Movilización en Cuidados Críticos

Klgo. MSc. Felipe González Seguel

Profesor Adjunto Asociado Universidad del Desarrollo
Servicio Medicina Física y Rehabilitación
Unidad de Cuidados Intensivos
Clínica Alemana Santiago
Pérdida de masa muscular al 10º día de UCI

≈20% ≈30%

Puthucheary JAMA 2013 Parry J Crit Care 2015

Debilidad muscular adquirida en UCI
≈50% DA-UCI

DA-UCI está asociada con:

éTiempo con VM
éEstancia en UCI
éMortalidad hasta 1 año
êFuncionamiento =sico
Intensive Care Med
https://doi.org/10.1007/s00134-020-05927-5

ORIGINAL

Five-year impact of ICU-acquired

neuromuscular complications: a prospective,
observational study
Nathalie Van Aerde1, Philippe Meersseman2, Yves Debaveye1,3, Alexander Wilmer2, Jan Gunst1,3,

and Greet Hermans1,2* ¿La UCI salva vidas

Michael P. Casaer1,3, Frans Bruyninckx4, Pieter J. Wouters1,3, Rik Gosselink5, Greet Van den Berghe1,3
Van Aerde et al. Intensive Care Med 2020

o fabrica víc3mas?
© 2020 Springer-Verlag GmbH Germany, part of Springer Nature

Abstract The new england

journal of medicine
Purpose: To assess the independent association between ICU-acquired neuromuscular complications and 5-year
mortality and morbidity. To explore the optimal threshold of the Medical Research Council (MRC) sum score, assessing
weakness, for the prediction of 5-year outcomes.
Methods: Sub-analyses of a prospective, 5-year follow-up study including 883 EPaNIC patients (Early versus Late Par-
established in 1812 april 7, 2011 vol. 364 no. 14
enteral Nutrition in Intensive Care) (Clinicaltrials.gov:NCT00512122), systematically screened in ICU for neuromuscular
complications with MRC sum score (‘MRC-cohort’, N = 600), electrophysiology on day 8 ± 1 to quantify compound mus-
cle action potential (‘CMAP-cohort’, N = 689), or both (‘MRC&CMAP-cohort’, N = 415). Associations between ICU-acquired
Functional Disability 5 Years after Acute Respiratory
neuromuscular complications and 5-year mortality, hand-grip strength (HGF, %predicted), 6-min-walk distance (6-MWD,
%predicted) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36) at 5-years were assessed with Cox
Distress Syndrome
regression and linear regression, adjusted for confounders. The optimal threshold for MRC at ICU discharge to predict
5-year outcomes was determined by martingale residual plots (survival) and scatterplots (morbidity).
Results:S.Both
Margaret lower MRC
Herridge, M.D.,sum score Catherine
M.P.H., at ICU discharge, indicating
M. Tansey, lessAndrea
M.Sc., strength [HR, per-point-increase:
Matté, 0.946 (95%
B.Sc., George Tomlinson, CI
Ph.D.,
0.928–0.968), p = 0.001], and abnormal CMAP, indicating nerve/muscle dysfunction [HR: 1.568
Natalia Diaz-Granados, M.Sc., Andrew Cooper, M.D., Cameron B. Guest, M.D., C. David Mazer, M.D., (95% CI 1.165–2.186),
p = 0.004],Sangeeta
independently
Mehta,associated with increased
M.D., Thomas 5-year
E. Stewart, mortality.
M.D., In the MRC&CMAP-cohort,
Paul Kudlow, B.Sc., Deborah Cook,MRCM.D.,
[HR: 0.956 (95%
CI 0.934–0.980), p = 0.001]Arthur
but notS.CMAP [HR:M.D.,
Slutsky, 1.478 and
(95%Angela
CI 0.875–2.838),
M. Cheung, 0.088] Ph.D.,
p = M.D., independently associated with
5-year mortality. Among 205 survivors, low MRC independently associated with low
for the Canadian Critical Care Trials Group Herridge HGF [0.866 (95% CI 0.237–1.527),
et al. NEJM 2011
p = 0.004], low 6-MWD [105.1 (95% CI 12.1–212.9), p = 0.043] and low PF-SF-36 [− 0.119 (95% CI − 0.186 to − 0.057),
Inoue et al Acute Med Surg 2019
 Post Intensive Care Syndrome (PICS)
Improving long-term outcomes after discharge from intensive care “Trastorno Mental, Físico y Cognitivo que ocurre
unit: Report from a stakeholders’ conference*
durante la estadía en la UCI o después del alta
Dale M. Needham, MD, PhD; Judy Davidson, DNP, RN; Henry Cohen, PharmD; Ramona O. Hopkins, PhD;
Craig Weinert, MD, MPH; Hannah Wunsch, MD, MSc; Christine Zawistowski, MD; hospitalaria. Incluye el pronóstico a largo plazo de
Anita Bemis-Dougherty, PT, DPT; Susan C. Berney, PT, PhD; O. Joseph Bienvenu, MD, PhD;
Susan L. Brady, MS; Martin B. Brodsky, PhD; Linda Denehy, PT, PhD; Doug Elliott, RN, PhD; Carl Flatley, DDS; los pacientes de la UCI y los efectos en la familia”
Andrea L. Harabin, PhD; Christina Jones, RN, PhD; Deborah Louis, RN; Wendy Meltzer, JD;
Sean R. Muldoon, MD, MPH, MS; Jeffrey B. Palmer, MD; Christiane Perme, PT, CCS;
Marla Robinson, OTR/L, MSc, BCPR; David M. Schmidt, MD, PhD; Elizabeth Scruth, RN; Gayle R. Spill, MD;
C. Porter Storey, MD; Marta Render, MD; John Votto, DO; Maurene A. Harvey, RN, MPH, FCCM

