Early ambulation protocol after diagnostic transfemoral cerebral angiography: an evidence-based practice project.

BACKGROUND: No uniform consensus has been achieved regarding the ambulation protocol after transfemoral cerebral angiography (TFA). Until now, in most hospitals patients are prescribed 8-12 h strict immobilization along with bed rest in the supine position after TFA in China, which causes great discomfort to patients. OBJECTIVE: To evaluate the effect of an evidence-based early ambulation protocol on the prevention of vascular complications and general discomfort in patients following transfemoral cerebral angiography (TFA). METHODS: A prospective quasi-experimental study was conducted on 214 patients undergoing TFA with manual compression. Patients in the experimental group were placed supine position for 2 h with a sandbag placed on the wound dressing, followed by a semi-seated position for another 2 h. After this period, patients took 2 h bed rest (move freely) with the sandbag removed, and were allowed to get out of bed 6 h after TFA. Patients in the control group were restricted to an 8 h bed rest in a supine position with the affected leg straight and immobilized. The vascular complications (bleeding, hematoma, ecchymosis) and levels of comfort (low back pain, leg pain, and blood pressure) were evaluated after the procedure. Numeric Rating Scale (NRS) pain scores, systolic blood pressure (SBP); diastolic blood pressure (DBP) were measured hourly for 8 h after TFA. RESULTS: There was no significant difference in the two groups with regard to vascular complications including bleeding events (P = 0.621), bleeding volume (P = 0.321), and area of hematoma (P = 0.156). The area of ecchymosis in the experimental group was significantly smaller than the control group (P = 0.031). Compared with the control group, the NRS score for low back pain in the 4th, 5th, 6th, 7th, and 8th hour after TFA were significantly lower (P < 0.05), and the NRS score for leg pain in the 5th, 6th, 7th, 8th hour after TFA were significantly lower (P < 0.05). The SBP and DBP in the 6th, 7th, and 8th hour after TFA were significantly lower than the control group (all P < 0.05). CONCLUSIONS: The evidence-based early ambulation protocol can effectively and safely increase comfort and decrease the pain level for patients undergoing TFA, without change in the incidence of vascular complications.

Assessing the impact of early progressive mobilization on moderate-to-severe traumatic brain injury: a randomized controlled trial.

INTRODUCTION: Traumatic brain injury (TBI) is a major cause of neurodisability worldwide, with notably high disability rates among moderately severe TBI cases. Extensive previous research emphasizes the critical need for early initiation of rehabilitation interventions for these cases. However, the optimal timing and methodology of early mobilization in TBI remain to be conclusively determined. Therefore, we explored the impact of early progressive mobilization (EPM) protocols on the functional outcomes of ICU-admitted patients with moderate to severe TBI. METHODS: This randomized controlled trial was conducted at a trauma ICU of a medical center; 65 patients were randomly assigned to either the EPM group or the early progressive upright positioning (EPUP) group. The EPM group received early out-of-bed mobilization therapy within seven days after injury, while the EPUP group underwent early in-bed upright position rehabilitation. The primary outcome was the Perme ICU Mobility Score and secondary outcomes included Functional Independence Measure motor domain (FIM-motor) score, phase angle (PhA), skeletal muscle index (SMI), the length of stay in the intensive care unit (ICU), and duration of ventilation. RESULTS: Among 65 randomized patients, 33 were assigned to EPM and 32 to EPUP group. The EPM group significantly outperformed the EPUP group in the Perme ICU Mobility and FIM-motor scores, with a notably shorter ICU stay by 5.9 days (p < 0.001) and ventilation duration by 6.7 days (p = 0.001). However, no significant differences were observed in PhAs. CONCLUSION: The early progressive out-of-bed mobilization protocol can enhance mobility and functional outcomes and shorten ICU stay and ventilation duration of patients with moderate-to-severe TBI. Our study's results support further investigation of EPM through larger, randomized clinical trials. Clinical trial registration ClinicalTrials.gov NCT04810273 . Registered 13 March 2021.

Prediction Model for Delayed Behavior of Early Ambulation After Surgery for Varicose Veins of the Lower Extremity: A Prospective Case-Control Study.

