European Journal of Cardiovascular Nursing 6 (2007) 40 – 45

www.elsevier.com/locate/ejcnurse

Kinetic therapy reduces complications and shortens hospital stay in

patients with cardiogenic shock—a retrospective analysisB
Gregor Simonis *, Kerstin Flemming, Enrico Ziegs, Katrin Haacke,
Thomas Rauwolf, Ruth H. Strasser
Department of Medicine/Cardiology, Heart Center, Dresden University of Technology, Fetscherstr. 76, 01307 Dresden, Germany

Received 7 November 2005; received in revised form 27 March 2006; accepted 30 March 2006
Available online 15 May 2006

Abstract

Background: Kinetic therapy (KT) has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-
surgical patients are inconclusive, and kinetic therapy has not been tested in patients with cardiogenic shock.
Objective: The present analysis compares KT with standard care in patients with cardiogenic shock.
Methods: A retrospective analysis of 133 patients with cardiogenic shock admitted to 1 academic heart center was performed. Patients with
standard care (SC, turning every 2 h by the staff) were compared with kinetic therapy (KT, using oscillating air-flotation beds).
Measurements and main results: 68 patients with KT were compared with 65 patients with SC. Length of ventilator therapy was 11 days in
KT and 18 days in SC ( p = 0.048). The mortality was comparable in both groups. Pneumonia occurred in 14 patients in KT and 39 patients in
SC ( p < 0.001); pressure ulcers were reduced by 50% ( p < 0.001). Length of ICU stay (21 days in SC and 13 days in KT, p = 0.009) and
length of hospital stay were reduced in the patients treated with kinetic therapy.
Conclusion: The use of KT shortens hospital stay and reduces rates of pneumonia and pressure ulcers as compared to SC.
D 2006 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Keywords: Cardiogenic shock; Kinetic therapy; Critical care; Resource use

