Year in Review 2022: Noteworthy Literature in Cardiothoracic Critical Care.

The past year in critical care medicine was notable for ongoing sequelae of the COVID-19 pandemic, including nationwide shortages and critical care demand in many regions in excess of usual operating capacity. Despite these challenges, evidence-based medicine and investigations into the optimal management of the critically ill continued to be at the forefront. This article is a collection of studies published in 2022 which are specifically relevant to cardiothoracic critical care. These noteworthy publications add to the existing literature across a broad spectrum of topics, from optimal timing of mechanical circulatory support (MCS), delirium prevention, updates in nutrition guidelines, alternative defibrillation techniques, novel ventilator management, and observing the downstream psychological impact of extracorporeal membrane oxygenation (ECMO) therapy.

Early Rehabilitation Interventions and Physical Therapy in Adults Who Were Critically Ill With COVID-19 Pneumonia: A Retrospective Observational Study.

OBJECTIVE: The primary objective of this observational study was to analyze the time to the first edge-of-bed (EOB) mobilization in adults who were critically ill with severe versus non-severe COVID-19 pneumonia. Secondary objectives included the description of early rehabilitation interventions and physical therapy delivery. METHODS: All adults with laboratory-confirmed COVID-19 requiring intensive care unit admission for ≥72 hours were included and divided according to their lowest PaO2/FiO2 ratio into severe (≤100 mmHg) or non-severe (>100 mmHg) COVID-19 pneumonia. Early rehabilitation interventions consisted of in-bed activities, EOB or out-of-bed mobilizations, standing, and walking. The Kaplan-Meier estimate and logistic regression were used to investigate the primary outcome time-to-EOB and factors associated with delayed mobilization. RESULTS: Among the 168 patients included in the study (mean age = 63 y [SD = 12 y]; Sequential Organ Failure Assessment = 11 [interquartile range = 9-14]), 77 (46%) were classified as non-severe, and 91 (54%) were classified as severe COVID-19 pneumonia. Median time-to-EOB was 3.9 days (95% CI = 2.3-5.5) with significant differences between subgroups (non-severe = 2.5 days [95% CI = 1.8-3.5]; severe = 7.2 days [95% CI = 5.7-8.8]). Extracorporeal membrane oxygenation use and high Sequential Organ Failure Assessment scores (adjusted effect = 13.7 days [95% CI = 10.1-17.4] and 0.3 days [95% CI = 0.1-0.6]) were significantly associated with delayed EOB mobilization. Physical therapy started within a median of 1.0 days (95% CI = 0.9-1.2) without subgroup differences. CONCLUSION: This study shows that early rehabilitation and physical therapy within the recommended 72 hours during the COVID-19 pandemic could be maintained regardless of disease severity. In this cohort, the median time-to-EOB was fewer than 4 days, with disease severity and advanced organ support significantly delaying the time-to-EOB. IMPACT: Early rehabilitation in the intensive care unit could be sustained in adults who are critically ill with COVID-19 pneumonia and can be implemented with existing protocols. Screening based on the PaO2/FiO2 ratio might reveal patients at risk and increased need for physical therapy.

[Robotic-assisted mobilization for an effective mobilization in a COVID-19 patient with ECMO treatment]. / Robotik für eine qualitativ hochwertige Mobilisation: Verbesserte Regeneration eines COVID-19-Patienten mit ECMO-Therapie.

An effective (early) mobilization in COVID-19 intensive care patients with ECMO treatment is very important. Sedation, extracorporeal procedures with the danger of circuit malfunction, large lumen ECMO cannulas with a risk of dislocation and a very severe neuromuscular weakness are factors that could deem mobilization beyond stage 1 of the ICU mobility score (IMS) in some cases difficult or impossible; however, early mobilization is a key point of the ABCDEF bundle to counteract pulmonary complications, neuromuscular dysfunction and enable recovery. The case of a 53-year-old, previously healthy and active male patient with a severe and complicated course of COVID-19 and pronounced ICU-acquired weakness is described. While receiving ECMO the patient could be mobilized using a robotic system. Due to severe and rapidly progressing pulmonary fibrosis, additional low-dose methylprednisolone therapy (Meduri protocol) was implemented. Under this multimodal treatment the patient was successfully weaned from the ventilator and decannulated. Robotic assisted mobilization has the potential to be a novel and safe therapeutic option for a customized and highly effective mobilization in ECMO patients.