OBJECTIVE: To analyze influencing factors and establish a prediction model for delayed behavior of early ambulation after surgery for varicose veins of the lower extremity (VVLE). DESIGN: A prospective case-control study. SETTING: Patients with VVLE were recruited from 2 local hospitals. PARTICIPANTS: In total, 498 patients with VVLE were selected using convenience sampling and divided into a training set and a test set. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We collected information from the selected participants before surgery and followed up until the day after surgery, then divided them into a normal and delayed ambulation group. Propensity score matching was applied to all participants by type of surgery and anesthesia. All the characteristics in the 2 groups were compared using logistic regression, back propagation neural network (BPNN), and decision tree models. The accuracy, sensitivity, specificity, and area under the curve (AUC) values of the 3 models were compared to determine the optimal model. RESULTS: A total of 406 participants were included after propensity score matching. The AUC values for the training sets of logistic regression, BPNN, and decision tree models were 0.850, 0.932, and 0.757, respectively. The AUC values for the test sets were 0.928, 0.984, and 0.776, respectively. A BPNN was the optimal model. Social Support Rating Scale score, preoperative 30-second sit-stand test score, Clinical-Etiology-Anatomy-Pathophysiology (CEAP) grade, Medical Coping Modes Questionnaire score, and whether you know the need for early ambulation, in descending order of the result of a BPNN model. A probability value greater than 0.56 indicated delayed behavior of early ambulation. CONCLUSIONS: Clinicians should pay more attention to those with lower Social Support Rating Scale scores, poor lower limb strength, a higher CEAP grade, and poor medical coping ability, and make patients aware of the necessity and importance of early ambulation, thereby assisting decision-making regarding postoperative rehabilitation. Further research is needed to improve the method, add more variables, and transform the model into a scale to screen and intervene in the delayed behavior of early ambulation of VVLE in advance.

The association between objectively measured preoperative light-intensity physical activity and postoperative ambulation in patients with gastrointestinal cancer.

[Purpose] To clarify the association between preoperative physical activity and postoperative ambulation based on physical activity intensity, and independent of functional capacity and depression, in patients with gastrointestinal cancer. [Participants and Methods] Seventy patients who underwent surgery for primary colorectal or gastric cancer were enrolled. Preoperative moderate-to-vigorous-intensity physical activity, light-intensity physical activity, and sedentary behavior were assessed using an accelerometer. The primary outcome was the days to postoperative first ambulation (capable of independently and continuously walking 150 m). Functional capacity and depression, as confounders, were evaluated by measuring the 6-minute walk distance and using the Hospital Anxiety and Depression Scale. [Results] Of the 70 patients, 28 had insufficient accelerometer data, and 42 were included in the analysis. Preoperative light-intensity physical activity, but not moderate-to-vigorous-intensity physical activity and sedentary behavior, was negatively associated with the days to postoperative first ambulation, after adjusting for age, preoperative functional capacity, and preoperative depression. [Conclusion] Preoperative light-intensity physical activity was associated with the days to postoperative ambulation independently of age, functional capacity, and depression. Hence, predicting delayed ambulation by preoperative light-intensity physical activity in patients with gastrointestinal cancer may be useful.

Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU.

BACKGROUND: While early mobilization is commonly implemented in intensive care unit treatment guidelines to improve functional outcome, the characterization of the optimal individual dosage (frequency, level or duration) remains unclear. The aim of this study was to demonstrate that artificial intelligence-based clustering of a large ICU cohort can provide individualized mobilization recommendations that have a positive impact on the likelihood of being discharged home. METHODS: This study is an analysis of a prospective observational database of two interdisciplinary intensive care units in Munich, Germany. Dosage of mobilization is determined by sessions per day, mean duration, early mobilization as well as average and maximum level achieved. A k-means cluster analysis was conducted including collected parameters at ICU admission to generate clinically definable clusters. RESULTS: Between April 2017 and May 2019, 948 patients were included. Four different clusters were identified, comprising "Young Trauma," "Severely ill & Frail," "Old non-frail" and "Middle-aged" patients. Early mobilization (< 72 h) was the most important factor to be discharged home in "Young Trauma" patients (ORadj 10.0 [2.8 to 44.0], p < 0.001). In the cluster of "Middle-aged" patients, the likelihood to be discharged home increased with each mobilization level, to a maximum 24-fold increased likelihood for ambulating (ORadj 24.0 [7.4 to 86.1], p < 0.001). The likelihood increased significantly when standing or ambulating was achieved in the older, non-frail cluster (ORadj 4.7 [1.2 to 23.2], p = 0.035 and ORadj 8.1 [1.8 to 45.8], p = 0.010). CONCLUSIONS: An artificial intelligence-based learning approach was able to divide a heterogeneous critical care cohort into four clusters, which differed significantly in their clinical characteristics and in their mobilization parameters. Depending on the cluster, different mobilization strategies supported the likelihood of being discharged home enabling an individualized and resource-optimized mobilization approach. TRIAL REGISTRATION: Clinical Trials NCT03666286, retrospectively registered 04 September 2018.

