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).

Effect of in-bed cycling on acute muscle wasting in critically ill adults: A randomised clinical trial.

PURPOSE: To examine whether in-bed cycling assists critically ill adults to reduce acute muscle wasting, improve function and improve quality of life following a period of critical illness. MATERIALS AND METHODS: A single-centre, two-group, randomised controlled trial with blinded assessment of the primary outcome was conducted in a tertiary ICU. Critically ill patients expected to be mechanically ventilated for at least 48 h were randomised to 30 min daily in-bed cycling in addition to usual-care physiotherapy (n = 37) or usual-care physiotherapy (n = 37). The primary outcome was muscle atrophy of rectus femoris cross-sectional area (RFCSA) measured by ultrasound at Day 10 following study enrolment. Secondary outcomes included manual muscle strength, handgrip strength, ICU mobility score, six-minute walk test distance and health-related quality of life up to six-months following hospital admission. RESULTS: Analysis included the 72 participants (mean age, 56-years; male, 68%) who completed the study. There were no significant between-group differences in muscle atrophy of RFCSA at Day 10 (mean difference 3.4, 95% CI -6.9% to 13.6%; p = .52), or for secondary outcomes (p-values ranged p = .11 to p = .95). CONCLUSIONS AND RELEVANCE: In-bed cycling did not reduce muscle wasting in critically ill adults, but this study provides useful effect estimates for large-scale clinical trials. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12616000948493.

Acceptability, safety, and feasibility of in-bed cycling with critically ill patients.

BACKGROUND: In-bed cycling is a promising intervention that may assist critically ill patients to maintain muscle mass and improve their trajectory of recovery. The acceptability of in-bed cycling from the different perspectives of patients, clinicians, and families are unknown. In addition, the safety and feasibility of in-bed cycling in an Australian tertiary intensive care unit (ICU) is relatively unknown. OBJECTIVES: The objective of this study was to examine the acceptability, safety, and feasibility of in-bed cycling in an Australian tertiary, adult, mixed medical, surgical, trauma ICU. METHODS: An observational process evaluation was embedded in one arm of a two-arm parallel phase II randomised controlled trial that was conducted in an Australian tertiary ICU. The process evaluation was of the acceptability, safety, and feasibility of passive and active in-bed cycling for participants allocated to the trial intervention group. In-bed cycling acceptability questionnaires were designed through a three-step Delphi process. Questionnaire responses from patients, family members, and clinicians who participated in or observed the intervention during the Critical Care Cycling Study (CYCLIST) were evaluated to determine the acceptability of in-bed cycling. The congruence of responses between respondents was also compared. Safety and feasibility of the in-bed cycling intervention were assessed against predetermined criteria. RESULTS: Acceptability questionnaire responses demonstrated that in-bed cycling was an acceptable intervention from the perspectives of patients, family members, and clinicians. Questionnaire responses were congruent across the respondent groups. Safety was demonstrated with two minor transient adverse events occurring during 276 in-bed cycling sessions (adverse event rate: 0.7%). In-bed cycling sessions were feasible with 276 of 304 (90%) planned sessions conducted. CONCLUSIONS: Acceptability questionnaire responses found that in-bed cycling was regarded as an acceptable intervention to patients, family members, and clinicians. The implementation of in-bed cycling was safe and feasible to complete with critically ill patients during the early stages of their critical illness in an Australian tertiary ICU setting.

Exercise interventions are delayed in critically ill patients: a cohort study in an Australian tertiary intensive care unit.

OBJECTIVES: This study aims to (i) describe the time to exercise commencement (sitting and upright activities) relative to ICU admission and relative to achievement of initial neurological, respiratory and cardiovascular stability; (ii) examine factors associated with whether sitting and upright activities occurred in ICU; and (iii) examine factors associated with time taken to commence these activities after stability has been achieved. DESIGN: Five-year historical cohort study. SETTING: An Australian tertiary mixed medical, surgical, trauma ICU. PARTICIPANTS: The cohort (n=3222, mean (SD) age 54 (18) years, 67% male) included consecutive ICU patients with length of stay over 48hours admitted to a tertiary ICU who achieved stability. MAIN OUTCOME MEASURES: Time from stability to patients' first completed sitting and upright activities was calculated. Logistic regression (and Cox proportional hazard models) examined whether sitting and upright activities in ICU occurred (and time to these events). INTERVENTIONS: None. RESULTS: For patients who completed exercise interventions (n=1845/3222, 57%), this commenced a median (IQR) 2.3 (1.3-4.4) days after stability for upright activities and 2.7 (1.5-5.7) days for sitting. A large proportion of patients did not complete exercise interventions despite achieving stability (n=1377/3222, 43%). Elective surgical admissions, lower illness severity and older age were associated with completion (and earlier completion) of sitting and upright activity (P<0.01). CONCLUSIONS: Many stable patients did not commence sitting or upright activity in ICU despite known benefits, or commencement was somewhat delayed. Opportunities may exist to improve patient outcomes through timely implementation of exercise-based interventions.

Critical Care Cycling Study (CYCLIST) trial protocol: a randomised controlled trial of usual care plus additional in-bed cycling sessions versus usual care in the critically ill.

INTRODUCTION: In-bed cycling with patients with critical illness has been shown to be safe and feasible, and improves physical function outcomes at hospital discharge. The effects of early in-bed cycling on reducing the rate of skeletal muscle atrophy, and associations with physical and cognitive function are unknown. METHODS AND ANALYSIS: A single-centre randomised controlled trial in a mixed medical-surgical intensive care unit (ICU) will be conducted. Adult patients (n=68) who are expected to be mechanically ventilated for more than 48 hours and remain in ICU for a further 48 hours from recruitment will be randomly allocated into either (1) a usual care group or (2) a group that receives usual care and additional in-bed cycling sessions. The primary outcome is change in rectus femoris cross-sectional area at day 10 in comparison to baseline measured by blinded assessors. Secondary outcome measures include muscle strength, incidence of ICU-acquired weakness, handgrip strength, time to achieve functional milestones (sitting out of bed, walking), Functional Status Score in ICU, ICU Mobility Scale, 6 min walk test 1 week post-ICU discharge, incidence of delirium and quality of life (EuroQol Five Dimensions questionnaire Five Levels scale). Quality of life assessments will be conducted post-ICU admission at day 10, 3 and 6 months after acute hospital discharge. Participants in the intervention group will complete an acceptability of intervention questionnaire. ETHICS AND DISSEMINATION: Appropriate ethical approval from Metro South Health Human Research Ethics Committee has been attained. Results will be published in peer-reviewed publications and presented at scientific conferences to assist planning of future multicentre randomised controlled trials (if indicated) that will test in-bed cycling as an intervention to improve the physical, cognitive and health-related quality of life outcomes of patients with critical illness. TRIAL REGISTRATION NUMBER: This trial has been prospectively registered on the Australian and New Zealand Clinical Trial Registry (ACTRN12616000948493); Pre-results.

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.

INTRODUCTION: The aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients. METHODS: A systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients. RESULTS: Safety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations. CONCLUSION: Consensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.