Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults

doi:10.1186/s13054-014-0658-y

. 2014 Dec 4;18(6):658.

doi: 10.1186/s13054-014-0658-y.

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults

Carol L Hodgson^{1

2}, Kathy Stiller³, Dale M Needham⁴, Claire J Tipping⁵, Megan Harrold⁶, Claire E Baldwin^{7

8}, Scott Bradley⁹, Sue Berney¹⁰, Lawrence R Caruana¹¹, Doug Elliott¹², Margot Green¹³, Kimberley Haines^{14

15}, Alisa M Higgins¹⁶, Kirsi-Maija Kaukonen^{17

18}, Isabel Anne Leditschke^{19

20}, Marc R Nickels²¹, Jennifer Paratz^{22

23}, Shane Patman²⁴, Elizabeth H Skinner^{25

26}, Paul J Young^{27

28}, Jennifer M Zanni²⁹, Linda Denehy³⁰, Steven A Webb^{31

32}

Affiliations

¹ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. carol.hodgson@monash.edu.
² Department of Physiotherapy, The Alfred, 55 Commercial Road, Melbourne, Victoria, 3004, Australia. carol.hodgson@monash.edu.
³ Department of Physiotherapy, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia. kathy.stiller@health.sa.gov.au.
⁴ Outcomes After Critical Illness & Surgery (OACIS) Group, Division of Pulmonary & Critical Care Medicine, Department of Physical Medicine & Rehabilitation, Johns Hopkins Hospital, 600 N. Wolfe Street, Meyer 1-130, Baltimore, Maryland, 21287, USA. dale.needham@jhmi.edu.
⁵ Department of Physiotherapy, The Alfred, 55 Commercial Road, Melbourne, Victoria, 3004, Australia. c.tipping@alfred.org.au.
⁶ School of Physiotherapy & Exercise Science, Curtin University of Technology, Kent Street, Bentley, Western Australia, 6102, Australia. harroldm@hotmail.com.
⁷ School of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide, South Australia, 5001, Australia. claire.baldwin@unisa.edu.au.
⁸ Physiotherapy Department, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, 5042, Australia. claire.baldwin@unisa.edu.au.
⁹ Department of Physiotherapy, The Alfred, 55 Commercial Road, Melbourne, Victoria, 3004, Australia. S.Bradley@alfred.org.au.
¹⁰ Physiotherapy Department, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia. Sue.berney@austin.org.au.
¹¹ The Prince Charles Hospital, 627 Rode Road, Chermside, Queensland, 4032, Australia. Lawrence.Caruana@health.qld.gov.au.
¹² Faculty of Health, University of Technology, Sydney (UTS), 235 Jones Street, Broadway, New South Wales, 2007, Australia. doug.elliott@uts.edu.au.
¹³ Physiotherapy Department, Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, 2605, Australia. Margot.Green@act.gov.au.
¹⁴ Physiotherapy Department, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia. Kimberley.haines@svhm.org.au.
¹⁵ Department of Physiotherapy, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria, 3065, Australia. Kimberley.haines@svhm.org.au.
¹⁶ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. lisa.higgins@monash.edu.
¹⁷ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. maija.kaukonen@hus.fi.
¹⁸ Department of Anaesthesiology and Intensive Care, Töölö Hospital, Helsinki University Central Hospital, Topeliuksenkatu 5, Helsinki, Finland. maija.kaukonen@hus.fi.
¹⁹ Intensive Care Unit, Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, 2605, Australia. Anne.Leditschke@act.gov.au.
²⁰ Australian National University Medical School, The Canberra Hospital, Hospital Road, Garran, Australian Capital Territory, 2606, Australia. Anne.Leditschke@act.gov.au.
²¹ Physiotherapy Department, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, 4102, Australia. marc.nickels@health.qld.gov.au.
²² Burns, Trauma & Critical Care Research Centre, School of Medicine, The University of Queensland, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, 4029, Australia. j.paratz@uq.edu.au.
²³ School of Allied Health Sciences, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Queensland, 4215, Australia. j.paratz@uq.edu.au.
²⁴ School of Physiotherapy, The University of Notre Dame Australia, Fremantle Campus, 19 Mouat Street, Fremantle, Western Australia, 6959, Australia. shane.patman@nd.edu.au.
²⁵ Department of Physiotherapy, Western Health, Western Hospital, Gordon Street, Footscray, Victoria, 3011, Australia. elizabeth.skinner@wh.org.au.
²⁶ Department of Physiotherapy, School of Primary Health Care, Monash University, McMahons Road, Frankston, Victoria, 3199, Australia. elizabeth.skinner@wh.org.au.
²⁷ Capital and Coast District Health Board, Intensive Care Unit, Wellington Hospital, Riddiford Street, Wellington, 6021, New Zealand. paul.young@ccdhb.org.nz.
²⁸ Medical Research Institute of New Zealand, Wellington Hospital, Riddiford Street, Wellington, 6021, New Zealand. paul.young@ccdhb.org.nz.
²⁹ Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, 600 N. Wolfe Street, Meyer 1-130, Baltimore, Maryland, 21287, USA. Jzanni1@jhmi.edu.
³⁰ Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, 3010, Australia. l.denehy@unimelb.edu.au.
³¹ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. steve.webb@uwa.edu.au.
³² School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, Western Australia, 6006, Australia. steve.webb@uwa.edu.au.