Association between early ambulation exercise and short-term postoperative recovery after open transforaminal lumbar interbody fusion: a single center retrospective analysis.

BACKGROUND: Early ambulation in patients undergoing transforaminal lumbar interbody fusion (TLIF) surgery is recommended, however, the precise time interval after open surgery has never been specified. Current retrospective analysis was conducted aiming to clarify an accurate time interval. METHODS: A retrospective analysis of eligible patients was conducted using the databases of the Bone Surgery Department, Third Affiliated Hospital of Sun Yat-sen University from 2016 to 2021. Data pertaining to postoperative hospital stay length, expenses, incidence of complications were extracted and compared using Pearson's χ2 or Student's t-tests. A multivariate linear regression model was conducted to identify the relationship between length of hospital stay (LOS) and other outcomes of interest. A propensity analysis was conducted to minimize bias and to evaluate the reliability of results. RESULTS: A total of 303 patients met the criteria and were included for the data analysis. Multivariate linear regression results demonstrated that a high ASA grade (p = 0.016), increased blood loss (p = 0.003), cardiac disease (p < 0.001), occurrence of postoperative complications(p < 0.001) and longer ambulatory interval (p < 0.001) was significantly associated with an increased LOS. The cut-off analysis manifested that patients should start mobilization within 3 days after open TLIF surgery (B = 2.843, [1.395-4.292], p = 0.0001). Further comparative analysis indicated that patients who start ambulatory exercise within 3 days have shorter LOS (8.52 ± 3.28d vs 12.24 ± 5.88d, p < 0.001), total expenses ( 9398.12 ± 2790.82vs 10701.03 ± 2994.03 [USD], p = 0.002). Propensity analysis revealed such superiority was stable along with lower incidence of postoperative complications (2/61 vs 8/61, p = 0.0048). CONCLUSIONS: The current analysis suggested that ambulatory exercise within 3 days for patients who underwent open TLIF surgery was significantly associated with reduced LOS, total hospital expenses, and postoperative complications. Further causal relationship would be confirmed by future randomized controlled trials.

A Retrospective Study of Anticholinergic Use and Later Mobilization as Risk Factors for Urinary Retention After Major Lower Extremity Joint Arthroplasty.

BACKGROUND: Postoperative urinary retention (POUR) is a common surgical complication of major joint arthroplasty and is associated with increased lengths of stay and urinary tract infections. Studies have found that certain anticholinergic medications and reduced mobility are associated with POUR. This study assessed the effect of anticholinergic burden and later postoperative ambulation on POUR. METHODS: In this retrospective cohort study, we included subjects who had undergone elective primary or revision hip or knee arthroplasty (total hip arthroplasty [THA] or total knee arthroplasty [TKA]) between March 2015 and December 2017 in a single health system. Anticholinergic burden was measured using the Anticholinergic Drug Scale (ADS). We performed bivariate and multivariable logistic regression with POUR as the dependent variable. Of the 1,397 study subjects, 622 (45%) underwent THA and 775 (55%) underwent TKA. Their mean age was 65 years (range, 21 to 98), and 841 (60%) were women. POUR developed in 183 (13%) subjects. RESULTS: In multivariable analyses, ADS was associated with POUR after THA (P < .05), but not TKA (P = .08), while later ambulation was not associated with POUR after either procedure (P > .3 for both). CONCLUSION: Anticholinergic burden after THA was independently associated with POUR. Strategies to reduce anticholinergic burden may help reduce POUR after THA.

Effectiveness of patient education on total knee arthroplasty: A systematic review and meta-analysis.

