Eficacia del protocolo Start to move en funcionalidad, DA-UCI y delirio: ensayo clínico aleatorizado / Efficacy of the «Start to move» protocol on functionality, ICU-acquired weakness and delirium: Randomized clinical trial

Objetivo Evaluar la eficacia del protocolo Start to move comparado con el tratamiento convencional en sujetos mayores de 15 años hospitalizados en la UCI sobre una mejoría en funcionalidad, disminución de debilidad adquirida en la UCI (DA-UCI), incidencia de delirio, días de ventilación mecánica (VM), estadía en la UCI y mortalidad a los 28 días. Diseño Ensayo clínico controlado aleatorizado. Ámbito Unidad de paciente crítico. Participantes Incluye adultos mayores a 15 años con VMI mayor a 48h, asignación aleatoria. Intervenciones Protocolo «Start to move» y tratamiento convencional. Variables de interés principales Se analizó funcionalidad, incidencia DA-UCI, incidencia delirio, días VM, estadía UCI y mortalidad-28 días, ClinicalTrials.gov número, NCT05053724. Resultados Sesenta y nueve sujetos fueron ingresados al estudio, 33 al grupo Start to move y 36 a tratamiento convencional, comparables clínico y sociodemograficamente. En el grupo Start to move la incidencia DAUCI al egreso de la UCI fue de 35,7 vs. 80,7% grupo tratamiento convencional (p=0,001). La funcionalidad (FSS-ICU) al egreso de la UCI corresponde a 26 vs. 17 puntos a favor del grupo Start to move (p=0,001). La diferencia en Barthel al egreso de la UCI fue del 20% a favor del grupo Start to move (p=0,006). No hubo diferencias significativas en incidencia de delirio, días de VM, estadía UCI y mortalidad-28 días. El estudio no reportó eventos adversos, ni suspensión de protocolo. Conclusiones La aplicación del protocolo Start to move en la UCI se asoció reducción en la incidencia DA-UCI, aumento en funcionalidad y menor caída en puntaje Barthel al egreso. (AU)

Objective To evaluate the efficacy of the Start to move protocol compared to conventional treatment in subjects over 15 years of age hospitalized in the ICU on an improvement in functionality, decrease in ICU-acquired weakness (IUCD), incidence of delirium, days of mechanical ventilation (MV), length of stay in ICU and mortality at 28 days. Design Randomized controlled clinical trial. Setting Intensive care unit. Participants Includes adults older than 15 years with invasive mechanical ventilation more than 48h, randomized allocation. Interventions Start to move protocol and conventional treatment. Main variables of interest Functionality, incidence of ICU-acquired weakness, incidence of delirium, days on mechanical ventilation, ICU stay and mortality-28 days, ClinicalTrials.gov number, NCT05053724. Results Sixty-nine subjects were admitted to the study, 33 to the Start to move group and 36 to conventional treatment, clinically and sociodemographic comparable. In the “Start to move” group, the incidence of IUCD at ICU discharge was 35.7% vs. 80.7% in the “conventional treatment” group (P=.001). Functionality (FSS-ICU) at ICU discharge corresponds to 26 vs. 17 points in favor of the “Start to move” group (P=.001). The difference in Barthel at ICU discharge was 20% in favor of the “Start to move” group (P=.006). There were no significant differences in the incidence of delirium, days of mechanical ventilation, ICU stay and 28-day mortality. The study did not report adverse events or protocol suspension. Conclusions The application of the “Start to move” protocol in ICU showed a reduction in the incidence of IUCD, an increase in functionality and a smaller decrease in Barthel score at discharge. (AU)

Efficacy of the "Start to move" protocol on functionality, ICU-acquired weakness and delirium: A randomized clinical trial.

OBJECTIVE: To evaluate the efficacy of the Start to move protocol compared to conventional treatment in subjects over 15 years of age hospitalized in the ICU on an improvement in functionality, decrease in ICU-acquired weakness (DAUCI), incidence of delirium, days of mechanical ventilation (MV), length of stay in ICU and mortality at 28 days. DESIGN: randomized controlled clinical trial. SETTING: Intensive Care Unit. PARTICIPANTS: Includes adults older than 15 years with invasive mechanical ventilation more than 48h, randomized allocation. INTERVENTIONS: Start to move protocol and conventional treatment. MAIN VARIABLES OF INTEREST: Functionality, incidence of ICU-acquired weakness, incidence of delirium, days on mechanical ventilation, ICU stay and mortality-28 days, ClinicalTrials.gov number, NCT05053724. RESULTS: 69 subjects were admitted to the study, 33 to the Start to move group and 36 to conventional treatment, clinically and sociodemographic comparable. In the "Start to move" group, the incidence of IUCD at ICU discharge was 35.7% vs. 80.7% in the "conventional treatment" group (p=0.001). Functionality (FSS-ICU) at ICU discharge corresponds to 26 vs. 17 points in favor of the "Start to move" group (p=0.001). The difference in Barthel at ICU discharge was 20% in favor of the "Start to move" group (p=0.006). There were no significant differences in the incidence of delirium, days of mechanical ventilation, ICU stay and 28-day mortality. The study did not report adverse events or protocol suspension. CONCLUSIONS: The application of the "Start to move" protocol in ICU showed a reduction in the incidence of IUAD, an increase in functionality and a smaller decrease in Barthel score at discharge.