Background: Millions of patients are discharged from intensive
care units annually. These intensive care survivors and their
families frequently report a wide range of impairments in their
health status which may last for months and years after hospital
discharge.
Objectives: To report on a 2-day Society of Critical Care Med-
icine conference aimed at improving the long-term outcomes
after critical illness for patients and their families.
Participants: Thirty-one invited stakeholders participated in
the conference. Stakeholders represented key professional orga-
nizations and groups, predominantly from North America, which
are involved in the care of intensive care survivors after hospital
discharge.
Design: Invited experts and Society of Critical Care Medicine
members presented a summary of existing data regarding the po-
tential long-term physical, cognitive and mental health problems
after intensive care and the results from studies of postintensive care
unit interventions to address these problems. Stakeholders provided
reactions, perspectives, concerns and strategies aimed at improving
care and mitigating these long-term health problems.
Measurements and Main Results: Three major themes
emerged from the conference regarding: (1) raising awareness
and education, (2) understanding and addressing barriers to
practice, and (3) identifying research gaps and resources. Postin-
tensive care syndrome was agreed upon as the recommended OUTCOMES PACIENTES
term to describe new or worsening problems in physical, cogni-
tive, or mental health status arising after a critical illness and
persisting beyond acute care hospitalization. The term could be
Mentales (Depresión, Ansiedad, PTSD)
Pulmonares (Espirometría)
applied to either a survivor or family member.
Conclusions: Improving care for intensive care survivors and
their families requires collaboration between practitioners and
researchers in both the inpatient and outpatient settings. Strate-
gies were developed to address the major themes arising from the
conference to improve outcomes for survivors and families. (Crit
Neuromusculares/DA-UCI (Neuro-miopatía)
Care Med 2012; 40:502–509)
KEY WORDS: aftercare; caregivers; continuity of patient care; Función física (TM6min, ADL/IADL)
critical care; follow-up studies; intensive care units; outcome
assessment; patient care planning; patient care team; postinten-
sive care syndrome; stress disorders, post-traumatic; survivors
Cognitivos (Delirium, Fx ejecutiva, Memoria))

*See also p. 681.
From the OACIS Group, Pulmonary and Critical
Care Medicine, and Physical Medicine and Rehabilita-
tion (DMN), Johns Hopkins University, Baltimore, MD;
Nursing Excellence and Advanced Practice (JD),
Scripps Mercy Hospital, San Diego, CA; Pharmacother-
apy (HC), Kingsbrook Jewish Medical Center, Wood-
mere, NY; Medicine, Pulmonary, and Critical Care
(ROH), Intermountain Medical Center, and Psychology
and Neuroscience Center, Brigham Young University,
Salt Lake City, UT; Pulmonary, Allergy, Critical Care,
and Sleep Medicine (CW), Clinical Outcomes Research
Center, University of Minnesota, Minneapolis, MN; An-
esthesiology and Epidemiology (HW), Columbia Univer-
sity, New York, NY; Pediatrics (CZ), Mount Sinai Kravis
Children’s Hospital, Brooklyn, NY; Department of Prac-
tice (ABD), American Physical Therapy Association,
tation (MBB), Johns Hopkins University, Baltimore, MD;
Physiotherapy (LD), Melbourne School of Health Sci-
ences, University of Melbourne, Melbourne, Australia;
Faculty of Nursing (DE), University of Technology, Syd-
ney, Australia; Sepsis Alliance (CF), Tampa, FL; Divi-
sion of Lung Disease (ALH), National Heart, Lung, and
Blood Institute, Bethesda, MD; Critical Care Rehabili-
tation (CJ), Whiston Hospital, Prescot, United Kingdom;
Critical Care (DL), Kaiser Sunnyside Medical Center,
Clackamus, OR; Illinois Citizens for Better Care (WM),
Chicago, IL; Hospital Division (SRM), Kindred Health-
care, Louisville, KY; Physical Medicine and Rehabilita-
tion (JBP), Otolaryngology, and Functional Medicine,
Johns Hopkins University, Baltimore, MD; Physical
Therapy (CP), The Methodist Hospital, Houston, TX;
Occupational Therapy (MR), University of Chicago
Medical Center, Chicago, IL; Pulmonary and Critical
ative Medicine (CPS), Boulder, CO; Inpatient Evaluation
Center (MR), Veterans Affairs Medical Center–
Cincinnati, and Pulmonary/Critical Care/Sleep, Univer-
sity of Cincinnati College of Medicine, Cincinnati, OH;
Hospital for Special Care (JV), New Britain, CT; Critical
Care Educator and Consultant and Past President So-
ciety of Critical Care Medicine (MAH), Lake Tahoe, NV.
Dr. Needham has received grant support from the
National Institutes of Health. Dr. Bienvenu has received
funding from the National Institutes of Health. Ms.
Louis is employed by Kaiser Permanente. Dr. Muldoon
is employed by and has stock ownership in Kindred
Healthcare. The remaining authors have not disclosed
any potential conflicts of interest.
For information regarding this article, E-mail:
Dale.needham@jhmi.edu Needham et al CCM 2012
Copyright © 2012 by the Society of Critical Care
Contexto – Movilización temprana
Zhang et al. 10.3389/fneur.2022.848545

