Acute and Critical Care

Review Articles

Pulmonary
Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic: Miguel Ángel Martínez-Camacho, Robert Alexander Jones-Baro, Alberto Gómez-González, Dalia Sahian Lugo-García, Pía Carolina Gallardo Astorga, Andrea Melo-Villalobos, Bárbara Kassandra Gonzalez-Rodriguez, Ángel Augusto Pérez-Calatayud; Acute Crit Care. 2024;39(1):47-60. Published online February 2, 2024; DOI: https://doi.org/10.4266/acc.2023.01284

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Abstract PDF: During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.

Basic science and research
Brain–computer interface in critical care and rehabilitation: Eunseo Oh, Seyoung Shin, Sung-Phil Kim; Acute Crit Care. 2024;39(1):24-33. Published online January 12, 2024; DOI: https://doi.org/10.4266/acc.2023.01382

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Abstract PDF: This comprehensive review explores the broad landscape of brain–computer interface (BCI) technology and its potential use in intensive care units (ICUs), particularly for patients with motor impairments such as quadriplegia or severe brain injury. By employing brain signals from various sensing techniques, BCIs offer enhanced communication and motor rehabilitation strategies for patients. This review underscores the concept and efficacy of noninvasive, electroencephalogram-based BCIs in facilitating both communicative interactions and motor function recovery. Additionally, it highlights the current research gap in intuitive “stop” mechanisms within motor rehabilitation protocols, emphasizing the need for advancements that prioritize patient safety and individualized responsiveness. Furthermore, it advocates for more focused research that considers the unique requirements of ICU environments to address the challenges arising from patient variability, fatigue, and limited applicability of current BCI systems outside of experimental settings.

Trauma
Mobilization phases in traumatic brain injury: Tommy Alfandy Nazwar, Ivan Triangto, Gutama Arya Pringga, Farhad Bal’afif, Donny Wisnu Wardana; Acute Crit Care. 2023;38(3):261-270. Published online August 1, 2023; DOI: https://doi.org/10.4266/acc.2023.00640

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Abstract PDF

Mobilization in traumatic brain injury (TBI) have shown the improvement of length of stay, infection, long term weakness, and disability. Primary damage as a result of trauma’s direct effect (skull fracture, hematoma, contusion, laceration, and nerve damage) and secondary damage caused by trauma’s indirect effect (microvasculature damage and pro-inflammatory cytokine) result in reduced tissue perfusion & edema. These can be facilitated through mobilization, but several precautions must be recognized as mobilization itself may further deteriorate patient’s condition. Very few studies have discussed in detail regarding mobilizing patients in TBI cases. Therefore, the scope of this review covers the detail of physiological effects, guideline, precautions, and technique of mobilization in patients with TBI.

Citations

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Acute orthostatic responses during early mobilisation of patients with acquired brain injury - Innowalk pro versus standing frame
Matthijs F Wouda, Espen I Bengtson, Ellen Høyer, Alhed P Wesche, Vivien Jørgensen
Journal of Rehabilitation and Assistive Technologies Engineering.2024;[Epub] CrossRef
Aktuelle Aspekte der intensivmedizinischen Versorgung bei Schädel-Hirn-Trauma – Teil 2
André Hagedorn, Helge Haberl, Michael Adamzik, Alexander Wolf, Matthias Unterberg
AINS - Anästhesiologie · Intensivmedizin · Notfallmedizin · Schmerztherapie.2024; 59(07/08): 466. CrossRef
Reversing Persistent PTEN Activation after Traumatic Brain Injury Fuels Long‐Term Axonal Regeneration via Akt/mTORC1 Signaling Cascade
Ziyu Shi, Leilei Mao, Shuning Chen, Zhuoying Du, Jiakun Xiang, Minghong Shi, Yana Wang, Yuqing Wang, Xingdong Chen, Zhi‐Xiang Xu, Yanqin Gao
Advanced Science.2024;[Epub] CrossRef

Original Article

Nursing
Improving mobility in the intensive care unit with a protocolized, early mobilization program: observations of a single center before-and-after the implementation of a multidisciplinary program: Laptin Ho, Joe Hin Cheung Tsang, Emmanuel Cheung, Wing Yan Chan, Ka Wai Lee, Sweetie R Lui, Chung Yau Lee, Alfred Lok Hang Lee, Philip Koon Ngai Lam; Acute Crit Care. 2022;37(3):286-294. Published online June 29, 2022; DOI: https://doi.org/10.4266/acc.2021.01564