Movilización temprana en el paciente sometido a terapia de reemplazo renal continua: ¿el riesgo sobrepasa los beneficios? / Early mobilization in continuous renal replacement therapy: does the risk outweigh the benefits? / Mobilização precoce do paciente em terapia de substituição renal contínua: o risco supera os benefícios?

Resumen: La movilización temprana (MT) del paciente crítico ingresado a la UCI ha demostrado grandes beneficios en poblaciones cada vez más heterogéneas; sin embargo, pacientes que se encuentran vinculados a dispositivos extracorpóreos como la terapia de reemplazo renal continua (TRRC) suelen estar confinados por periodos prolongados a inmovilización en cama debido a la percepción del personal sobre posibles eventos adversos relacionados al paciente (desaturación, inestabilidad hemodinámica, caídas, etc.) o al catéter (desinserción, hemorragia, embolismo) durante la sesión de fisioterapia. Sin embargo, la evidencia actual demuestra que de manera general, si se cuenta con un protocolo de MT adaptado a las necesidades específicas de los pacientes vinculados a TRRC y esto se acompaña de un equipo humano multidisciplinario calificado y coordinado, el paciente podría realizar actividades en cama, sentado, parado e inclusive deambular sin necesidad de interrumpir la TRRC, y aun así, el riesgo de eventos adversos es casi nulo, lo que nos permitiría continuar priorizando la vida del paciente, al mismo tiempo que le permitimos ejercer su derecho de vivirla dignamente a través del movimiento corporal.

Abstract: Early mobilization (EM) of the critically ill patient admitted to the ICU has shown great benefits in increasingly heterogeneous populations, however, patients who are linked to extracorporeal devices such as continuous renal replacement therapy (CRRT) are often confined to prolonged periods of bed immobilization due to the staff's perception of possible adverse events related to the patient (desaturation, hemodynamic instability, falls, etc.) or to the catheter (disinsertion, bleeding, embolism, etc.) during the physical therapy session. However, current evidence shows that, in general, this is an unfounded fear since, if there is a EM protocol adapted to the specific needs of patients linked to CRRT and this is accompanied by a qualified and coordinated multidisciplinary team, the patient could perform activities in bed, sitting, standing and even walking without interrupting CRRT, and even then, the risk of adverse events is almost nil, which would allow us to continue to prioritize the patient's life, while allowing them to exercise their right to live life with dignity through bodily movement.

Resumo: A mobilização precoce (MP) do paciente em estado crítico internado na UTI tem mostrado grandes benefícios em populações cada vez mais heterogêneas, porém, pacientes que estão vinculados a dispositivos extracorpóreos como a terapia renal substitutiva contínua (TRRC) costumam ficar confinados à imobilização no leito por períodos prolongados devido à percepção da equipe sobre possíveis eventos adversos relacionados ao paciente (dessaturação, instabilidade hemodinâmica, quedas, etc.) ou ao cateter (desinserção, hemorragia, embolia) durante a sessão de fisioterapia. No entanto, as evidências atuais mostram que, em geral, se houver um protocolo de MP adaptado às necessidades específicas dos pacientes vinculados a TRRC e este for acompanhado por uma equipe humanizada multidisciplinar qualificada e coordenada, o paciente poderá realizar atividades no leito, sentado, ficar em pé e até andar sem a necessidade de interromper o TRRC, e mesmo assim o risco de eventos adversos é quase zero, o que nos permitiria continuar priorizando a vida do paciente, ao mesmo tempo que permitimos que ele exerça seu direito de viver com dignidade através do movimento corporal.

A mobilização precoce está associada à melhor funcionalidade no pós-operatório de cirurgias abdominais? / Is early mobilization associated with better functionality after abdominal surgery? / ¿Se asocia la movilización temprana con una mejor funcionalidad después de las cirugías abdominales?