1. Introduction became obvious that KT improves pulmonary conditions

Critically ill patients unable to move spontaneously are
often nursed in supine position for extended times, with
deleterious consequences on heart, vascular system, lungs,
skin, and other organ systems [1,2]. In 1978, Keane
demonstrated in a seminal work that healthy humans change
their position during sleep approximately every 11.6 min
[3]. This observation has led to the concept of kinetic
therapy (KT), defined as continuous turning of a patient
slowly along the longitudinal axis to > 40- onto each side.
Initially invented to prevent pressure ulcers, it rapidly
i
Parts of this analysis were presented on the congress of the European
Society of Cardiology 2004. There are no relationships or financial interests
influencing this work.
* Corresponding author. Tel.: +49 351 4500; fax: +49 351 4501702.
E-mail address: gsimonis@gmx.de (G. Simonis).
1474-5151/$ - see front matter D 2006 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcnurse.2006.03.008
in critically ill patients. A couple of smaller studies have
demonstrated beneficial effect of KT in patients with major
trauma [4– 7]. Recently, these results have been confirmed
in a larger, prospective, randomized trial, in which KT was
highly effective to prevent pulmonary complications in
critically ill trauma patients [8]. These data are further
supported by the work of Hildebrand et al. who performed a
database analysis of trauma patients treated in Great Britain
or in Germany [9]. In this retrospective comparison, they
demonstrated a significantly lower mortality in patients
treated in Germany, that was attributed mainly to more
intensive resource use in general and specifically to the use
of KT [9].
For non-trauma patients, evidence supporting KT is
limited. Summer et al. showed reductions of ICU stay in
patients with sepsis and pneumonia, but not in patients with
metabolic coma, drug overdose, or stroke [10]. Raoof et al.
 G. Simonis et al. / European Journal of Cardiovascular Nursing 6 (2007) 40 – 45
demonstrated reductions in atelectases, but not of pneumo-
nia rates in patients with respiratory failure treated with KT
[2]. Kelley et al. saw reductions of complications in stroke
patients confined to their beds when using KT [11]. Both
studies did not address length of hospital stay or ventilator
dependency. In contrast, four other studies could not
demonstrate a reduction in ventilator dependency or hospital
days in patients with non-traumatic critical illness despite a
reduction in the rate of pneumonia [12 – 15].
To our knowledge, the effect of KT has never been tested
in patients with cardiogenic shock. These patients differ
from other non-trauma patients with lung failure by their
hemodynamics, with a high rate of pulmonary congestion
and pulmonary edema due to left ventricular failure, a
condition secondary to the lung. In addition, an increasing
number of patients receive hemodynamic support by aortic
counterpulsation and are subjected to early revasculariza-
tion procedures following the favorable results of the
SHOCK trial [16]. This makes conventional turning of
patients even more difficult. Thus, the goal of this analysis
was to test the effects of KT compared with standard care
(SC) on complications, on the length of ventilator depen-
dency, and on the length of ICU and of hospital stay in
consecutive patients with cardiogenic shock requiring
ventilatory support.
2. Patients and methods
Charts from all patients with cardiogenic shock (defined
by a systolic blood pressure of < 90 mmHg, or a cardiac
index of < 2,2 l/m2 and a pulmonary wedge pressure
> 15 mmHg, or the need for inotropic or vasopressor
support, according to previously specified criteria [16])
treated at the cardiac-care ICU of a single University
hospital were screened. Kinetic therapy on this unit was
started on August, 2002. From August, 2002 till July,
2004, all patients with cardiogenic shock, and the need for
prolonged ventilatory support, defined as modified oxy-
genation index (PaO2/FiO2) <300 Torr [40 kPa] on day 2
of ventilator therapy were treated with KT. Data of those
patients were compared with consecutive patients treated
with standard care before KT was started, i.e. between
August, 2000 and July, 2002. Patients had to be excluded
from the analysis when they had rhythmogenic instability
or when their body weight was above the upper weight
limit for the KT device (i.e., more than 140 kg). At
inclusion, APACHE II and SOFA scores were recalculated
from the charts.
KT was routinely performed using oscillating air-
flotation beds (TriaDyne II\, KCI, San Antonio, USA). In
those beds, patients were continuously turned through an arc
of about 80- every 7 min by alternating inflation of air cells
within the bed’s support surface. Additionally, percussion
was administered by the automated percussion mode of the
beds at 9 beats/s for 10 min every 2 h. Suction was
41
performed after percussion. During KT, sedation was
performed with sulfentanil and propofol. Kinetic therapy
was performed until oxygenation indexes stabilized at
> 350 mmHg [46.7 kPa] for more than 24 h, with a FiO2
 0.3 and a positive end-expiratory pressure  8 cm H2O.
Then, sedation was stopped, and patients were transferred
into normal beds. Extubation was then rapidly performed
after the patients had regained alertness and cooperativeness
and were able to cough.
In the SC group, manual repositioning was performed
every 2 h according to the standardized care on this ward.
The effective number of rotation maneuvers was analyzed
from the charts in both groups.
The primary variables evaluated were the occurrence of
pneumonia, defined as combined occurrence of fever,
radiological infiltrate and growth of typical microorganism
in tracheal aspirates, and of pressure ulcer (defined as de-
novo-occurrence or progression on a 4-point Shea-scale),
the duration of ventilator therapy, the length of ICU stay,
and the time to discharge or referral to another hospital.
For this analysis, both radiographs and microbial findings
were re-analyzed to confirm pneumonia independent from
the chart records. The analysis of the chest radiographs
was done by a radiologist and had to confirm a pattern of
infiltrate more persistent with pneumonia than with
atelectasis. Further parameters analyzed were total mortal-
ity, the number of repositioning maneuvers achieved, and
complications directly related to the use of the oscillating
beds.
To exclude late differences in mortality, telephone
interviews with the patients or their relatives were
performed after 6 and 12 months. If not possible, the
survival status was checked by contacting the patient’s
health insurance. Using this method, a complete follow-up
of the patient’s mortality 1 year after inclusion could be
achieved.
Results are presented as mean values T S.E.M for
continuous normally distributed variables and as median
[25 –75% percentile range] for continuous non-normally
distributed data. Analysis of normality was performed with
the graphical method of normal probability-quantile plot in
combination with the Kolmogorov – Smirnov test. For the
comparisons between normally distributed variables, the t-
test (modified by Welch for non-equal variance) was used.
Non-normally distributed data were analyzed using the
notched box plots by Turkey according to modification
from McGill and Chambers. Additionally, the variable
differences between groups were compared with the
Mann –Whitney U-test and the m2 test by Pearson for
cross-tables. To analyze trends of data over time, two-way
ANOVA testing for repeated measurements was used.
Repeated measurements were analyzed by uni- and
multivariate analysis. A p-value <0.05 was considered
statistically significant. The statistical analysis was per-
formed with the Matlab software for Unix (The Math-
Works, Inc.i, Natick, MA).
42 G. Simonis et al. / European Journal of Cardiovascular Nursing 6 (2007) 40 – 45