AIMS AND OBJECTIVES: This study was designed to examine the contents and methods of patient educational interventions about total knee arthroplasty (TKA) and their effectiveness in reducing postoperative pain and enhancing range of motion (ROM) in the literature. BACKGROUND: Patient education has been provided to facilitate recovery after TKA; however, little is known about the contents and methods of the interventions and their effectiveness in reducing postoperative pain and enhancing ROM. DESIGN: This is a systematic review and meta-analysis of randomised controlled trials (RCTs). METHODS: Published studies from June 1998-June 2021 were identified from electronic databases. Two independent investigators assessed the quality of the studies by using the revised Cochrane risk-of-bias tool. Meta-analyses with random-effects models were conducted to assess the effectiveness of the interventions using the Comprehensive Meta-Analysis Software. The study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. RESULTS: Among 12 articles that met the inclusion criteria, three interventions provided education on pain management and mobility/exercises. The most common educational methods were the combinations of oral explanation, written materials, and audiovisual materials, group discussion, while four studies used information technology (IT) devices. The meta-analysis demonstrated that the educational interventions using IT devices were effective in improving pain and ROM, but not the interventions that did not use IT devices. CONCLUSION: Structured education for pain management, communication and/or exercise support programs utilising diverse methods have been provided to patients undergoing TKA. Using IT devices could successfully enhance the effectiveness of educational interventions for patients undergoing TKA. RELEVANCE TO CLINICAL PRACTICE: Integration of postoperative pain management and mobility/exercises with the use of IT devices should be actively considered in providing patient education in clinical nursing practice.

The effect of bed exercises following major abdominal surgery on early ambulation, mobilization, pain and anxiety: A randomized-controlled trial.

This randomized-controlled trial aimed to investigate the effect of bed exercises on postoperative anxiety, pain, early ambulation and mobilization. This study was conducted with a randomized-controlled trial design and in the general surgical clinic of a research and training hospital. A total of 120 patients (60 in the experimental group and 60 in the control group) scheduled for major abdominal surgery took part in the study. The data were collected using a patient information form, the Anxiety Specific to Surgery Questionnaire and the Visual Analog Scale through face-to-face interviews. The patients in the experimental group performed 15-min bed exercises on the day of their operation, as well as on the postoperative first and second days, and the control group underwent only the routinely performed procedures in the clinic. The data were analysed using descriptive statistics, analysis of variance and t-tests. The sample of our study included major abdominal surgery patients. Ambulation was achieved at a mean time of 4 h earlier in the experimental group. On the postoperative first and second days, the patients in the experimental group had mean mobilization durations that were approximately 2 h longer compared with the patients in the control group. Moreover, the postoperative pain and anxiety levels of the patients in the experimental group were significantly lower than those of the patients in the control group (p < 0.05). We recommend that bed exercises be performed to lower anxiety and pain severity, achieve early ambulation and increase the duration of mobilization among patients following major abdominal surgery.

Effect of early physical therapy interventions on post-operative ileus following abdominal hysterectomy.

This study was conducted to determine the effect of early physical therapy intervention on symptoms of post-operative ileus after abdominal hysterectomy. This randomised control trial was carried out at the Railway General Hospital, Rawalpindi, Pakistan, from February 2021 to July 2021. Participants were randomly allocated to experimental (n=21) and control (n=21) groups using sealed envelope method. The experimental group received an enhanced physiotherapy rehabilitation plan of care consisting of patient education, breathing exercises, early mobilisation, connective tissue manipulation, and transcutaneous electrical nerve stimulation, while the control group only performed ambulation. The intervention was carried out during the first three days after surgery. Subjective measures were used to determine post-operative ileus. The study results conclude that enhanced early post-operative rehabilitation programme following abdominal hysterectomy has the potential to improve symptoms of post-operative ileus.

A systematic review of the effect of early mobilisation on length of stay for adults in the intensive care unit.

BACKGROUND: EM has been hypothesized to help prevent the development of ICU acquired weakness and may therefore result in positive outcomes for ICU patients. AIM: To establish the impact of Early mobilisation (EM) on adult Intensive Care Unit (ICU) patients in terms of ICU length of stay (LOS), as well as hospital LOS, duration of mechanical ventilation, mortality, and functional independence. STUDY DESIGN: A Systematic Review. EMBASE, MEDLINE, CINAHL, and the Cochrane Library were searched on 24th November 2020. Included studies and other systematic reviews were hand-searched for further includable studies. The primary outcome was ICU LOS whilst secondary outcomes were duration of MV, mortality, hospital LOS and functional independence. The PRISMA guidelines were utilized to perform the review. Ten randomized controlled trials with a combined total of 1291 patients met inclusion criteria and were scrutinized using the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews. Revman 5.4.1 was used to conduct meta-analysis were possible. RESULTS: Results were limited by the evidence available for inclusion, in particular small sample sizes. However, a trend towards a shorter duration of ICU LOS and duration of mechanical ventilation emerged. There was also a trend towards higher rates of functional independence for intervention groups. Mortality rates appeared unaffected and results of meta-analysis were statistically non-significant (p = 0.90). CONCLUSION: By applying a stricter time limit than previous systematic reviews a trend emerged that the commencement of EM has a positive effect on patient outcomes, in particular ICU LOS. RELEVANCE TO CLINICAL PRACTICE: The evidence base surrounding EM remains poor; however on the balance of the available evidence the application of EM should not be delayed.

