an EM program in a heterogeneous neurocritically
with external ventricular drains, intracranial monitors, or devices for ill population resulted in a significant increase in opioid use with no
multimodality monitoring that can be physically cumbersome or irritat- significant change in benzodiazepine, propofol, or dexmedetomidine
ing. Specific neurologic injuries require unique considerations as well. use, potentially due to differences in disease states between populations.
For instance, patients with elevated intracranial pressures, who are Despite an increase in the number of PT and OT sessions provided to
managed with paralytics, or who require sedative agents for the treat- patients, there was no statistical difference in duration of mechanical
ment of status epilepticus would not be candidates for sedation holidays ventilation or hospital or ICU LOS.
or EM given their requirement for continuous sedative agents.
The trend toward increased hospital and ICU LOS is a surprising Acknowledgments
finding that is inconsistent with prior literature, and the statistical
difference of fewer acute ischemic stroke patients in the pre-EM group The authors thank Christine Kubin, Jennifer Michaels, and Kevin
could contribute to this difference in LOS. Studies of acute ischemic McConeghy for their assistance with statistical analysis of these data.
stroke patients reported a median LOS of 5 days [14,15]. Given this
information, one may expect to see a shorter LOS in the group References
with more acute ischemic stroke patients, which was seen in the pre-
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