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Abstract PDF Supplementary Material

Background
Early intensive care unit (ICU) protocolized rehabilitative programs have been described previously, yet with differing starting time points and mostly on mechanically ventilated patients. We extended the concept to all admitted ICU patients and investigate the efficacy of early mobilization in improving mobility of the critically ill, address issues surrounding the timing and intensity of an early rehabilitative program.
Methods
Prospective cohorts of patients admitted consecutively before-and-after (control, n=92; intervention, n=90) the introduction of an early mobilization program in a single center, general hospital ICU. Improvement in mobility as assessed by ICU mobility score, on ICU admission and upon ICU discharge, was measured as a primary outcome.
Results
Those receiving early mobilization in the intensive care unit had higher ICU mobility score (2.63; 95% confidence interval, 0.65–4.61; P<0.001) upon discharge from the intensive care, with earlier out of bed mobilization on day 5 compared to the control group of day 21 (P<0.001). No differences were found in terms of mortality, intensive care hospitalization and subsequent hospitalization duration after discharge from ICU.
Conclusions
Here, we report that improvement in mobility score earlier in the course of intensive care hospitalization with the introduction of a protocolized early rehabilitative program.

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Early mobilization and its impact on recovery in ICU patients with severe COVID-19: A randomized controlled trial
J Saravankumar, Rathna Paramaswamy, Buvanesh Annadurai, Iswarya S, Santhana Lakshmi S S, Surya Vishnuram, Jeslin G N, Shenbaga Sundaram Subramanian, Senthilkumar N
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Early Active Mobilization during Mechanical Ventilation in the ICU

New England Journal of Medicine.2023; 388(6): 572. CrossRef
Yoğun Bakım Hastası İçin Erken Mobilizasyonun Önemi
Ebubekir Kaplan, Aylin Aktaş Özakgül, Özkan Sir
Sakarya Üniversitesi Holistik Sağlık Dergisi.2023; 6(3): 510. CrossRef

Guideline

Pharmacology
2021 KSCCM clinical practice guidelines for pain, agitation, delirium, immobility, and sleep disturbance in the intensive care unit: Yijun Seo, Hak-Jae Lee, Eun Jin Ha, Tae Sun Ha; Acute Crit Care. 2022;37(1):1-25. Published online February 28, 2022; DOI: https://doi.org/10.4266/acc.2022.00094; Correction in: Acute Crit Care 2023;38(1):149

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Abstract PDF

We revised and expanded the “2010 Guideline for the Use of Sedatives and Analgesics in the Adult Intensive Care Unit (ICU).” We revised the 2010 Guideline based mainly on the 2018 “Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) in Adult Patients in the ICU,” which was an updated 2013 pain, agitation, and delirium guideline with the inclusion of two additional topics (rehabilitation/mobility and sleep). Since it was not possible to hold face-to-face meetings of panels due to the coronavirus disease 2019 (COVID-19) pandemic, all discussions took place via virtual conference platforms and e-mail with the participation of all panelists. All authors drafted the recommendations, and all panelists discussed and revised the recommendations several times. The quality of evidence for each recommendation was classified as high (level A), moderate (level B), or low/very low (level C), and all panelists voted on the quality level of each recommendation. The participating panelists had no conflicts of interest on related topics. The development of this guideline was independent of any industry funding. The Pain, Agitation/Sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep Disturbance panels issued 42 recommendations (level A, 6; level B, 18; and level C, 18). The 2021 clinical practice guideline provides up-to-date information on how to prevent and manage pain, agitation/sedation, delirium, immobility, and sleep disturbance in adult ICU patients. We believe that these guidelines can provide an integrated method for clinicians to manage PADIS in adult ICU patients.