Development of a performance standard for physiotherapists delivering exercise and mobilisation to the critically ill: A modified Delphi consensus study.

BACKGROUND: The provision of early mobilisation to critically ill patients has the potential to improve long term outcomes, but, is complex to deliver. There is minimal literature detailing the training and expertise required to deliver these interventions safely and effectively. OBJECTIVE: The objective of this study was to determine the key elements of a performance standard for assessment of physiotherapists delivering exercise and mobilisation interventions to the critically ill. METHOD: This is a modified eDelphi expert consensus study. Fifty-one physiotherapists from Australia and New Zealand with relevant clinical, educational, or research experience were included on the expert panel. Background information and the initial pool of items were developed from review of relevant literature. Five survey rounds were administered across two study phases to determine the elements, performance criteria, and assessment scale of the performance standard. Items were modified, amalgamated, and added based upon panel comments. RESULTS: Consensus was achieved for 69 mandatory, and two supplementary performance criteria which were arranged under 15 elements encompassing knowledge, assessment, analysis, intervention, and professional behaviours. A 3-point rating scale was selected to assess item achievement and global performance. CONCLUSION: Binational expert consensus was reached to define the assessment criteria for physiotherapists delivering exercise and mobilisation interventions to the critically ill. This standard can be utilised in clinical, educational, and research practice environments to guide training, assessment, and skill recognition in critical care physiotherapy.

Predictors of acute muscle loss in the intensive care unit: A secondary analysis of an in-bed cycling trial for critically ill patients.

PURPOSE: The purpose of this study was to assist clinicians to identify critically ill patients at greatest risk of acute muscle loss and to analyse the associations between protein intake and exercise on acute muscle loss. MATERIALS AND METHODS: Secondary analysis of a single-centre randomised clinical trial of in-bed cycling using a mixed effects model was undertaken to examine the association between key variables and rectus femoris cross-sectional area (RFCSA). Groups were combined, and key variables for the cohort were modified Nutrition Risk in the Critically Ill (mNUTRIC) scores within the first days following intensive care unit admission, longitudinal RFCSA measurements, percent of daily recommended protein intake, and group allocation (usual care, in-bed cycling). RFCSA ultrasound measurements were taken at baseline and days 3, 7, and 10 to quantify acute muscle loss. All patients received usual care nutritional intake while in the intensive care unit. Patients allocated to the cycling group commenced in-bed cycling once safety criteria were met. RESULTS: Analysis included all 72 participants, of which 69% were male, with a mean (standard deviation) age of 56 (17) years. Patients received a mean (standard deviation) of 59% (26%) of the minimum protein dose recommended for critically ill patients. Mixed-effects model results indicated that patients with higher mNUTRIC scores experienced greater RFCSA loss (estimate = -0.41; 95% confidence interval [CI] = -0.59 to -0.23). RFCSA did not share a statistically significant association with cycling group allocation (estimate = -0.59, 95% CI = -1.53 to 0.34), the percentage of protein requirements received (estimate = -0.48; 95% CI = -1.16 to 0.19), or a combination of cycling group allocation and higher protein intake (estimate = 0.33, 95% CI = -0.76 to 1.43). CONCLUSIONS AND RELEVANCE: We found that a higher mNUTRIC score was associated with greater muscle loss, but we did not observe a relationship between combined protein delivery and in-bed cycling and muscle loss. The low protein doses achieved may have impacted the potential for exercise or nutrition strategies to reduce acute muscle loss. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN 12616000948493).

[The use of robotic and technical systems for early mobilization of intensive care patients: A scoping review]. / Der Einsatz von robotischen und technischen Systemen zur Frühmobilisation von Intensivpatient_innen.

