Awaking, exercising, sitting, walking and extubating: moving on the paradigms for mechanically ventilated patients - Critical Care Science (CCS)
In the intensive care unit (ICU) patients are exposed to catheters, tubes, alarms and noise, and they experience thirst, hunger, immobility and several other sources of discomfort. How hostile is the ICU environment to patients and to caregivers? It is intuitive to put patients to sleep while they stay in this inhospitable place for life support. Moreover, during sleep, respiration is controllable, oxygen consumption may be reduced, and patients’ appearances are placid to observers. Hibernation during critical illness was the gold standard of care for a long time.
In 2000, Kress et al. showed that daily interruption of continuous sedation was associated with less time spent on mechanical ventilation and less time needing ICU support.( ) However, critics questioned whether the price of sleep deprivation, pain, anxiety, depression, agitation, and delirium paid by those patients was really worth the benefit.( ) The authors’ response came three years later with a long-term follow-up of those patients, evaluating the psychological impact of daily sedative interruption as positive.( ) Afterwards, these same findings were replicated in other studies.( , ) In one such study, daily sedative interruption was substituted with a no-sedation protocol, resulting in a reduction in the time needed for critical care support and no long-term psychological negative impact.( ) Ultimately, the reduction of sedation levels associated with early passive and active mobilization was coupled with a more precocious functional independence.( ) Patients were incentivized to early mobilization using a cycle ergometer and had high satisfaction in doing so.( ) Currently, some ICUs propose the judicious early mobilization of critically ill patients. They consider progressive levels of mobilization, from active on-bed mobilization to exercising while sitting, exercising while standing, and ambulating. All of these levels could be offered to the patient regardless of the need for mechanical ventilation.( )
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In the intensive care unit (ICU) patients are exposed to catheters, tubes, alarms and noise, and they experience thirst, hunger, immobility and several other sources of discomfort. How hostile is the ICU environment to patients and to caregivers? It is intuitive to put patients to sleep while they stay in this inhospitable place for life support. Moreover, during sleep, respiration is controllable, oxygen consumption may be reduced, and patients' appearances are placid to observers. Hibernation during critical illness was the gold standard of care for a long time.
In 2000, Kress et al. showed that daily interruption of continuous sedation was associated with less time spent on mechanical ventilation and less time needing ICU support.( ) However, critics questioned whether the price of sleep deprivation, pain, anxiety, depression, agitation, and delirium paid by those patients was really worth the benefit.( ) The authors' response came three years later with a long-term follow-up of those patients, evaluating the psychological impact of daily sedative interruption as positive.( ) Afterwards, these same findings were replicated in other studies.( , ) In one such study, daily sedative interruption was substituted with a no-sedation protocol, resulting in a reduction in the time needed for critical care support and no long-term psychological negative impact.( ) Ultimately, the reduction of sedation levels associated with early passive and active mobilization was coupled with a more precocious functional independence.( ) Patients were incentivized to early mobilization using a cycle ergometer and had high satisfaction in doing so.( ) Currently, some ICUs propose the judicious early mobilization of critically ill patients. They consider progressive levels of mobilization, from active on-bed mobilization to exercising while sitting, exercising while standing, and ambulating. All of these levels could be offered to the patient regardless of the need for mechanical ventilation.( )
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