Mobilizing ICU Patients May Not Affect Risk of Adverse Events, Death

Mobilizing patients who required mechanical ventilation in the intensive care unit (ICU) was associated with a less than 3% risk of adverse events such as falls, desaturation, and hemodynamic instability, a systematic review and meta-analysis found.

Compared with usual care, very-low-certainty evidence showed that mobilization did not lead to adverse events (risk ratio [RR] 1.09, 95% CI 0.69-1.74, P=0.71), with an occurrence rate of 2.96%, reported Carol Hodgson, PhD, of Monash University in Melbourne, Australia, and co-authors.

Moderate-certainty evidence showed that mobilization had no effect on mortality (RR 0.98, 95% CI 0.87-1.12, P=0.81), they wrote in Lancet Respiratory Medicine.

The results challenged previous notions of harm associated with mobilization. “With mobilization leading to a less than 3% incidence of adverse events, with all bar one event reported as transient or resolving with cessation of the intervention or minor medical attention, our review provides clinicians with reassurance about the safety of providing this treatment,” the authors wrote.

In an invited comment, Eddy Fan, MD, PhD, of the University of Toronto, and co-authors noted that the meta-analysis was a good step in addressing the effects of implementing mobilization among critically ill patients in the ICU.

“Overall, the findings of this detailed review deliver a clear message: starting mobilization activities in the ICU does not increase adverse events or mortality compared with usual care,” they wrote. “Mobilization activities are safe and are an important intervention as an integral standard of care for patients who are critically ill.”

Several previous meta-analyses have reported mixed results regarding mobilization, some suggesting only small benefits to the practice, and some highlighting potential harm, such as increased risk of mortality and adverse events.

Active mobilization as a tool to address the potential effects of long-term hospitalization, such as muscle wasting, among others, has been a component of treating both the physical and cognitive well-being of patients and is listed among various clinical practice guidelines. Despite this, Hodgson and team noted that the evidence for mobilization’s benefits comes largely from smaller, early-phase trials and observational studies, leaving several factors of the practice unaddressed.

For this study, the researchers searched Medline, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Scopus, Web of Science, and the Physiotherapy Evidence Database, as well as clinical trial registries, from inception to March 16, 2023. Studies were eligible if they were randomized controlled trials that examined active mobilization compared with either no mobilization or mobilization starting later, or at a lower frequency or intensity, in adults who were critically ill during or after a period of mechanical ventilation in an acute ICU setting. There were no exclusions based on language.

Hodgson and colleagues included 67 trials with 7,004 participants, with 59 trials contributing data for the meta-analysis — 20 for adverse event data and 58 for mortality data.

The majority of data came from trials that completed a longer (≥20 minutes per day) duration of mobilization (37%) while participants were still invasively ventilated (62%), early (≤72 hours from admission) in the ICU admission (57%), and in mixed ICU cohorts (i.e., in terms of admission diagnosis; 53%).

The researchers noted that severity of illness, an important confounding factor, was not taken into account for this meta-analysis, which was a limitation. Furthermore, there was some missing information regarding the intensity/frequency of mobilization.

In addition, “the large amount of data unable to be allocated to subgroup analyses and the inconsistent results prevented the clear identification of any specific variable of mobilization implementation that increased harm, which means that the results should be regarded as hypothesis generating only,” they wrote.

Both the researchers and editorialists encouraged further research into the details of the implementation of mobilization, such as the ideal timing in which to begin the process and which patient populations will benefit the most.

“The optimal approach for providing mobilization to specific patients remains uncertain,” wrote Fan and colleagues. “This complexity suggests that a one-size-fits-all guideline might not apply to diverse patient profiles, which is especially true in the heterogeneous ICU population, and some patients might face barriers to early mobilization, such as heavy sedation.”

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