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Margot Green1, Vince Marzano1, I Anne Leditschke2,3, Imogen Mitchell2,3, Bernie Bissett1,4,5 1Physiotherapy Department, Canberra Hospital, Canberra, ACT, Australia; 2Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia; 3School of Medicine, Australian National University, Canberra, ACT, Australia; 4Discipline of Physiotherapy, University of Canberra, Canberra, ACT, Australia; 5School of Medicine, University of Queensland, Brisbane, QLD, Australia Objectives: To describe our experience and the practical tools we have developed to facilitate early mobilization in the intensive care unit (ICU) as a multidisciplinary team.Background: Despite the evidence supporting early mobilization for improving outcomes for ICU patients, recent international point-prevalence studies reveal that few patients are mobilized in the ICU. Existing guidelines rarely address the practical issues faced by multidisciplinary ICU teams attempting to translate evidence into practice. We present a comprehensive strategy for safe mobilization utilized in our ICU, incorporating the combined skills of medical, nursing, and physiotherapy staff to achieve safe outcomes and establish a culture which prioritizes this intervention.Methods: A raft of tools and strategies are described to facilitate mobilization in ICU by the multidisciplinary team. Patients without safe unsupported sitting balance and without ≥3/5 (Oxford scale) strength in the lower limbs commence phase 1 mobilization, including training of sitting balance and use of the tilt table. Phase 2 mobilization involves supported or active weight-bearing, incorporating gait harnesses if necessary. The Plan B mnemonic guides safe multidisciplinary mobilization of invasively ventilated patients and emphasizes the importance of a clearly articulated plan in delivering this valuable treatment as a team.Discussion: These tools have been used over the past 5 years in a tertiary ICU with a very low incidence of adverse outcomes (

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.

Introduction: Inspiratory muscle weakness is a known consequence of mechanical ventilation and a potential contributor to difficulty in weaning from ventilatory support. Inspiratory muscle training (IMT) reduces the weaning period and increases the likelihood of successful weaning in some patients. However, it is not known how this training affects the residual inspiratory muscle fatigability following successful weaning nor patients' quality of life or functional outcomes., Methods and Analysis: This dual centre study includes two concurrent randomised controlled trials of IMT in adult patients who are either currently ventilator-dependent (>7 days) (n=70) or have been recently weaned from mechanical ventilation (>7 days) in the past week (n=70). Subjects will be stable, alert and able to actively participate and provide consent. There will be concealed allocation to either treatment (IMT) or usual physiotherapy (including deep breathing exercises without a resistance device). Primary outcomes are inspiratory muscle fatigue resistance and maximum inspiratory pressures. Secondary outcomes are quality of life (Short Form-36v2, EQ-5D), functional status (Acute Care Index of Function), rate of perceived exertion (Borg Scale), intensive care length of stay (days), post intensive care length of stay (days), rate of reintubation (%) and duration of ventilation (days)., Ethics and Dissemination: Ethics approval has been obtained from relevant institutions, and results will be published with a view to influencing physiotherapy practice in the management of long-term ventilator-dependent patients to accelerate weaning and optimise rehabilitation outcomes., Trial Registration Number: ACTRN12610001089022.

Purpose: Recently there has been increased interest in early mobilization of critically ill patients. Proposed benefits include improvements in respiratory function, muscle wasting, intensive care unit (ICU), and hospital length of stay. We studied the frequency of early mobilization in our intensive care unit in order to identify barriers to early mobilization., Methods: A 4-week prospective audit of 106 patients admitted to a mixed medical-surgical tertiary ICU (mean age 60 ± 20 years, mean APACHE II score 14.7 ± 7.8) was performed. Outcome measures included number of patient days mobilized, type of mobilization, adverse events, and reasons for inability to mobilize., Results: Patients were mobilized on 176 (54%) of 327 patient days. Adverse events occurred in 2 of 176 mobilization episodes (1.1%). In 71 (47%) of the 151 patient days where mobilization did not occur, potentially avoidable factors were identified, including vascular access devices sited in the femoral region, timing of procedures and agitation or reduced level of consciousness., Conclusions: Critically ill patients can be safely mobilized for much of their ICU stay. Interventions that may allow more patients to mobilize include: changing the site of vascular catheters, careful scheduling of procedures, and improved sedation management.

Objective: To determine the safety and efficacy of an intensive insulin regimen compared with a conventional insulin regimen in general intensive care unit patients., Methods: A phase II, randomised controlled trial was conducted in 70 critically ill patients in a closed multidisciplinary ICU of a university-affiliated tertiary hospital. We assessed patient characteristics at baseline. Trial process measures included number of blood glucose measurements per day and number in target range, type and quantity of caloric intake, patient outcome and insulin dosing. The primary outcome was the median blood glucose concentration. Secondary outcome measures were incidence of hypoglycaemia (blood glucose level < 2.2 mmol/L), clinical sequelae of hypoglycaemia and hospital mortality., Results: Thirty-five patients were randomised to each of the two groups. More blood glucose samples were taken per day in the intensive insulin group (16 versus 9), but the number of samples in the normoglycaemic range was 48.5%, compared with 79.8% within the target glucose range in the conventional insulin group. The median (interquartile range) blood glucose concentrations in the intensive and conventional insulin therapy groups were 5.4 (5.1-5.7) mmol/L and 7.9 (7.2-9.0) mmol/L, respectively (difference, 2.5 mmol/L; P < 0.0001). Five patients (14.3%) in the intensive insulin therapy group became hypoglycaemic versus none in the conventional insulin therapy group. There were no detected clinical sequelae of hypoglycaemia., Conclusion: The intensive insulin regimen was effective in achieving the target blood glucose concentration, with clear separation from the conventional insulin regimen. Although the incidence of hypoglycaemia was increased, there was no detectable harm.

An acute cardiac tamponade from any cause may result in rapid deterioration of hepatic function in a previously healthy patient. We describe a case of an acute ascending aortic dissection that presented as acute hepatic failure, due to an acute cardiac tamponade and severe right heart failure. The differential diagnosis of the aetiology of acute liver failure is extensive and includes poisonings, vascular obstruction and sepsis, particularly on the background of decompensated liver disease. Many of these conditions are associated with hypotension. The acute presentation in our patient, combined with the lack of a characteristic history delayed the diagnosis of a proximal (type A) dissection with tamponade and subsequent hepatic failure. Severe right-sided heart failure as a result of conditions such as cardiac tamponade should be excluded in patients presenting with acute hepatic failure of unknown aetiology.