COVID-19

PICS

FIGURE 1
Global trend in publications on ICU early mobilization. Zhang et al. Frontiers in Neurology 2022
Revisiones sistemáticas > Ensayos clínicos
 in the
a trea
Países destacados - Movilización temprana
early m
of ear
teamw
rehabi
discip
linkag
gradu
paralle
illustr
(Table
of com
FIGURE 3
of Me
Co-occurrence network mapping (larger circles indicate more critica
Zhang et al Frontiers in Neurology 2022
≥0.1. The higher the centrality of a node, the more influential
and important it is). and rehabilitation medicine (Archives of Physical Medicine
and Rehabilitation).
Autores destacados - Movilización temprana

Autores con > 100 citas

FIGURE 4
Zhang et al Frontiers in Neurology 2022
 Autores destacados - Movilización temprana

Referencias con >50 citas

FIGURE 5
Zhang et al Frontiers in Neurology 2022
 Contexto - Movilización temprana
• Fac5ble SYSTEMATIC REVIEW
Safety of Patient Mobilization and Rehabilitation in the Intensive
Care Unit
Systematic Review with Meta-Analysis

• Segura
Peter Nydahl1*, Thiti Sricharoenchai2*, Saurabh Chandra3, Firuzan Sari Kundt4, Minxuan Huang5, Magdalena Fischill6,
and Dale M. Needham7
1
Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany; 2Division of Pulmonary and Critical Care Medicine,
Nydahl et al. AnnalsATS 2016
Thammasat University, PathumThani, Thailand; 3Telehealth Program, Northwell Health, New York, New York; 4Institute of Nursing
Science and Practice, Paracelsus Medical University, Salzburg, Austria; 5Department of Epidemiology, Rollins School of Public Health,
Emory University, Atlanta, Georgia; 6Nursing Development, University Hospital Salzburg, Salzburg, Austria; and 7Division of Pulmonary
and Critical Care Medicine and Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
ORCID ID: 0000-0002-5178-0364 (P.N.).

Abstract FOCUSED REVIEWS

Synthesis: Heterogeneity was assessed 2
by I statistics, and bias assessed

• Barreras
by the Newcastle–Ottawa Scale and Cochrane risk of bias assessment.
Background: Early mobilization and rehabilitation of patients in The literature search identified 20,660 titles. There were 48 eligible
Barriers and Strategies for Early Mobilization of Patients
intensive care units (ICUs) may improve physical function, and
reduce the duration of delirium, mechanical ventilation, and ICU
publications evaluating 7,546 patients, with 583 potential safety events
occurring in 22,351 mobilization/rehabilitation sessions. There was a total
in Intensive Care Units
length of stay. However, safety concerns are an important barrier to of 583 (2.6%) potential safety events with heterogeneity in the definitions
widespread implementation. for these events. For the safety event types that could be meta-analyzed,
Rolf Dubb1*, Peter Nydahl2*, Carsten Hermes3, Norbert Schwabbauer 4
, Amy per
pooled incidences Toonstra 5
, Ann M. Parker6, sessions (95%
1,000 mobilization/rehabilitation
Objectives: To synthesize
1 safety
Arnold Kaltwasser , and Dale M. Needham data regarding patient
7 mobilization and
confidence interval), were: hemodynamic changes, 3.8 (1.3–11.4), and
rehabilitation
1
in the ICU, including falls, removal of endotracheal tubes, desaturation, 1.9 (0.9–4.3). A total of 24 studies of 3,404 patients reported
Department of Continuing Education of Critical Care of
Nursing,
other District onHospital of Reutlingen, Reutlingen, Germany; 2Neurological
Dubb et al. AnnalsATS 2016
removal or dysfunction of intravascular catheters, removal any consequences of potential safety events
Intensive Care Unit and Stroke Unit, University Hospital of Schleswig-Holstein, Kiel, Germany; 3
Intensive Care Unit,(e.g.,
Heliosneeding to
Klinikum
catheters/tubes, cardiac arrest, hemodynamic
4 changes, and desaturation.
Siegburg, Siegburg, Germany; Department of Medicine, University Hospital increase dose of vasopressor
Tübingen, Tübingen, Germany; and 5Physicalhypotension),
due to mobility-related Medicine andwith
6
Rehabilitation, Johns Hopkins Hospital, Division of Pulmonary and Critical Care Medicine,
of 0.6%Johns Hopkins University School of Medicine,
Data Sources: and
and 7Pulmonary Systematic
Critical literature review,Johns
Care Medicine, including searches
Hopkins of aBaltimore,
University,
frequency
Maryland
in 14,398 mobilization/rehabilitation sessions.
five databases. Eligible studies evaluated patients who received Conclusions: Patient mobilization and physical rehabilitation in the

