The Latest in Critical Care, 9/11/23 (Issue #14)
The Latest in Critical Care, 9/11/23 (Issue #14)
Can early mobility in the ICU improve cognitive outcomes?
Intensive, early mobilization of patients in the ICU seems like it just has to help. Get patients moving as much as possible, as early as possible—walking down the halls trailing their ventilators and arterial lines—and surely it will prevent muscle atrophy, improve strength and mobility, and reduce long-term disability.
But it didn’t, in the largest multicenter randomized trial conducted to date. (At least, not over and above regular physical therapy in the ICU— which most centers have a long way to go yet to achieve.)
Although intensive early mobility didn’t improve physical outcomes, a small study suggests that frequent physical therapy initiated by default early in an ICU stay might improve cognitive outcomes.
About 200 ventilated med-surg ICU patients at a single center (the University of Chicago, where the groundbreaking work of sedation interruptions and breathing trials was originally done) were randomized to receive frequent early mobilization (daily physical and occupational therapy) automatically on day 1, or usual care (whenever the attending decided to order it). Those randomized to early PT/OT got it on day 1, vs. day 4 or 5 for most usual care patients.
After one year, fewer patients receiving early mobilization were cognitively impaired (24% vs 43% scoring less than 26 on this test). They also had fewer persistent weaknesses attributed to the ICU stay (none vs 14%) and better physical quality-of-life scores.
However, they had no difference in functional independence (65% vs 62%). There were six adverse events in the early mobility group (hemodynamic instability, respiratory distress, arterial line dislodgement, etc.) and none in the usual care group.
Although post-ICU disability, present in a large proportion of ICU survivors, is gaining more attention, preventing it is still barely thought of during the acute phase of illness at most centers. Protocolizing interventions like sedation interruptions and breathing trials have probably saved many thousands of lives and shortened ICU stays for many thousands more.
Those interventions’ eventual dissemination was in large part because they require minimal additional outlays in human resources, or extra effort on the part of care teams. Increasing the frequency and intensity of physical therapy, on the other hand, would require hiring many additional (expensive) therapists. It would also require a culture change among ICU attendings and staff, to gain a comfort level with critically ill patients being pushed into physiologic stress zones.
That being said, in most ICUs, physical therapy usually isn’t tried at all, or only in a perfunctory way, either due to attendings’ trepidation or physical therapists’ anxieties. In the landmark study above that showed “no benefit” of intensive mobilization, it’s important to note the usual care control arm was also receiving regular PT that would be considered intensive in most U.S. ICUs today. That baseline would seem like a good target for most centers to aim for, as a start. Read in Lancet Respiratory Medicine
In the News
Covid BA.2.86 (‘Pirola’, the new strain of interest, with three mutations on the spike protein rendering it less susceptible to neutralizing antibodies, and possibly vaccines) continues to spread, now to 10 countries.
But how dangerous is it?
Based on its mutations, BA.2.86 was expected to escape neutralizing antibodies 10x better than the prevalent XBB strain. In cell cultures, BA.2.86 only escapes antibodies 2-3x better than XBB.
BA.2.86 latches on and infects cells less effectively than XBB.
Previous infection with XBB helps protect against BA.2.86, which means vaccines will probably work against it (as the shots are now partially based on XBB).
Paxlovid works against BA.2.86. (But I am aware of no data showing Paxlovid is helpful in people under 65 without health conditions.)
Antigen tests can identify BA.2.86.
Monoclonal antibodies don’t work against it.
Because the number of documented cases is low, official sources are hesitating to declare BA.2.86 no less virulent or lethal than Omicron.
However, the cases reported as of last week were nearly all mild. No deaths have been reported to the media. There was a large outbreak at a nursing home in Great Britain which resulted in one patient hospitalized out of 28 cases.