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[NEJM发表述评]:危重患者的早期活动—还有很多需要学习
2022年11月03日 研究点评, 进展交流 [NEJM发表述评]:危重患者的早期活动—还有很多需要学习已关闭评论

EDITORIAL

Early Mobilization of Critical Care Patients — Still More to Learn

Marc Moss

N Engl J Med October 26, 2022
DOI: 10.1056/NEJMe2212360

Each year, intensive care unit (ICU)–acquired weakness occurs in approximately 1 million critically ill patients who are undergoing mechanical ventilation worldwide.1 ICU-acquired weakness begins early in the course of critical illness and is related to multiple mechanisms, including deconditioning, myopathy, and neuropathy. Its development is associated with several deleterious outcomes, including increased mortality and diminished long-term quality of life.2 By improving muscle strength, endurance, and the performance of functional activities, early patient mobilization may be a treatment option for ICU-acquired weakness. However, previous studies examining early mobilization have shown conflicting results.3-7

As reported now in the Journal, the Treatment of Mechanically Ventilated Adults with Early Activity and Mobilization (TEAM) trial provides additional insight regarding the efficacy of early mobilization.8 In this trial, which was performed in 49 hospitals across three continents, the ICU population reflected similar patients in other high-income countries. A total of 750 adult patients who were undergoing mechanical ventilation in the ICU were randomly assigned to receive either early mobilization or usual care. The early-mobilization strategy included a novel approach of aiming for the highest level of mobilization for the longest duration of time before intensity was decreased according to patient fatigue. The authors concluded that early mobilization was not associated with an increased number of days that patients were alive and out of the hospital at 180 days after randomization (the primary outcome) or with a difference in 180-day mortality (a secondary outcome), as compared with the usual level of mobilization in the ICU. Furthermore, the two groups had similar scores with respect to cognitive and psychological function, quality of life, and disability among survivors at 180 days. Greater exposure to mobilization in the intervention group was associated with increased adverse events — specifically, cardiac arrhythmia and oxygen desaturation. However, the frequency of these adverse event was similar to that in previous studies.3-7

Researchers design studies to answer unique hypotheses. The TEAM trial was designed to test different “doses” of early mobilization and should not lead to the conclusion that early mobilization is ineffective in general. The investigators found only that the TEAM mobilization strategy did not improve patient outcomes as compared with usual care in the participating hospitals. Also, the high frequency of early mobilization in the usual-care group was surprising. A physiotherapist assessed the patients on 81% of ICU days in the usual-care group, as compared with 94% of ICU days in the intervention group. Therefore, the lack of separation in treatment exposure between the two groups may have contributed to the negative results. In contrast, in a 2016 mobilization trial, patients in the usual-care group received a median of only 1 day of therapy during their entire hospitalization.4 In a 2017 survey of 42 ICUs, mobilization of similar patients occurred on 32% of ICU days.9 In determining how to incorporate the TEAM results into clinical practice, we should consider whether the usual-care strategy that was used in the trial reflects current practice patterns in other hospitals.

There are some additional caveats about this trial. The patients received mobilization therapy only while they were in the ICU. However, the ICU represents the beginning of a long course of recovery for many of these patients. Some may require longer, coordinated interventions extending into the outpatient setting. In the universal setting of finite resources, a broad implementation of the TEAM protocol could result in lost opportunities in other areas of care. Some of the resources that are required to initiate and maintain an early-mobilization protocol could be shifted to expand traditionally underfunded programs (e.g., addiction medicine services after an overdose or mental health support for ICU survivors). However, resource allocations for early mobilization and for other therapies are not necessarily mutually exclusive.

The TEAM results should be interpreted in the context of the unique hypotheses that have been evaluated in previous mobilization trials, including the appropriate time frame and coordination of the intervention, and the potential benefits for a variety of outcomes. For example, in one study, facilitator-enhanced coordination of mobilization shortened the ICU length of stay and improved functional independence of surgical patients at the time of ICU discharge.6 In the TEAM trial, the outcome of the number of days alive and out of the hospital could be too rigorous and may require larger sample sizes that are difficult to achieve while providing adequate power to detect meaningful differences.

The rigor of the TEAM trial provides a valuable advancement for early-mobilization research and clarifies the pathway for future studies. By analogy, the evaluation of prone positioning has required multiple well-performed trials with different durations of therapy in various patient populations to identify a unique strategy that reduced patient mortality.10 The next stage of early-mobilization research in critically ill patients should focus on identifying which patients receive the most benefit from early mobilization, implementing the appropriate comparison group, examining outcomes that are attainable and inform clinical practice, and determining the appropriate type, timing, intensity, coordination, and duration of therapy. Ultimately, these studies should lend more clarity to the role of early mobilization in critically ill patients.

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