• Efectiva ?
mobilization-related interventions in the ICU. Exclusion criteria ICU appears safe, with a low incidence of potential safety events, and
included:
Abstract (1) case series with fewer than 10 patients; (2) majority of setting, attitude,
only rare events and ICU
having anyculture. To overcome
consequences the management.
for patient identified
patients under 18 years of age; and (3) data not reported to permit barriers, over 70instrategies
Heterogeneity wereof
the definition reported and are
safety events synthesized
across in this
studies emphasizes
calculation of incidence of safety events.
Early mobilization of patients in the intensive care unit (ICU) is review, including:ofimplementation
the importance implementing existingof safety guidelines; use
consensus-based of
definitions.
safe, feasible,
Data and beneficial.
Extraction: Number However,
of patients,implementation of early
mobilization/rehabilitation mobility protocols; interprofessional training, education, and
mobility potential
sessions, as part of safety
routine clinical
events, andcare can be
events withchallenging.
negative The rounds;
Keywords:and involvement of physician
early ambulation; champions.
exercise; patient Systematic
safety; adverse
objective of this review is to identify barriers to early mobilization efforts to change ICU culture to prioritize early mobilization using
consequences (e.g., requiring intervention or additional therapy). effects
and discuss strategies to overcome such barriers. Based on a an interprofessional approach and multiple targeted strategies are
literature search, we synthesize data from 40 studies reporting important components of successfully implementing early mobility
28 unique barriers to early mobility, of which 14 (50%) were patient- in clinical practice.
related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%)

• Dosis ?
(Received in original form November 3, 2016; accepted in final form February 21, 2017 )
process-related barriers. These barriers varied across ICUs and Keywords: critical care; intensive care; rehabilitation; physical
*These
within authors contributed
disciplines, equally
depending ontothe
thisICU
study.
patient population, therapy; review
This work was performed at Johns Hopkins University (Baltimore, MD) and University Hospital of Schleswig-Holstein (Kiel, Germany).
S9ller. Chest 2013
Author Contributions: P.N., T.S., S.C., and D.M.N. were responsible for conception and design of the study; all authors made substantial contributions to data
collection, analysis, and interpretation; P.N., S.C., F.S.K., M.H., and M.F. drafted the manuscript, and all authors critically reviewed the manuscript and
approved
(Received the final version.
in original form September 5, 2015; accepted in final form February 1, 2016 )
Correspondence and requests
*These authors contributed for reprints
equally should
to the work andbeshould
addressed to Peter Nydahl,
be considered co–first R.N., M.Sc.N., Nursing Research, University Hospital of Schleswig-Holstein,
authors.
Brunswiker Strasse 10, 24105 Kiel, Germany. E-mail: peter.nydahl@uksh.de
Correspondence and requests for reprints should be addressed to Peter Nydahl, R.N., B.Sc.N., University Hospital of Schleswig-Holstein, Nursing Research,
This article has
Brunswiker an online
Strasse, supplement,
10 Kiel which is
24105, Germany. accessible
E-mail: from this issue’s table of contents at www.atsjournals.org
peter.nydahl@uksh.de
 La rehabilitación temprana en la UCI no se asoció
con mejoras en el estado funcional, fuerza
RESEARCH ARTICLE
muscular, calidad de vida o resultados de salud.
Effect of Early Rehabilitation during Intensive
Care Unit Stay on Functional Status:
Systematic Review and Meta-Analysis Parece mejorar la capacidad para caminar en
Ana Cristina Castro-Avila1*, Pamela Serón2, Eddy Fan3, Mónica Gaete2, Sharon Mickan4 comparación con la atención habitual.
1 Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago,
Chile, 2 Internal Medicine Department, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile,
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada,
4 Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom

* anacastro@udd.cl

Abstract Castro-Ávila et al. Plos One 2015

 “Timing” de la movilización temprana
¿Qué es temprano?
• Estabilidad fisiológica?

• Dentro de las primeras 48hrs?

• 5 días?

