Multidisciplinary Approach to Sedation and Early Mobility of Intubated Critically Ill Neurologic Patients Improves Mobility at Discharge

Abstract

Background and purpose: Over-sedation may confound neurologic assessment in critically ill neurologic patients and prolong duration of mechanical ventilation (MV). Decreased sedative use may facilitate early functional independence when combined with early mobility. The objective of this study was to evaluate the impact of a stepwise, multidisciplinary analgesia-first sedation pathway and early mobility protocol on medication use and mobility in the neuroscience intensive care unit (ICU).

Methods: We performed a single-center prospective cohort study with adult patients admitted to a neuroscience ICU between March and June 2016-2018 who required MV for greater than 48 hours. Patients were included from three separate phases of the study: Phase I - historical controls (2016); Phase II - analgesia-first pathway (2017); Phase III - early mobility protocol (2018). Primary outcomes included propofol requirements during MV, total rehabilitation therapy provided, and functional mobility during ICU admission.

Results: 156 patients were included in the analysis. Decreasing propofol exposure was observed during Phase I, II, and III (median 2243.7 mg/day vs 2065.6 mg/day vs 1360.8 mg/day, respectively; P = .04 between Phase I and III). Early mobility was provided in 59.7%, 40%, and 81.6% of patients while admitted to the ICU in Phase I, II, and III, respectively (P < .01). An increased proportion of patients in Phase III were walking or ambulating at ICU discharge (26.7%; 8/30) compared to Phase I (7.9%, 3/38, P = .05).

Conclusions: An interdisciplinary approach with an analgesia-first sedation pathway with early mobility protocol was associated with less sedative use, increased rehabilitation therapy, and improved functional mobility status at ICU discharge.

Keywords: analgesia; analgosedation; early mobility; neurocritical care; sedation.

Figure 1.

Methods.

Figure 2.

Significant Increase in Mobility at ICU Discharge in Patients who Survived to Hospital Discharge. After implementation of an early mobility protocol in the neuroscience intensive care unit (ICU), a significant increase in physical therapy evaluations performed while patient was admitted in the ICU (Figure 2a), number of physical therapy sessions during ICU admission (Figure 2b) was observed. This translated into increased in the proportion of patients standing or walking at hospital discharge (Figure 2c) and JH-HLM Scores are ICU discharge (Figure 2d). * denotes P-value <.05; ** denotes P-value <.01; *** denotes P-value <.001.