PMID: 25475522
PMCID: PMC4301888
DOI: 10.1186/s13054-014-0658-y

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults

Carol L Hodgson et al. Crit Care. 2014.

. 2014 Dec 4;18(6):658.

doi: 10.1186/s13054-014-0658-y.

Authors

Affiliations

¹ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. carol.hodgson@monash.edu.
² Department of Physiotherapy, The Alfred, 55 Commercial Road, Melbourne, Victoria, 3004, Australia. carol.hodgson@monash.edu.
³ Department of Physiotherapy, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia. kathy.stiller@health.sa.gov.au.
⁴ Outcomes After Critical Illness & Surgery (OACIS) Group, Division of Pulmonary & Critical Care Medicine, Department of Physical Medicine & Rehabilitation, Johns Hopkins Hospital, 600 N. Wolfe Street, Meyer 1-130, Baltimore, Maryland, 21287, USA. dale.needham@jhmi.edu.
⁵ Department of Physiotherapy, The Alfred, 55 Commercial Road, Melbourne, Victoria, 3004, Australia. c.tipping@alfred.org.au.
⁶ School of Physiotherapy & Exercise Science, Curtin University of Technology, Kent Street, Bentley, Western Australia, 6102, Australia. harroldm@hotmail.com.
⁷ School of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide, South Australia, 5001, Australia. claire.baldwin@unisa.edu.au.
⁸ Physiotherapy Department, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, 5042, Australia. claire.baldwin@unisa.edu.au.
⁹ Department of Physiotherapy, The Alfred, 55 Commercial Road, Melbourne, Victoria, 3004, Australia. S.Bradley@alfred.org.au.
¹⁰ Physiotherapy Department, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia. Sue.berney@austin.org.au.
¹¹ The Prince Charles Hospital, 627 Rode Road, Chermside, Queensland, 4032, Australia. Lawrence.Caruana@health.qld.gov.au.
¹² Faculty of Health, University of Technology, Sydney (UTS), 235 Jones Street, Broadway, New South Wales, 2007, Australia. doug.elliott@uts.edu.au.
¹³ Physiotherapy Department, Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, 2605, Australia. Margot.Green@act.gov.au.
¹⁴ Physiotherapy Department, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia. Kimberley.haines@svhm.org.au.
¹⁵ Department of Physiotherapy, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria, 3065, Australia. Kimberley.haines@svhm.org.au.
¹⁶ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. lisa.higgins@monash.edu.
¹⁷ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. maija.kaukonen@hus.fi.
¹⁸ Department of Anaesthesiology and Intensive Care, Töölö Hospital, Helsinki University Central Hospital, Topeliuksenkatu 5, Helsinki, Finland. maija.kaukonen@hus.fi.
¹⁹ Intensive Care Unit, Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, 2605, Australia. Anne.Leditschke@act.gov.au.
²⁰ Australian National University Medical School, The Canberra Hospital, Hospital Road, Garran, Australian Capital Territory, 2606, Australia. Anne.Leditschke@act.gov.au.
²¹ Physiotherapy Department, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, 4102, Australia. marc.nickels@health.qld.gov.au.
²² Burns, Trauma & Critical Care Research Centre, School of Medicine, The University of Queensland, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, 4029, Australia. j.paratz@uq.edu.au.
²³ School of Allied Health Sciences, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Queensland, 4215, Australia. j.paratz@uq.edu.au.
²⁴ School of Physiotherapy, The University of Notre Dame Australia, Fremantle Campus, 19 Mouat Street, Fremantle, Western Australia, 6959, Australia. shane.patman@nd.edu.au.
²⁵ Department of Physiotherapy, Western Health, Western Hospital, Gordon Street, Footscray, Victoria, 3011, Australia. elizabeth.skinner@wh.org.au.
²⁶ Department of Physiotherapy, School of Primary Health Care, Monash University, McMahons Road, Frankston, Victoria, 3199, Australia. elizabeth.skinner@wh.org.au.
²⁷ Capital and Coast District Health Board, Intensive Care Unit, Wellington Hospital, Riddiford Street, Wellington, 6021, New Zealand. paul.young@ccdhb.org.nz.
²⁸ Medical Research Institute of New Zealand, Wellington Hospital, Riddiford Street, Wellington, 6021, New Zealand. paul.young@ccdhb.org.nz.
²⁹ Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, 600 N. Wolfe Street, Meyer 1-130, Baltimore, Maryland, 21287, USA. Jzanni1@jhmi.edu.
³⁰ Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, 3010, Australia. l.denehy@unimelb.edu.au.
³¹ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. steve.webb@uwa.edu.au.
³² School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, Western Australia, 6006, Australia. steve.webb@uwa.edu.au.