Carol Hodgson
Carol Hodgson
 The n e w e ng l a n d j o u r na l of m e dic i n e

Original Article

Early Active Mobilization during Mechanical

Ventilation in the ICU
The TEAM Study Investigators and the ANZICS Clinical Trials Group*

A BS T R AC T

BACKGROUND
Intensive care unit (ICU)–acquired weakness often develops in patients who are The members of the writing committee
undergoing invasive mechanical ventilation. Early active mobilization may mitigate (Carol L. Hodgson, Ph.D., Michael Bailey
Ph.D., Rinaldo Bellomo, Ph.D., Kathy Brick
ICU-acquired weakness, increase survival, and reduce disability. ell, R.G.N., Tessa Broadley, B.Biomed.Sci.
Heidi Buhr, M.Sc.Med., Belinda J. Gabbe
METHODS Ph.D., Doug W. Gould, Ph.D., Meg Harr
We randomly assigned 750 adult patients in the ICU who were undergoing invasive old, Ph.D., Alisa M. Higgins, Ph.D., Sall
Hurford, P.G.Dip., Theodore J. Iwashyna
mechanical ventilation to receive increased early mobilization (sedation minimiza- Ph.D., Ary Serpa Neto, Ph.D., Alistair D
tion and daily physiotherapy) or usual care (the level of mobilization that was Nichol, Ph.D., Jeffrey J. Presneill, Ph.D.
normally provided in each ICU). The primary outcome was the number of days that Stefan J. Schaller, M.D., Janani Sivasuthan
M.P.H., Claire J. Tipping, Ph.D., Steven
the patients were alive and out of the hospital at 180 days after randomization. Webb, Ph.D., and Paul J. Young, M.B.
Ch.B., Ph.D.) assume responsibility for the
RESULTS Hodgson
overall content andet al. NEJM
integrity 2022
of this article.
 The n e w e ng l a n d j o u r na l of m e dic i n e

Original Article

Early Active Mobilization during Mechanical

Ventilation in the ICU
The TEAM Study Investigators and the ANZICS Clinical Trials Group*

A BS T R AC T

BACKGROUND
Intensive care unit (ICU)–acquired weakness often develops in patients who are The members of the writing committee
undergoing invasive mechanical ventilation. Early active mobilization may mitigate (Carol L. Hodgson, Ph.D., Michael Bailey,
Ph.D., Rinaldo Bellomo, Ph.D., Kathy Brick-
ICU-acquired weakness, increase survival, and reduce disability. ell, R.G.N., Tessa Broadley, B.Biomed.Sci.,
Heidi Buhr, M.Sc.Med., Belinda J. Gabbe,
METHODS Ph.D., Doug W. Gould, Ph.D., Meg Harr-
We randomly assigned 750 adult patients in the ICU who were undergoing invasive old, Ph.D., Alisa M. Higgins, Ph.D., Sally
Hurford, P.G.Dip., Theodore J. Iwashyna,
mechanical ventilation to receive increased early mobilization (sedation minimiza- Ph.D., Ary Serpa Neto, Ph.D., Alistair D.
tion and daily physiotherapy) or usual care (the level of mobilization that was Nichol, Ph.D., Jeffrey J. Presneill, Ph.D.,
normally provided in each ICU). The primary outcome was the number of days that Stefan J. Schaller, M.D., Janani Sivasuthan,
M.P.H., Claire J. Tipping, Ph.D., Steven
the patients were alive and out of the hospital at 180 days after randomization. Webb, Ph.D., and Paul J. Young, M.B.,
Ch.B., Ph.D.) assume responsibility for the
RESULTS overall content and integrity of this article.
The median number of days that patients were alive and out of the hospital was 143
The affiliations of the members of the
(interquartile range, 21 to 161) in the early-mobilization group and 145 days (inter- writing committee are listed in the Ap-
quartile range, 51 to 164) in the usual-care group (absolute difference, −2.0 days; pendix. Dr. Hodgson can be contacted at
95% confidence interval [CI], −10 to 6; P = 0.62). The mean (±SD) daily duration of carol.hodgson@monash.edu or at the
Australian and New Zealand Intensive Care
active mobilization was 20.8±14.6 minutes and 8.8±9.0 minutes in the two groups, Research Centre, 553 St. Kilda Rd., Mel-
respectively (difference, 12.0 minutes per day; 95% CI, 10.4 to 13.6). A total of 77% bourne, VIC 3004, Australia.
of the patients in both groups were able to stand by a median interval of 3 days *A complete list of the TEAM trial inves-
and 5 days, respectively (difference, −2 days; 95% CI, −3.4 to −0.6). By day 180, death tigators and the ANZICS Clinical Trials
had occurred in 22.5% of the patients in the early-mobilization group and in 19.5% Group is provided in the Supplemen-
tary Appendix, available at NEJM.org.
of those in the usual-care group (odds ratio, 1.15; 95% CI, 0.81 to 1.65). Among
survivors, quality of life, activities of daily living, disability, cognitive function, and This article was published on October 26,
2022, at NEJM.org.
psychological function were similar in the two groups. Serious adverse events were
reported in 7 patients in the early-mobilization group and in 1 patient in the usual- DOI: 10.1056/NEJMoa2209083
Copyright © 2022 Massachusetts Medical Society.
care group. Adverse events that were potentially due to mobilization (arrhythmias,
altered blood pressure, and desaturation) were reported in 34 of 371 patients (9.2%)
in the early-mobilization group and in 15 of 370 patients (4.1%) in the usual-care
group (P = 0.005).
CONCLUSIONS
Among adults undergoing mechanical ventilation in the ICU, an increase in early
active mobilization did not result in a significantly greater number of days that pa-
tients were alive and out of the hospital than did the usual level of mobilization in
the ICU. The intervention was associated with increased adverse events. (Funded by the
National Health and Medical Research Council of Australia and the Health Research
Council of New Zealand; TEAM ClinicalTrials.gov number, NCT03133377.)