Introdução: Pacientes submetidos a grandes cirurgias abdominais apresentam riscos de complicações pós-operatórias. A mobilização precoce vem sendo implementada e cada vez mais aplicada, no intuito de prevenir esses eventos. Objetivo: Demonstrar se a mobilização precoce está associada à melhor funcionalidade no pós-operatório de cirurgias abdominais. Métodos: Revisão integrativa de literatura realizada por meio de uma busca bibliográfica junto aos bancos de dados: BVS, Scielo, PedRO e Pubmed por meio dos descritores: mobilização precoce, deambulação precoce, cuidados pós-operatórios, período pós-operatório, estado funcional, exercício físico, reabilitação, funcionalidade e cirurgia abdominal, nos idiomas inglês, português e espanhol. Resultados: A amostra final foi constituída por 08 artigos científicos, que foram estruturados em forma de quadro para apresentação de suas principais características, dos métodos e os principais resultados. Conclusão: A mobilização precoce está associada ao retorno rápido à funcionalidade da linha de base pré- operatória, as atividades de vida diária, independência funcional, além do tempo de internação mais curto e menor duração dos desagradáveis sintomas pós-operatórios.

Introduction: Patients undergoing major abdominal surgery are at risk of postoperative complications. Early mobilization has been implemented and increasingly applied in order to prevent these events. Objective: to demonstrate whether early mobilization is associated with better functionality in the postoperative period of abdominal surgeries. Methods: an integrative literature review carried out through a literature search in the following databases: BVS, Scielo, PedRO and Pubmed using the descriptors: early mobilization, early ambulation, postoperative care, postoperative period, functional status, physical exercise, rehabilitation, functionality and abdominal surgery, in English, Portuguese and Spanish. Results: The final sample consisted of 08 scientific articles, which were structured in the form of a table to present their main characteristics, methods and main results. Conclusion: Early mobilization interferes with the rapid return to preoperative baseline functionality, activities of daily living, functional independence, in addition to a shorter hospital stay and shorter duration of unpleasant postoperative symptoms.

Introducción: Los pacientes sometidos a cirugías abdominales mayores corren el riesgo de sufrir complicaciones postoperatorias. La movilización temprana se ha implementado y aplicado cada vez más para prevenir estos eventos. Objetivo: Demostrar si la movilización temprana se asocia con una mejor funcionalidad después de la cirugía abdominal. Métodos: Revisión bibliográfica integrativa realizada a través de una búsqueda bibliográfica en las siguientes bases de datos: BVS, Scielo, PedRO y Pubmed utilizando los descriptores: early mobilisation, early ambulation, postoperative care, postoperative period, functional status, physical exercise, rehabilitation, functionality and abdominal surgery, en inglés, portugués y español. Resultados: La muestra final consistió en 08 artículos científicos, que se estructuraron en forma de tabla para presentar sus principales características, los métodos y los principales resultados. Conclusión: La movilización temprana se asocia con un rápido retorno a la funcionalidad de base preoperatoria, a las actividades de la vida diaria, a la independencia funcional, así como a una estancia hospitalaria más corta y a una menor duración de los síntomas postoperatorios desagradables.

Algoritmo de movilización temprana para el paciente crítico. Recomendaciones de expertos / Early mobilisation algorithm for the critical patient. Expert recommendations

Introducción La debilidad adquirida en la unidad de cuidados intensivos (DAU) es desarrollada por el 40-46% de los pacientes ingresados en UCI. Diferentes estudios han mostrado que la movilización temprana (MT) es segura, factible, costo-efectiva y mejora los resultados del paciente a corto y largo plazo. Objetivo Diseñar un algoritmo de MT para el paciente crítico en general y enumerar unas recomendaciones para la MT en subpoblaciones específicas de paciente crítico con más riesgo para la movilización: neurocrítico, traumático, sometido a terapias continuas de depuración renal (TCDR) y con dispositivos de asistencia ventricular (DAV) o membrana de oxigenación extracorpórea (ECMO). Metodología Revisión en las bases de datos Medline, CINAHL, Cochrane y PEDro de estudios publicados en los últimos 10 años, que aporten protocolos/intervenciones de MT. Resultados Se incluyeron 30 artículos. De ellos, 21 eran para guiar la MT en el paciente crítico en general, 7 en pacientes neurocríticos y/o traumáticos, uno en pacientes portadores de TCDR y uno en pacientes portadores de ECMO y/o DVA. Se diseñan 2 figuras: una para la toma de decisiones teniendo en cuenta el bundle ABCDEF y la otra con los criterios de seguridad y objetivo de movilidad para cada uno. Conclusiones Los algoritmos de MT aportados pueden promover la movilización precoz (entre el 1.er y 5.o día de ingreso en UCI), junto a aspectos a tener en cuenta antes de la movilización y criterios de seguridad para suspenderla. (AU)