The use of robotic and technical systems for early mobilization of intensive care patients: A scoping review Abstract: Background: Intensive care patients are often subjected to immobility for too long. However, when they are mobilized early, positive effects on patient outcomes, such as improvement in physical function, can be demonstrated. One of the reasons for rare mobilization is that too less therapeutic equipment is available. Aims: This paper provides an overview of previous research on early robot- or technology-assisted mobilization of intensive care patients. Which robotic and technical aids are used in studies on early mobilization of adult intensive care patients by nurses or physiotherapists? What effect of early mobilization using robotic and technical systems on patient outcomes are reported in the studies? Methods: A systematic literature search was undertaken within the Databases Medline, Web of Science, CINAHL, Cochrane Library, Embase, IEEE Xplore, Scopus and WTI between May and July 2020 and in January 2022. In addition, a marginal search was performed via GoogleScolar and ResearchGate in the first search run. Results: 27 publications were included (9 RCTs, 7 texts and opinions, 3 cross-sectional studies, 2 case-control studies, 2 literature reviews, 2 case reports, 2 quasi-experimental intervention studies). It is evident that electronic bed-mounted exercise bicycles and tilt tables are the most commonly used assistive devices. There is an inconsistent data situation with regard to different patient outcomes. Conclusion: Further research on the use of technical and robotic early mobilization is, particularly in relation to different study populations, needed. Early mobilization robotics is not yet part of standard care.

Guillotine Transmetatarsal Amputations With Staged Closure Promote Early Ambulation and Limb Salvage in Patients With Advanced Chronic Limb-Threatening Ischemia.

PURPOSE: Transmetatarsal amputation (TMA) with primary closure has long been an option for limb salvage in patients with advanced chronic limb-threatening ischemia (CLTI) with extensive tissue loss of the forefoot. However, TMA healing and closure techniques are challenging, specifically in high-risk patients. Guillotine transmetatarsal amputations (gTMA) with staged closure may provide an alternative treatment in this population. We report long-term outcomes of such technique. MATERIALS AND METHODS: A single-center retrospective cohort study of CLTI patients undergoing gTMA between 2017 and 2020 was performed. Limb salvage, wound healing, and survival rates were quantified using Kaplan-Meier (KM) analysis. Multivariate regression was used to identify the effect of patient characteristics on the outcomes. RESULTS: Forty-four gTMA procedures were reviewed. Median follow-up was 381 (interquartile range [IQR], 212-539.75) days. After gTMA, 87.8% (n=36) of the patients were able to ambulate after a median interval of 2 (IQR, 1-3) days. Eventual coverage was achieved in a personalized and staged approach by using a combination of skin substitutes (88.6%, n=39) ± split thickness skin grafts (STSG, 61.4%, n=27). KM estimates for limb salvage, wound healing, and survival were 84.1%, 54.5%, and 88.6% at 1 year and 81.8%, 63.8%, and 84.1% at 2 years. Wound healing was significantly associated with STSG application (p=0.002, OR=16.5, 95% CI 2.87-94.81). CONCLUSION: gTMA resulted in high limb salvage rates during long-term follow-up in CLTI patients. Adjunctive STSG placement may enhance wound healing at the gTMA site, thus leading to expedited wound closure. Surgeons may consider gTMA as an alternative to reduce limb loss in CLTI patients at high risk of major amputation. CLINICAL IMPACT: Currently, the clinical presentation of CLTI is becoming more complex to deal with due to the increasing comorbidities as the society becomes older. The data shown in this article means for clinicians that when facing diffused forefoot gangrene and extensive tissue loss, limb preservation could still be considered instead of major amputation. Guillotine transmetatarsal amputations in the setting of an aggressive multidisciplinary group, can be healed by the responsibly utilization of dermal substitutes and skin grafts leading to the preservation of the extremity, allowing mobility, avoiding of sarcopenia, and decreasing frailty. This will equate to maintenance of independent living and preservation of lifespan.

Mobilisation of critically ill patients receiving norepinephrine: a retrospective cohort study.