n engl j med nejm.org 1

The New England Journal of Medicine
Downloaded from nejm.org by DAVID KRAUNIK on October 26, 2022. For personal use only. No other uses without permission.
Copyright © 2022 Massachusetts Medical Society. All rights reserved.

Hodgson et al. NEJM 2022

Uninterrupted actigraphy recording to quantify physical activity and sedentary behaviors in
mechanically ventilated adults: a feasibility prospective observational study

ACCelera Study

González-Seguel et al J Acute Care Phys Ther 2022

Movilización en UCI

Estudios Ensayos Revisiones Práctica

Observacionales Clínicos Sistemá4cas Clínica
 Movilización en la UCI

1. Clasificaciones de la Movilización en la UCI

• Según nivel de actividad física
• Según lugar de realización
• Según materiales requeridos
 Clasificación de la Movilización
Según nivel de actividad física
Movilizaciones pasivas y Posicionamiento Electroestimulación

¿Movimiento, Actividad Física, Ejercicio o Entrenamiento?

Movilizaciones en cama Sedente al borde cama Marcha
 Clasificación de la Movilización
Según lugar de realización
En cama
Pasiva (no-cooperador) Activa (cooperador)
 Clasificación de la Movilización
Según lugar de realización
Fuera de la cama
Pasiva (no-cooperador) Activa (cooperador)
 Clasificación de la Movilización
Según materiales requeridos
1. Equipamiento-dependientes
• Cicloergómetros (EESS, EEII)
• Electroes4mulación
• Tilt-table
• FES
• Plataformas vibratorias
2. Terapeuta-dependientes
• Movilidad progresiva (giros, transferencias, marcha)
• ROM ac4vo
• ROM pasivo
• Balance
• Tolerancia al ejercicio
• Posicionamiento
3. Mixto
PICUPS

PICUPS. Journal of the Intensive Care Society 2021

Desafíos
• Dosis de movilización, desconocida?
• Dosis de nutrición, desconocida?
• Barreras para la movilización
• Tiempo de inicio
• Outcomes evaluados (Timing, type)
• Seguimiento (Follow up)
early rehabilitation in the ICU. The majority of studies
RESEARCH Open Access

simply report cardiac

Comparison of exercise frequency
intensity during or SpO2 [24, 25].
four early rehabilitation techniques in
sedated and ventilated patients in ICU: a Effec
randomised cross-over trial
Clément Medrinal1,2*, Yann Combret3,4, Guillaume Prieur2, Aurora Robledo Quesada2, Tristan Bonnevie5,6,7,
Chan
Francis Edouard Gravier7, Elise Dupuis Lozeron8, Eric Frenoy9, Olivier Contal10 and Bouchra Lamia5,6,11,12
musc
Abstract
Background: In the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity.
Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the
highest intensity. The aim of this study was to compare the physiological effects of four common types of bed
NIRS
exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most
intensive.
Methods: A randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of
the p
four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation
and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes
in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims
were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the
O2 e
volum
microcirculation of the vastus lateralis muscle.
Results: The results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output,
with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting
that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or

ition
systemic effects were induced by the passive techniques.
Conclusion: Most bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the
only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies
of the effect of FES cycling on functional outcomes should be carried out.
Trial registration: ClinicalTrials.gov, NCT02920684. Registered on 30 September 2016.
Prospectively registered.
Keywords: Early rehabilitation, Intensive care unit, Mechanical ventilation, Metabolism, Sedation
been
lack
* Correspondence: medrinal.clement.mk@gmail.com
1
Normandie Univ, UNIROUEN, UPRES EA3830 - GRHV, Institute for Research
the
verse
and Innovation in Biomedicine (IRIB), 76000 Rouen, France
2
Intensive Care Unit Department, Groupe Hospitalier du Havre, Hôpital
Jacques Monod, Pierre Mendes France, 76290 Montivilliers, France
Full list of author information is available at the end of the article

decr
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to

Fig. 2 Cardiac output over time for each exercise. Black circles represent
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Medrinal et al. Critical Care 2018
 PROM Passive Cycle Ergometry

Quad-ES FES-Cycling
 Fisiología del ejercicio –
822 DETERMINANTS OF EXERCISE-INDUCED RESPIRATORY AND LOCOMOTOR MUSCLE