3. Results group demonstrates that in patients with cardiogenic shock,

3.1. Patients
Between August, 2002 and May, 2004, 68 patients with
cardiogenic shock and a PaO2 /FiO2 <300 mmHg [40 kPa] on
day 2 of respirator therapy were treated with KT and included
in this analysis. These data were compared with 65 consecutive
patients with cardiogenic shock treated with standard care
between August, 2000, and July, 2002. Together, 133 patients
were included in the analysis. 10 further patients treated
between August, 2000, and May, 2004, were excluded from
this analysis. 5 had unstable cardiac rhythm with multiple
resuscitation maneuvers, 1 patient was subjected to emergency
implantation of a percutaneous left ventricular assist device,
and 4 patients were too obese (the KT device has a upper
weight limit of 140 kg). Using this design, this analysis
included all patients with cardiogenic shock treated during the
time period examined. The baseline characteristics of both
groups are given in Table 1. There were no significant
differences between the groups.
3.2. Number of turning maneuvers
In the KT group, KT was administered for mean (SEM)
8.5 (0.9) days (range, 2 – 31 days). The number of rotation
maneuvers effectively administered was 93 T 31 in KT and
11 T 2 in SC. The very high number of maneuvers in the KT
the goal of continuous rotation was achieved. In the SC
groups, the goal of turning the patients every 2 h was
realized.
3.3. Pneumonia and pressure ulcer
As shown in Fig. 1, rates of pneumonia were signifi-
cantly reduced by 60% in the KT group. The microorganism
detected in those patients were Staphylococcus aureus,
Klebsiella pneumoniae, Streptococcus pneumoniae, Pseu-
domonas aeruginosa, Stenotrophomonas maltophilia, or
Acinetobacter spp. Comparably, the rate of pressure ulcers
was halved by KT.
To exclude that other covariables could have contributed
to this effect of KT on pneumonia and pressure ulcer, a
multivariate statistical analysis was performed including the
baseline conditions shown in Table 1 which had a p-value
below 0.2, i. e. body mass index, acute myocardial infarction
on admission, use of intraaortic counterpulsation, and emer-
gency coronary artery bypass grafting. In this multivariate
analysis using multiple statistical tests, only the mode of
therapy, i. e. KT or SC, was an independent predictor for the
occurrence of pneumonia or pressure ulcer.
In addition to the results shown above, the overall rates
of ventilator-dependent pneumonia in the ICU where this
analysis was performed were externally evaluated by the
local infectious disease monitoring board. This evaluation

Table 1
Baseline characteristics and treatment
Kinetic therapy (n = 68) Standard care (n = 65) p-value
Population characteristics
Age (years, mean T S.D.) 65 T 11 66 T 12 0.76
Gender (m/f, n) 48 / 20 48 / 17 0.46
Body mass index (kg/m2, mean T S.D.) 27.4 T 4.1 26.2 T 3.7 0.07

Underlying disease
Ischemic heart disease (n (%)) 51 (75%) 47 (73%) 0.37
Acute myocardial infarction (n (%)) 43 (63%) 35 (54%) 0.11
Decompensated valvular heart disease (n (%)) 14 (21%) 14 (22%) 0.67
CPR due to malignant arrhythmia (n (%))) 11 (16%) 16 (24%) 0.24
Previously known COPD (n (%)) 12 (17%) 10 (15%) 0.52
Previously known Diabetes (n (%)) 38 (56%) 32 (49%) 0.24
Elevated creatinine at admission (n (%)) 24 (35%) 27 (41%) 0.26