PMID: 25475522
PMCID: PMC4301888
DOI: 10.1186/s13054-014-0658-y

Abstract

Introduction: The aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients.

Methods: A systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients.

Results: Safety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations.

Conclusion: Consensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

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Figures

**Figure 1**
**Color coding definitions.**

**Figure 2**
**Respiratory safety considerations.** PEEP, positive end-expiratory pressure.

**Figure 3**
**Cardiovascular safety considerations.**

**Figure 4**
**Neurological safety considerations.** RASS, Richmond Agitation Assessment Scale; CAM-ICU, confusion assessment method for the ICU.

**Figure 5**
**Medical, surgical and other safety considerations.**

See this image and copyright information in PMC

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References

1. Lee SM, Schneider SM, Feiveson AH, Macias BR, Smith SM, Watenpaugh DE, Hargens AR. WISE-2005: Countermeasures to prevent muscle deconditioning during bed rest in women. J Appl Physiol (1985) 2014;116:654–667. doi: 10.1152/japplphysiol.00590.2013. - DOI - PubMed
1. Lee SM, Moore AD, Everett ME, Stenger MB, Platts SH. Aerobic exercise deconditioning and countermeasures during bed rest. Aviat Space Environ Med. 2010;81:52–63. doi: 10.3357/ASEM.2474.2010. - DOI - PubMed
1. Stiller K. Physiotherapy in intensive care: towards an evidence-based practice. Chest. 2000;118:1801–1813. doi: 10.1378/chest.118.6.1801. - DOI - PubMed
1. Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest. 2013;144:825–847. doi: 10.1378/chest.12-2930. - DOI - PubMed
1. Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23:35–53. doi: 10.1016/j.ccc.2006.11.005. - DOI - PubMed

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[1] Lee SM, Schneider SM, Feiveson AH, Macias BR, Smith SM, Watenpaugh DE, Hargens AR. WISE-2005: Countermeasures to prevent muscle deconditioning during bed rest in women. J Appl Physiol (1985) 2014;116:654–667. doi: 10.1152/japplphysiol.00590.2013. - DOI - PubMed

[2] Lee SM, Schneider SM, Feiveson AH, Macias BR, Smith SM, Watenpaugh DE, Hargens AR. WISE-2005: Countermeasures to prevent muscle deconditioning during bed rest in women. J Appl Physiol (1985) 2014;116:654–667. doi: 10.1152/japplphysiol.00590.2013. - DOI - PubMed

[3] Lee SM, Moore AD, Everett ME, Stenger MB, Platts SH. Aerobic exercise deconditioning and countermeasures during bed rest. Aviat Space Environ Med. 2010;81:52–63. doi: 10.3357/ASEM.2474.2010. - DOI - PubMed

[4] Lee SM, Moore AD, Everett ME, Stenger MB, Platts SH. Aerobic exercise deconditioning and countermeasures during bed rest. Aviat Space Environ Med. 2010;81:52–63. doi: 10.3357/ASEM.2474.2010. - DOI - PubMed

[5] Stiller K. Physiotherapy in intensive care: towards an evidence-based practice. Chest. 2000;118:1801–1813. doi: 10.1378/chest.118.6.1801. - DOI - PubMed

[6] Stiller K. Physiotherapy in intensive care: towards an evidence-based practice. Chest. 2000;118:1801–1813. doi: 10.1378/chest.118.6.1801. - DOI - PubMed

[7] Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest. 2013;144:825–847. doi: 10.1378/chest.12-2930. - DOI - PubMed

[8] Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest. 2013;144:825–847. doi: 10.1378/chest.12-2930. - DOI - PubMed

[9] Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23:35–53. doi: 10.1016/j.ccc.2006.11.005. - DOI - PubMed

[10] Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23:35–53. doi: 10.1016/j.ccc.2006.11.005. - DOI - PubMed

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Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults

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Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults

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