Interruption of sedation for early rehabilitation improves outcomes in ventilated, critically ill adults

Question

Does early provision of rehabilitation improve the likelihood of functional independence at discharge in ventilated, critically ill patients?

Design

Randomised, controlled trial with concealed allocation and blinded assessment of some outcomes.

Setting

Two tertiary medical centres in the USA.

Participants

Adults in a medical intensive care unit (ICU) who had been on mechanical ventilation for less than 72 hours and were expected to continue for at least another 24 hours, and who had been functionally independent two weeks before admission. Exclusion criteria included: rapid onset neuromuscular disease, cardiopulmonary arrest, irreversible disorders with high mortality, and raised intracranial pressure. Randomisation of 104 participants allotted 49 to receive the early intervention and 55 to a control group.

Interventions

Both groups received sedation guided by the Richmond Agitation Sedation Scale and underwent daily interruption of sedatives or narcotics or both, unless contraindicated. Weaning from mechanical ventilation and insulin for glycaemic control were also protocol-directed. During the daily interruption of sedation, the intervention group commenced rehabilitation as appropriate to their clinical status: passive movements for those who were unresponsive, and active assisted or active movements in supine for those who were responsive. If well tolerated, these exercises were progressed to sitting balance activities, activities of daily living, transfer training, pre-gait exercises, and walking. Extensive physiological stability criteria guided whether the intervention could be initiated or continued. Overall progression of the intervention was continued until the participant regained functional independence or was discharged from hospital.

Outcome measures

The primary outcome was return to functional independence by discharge from hospital (ie, able to walk, bathe, dress, groom, transfer, and toilet independently). Secondary outcome measures included the number of hospital days with delirium, the duration of mechanical ventilation, lengths of stay in the ICU and in hospital, and adverse events.

Results

All participants were followed up. Functional independence at discharge was more likely in the intervention group (59% vs 35%, p = 0.02). The intervention group also had fewer days of delirium in hospital (median 2 vs 4 days, p = 0.02), and shorter duration of mechanical ventilation (median 3.4 vs 6.1 days, p = 0.02). Adverse events were rare and discontinuation of the intervention (most commonly, due to perceived patient-ventilator asynchrony) occurred in only 4% of all intervention sessions.

Conclusion

Early rehabilitation during daily interruption of sedation was safe and well tolerated. It reduced the duration of delirium and mechanical ventilation, and improved functional status at hospital discharge.