Treatment
Urgent coronary revascularization (n (%)) 42 (62%) 42 (64%) 0.38
- percutaneous coronary intervention (n (%)) 37 (54%) 31 (48%) 0.24
- coronary bypass grafting (n (%)) 10 (15%) 15 (23%) 0.08
Aortic counterpulsation (n (%)) 28 (41%) 21 (32%) 0.11
Inotropes (n (%)) 68 (100%) 65 (100%) –
Vasopressors (n (%)) 48 (70%) 46 (71%) 0.65
Hemofiltration/dialysis (n (%)) 26 (38%) 29 (44%) 0.25
Blood transfusions (n (%)) 28 (41%) 24 (37%) 0.40

Disease severity at inclusion

APACHE II score (points, mean T S.D.) 26.8 T 5.2 27.1 T 5.0 0.69
SOFA score (points, mean T S.D.)) 10.9 T 2.3 10.6 T 2.1 0.35
LV ejection fraction (Echo; mean T S.D.)) 36 T 8% 35 T 6% 0.81
 G. Simonis et al. / European Journal of Cardiovascular Nursing 6 (2007) 40 – 45
Fig. 1. Occurrence of pneumonia, pressure ulcers, and mortality in SC and
KT. Data are expressed as number of patients.
is mainly based on microbiological findings. The vigorous
use of the KT protocol invented in this analysis, which
additionally has been applied to all patients with cardio-
genic shock after completing this analysis, lead to a 40%
overall reduction of ventilator-dependent pneumonia (from
12.5 events per 1000 days of ventilator therapy in 2001
and 2002 to 7.5 events in 2004), despite of a constant
number of 19 –20 days of ventilator use per 100 patient
days. Thus, the result of a decreased pneumonia rate could
be confirmed by a second, external analysis.
3.4. Ventilator dependency, ICU and hospital stay
The length of ventilator dependency, of ICU stay and of
hospital stay is given in Fig. 2. Ventilator use has been
reduced by a median [25th, 75th percentile] of 7 days (KT,
11 [5– 23], SC 18 [9– 23] days). In consequence, ICU stay
was reduced by a median of 8 days, and the time to
discharge or referral was reduced by a median of 5 days.
Fig. 2. KT reduces ventilator dependency and time of ICU stay and of hospital stay. The boxplot gives the median, the 25th and 75th percentile (box) and the
10th and 90th percentile (lines) of every data set.
43
Fig. 3. 1-year survival after cardiogenic shock. The Kaplan – Meyer-
analysis was performed with the data obtained from telephone interviews.
Follow-up of the patients was complete (100%). No differences were
detected between SC and KT.
3.5. Procedure-related complications
In this analysis, a total of 580 days of KT were
administered. During this period, 1 dislocation of an
endotracheal tube and 4 dislocations of central venous lines
were observed as complications directly related to automat-
ed rotation. It is noteworthy that all these events occurred in
the initial 2 months, when the devices were new to the staff.
This has lead to a more conscientious use of the fixation aids
for tubings and lines implemented in the KT devices, with
the consequence of no further events occurring.
3.6. Mortality
In-hospital mortality of the patients was analyzed to
exclude an excess mortality in patients subjected to KT. In
the KT group, 19 of 68 patients died, and in the SC group,
19 of 65 patients died during the hospital stay ( p = n.s.,
44 G. Simonis et al. / European Journal of Cardiovascular Nursing 6 (2007) 40 – 45
Fig. 1). In both groups, the majority of the patients died by
worsening heart failure or progressive multi-organ dys-
function (17 patients in KT and 15 patients in SC). To
exclude long-term effects of KT on mortality, patients were
followed up for 1 year. During this period, mortality of the
groups was not different (Fig. 3). Both groups had a 1-year
mortality of about 65%.
4. Discussion
The basic findings of this analysis are that in patients
with cardiogenic shock, use of kinetic therapy can reduce
complications and shorten ventilator dependency and
hospital stay. The analysis includes over 90% of all patients
with cardiogenic shock admitted during the observational
period, showing the high feasibility of the devices. A clear
limitation of this work is that this is a retrospective analysis.
We want to emphasize that this retrospective analysis may
be influenced, due to the sequential treatment of the patient
groups, by practice changes occurring during the observa-
tion period. We are, however, not aware of any obvious
changes, since the ventilator regimen and machines were