Citations

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Psychiatric Consults Associated With Longer Length of Stay in Trauma Patients—A Retrospective Study
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Review Article

Pulmonary
Pulmonary and Physical Rehabilitation in Critically Ill Patients: Myung Hun Jang, Myung-Jun Shin, Yong Beom Shin; Acute Crit Care. 2019;34(1):1-13. Published online February 28, 2019; DOI: https://doi.org/10.4266/acc.2019.00444

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Abstract PDF

Some patients admitted to the intensive care unit (ICU) because of an acute illness, complicated surgery, or multiple traumas develop muscle weakness affecting the limbs and respiratory muscles during acute care in the ICU. This condition is referred to as ICU-acquired weakness (ICUAW), and can be evoked by critical illness polyneuropathy (CIP), critical illness myopathy (CIM), or critical illness polyneuromyopathy (CIPNM). ICUAW is diagnosed using the Medical Research Council (MRC) sum score based on bedside manual muscle testing in cooperative patients. The MRC sum score is the sum of the strengths of the 12 regions on both sides of the upper and lower limbs. ICUAW is diagnosed when the MRC score is less than 48 points. However, some patients require electrodiagnostic studies, such as a nerve conduction study, electromyography, and direct muscle stimulation, to differentiate between CIP and CIM. Pulmonary rehabilitation in the ICU can be divided into modalities intended to remove retained airway secretions and exercise therapies intended to improve respiratory function. Physical rehabilitation, including early mobilization, positioning, and limb exercises, attenuates the weakness that occurs during critical care. To perform mobilization in mechanically ventilated patients, pretreatment by removing secretions is necessary. It is also important to increase the strength of respiratory muscles and to perform lung recruitment to improve mobilization in patients who are weaned from the ventilator. For these reasons, pulmonary rehabilitation is important in addition to physical therapy. Early recognition of CIP, CIM, and CIPNM and early rehabilitation in the ICU might improve patients’ functional recovery and outcomes.

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Case Report

Pulmonary
Central extracorporeal membrane oxygenation and early rehabilitation for persistent severe pulmonary hypertension following pulmonary endarterectomy: Gil Myeong Seong, Sang-Bum Hong, Jin Won Huh, Chae-Man Lim, Younsuck Koh, Jae Won Lee, Sung-Ho Jung, Duck-Woo Park, Jae Seung Lee; Acute Crit Care. 2019;34(2):158-164. Published online November 7, 2018; DOI: https://doi.org/10.4266/acc.2016.01032

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Abstract PDF

Chronic thromboembolic pulmonary hypertension is potentially curable with a pulmonary endarterectomy. However, approximately 20% of patients have persistent pulmonary hypertension after pulmonary endarterectomy, which is a major risk factor for postoperative death. Here, we report a 34-year-old woman who suffered persistent severe pulmonary hypertension following a successful pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Extracorporeal membrane oxygenation (ECMO) and atrial septostomy were successfully performed as rescue treatments, and active rehabilitation during ECMO was prescribed to facilitate recovery.

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Transatrial balloon atrial septostomy to facilitate weaning off venoarterial ECMO after pulmonary endarterectomy
Koray Ak, Gökhan Arslanhan, Yakup Tire, Sinan Tosun, Alper Kararmaz, İsmail Hanta, Bedrettin Yıldızeli
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Cardiac Rehabilitation in Heart Failure
Kyeong-hyeon Chun, Seok-Min Kang
International Journal of Heart Failure.2021; 3(1): 1. CrossRef

Original Article

Pulmonary
Feasibility of Immediate in-Intensive Care Unit Pulmonary Rehabilitation after Lung Transplantation: A Single Center Experience: Joo Han Song, Ji-Eun Park, Sang Chul Lee, Sarang Kim, Dong Hyung Lee, Eun Kyoung Kim, Song Yee Kim, Ji Cheol Shin, Jin Gu Lee, Hyo Chae Paik, Moo Suk Park; Acute Crit Care. 2018;33(3):146-153. Published online August 31, 2018; DOI: https://doi.org/10.4266/acc.2018.00129