Competitividad entre músculos periféricos y músculos respiratorios

Unloading the Inspiratory Muscles at >
A
Reducing Inspira

Pes (cmH2O)
Fig. 1. Summary of the effects of unloading
the inspiratory muscles during heavy-inten- • prevents exercise
sity exercise. Shown are representative with-
in-breath esophageal (A: Pes) and trans- • ↓ sympathetic ton
diphragmatic pressure-time (B: Pdi) traces for
and ↑ blood flow
1 subject ensemble averaged over 1 min dur-
ing spontaneous breathing (control) and pro- Control
portional assist ventilation (PAV) at exercise B PAV
• ↓ locomotor mus
iso-time. Note that with the use of PAV the

Pdi (cmH2O)
esophageal and Pdi during inspiration were • ↓ perceived sens
reduced by 50 –70% vs control. Tracings from discomfort
Romer et al. (64).
• ↑ exercise duratio

• ↓ blood flow to ac
Breath Time (s)

coincident changes in blood flow. Thus, with respiratory mus- striction in the limb was recently
cle unloading, limb vascular conductance and blood flow were the demonstration during two-legg
increased significantly despite a coincident reduction in stroke sured MSNA in the median nerv
volume and cardiac output (32, 33). Conversely, increasing the reduced with respiratory muscle
Sheel et al. Journal of Applied Physiology 2018
on (Tlim) in
was reduced exercise required that peak inspiratory Pes match that obtained at rest.
out all exer- Ejercicio en sanos con/sin VNI
he recording
ed (%10 s).
.5 min after FiO2 18%
omized. The
linded to the
Esfuerzo respiratorio

PAV. A FIO2
FiO2 21%
altitude and
that heavy
se oximetry
.
FiO2 18%

ed breath by
rcuit system FiO2 21%
llcor N-595,
r PO2 (PAO2)

Fig. 1. Inspiratory muscle work during exercise at the same absolute workload
Amann et al. Am J Physiol Regul Integr Comp Physiol 2007
 Hallazgos Scoping Review – Estudios de Movilzación Temprana

7 estudios reportaron ajustes ventilatorios durante

la MT
40%
n = 14
FiO2

NO reportaron detalles sobre el Nivel de PS

L ASSIST VENTILATION AND NEURALLY ADJUSTED VENTILATORY ASSIST
Soporte Respiratorio

and PSV

≈70%
n = 26
≈70%
n = 26

NO reportaron la configuración de los NO reportaron la marca y el modelo de

Fig. 2. Relationship between patient effort and ventilator Kacmarek.
pressure Respir Care 2011

during various ventilation modes. During volume ventilation, pa-

tient effort and ventilator pressure are inversely related. During
pressure ventilation, ventilator pressure in unaffected by patient

modos y variables ventilatorias

effort. During proportional assist ventilation (PAV) and neurally ad-
justed ventilatory assist (NAVA), patient effort and ventilator pres- los ventiladores mecánicos utilizados.
sure are directly related. (Adapted from Reference 5.)
vating a ventilator breath. Neu-
entilation modes are activated
tation. Proportional assist ven-
hange in airway pressure, flow, gas delivery begins when the diaphragm is simulated, not González-Seguel et al. Crit Care Explor 2021
 Mortality reported during follow-up
Reported lost to follow-up rates combined with mortality
Included flow chart with retention rates for each follow-up
point
Reported reasons for lost to follow-up at each follow-up point
Dificultades en el seguimiento post UCI
Data are presented as n (%). Total number of studies ¼ 21.
19 (90)
was 85% (95% CI 57–96%, I2 44%) at 3 months, 89%
1 (5) (95% CI 72–96%, I2 95%) at 6 months, 82% (95% CI 61–
10 (48) 93%, I2 97%) at 12 months, and 88% (95% CI 44–99%, I2
75%) at 24 months (Fig. 2). As part of post hoc analyses to
9 (43) explore potential contributors to high heterogeneity, we
pooled retention rates by following subgroups: ARDS stud-
ies, studies that conducted only in-person visits, and studies
that used different modes of visits instead of or in addition

100

(pooled estimate, 95% CI)

Participants retained
75
Capacidad de
retención entre
32% & 100%
50

3 6 12 24
Time (months)
Studies, no. 5 11 8 3
Subjects, N 695 1,605 1,692 316
Subjects retained, % 85 89 82 88
Nunna et al. Respir Care 2020
 Open access Protocol

BMJ Open: first published as 10.1136/bmjopen-2021-053610 on 8 September 2021. Downloaded

Impact on Mental, Physical and
Cognitive functioning of a Critical care
sTay during the COVID-19 pandemic
(IMPACCT COVID-19): protocol for a
prospective, multicentre, mixed-
methods cohort study
Ana Cristina Castro-Ávila ,1,2 Catalina Merino-Osorio ,1
Felipe González-Seguel ,1,3 Agustín Camus-Molina ,1,3 Jaime Leppe ,1 The
IMPACCT COVID-19 study group
NCT04979897