BACKGROUND: Mobilisation and exercise intervention in general are safe and feasible in critically ill patients. For patients requiring catecholamines, however, doses of norepinephrine safe for mobilisation in the intensive care unit (ICU) are not defined. This study aimed to describe mobilisation practice in our hospital and identify doses of norepinephrine that allowed a safe mobilisation. METHODS: We conducted a retrospective single-centre cohort study of 16 ICUs at a university hospital in Germany with patients admitted between March 2018 and November 2021. Data were collected from our patient data management system. We analysed the effect of norepinephrine on level (ICU Mobility Scale) and frequency (units per day) of mobilisation, early mobilisation (within 72 h of ICU admission), mortality, and rate of adverse events. Data were extracted from free-text mobilisation entries using supervised machine learning (support vector machine). Statistical analyses were done using (generalised) linear (mixed-effect) models, as well as chi-square tests and ANOVAs. RESULTS: A total of 12,462 patients were analysed in this study. They received a total of 59,415 mobilisation units. Of these patients, 842 (6.8%) received mobilisation under continuous norepinephrine administration. Norepinephrine administration was negatively associated with the frequency of mobilisation (adjusted difference -0.07 mobilisations per day; 95% CI - 0.09, - 0.05; p ≤ 0.001) and early mobilisation (adjusted OR 0.83; 95% CI 0.76, 0.90; p ≤ 0.001), while a higher norepinephrine dose corresponded to a lower chance to be mobilised out-of-bed (adjusted OR 0.01; 95% CI 0.00, 0.04; p ≤ 0.001). Mobilisation with norepinephrine did not significantly affect mortality (p > 0.1). Higher compared to lower doses of norepinephrine did not lead to a significant increase in adverse events in our practice (p > 0.1). We identified that mobilisation was safe with up to 0.20 µg/kg/min norepinephrine for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation. CONCLUSIONS: Mobilisation with norepinephrine can be done safely when considering the status of the patient and safety guidelines. We demonstrated that safe mobilisation was possible with norepinephrine doses up to 0.20 µg/kg/min for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation.

Impact of ABCDE Bundle Implementation in the Intensive Care Unit on Specific Patient Costs.

OBJECTIVES: To measure the impact of full versus partial ABCDE bundle implementation on specific cost centers and related resource utilization. DESIGN: Retrospective cohort study. SETTING: Two medical ICUs within Montefiore Health System (Bronx, NY). PATIENTS: Four hundred and seventy-two mechanically ventilated patients admitted to the medical ICUs during a hospitalization which began and ended between January 1, 2013 and December 31, 2013. INTERVENTIONS: The full (A)wakening, (B)reathing, (C)oordination, (D)elirium Monitoring/Management and (E)arly Mobilization bundle was implemented in the intervention ICU while a portion of the bundle (A, B, and D components) was implemented in the comparison ICU. MEASUREMENTS AND MAIN RESULTS: Relative to the comparison ICU, implementation of the entire bundle in the intervention ICU was associated with a 27.3% (95% CI: 9.9%, 41.3%; P = 0.004) decrease in total hospital laboratory costs and a 2,888.6% (95% CI: 77.9%, 50,113.2%; P = 0.018) increase in total hospital physical therapy costs. Cost of total hospital medications, diagnostic radiology and respiratory therapy were unchanged. Relative to the comparison ICU, total hospital resource use decreased in the intervention ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], P = 0.002; diagnostic radiology: 0.75 [0.59, 0.96], P = 0.020). CONCLUSIONS: Full ABCDE bundle implementation resulted in a decrease in total hospital laboratory costs and total hospital laboratory and diagnostic resource utilization while leading to an increase in physical therapy costs.

Significantly earlier ambulation and reduced risk of near-falls with continuous infusion nerve blocks: a retrospective pilot study of adductor canal block compared to femoral nerve block in total knee arthroplasty.