Early physiotherapy management of patients with Covid-19 admitted to a university hospital in Norway (March 2020 to July 2021).

AIM: The aim of this retrospective observational study was to describe the scope of physiotherapy, the population and the physiotherapy management of Covid-19 patients referred to physiotherapy at a university hospital in the period from March 2020 to July 2021. METHOD: A descriptive observational study with access to data from a quality register, which contains clinical data of all patients admitted with Covid-19 to a university hospital in Norway. Data was obtained from electronic data sheets, where daily parameters for physiotherapy treatment were registered. RESULTS: In total, 729 Covid-19 patients were admitted during this period. Of these, 507 (69.6%) received treatment by a physiotherapist (3510 sessions). The physiotherapy treatments were performed on intensive care units (ICU) (50%), intermediate care units (11%) and general medical units (39%), respectively. Patients were mainly treated during the day (98.5%) and 21% of the sessions were given on weekends or holidays. Within the 3510 sessions, 9459 interventions were performed in total (one to seven interventions per session). The most common intervention provided was positioning (35.4%). The most common interventions in medical units and intermediate care units were training with a positive expiratory pressure device (17.3% and 15.9% respectively), and techniques for reducing work of breathing (13% and 15% respectively). The most common intervention in the ICUs was passive mobilization (21.3%), mostly in combination with positioning, manual techniques and/or airway clearance. CONCLUSION: This study provides characteristics of, and experiences with early physiotherapy, in sequentially hospitalized patients at a university hospital in Norway.

Timing to out-of-bed mobilization and mobility levels of COVID-19 patients admitted to the ICU: Experiences in Brazilian clinical practice.

INTRODUCTION: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there was scarce data about clinical/functional conditions during hospitalization or after hospital discharge. Little was known about COVID-19 repercussions and how to do early mobilization in intensive care unit (ICU). OBJECTIVE: Identify the time to the initiation of out-of-bed mobilization and the levels of mobility (sitting over the edge of the bed, sitting in a chair, standing, and ambulating) reached by critically ill patients with COVID-19 during hospitalization and the factors that could impact early mobilization. METHODS: This was a retrospective observational study of patients with COVID-19 in the ICU. RESULTS: There were 157 surviving COVID-19 patients included in the study (median age: 61 years; median ICU length of stay: 12 days). The median time to initiate out-of-bed mobilization in the ICU was 6 days; between patients who received mechanical ventilation (MV) compared with those who did not, this time was 8 vs. 2.5 days (p < .001). Most patients who used MV were mobilized after extubation (79.6%). During ICU stays, 88.0% of all patients were mobilized out of bed, and 41.0% were able to ambulate either with assistance or independently. The time to initiate out-of-bed mobilization is associated with sedation time and MV time. CONCLUSION: Despite the pandemic scenario, patients were quickly mobilized out of bed, and most of the patients achieved higher mobility levels in the ICU and at hospital discharge. Sedation time and MV time were associated with delays in initiating mobilization.

Quadriplegia after ECMO therapy with sluggish recovery in a COVID-19 patient: A case report with a 14-month follow-up.

COVID-19 patients often develop neuromuscular complications, and critically ill patients often develop ICU-acquired weakness. We report a COVID-19 patient who developed flaccid quadriplegia after ECMO therapy and achieved a slow but consistent recovery during a 14-month period of sustained holistic rehabilitation including early mobilization to an outdoor environment.

[Robotic-assisted mobilization for an effective mobilization in a COVID-19 patient with ECMO treatment]. / Mobilisationsrobotik für eine qualitativ hochwertige Mobilisation bei einem COVID-19-Patienten mit ECMO-Therapie.

An effective (early) mobilization in COVID-19 intensive care patients with ECMO treatment is very important. Sedation, extracorporeal procedures with the danger of circuit malfunction, large lumen ECMO cannulas with a risk of dislocation and a very severe neuromuscular weakness are factors that could deem mobilization beyond stage 1 of the ICU mobility score (IMS) in some cases difficult or impossible; however, early mobilization is a key point of the ABCDEF bundle to counteract pulmonary complications, neuromuscular dysfunction and enable recovery. The case of a 53-year-old, previously healthy and active male patient with a severe and complicated course of COVID-19 and pronounced ICU-acquired weakness is described. While receiving ECMO the patient could be mobilized using a robotic system. Due to severe and rapidly progressing pulmonary fibrosis, additional low-dose methylprednisolone therapy (Meduri protocol) was implemented. Under this multimodal treatment the patient was successfully weaned from the ventilator and decannulated. Robotic-assisted mobilization has the potential to be a novel and safe therapeutic option for a customized and highly effective mobilization in ECMO patients.