unaltered during this period, and newer drugs and devices
such as Drotrecogin alfa (activated protein C), drug-eluting
stents, and newer vasopressors were used only after the
observation period. Moreover, the criteria for extubation
were not fully characterized and to some extent left to the
treating physicians (see methods), and discharge from ICU
and from the hospital was completely at the discretion of
the treating physician. This regimen, however was un-
changed during the observation period. Unfortunately,
hemodynamic data were obtained only in a minority of
patients. Since we, however, included all suitable consec-
utive patients during the observation period in this analysis,
we believe that the cohort of patients examined represents
the ‘‘real world’’ of a cardiac-care ICU. To overcome the
shortcomings of the current analysis, are we currently
preparing a prospective randomized trial of KT in patients
with cardiogenic shock. It will, however, take several years
to complete this study.
It has to be mentioned that in this analysis, not only
patients with acute myocardial infarction were included. In
both groups, about 20% of patients had decompensation of
valvular disease and with survived sudden cardiac death.
Thus, the left ventricular ejection fraction was higher than in
comparable trials [14], and the use of aortic counter-
pulsation was lower than expected. Hemodynamic param-
eters are not available for all patients. All variables
monitored were equally distributed between the groups.
In a couple of studies, KT was investigated before in
trauma patients (see introduction for details). Nearly all
studies performed before in non-trauma patients showed a
reduction in the number of complications such as pneumo-
nia [2,11 – 15]. A reduction of ICU stay could be shown for
some subgroups of patients in one study [10], whereas four
other studies saw no effect of KT on this parameter [12 – 15].
To our knowledge, the data presented here is the first
analysis of KT in patients with cardiogenic shock. This
analysis shows that this subgroup of patients, with
respiratory failure primary due to congestion, benefits from
KT. Furthermore it demonstrates that KT is feasible in those
patients and/or that continuous rotation does not lead to
hemodynamic or rhythmogenic instability due to fluid shifts
or other mechanisms. The number of procedure-related
complications was low and was further reduced by
improved handling of the devices (see above). KT reduced
hospitalization. A cost-effectiveness analysis was not
performed.
KT has to be compared with other repositioning
maneuvers. Among them, prone positioning is one of the
most promising. Prone positioning has been reported to
improve oxygenation in patients with acute respiratory
failure when compared to SC [17], with unchanged overall
outcome. One study found comparable outcome of KT
compared to prone positioning in patients with the acute
respiratory distress syndrome [18]. Prone positioning has
the advantage of no additional cost for devices. It was,
however, only recommended for acute respiratory failure
among other cardiac conditions. For the subgroup of
patients with cardiogenic shock, prone positioning seems
inadvisable since patients subjected to aortic counterpulsa-
tion are at a high risk for complications when proned. So,
proning of patients was not performed in the patients
analyzed.
It was not intended to examine mortality, and the analysis
was not sufficiently powered to detect differences in that
parameter. Total mortality was somewhat lower than in the
previous SHOCK trial [16]. A mortality rate of about 30%
as shown in this study, however, is within the range of
currently published trials in patients with the acute
respiratory distress syndrome and has been recently stated
as a ‘‘standard’’ for future trials [19].
In summary, this analysis gives preliminary evidence that
early use of kinetic therapy can reduce complications and
reduce hospital stay in ventilator-dependent patients with
cardiogenic shock. Thus, early use of KT should be
considered in patients with cardiogenic shock requiring
ventilatory support. The data, however, have to be
confirmed in a prospective study.
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