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Abstract PDF

Background
Physical function may influence perioperative outcomes of lung transplantation. We investigated the feasibility of a pulmonary rehabilitation program initiated in the immediate postoperative period at an intensive care unit (ICU) for patients who underwent lung transplantation.
Methods
We retrospectively evaluated 22 patients who received pulmonary rehabilitation initiated in the ICU within 2 weeks after lung transplantation at our institution from March 2015 to February 2016. Levels of physical function were graded at the start of pulmonary rehabilitation and then weekly throughout rehabilitation according to criteria from our institutional pulmonary rehabilitation program: grade 1, bedside (G1); grade 2, dangling (G2); grade 3, standing (G3); and grade IV, gait (G4).
Results
The median age of patients was 53 years (range, 25 to 73 years). Fourteen patients (64%) were males. The initial level of physical function was G1 in nine patients, G2 in seven patients, G3 in four patients, and G4 in two patients. Patients started pulmonary rehabilitation at a median of 7.5 days (range, 1 to 29 days) after lung transplantation. We did not observe any rehabilitation-related complications during follow-up. The final level of physical function was G1 in six patients, G3 in two patients, and G4 in 14 patients. Fourteen of the 22 patients were able to walk with or without assistance, and 13 of them maintained G4 until discharge; the eight remaining patients never achieved G4.
Conclusions
Our results suggest the feasibility of early pulmonary rehabilitation initiated in the ICU within a few days after lung transplantation.

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Post-operative, inpatient rehabilitation after lung transplant evaluation (PIRATE): A feasibility randomized controlled trial
Benjamin J Tarrant, Elizabeth Quinn, Rebecca Robinson, Megan Poulsen, Louise Fuller, Greg Snell, Bruce R Thompson, Brenda M Button, Anne E Holland
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Early Gait Function After Lung Transplantation in Patients With and Without Pretransplant Extracorporeal Membrane Oxygenation Support
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Case Report

Surgery
Critical Illness Neuromyopathy Complicating Cardiac Surgery: Wan Ki Baek, Young Sam Kim, Joung Taek Kim, Byoung-Nam Yoon; Acute Crit Care. 2018;33(1):51-56. Published online July 11, 2017; DOI: https://doi.org/10.4266/acc.2016.00255

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Abstract PDF

Critical illness neuromyopathy (CINM) is a sporadically reported disease in the setting of an intensive care unit developing in the process of managing a critical illness. The disease primarily affects the motor and sensory axons and results in severe limb weakness rendering ventilator weaning extremely difficult. We report a case of CINM after cardiac valve surgery. Quadriplegia developed after the operation and resolved slowly over the following 2 months. The patient was discharged home free of neurologic symptoms.

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Ji Min Lee, Seon Yeong Heo, Dong Kyu Kim, Jong Pil Jung, Chang Ryul Park, Yong Jik Lee, Gwan Sic Kim
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Original Article

Neurology
The Effect of Electrical Muscle Stimulation and In-bed Cycling on Muscle Strength and Mass of Mechanically Ventilated Patients: A Pilot Study: Kyeongyoon Woo, Jeongmin Kim, Hye Bin Kim, Hyunwoo, Choi, Kibum Kim, Donghyung Lee, Sungwon Na; Acute Crit Care. 2018;33(1):16-22. Published online February 14, 2017; DOI: https://doi.org/10.4266/acc.2017.00542

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Abstract PDF

Background
Critically ill patients experience muscle weakness, which leads to functional disability. Both functional electrical stimulation (FES) and in-bed cycling can be an alternative measure for intensive care unit (ICU) patients who are not feasible for active exercise. The aim of this study was to examine whether FES and in-bed cycling have a positive effect on muscle mass in ICU patients.
Methods
Critically ill patients who received mechanical ventilation for at least 24 hours were included. After passive range of motion exercise, in-bed cycling was applied for 20 minutes, and FES was applied for 20 minutes on the left leg. The right leg received in-bed cycling and the left leg received both FES and in-bed cycling. Thigh circumferences and rectus femoris cross-sectional area (CSA) were assessed with ultrasonography before and after the intervention. Muscle strength was assessed by Medical Research Council scale.
Results
A total of 10 patients were enrolled in this study as a pilot study. Before and after the intervention, the CSA of right rectus femoris increased from 5.08 ± 1.51 cm² to 6.01 ± 2.21 cm² , which was statistically significant (P = 0.003). The thigh circumference was also increased and statistically significant (P = 0.006). There was no difference between left and right in regard to FES application. There is no significant change in muscle strength before and after the intervention (right and left, P = 0.317 and P = 0.368, respectively).
Conclusions
In-bed cycling increased thigh circumferences rectus femoris CSA. Adding FES did not show differences.

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