Recovery of skeletal muscle strength and physical function in a patient with (post) COVID-19 requiring extra-corporeal membrane oxygenation.

BACKGROUND: The ongoing coronavirus-19 disease (COVID-19) has taught us that early mobilization is essential for functional recovery during and after prolonged intensive care unit (ICU) stay. This especially applies for patients receiving a challenging combination of prolonged invasive treatments such as mechanical ventilation (MV) and extra-corporeal membrane oxygenation (ECMO). This case report describes the recovery of skeletal muscle strength and physical function in a patient (post) COVID-19 during ICU stay. CASE DESCRIPTION: A 54 year old female patient was diagnosed with COVID-19 pneumonia, and ultimately needed ICU treatment with MV and ECMO for 69 days during which she received physiotherapy treatment. OUTCOMES: The patient recovered from intensive care acquired muscle weakness (ICUAW) at day 53, resulting in the ability to walk at day 62. She was discharged from the ICU after 69 days with the ability to walk 20 meters with support of one person and a mobility aid. No evident adverse events were noted during or after physiotherapy sessions. DISCUSSION: Early mobilization is feasible and safe in a patient (post) COVID-19 with prolonged ECMO treatment and facilitates functional recovery during ICU stay. This single case observation should be handled with caution and needs further validation.

Time to active sitting position: One-year findings from a temporary COVID-19 intensive care unit.

OBJECTIVE: To investigate the association between time to active sitting position and clinical features in people with COVID-19 admitted to intensive care unit (ICU) and referred to physiotherapists. METHOD: Prospective study conducted in the largest temporary ICU in Lombardy (Italy) between April 2020 and June 2021. All individuals with COVID-19 who received physiotherapy were included. Multivariable Cox proportional hazard model was fitted to explore the statistical association between active sitting position and characteristics of patients referred to physiotherapists, also accounting for the different multidisciplinary teams responsible for patients. RESULTS: 284 individuals over 478 (59.4%) had access to physiotherapy, which was performed for a median of 8 days, without difference between multidisciplinary teams (P = 0.446). The active sitting position was reached after a median of 18 (IQR: 10.0-32.0) days. Sex was the only characteristic associated with the time to active sitting position, with males showing a reduced hazard by a factor of 0.65 (95% CI: 0.48-0.87; P = 0.0042) compared to females. At ICU discharge, nearly 50% individuals increased Manchester Mobility Score by 3 points. During physiotherapy no major adverse event was recorded. CONCLUSION: Individuals with COVID-19 take long time to reach active sitting position in ICU, with males requiring longer rehabilitation than females.

Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. OBJECTIVE: We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. METHODS: We divided our study into 4 phases-phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post-CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post-CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. RESULTS: A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre-CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). CONCLUSIONS: This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.

Impairment in Physical Function and Mental Status in a Survivor of Severe COVID-19 at Discharge from an Acute Care a Hospital: A Case Report.

BACKGROUND: Early mobilization and rehabilitation interventions should be provided to patients who survived severe COVID-19 to improve their physical function and activities of daily living (ADL). However, their physical and mental status at discharge has not been well described in Japan. We report the intervention provided for a survivor of severe COVID-19 and his physical and mental status at discharge from an acute care hospital. CASE REPORT: A 62-year-old man was admitted to our emergency department with a diagnosis of COVID-19 with severe acute respiratory dysfunction. He had complicated intensive care unit-acquired weakness (ICU-AW) and delirium during mechanical ventilation therapy. Rehabilitation intervention was initiated on the seventh day post-admission and was gradually performed according to his respiratory and hemodynamic status. As a result of the rehabilitation intervention, ICU-AW and cognitive function gradually improved. On hospital day 37, he independently performed basic ADL and was discharged. However, he lost approximately 9% of his body weight at discharge. In addition, his hand grip strength and six-minute walking distance were lower and shorter than the reference values, respectively. His mental component summary of the Short Form-8™ was lower than the national standard deviation for the Japanese population. CONCLUSION: Although survivors of severe COVID-19 who undergo early rehabilitation can be discharged from an acute care hospital, they may have several impairments in their physical and mental status, including muscle function, diffusion capacity, exercise tolerance, and health-related quality of life.