Introduction Intensive care unit (ICU)-acquired weakness is developed by 40%-46% of patients admitted to ICU. Different studies have shown that Early Mobilisation (EM) is safe, feasible, cost-effective and improves patient outcomes in the short and long term. Objective To design an EM algorithm for the critical patient in general and to list recommendations for EM in specific subpopulations of the critical patient most at risk for mobilisation: neurocritical, traumatic, undergoing continuous renal replacement therapy (CRRT) and with ventricular assist devices (VAD) or extracorporeal membrane oxygenation (ECMO). Methodology Review undertaken in the Medline, CINAHL, Cochrane and PEDro databases of studies published in the last 10 years, providing EM protocols/interventions. Results 30 articles were included. Of these, 21 were on guiding EM in critical patients in general, 7 in neurocritical and/or traumatic patients, 1 on patients undergoing CRRT and 1 on patients with ECMO and/or VAD. Two figures were designed: one for decision-making, taking the ABCDEF bundle into account and the other with the safety criteria and mobility objective for each. Conclusions The EM algorithms provided can promote early mobilisation (between the 1st and 5th day from admission to ICU), along with aspects to consider before mobilisation and safety criteria for discontinuing it. (AU)

Early mobilisation algorithm for the critical patient. Expert recommendations.

INTRODUCTION: Intensive care unit (ICU)-acquired weakness is developed by 40%-46% of patients admitted to ICU. Different studies have shown that Early Mobilisation (EM) is safe, feasible, cost-effective and improves patient outcomes in the short and long term. OBJECTIVE: To design an EM algorithm for the critical patient in general and to list recommendations for EM in specific subpopulations of the critical patient most at risk for mobilisation: neurocritical, traumatic, undergoing continuous renal replacement therapy (CRRT) and with ventricular assist devices (VAD) or extracorporeal membrane oxygenation (ECMO). METHODOLOGY: Review undertaken in the Medline, CINAHL, Cochrane and PEDro databases of studies published in the last 10 years, providing EM protocols/interventions. RESULTS: 30 articles were included. Of these, 21 were on guiding EM in critical patients in general, 7 in neurocritical and/or traumatic patients, 1 on patients undergoing CRRT and 1 on patients with ECMO and/or VAD. Two figures were designed: one for decision-making, taking the ABCDEF bundle into account and the other with the safety criteria and mobility objective for each. CONCLUSIONS: The EM algorithms provided can promote early mobilisation (between the 1st and 5th day from admission to ICU), along with aspects to consider before mobilisation and safety criteria for discontinuing it.

Movilización temprana en la Unidad de Cuidados Intensivos / Early mobilization in the Intensive Care Unit / Mobilização precoce na Unidade de Terapia Intensiva

Resumen: La movilización temprana (MT) es la implementación de ejercicio físico en los pacientes ingresados en la Unidad de Cuidados Intensivos (UCI) observándose beneficios importantes como reducción de neumonías asociadas con ventilación mecánica (NAVM), trombosis venosa profunda, úlceras por presión, debilidad adquirida en la UCI (DAUCI). Además, tiene un impacto financiero al reducir los días de estancia hospitalaria y en la UCI. Cabe mencionar que la MT impacta en el desenlace posterior al alta hospitalaria reduciendo la aparición de síndrome postcuidados intensivos (PICS).

Abstract: Early mobilization (EM) is the implementation of physical exercise in patients admitted to the Intensive Care Unit (ICU), with important benefits being observed such as reduction of ventilator-associated pneumonia, deep vein thrombosis, pressure ulcers and ICU-acquired weakness (ICU-AW). It also has a financial impact by reducing hospital length of stay and in the ICU. Also, EM has an important role in the outcome once the patient leaves the hospital reducing the post-intensive care syndrome (PICS).

Resumo: A mobilização precoce (MP) é a implementação de exercícios físicos em pacientes internados em Unidade de Terapia Intensiva (UTI), observando benefícios importantes como redução da pneumonia associada à ventilação mecânica (PAV), trombose venosa profunda, úlceras por pressão, fraqueza adquirida no UTI (DAUCI). Além disso, tem impacto financeiro ao reduzir os dias de internação e internação na UTI. Vale ressaltar que a MT tem impacto no desfecho após a alta hospitalar por reduzir o aparecimento da Síndrome de Terapia Pós-Intensiva (PICS).