Early Mobilization in ICU and Its Barriers

Introduction

People recovering from critical illness suffer many problems, such as weakness due to prolonged immobilization in the intensive care unit (ICU) and physical, mental, and cognitive issues. Early mobilization in the ICU helps patients in improving their functions. But there are many barriers affecting the benefits of early mobilization. There are some effective strategies to overcome the barriers affecting early mobilization.

What Is Early Mobilization in the Intensive Care Unit?

The early mobilization in the intensive care unit includes physical activities to bring physiological changes. It starts as early as two to five days after a critical illness or injury. Long-term ICU stays always cause complications for critical illness survivors, reducing their quality of life.

Why Is Early Mobilization in the Intensive Care Unit Important?

New medications and technologies have increased the survival rate of patients with critical illness in the ICU. It is equally important to promote the complete recovery of the survivors. So the patients in the ICU are assessed for stability to start an early mobilization program. Early mobilization is essential to prevent patients from post-intensive care syndrome (PICS) and intensive care unit-acquired weakness (ICU-AW). Patients are safely mobilized with mechanical ventilation to reduce the complications of prolonged immobility.

What Are the Complications of Prolonged Immobility?

The bedridden patients suffer the following complications due to prolonged immobility.

• Cardiovascular Complications - Orthostatic hypertension (sudden increase in blood pressure when a person stands up), hypovolemia (decreased volume of circulating blood), and embolism (blood clot, fatty deposit, or air bubble in the circulating blood).

• Respiratory Complications - Pneumonia (inflammation of lung tissue), reduced respiratory rate, reduced pulmonary secretions, and atelectasis (partial or complete collapse of the lungs).

• Musculoskeletal Complications - Weakness of muscles, loss of muscles or muscle wasting, demineralization of the bone (the decreased mineral substance of the bone), and ossification (hardening of muscle tissue into a bony substance).

• Gastrointestinal Complications - Constipation (difficulty in passing stools), ileus (intestines not working correctly).

• Neurological Complications - Such as polyneuropathy (multiple nerve damage).

• Endocrine Complications - Such as hyperglycemia (high blood sugar level).

• Psychological Complications - Such as depression and delirium (serious disturbance in mental abilities causing confusion and reducing awareness).

What Are the Effects of Early Mobilization in the ICU?

The physiological effects of early mobilization in the intensive care unit are listed below.

1. Respiratory or Pulmonary System -Early mobilization in the ICU increases the efficiency of respiratory mechanics, increases regional perfusion, increases ventilation, increases regional diffusion, maintains breathing frequency, promotes airway clearance, increases mucociliary transport, increases tidal volume, and increases strength and pulmonary immune factors.

2. Cardiovascular System - Increases heart rate, increases circulating blood volume, venous return, stroke volume, cardiac output, coronary perfusion, chest tube drainage, blood flow, and peripheral tissue oxygen extraction, and reduces peripheral vascular resistance.

3. Neurological System - Increases cerebral electrical activity and increases the stimulus to breathe and postural reflexes.

4. Endocrine System - Maintains the release, distribution, and degradation of catecholamines (chemicals provided by the nerve cells which are important in stress responses).

5. Multisystemic Effects - The effect of early mobilization in the lymphatic system includes increased lymphatic flow and improved lymphatic drainage. The impact on the hematologic system is the maintenance of hemostasis. In the gastrointestinal system, early mobilization improves gut mobility and reduces constipation. The impact on the urinary system is an increase in urine output. It also reduces the effects of anesthesia and sedation and the effects of surgery. It also reduces the risk of loss of stimulus.

What Are the Barriers to Early Mobilization?

The barriers to early mobilization in the intensive care unit are classified as follows:

1. Patient-related barriers.

2. Structural barriers.

3. Intensive care unit cultural barriers.

4. Process-related barriers.

Patient-Related Barriers

• High severity of illness (patient too sick).

• Hemodynamic instability (unstable blood pressure causing inadequate blood flow).

• Arrhythmias (irregular heartbeat).

• Respiratory instability or distress.

• Pain due to inadequate painkillers.

• Obesity.

• Poor nutritional status.

• Lack of patient cooperation.

• Weakness, diarrhea, and wound.

• Neuropsychological barriers of the patient such as excessive sedation (use of drugs to make patients sleep), paralysis (loss of ability to move parts of the body), anxiety, agitation (nervous behavior), and delirium (confused thinking and lack of awareness).

Structural Barriers

• Limited staff.

• Lack of knowledge and awareness of early mobility protocol.

• Lack of equipment.

• Inadequate staff training.

• Staff and patient security concerns.

• Early discharge of the patient before mobilization.

Intensive Care Unit Cultural Barriers

• Communication barriers.

• Lack of management or leadership.

• The increased workload of clinicians in the intensive care unit and lack of time.

• Physical environment and equipment in the ICU.

• Safety concerns of the patient.

• Lack of staff knowledge about benefits or risks of mobility.

• Lack of understanding of the patient’s family.

Process-Related Barriers

• Lack of planning and coordination.

• Unclear or unavailability of the protocol.

• Lack of clarity to implement the protocol.

• Risks for mobility providers (stress and injuries).

What Are the Strategies to Overcome the Barriers to Early Mobilization?

Evaluation of the barriers and strategies development help the professionals to overcome the obstacles to early mobilization. The strategies are:

1. Regular screening of the patients in the ICU.

2. Pain management with medications before starting the mobilization program.

3. Lighter sedation to the patients.

4. Antipsychotic drugs to manage depression, agitation, and delirium.

5. Education and encouragement of the patients to motivate them.

6. Portable devices and monitors.

7. Additional staff and team members to compensate for limited staff.

8. Develop protocols for early mobilization.

9. Interprofessional education and promotion of mobility programs.

10. Safety checks.

11. Full-time physiotherapists and occupational therapists are appointed dedicatedly to the ICU.

12. Prior planning of the discharge of the patients.

13. Proper education to the caregivers of the patient about early mobilization programs.

When to Terminate Early Mobilization?

The early mobilization should be terminated in the following situations.

• Tachycardia (heartbeat of more than 140 beats per minute).

• Bradycardia (heartbeat less than 50 beats per minute).

• Hypertension (systolic blood pressure of more than 180 mm Hg).

• Hypotension (systolic blood pressure less than 80 mm Hg).

• Hemorrhage (heavy bleeding).

• Chest pain or extreme fatigue.

• When the patients request to stop.

Conclusion

Early mobilization in the intensive care unit (ICU) has positive effects, such as a reduction in the length of hospital or ICU stay and improved functional capacity of the patients. Systemic reviews suggest conducting further studies to know the long-term outcomes of early mobilization.