BACKGROUND: Near-falls should be detected to prevent falls related to the earlier ambulation after Total knee arthroplasty (TKA). The quadriceps weakness with femoral nerve block (FNB) has led to a focus on adductor canal block (ACB). We purposed to examine the risk of falls and the earlier ambulation in each continuous infusion nerve block. METHODS: Continuous infusion nerve block (FNB or ACB) was performed until postoperative day (POD) 2 or 3. Pain levels and falls/near-falls with knee-buckling were monitored from POD 1 to POD 3. The score on the manual muscle test, MMT (0 to 5, 5 being normal), of the patients who could ambulate on POD 1, was investigated. RESULTS: A total of 73 TKA cases, 36 FNB and 37 ACB, met the inclusion criteria. No falls were noted. But episodes of near-falls with knee-buckling were witnessed in 14 (39%) cases in the FNB group and in 4 (11%) in the ACB group (p = 0.0068). In the ACB group, 81.1% of patients could ambulate with parallel bars on POD 1, while only 44.4% of FNB patients could do so (p = 0.0019). The quadriceps MMT values in the ACB group was 2.82, significantly higher than 1.97 in the FNB group (p = 0.0035). There were no significant differences in pain as measured with a numerical rating scale (NRS) and rescue analgesia through POD 3. CONCLUSION: ACB was associated with significantly less knee-buckling and earlier ambulation post-TKA, with better quadriceps strength. Our study indicated the incidence of falls and near-falls with continuous infusion nerve blocks, and support the use of ACB to reduce the risk of falls after TKA. It is suggested that a certain number of the patients even with continuous ACB infusion should be considered with the effect of motor branch to prevent falls.

Extended mobility scale (AMEXO) for assessing mobilization and setting goals after gastrointestinal and oncological surgery: a before-after study.

BACKGROUND: Early structured mobilization has become a key element of Enhanced Recovery After Surgery programs to improve patient outcomes and decrease length of hospital stay. With the intention to assess and improve early mobilization levels, the 8-point ordinal John Hopkins Highest Level of Mobility (JH-HLM) scale was implemented at two gastrointestinal and oncological surgery wards in the Netherlands. After the implementation, however, healthcare professionals perceived a ceiling effect in assessing mobilization after gastrointestinal and oncological surgery. This study aimed to quantify this perceived ceiling effect, and aimed to determine if extending the JH-HLM scale with four additional response categories into the AMsterdam UMC EXtension of the JOhn HOpkins Highest Level of mObility (AMEXO) scale reduced this ceiling effect. METHODS: All patients who underwent gastrointestinal and oncological surgery and had a mobility score on the first postoperative day before (July-December 2018) or after (July-December 2019) extending the JH-HLM into the AMEXO scale were included. The primary outcome was the before-after difference in the percentage of ceiling effects on the first three postoperative days. Furthermore, the before-after changes and distributions in mobility scores were evaluated. Univariable and multivariable logistic regression analysis were used to assess these differences. RESULTS: Overall, 373 patients were included (JH-HLM n = 135; AMEXO n = 238). On the first postoperative day, 61 (45.2%) patients scored the highest possible mobility score before extending the JH-HLM into the AMEXO as compared to 4 (1.7%) patients after (OR = 0.021, CI = 0.007-0.059, p < 0.001). During the first three postoperative days, 118 (87.4%) patients scored the highest possible mobility score before compared to 40 (16.8%) patients after (OR = 0.028, CI = 0.013-0.060, p < 0.001). A change in mobility was observed in 88 (65.2%) patients before as compared to 225 (94.5%) patients after (OR = 9.101, CI = 4.046-20.476, p < 0.001). Of these 225 patients, the four additional response categories were used in 165 (73.3%) patients. CONCLUSIONS: A substantial ceiling effect was present in assessing early mobilization in patients after gastrointestinal and oncological surgery using the JH-HLM. Extending the JH-HLM into the AMEXO scale decreased the ceiling effect significantly, making the tool more appropriate to assess early mobilization and set daily mobilization goals after gastrointestinal and oncological surgery.

Feasibility, safety and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery.

AIMS: The aims of this study were to evaluate the safety, feasibility and outcomes of ambulation within 2 h after thoracoscopic surgery in patients with lung cancer. BACKGROUND: There are no consensus guidelines on the ideal time for early ambulation following thoracic surgery, although enhanced recovery programmes have been proposed since years. METHODS: This non-randomized, concurrent-control study was conducted on patients who underwent thoracoscopic surgery between October 2020 and February 2021. Participants were assigned to either the observation group (ambulation within 2 h of extubation) or the control group (ambulation on the first postoperative day). RESULTS: Of the 325 patients who were eligible, 227 were included in the study. Eighty-three per cent of patients were able to walk any distance within 2 h of extubation, and no adverse events occurred in patients. The length of hospital stay and time to first postoperative flatus were significantly shorter in the observation group than in the control group. There were no differences in the occurrence of postoperative complications and orthostatic hypotension, readmission rate and 6-min walk distance at discharge. CONCLUSION: Ambulation within 2 h of extubation was safe and feasible and could lead to better recovery in patients with lung cancer undergoing thoracoscopic surgery.