To cite: Castro-Ávila AC, ABSTRACT

Merino-Osorio C, González- Strengths and limitations of this study
Introduction The ongoing pandemic could affect the
Seguel F, et al. Impact on duration, variety and severity of the mental, physical,
Mental, Physical and Cognitive This is the first Chilean multicentre study assessing
and cognitive impairments intensive care unit (ICU)
functioning of a Critical care postintensive care unit (ICU) sequalae.
survivors and their families frequently present. We aim to FelipeExperiences
González- of family
sTay during the COVID-19
Ana Cristina Castro Catalina Merino- Jaime Leppe Zamora members
Agustín and healthcare pro-
Camus-
pandemic (IMPACCT COVID-19): Ávila determine the impact of the COVID-19 pandemic
Osorio PT MSc.on the Seguel Molina will also explored.
fessionals during the pandemic
PT MSc PhD
protocol for a prospective, mental, physical,PTandMSc
cognitive health of survivors, the PT MScto infection control PT MSc
Due protocols and lock-
multicentre, mixed-methods experience of their families and their treating healthcare downs, most physical functioning measures are
cohort study. BMJ Open professionals. self-reported.
2021;11:e053610. doi:10.1136/ Methods and analysis Prospective, multicentre,
bmjopen-2021-053610
Patient’s ICU assessments were limited by increased
× W !"#$%&'()*+,-./BMJ Open
IMPACCT COVID-19
Impact on Mental, Physical, And Cognitive functioning of a Critical care sTay during the COVID-19 pandemic

Obje%vo
Comparar la trayectoria de los deterioros Mentales, Físicos y Cognitivos al egreso
de la UCI, a los 3 y 6 meses de pacientes ventilados sobrevivientes a la UCI
durante alta y baja ocupación de camas en la Pandemia.

Castro-Ávila et al. BMJ Open 2019

IMPACCT COVID-19
Impact on Mental, Physical, And Cognitive functioning of a Critical care sTay during the COVID-19 pandemic

19 UCIs

7
Egreso UCI 3 meses 6 meses
CFS, Charlson & Nivel educacional
centros
Adultos MRC-SS & FSS-ICU

4
Empleabilidad & WHODAS 2.0
>48h VMI
públicos Marcha independiente previa HADS, IES-R & MoCA Blind
EQ-5D-3L

3 privados
CFS = Clinical Frailty Scale; MRC-SS = Medical Research Council Sum Score; FSS-ICU = Functional Status Score for the Intensive
Care Unit; WHODAS = WHO Disability Assessment Schedule; HADS = Hospital Anxiety and Depression Scale; IES-R = Impact of
Event Scale-Revised; MoCA-blind = Montreal Cognitive Assessment-blind; EQ-5D-3L = European Quality of Life Health
Questionnaire 5 Domains

#2020-78

Castro-Ávila et al. BMJ Open 2019

 Enrollment
Patients discharged from
the ICU (n= 1,317)

Does not meet selection criteria (n= 552)

♦ Age < 18 years (n= 6)
♦ Died (n= 250 [19%])
♦ Non-ventilated/ventilated per < 48 hours (n= 446)
♦ Transferred to a non-participating ICU (n= 110)
♦ Unable to walk independent 2 weeks prior ICU
admission (n= 22)
♦ Does not speak Spanish (n= 16)
♦ Unable to communicate verbally (n= 26)
♦ Burn, severe trauma or neurological disorder as
admission diagnosis (n= 59)
♦ Recent prolonged hospital stay (n= 14)

Eligible at ICU discharge

(n= 405)
Not recruited (n= 153)
♦ Declined to participate (n= 18)
♦ Unable to cooperate (n= 45)
Considering CAM-ICU positive (n= 20)
Considering s5q<5 (n= 25)
♦ Lack of evaluator (n= 90)
Evaluated at ICU discharge
(n= 252)

58% pérdidas de
Lost to follow-up (n= 147 [58%])
♦ Unable to contact (n= 125)
♦ Unable to respond due to health problems (n= 9)
♦
♦
Withdrawal of consent (n= 8)
Died (n= 5) seguimiento
Follow-Up
Evaluated at 3 months after
ICU discharge (n= 105)

38% pérdidas de
Lost to follow-up (n= 38 [36%])
♦ Unable to contact (n= 35)
♦ Unable to respond due to health problems (n= 1)
♦
♦
Withdrawal of consent (n= 1)
Died (n= 1) seguimiento
Evaluated at 6 months after
ICU discharge (n= 67)

Analysis
COVID-19 patients evaluated at 6 months (n= 52)
Non-COVID-19 patients at 6 months (n= 15)

IMPACCT-COVID19 Study 2022 [Datos no publicados aún]

 Hallazgos – IMPACCT-COVID19

6 meses
1er estudio multicéntrico
de seguimiento post-UCI
en Chile 57%
Al menos un problema
físico, mental o cognitivo

No hubo diferencias según No hubo diferencias según

presencia COVID-19 ocupación de camas
IMPACCT-COVID19 Study 2022 [Datos no publicados aún]
 Mensajes finales

• La inactividad de los pacientes críticos sigue siendo alta

• Aún existen desafíos para trasladar la evidencia a la práctica clínica

• Debemos seguir enfocados en minimizar víctimas de la UCI

¡Gracias!
feligonzalezs@udd.cl