Evidence-based National Consensus: Recommendations for Physiotherapy Management in COVID-19 in Acute Care Indian Setup.

BACKGROUND: With the Wuhan pandemic spread to India, more than lakhs of population were affected with COVID-19 with varying severities. Physiotherapists participated as frontline workers to contribute to management of patients in COVID-19 in reducing morbidity of these patients and aiding them to road to recovery. With infrastructure and patient characteristics different from the West and lack of adequate evidence to existing practices, there was a need to formulate a national consensus. MATERIALS AND METHODS: Recommendations were formulated with a systematic literature search and feedback of physiotherapist experiences. Expert consensus was obtained using a modified Delphi method. RESULTS: The intraclass coefficient of agreement between the experts was 0.994, significant at p < 0.001. CONCLUSION: This document offers physiotherapy evidence-based consensus and recommendation to planning physiotherapy workforce, assessment, chest physiotherapy, early mobilization, preparation for discharge planning, and safety for patients and therapist in acutec are COVID 19 setup of India. The recommendations have been integrated in the algorithm and are intended to use by all physiotherapists and other stakeholders in management of patients with COVID-19 in acute care settings. HOW TO CITE THIS ARTICLE: Jiandani MP, Agarwal B, Baxi G, Kale S, Pol T, Bhise A, et al. Evidence-based National Consensus: Recommendations for Physiotherapy Management in COVID-19 in Acute Care Indian Setup. Indian J Crit Care Med 2020;24(10):905-913.

Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series.

OBJECTIVE: The aim of this case series was to describe the experience of Swiss physical therapists in the treatment of patients with COVID-19 during their acute care hospital stay and to discuss challenges and potential strategies in the clinical management of these patients. METHODS: We report 11 cases of patients with COVID-19 from 5 Swiss hospitals that illustrate the various indications for physical therapy, clinical challenges, potential treatment methods, and short-term response to treatment. RESULTS: Physical therapists actively treated patients with COVID-19 on wards and in the intensive care unit. Interventions ranged from patient education, to prone positioning, to early mobilization and respiratory therapy. Patients were often unstable with quick exacerbation of symptoms and a slow and fluctuant recovery. Additionally, many patients who were critically ill developed severe weakness, postextubation dysphagia, weaning failure, or presented with anxiety or delirium. In this setting, physical therapy was challenging and required specialized and individualized therapeutic strategies. Most patients adopted the proposed treatment strategies, and lung function and physical strength improved over time. CONCLUSION: Physical therapists clearly have a role in the COVID-19 pandemic. Based on our experience in Switzerland, we recommend that physical therapists routinely screen and assess patients for respiratory symptoms and exercise tolerance on acute wards. Treatment of patients who are critically ill should start as soon as possible to limit further sequelae. More research is needed for awake prone positioning and early breathing exercises as well as post-COVID rehabilitation. IMPACT: To date, there are few data on the physical therapist management of patients with COVID-19. This article is among the first to describe the role of physical therapists in the complex pandemic environment and to describe the potential treatment strategies for countering the various challenges in the treatment of these patients.

Maintaining Mobility in a Patient Who Is Pregnant and Has COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Case Report.

OBJECTIVE: Mobilization while receiving life support interventions, including mechanical ventilation and extracorporeal membrane oxygenation (ECMO), is a recommended intensive care unit (ICU) intervention to maintain physical function. The purpose of this case report is to describe a novel approach to implementing early mobility interventions for a patient who was pregnant and receiving ECMO while continuing necessary infectious disease precautions because of diagnosed coronavirus disease-19 (COVID-19). METHODS: A 27-year-old woman who was pregnant was admitted to the ICU with COVID-19 and rapidly developed acute respiratory failure requiring 9 days of ECMO support. After a physical therapist consultation, the patient was standing at the bedside by hospital day 5 and ambulating by hospital day 9. RESULTS: The patient safely participated in physical therapy during ICU admission and was discharged to home with outpatient physical therapy follow-up after 14 days of hospitalization. CONCLUSION: Early mobility is feasible during ECMO with COVID-19, and active participation in physical therapy, including in-room ambulation, may facilitate discharge to home. Innovative strategies to facilitate routine activity in a patient who is critically ill with COVID-19 require an established and highly trained team with a focus on maintaining function. IMPACT: Early mobility while intubated, on ECMO, and infected with COVID-19 is feasible while adhering to infectious disease precautions when it is performed by an experienced interdisciplinary team.

Adaptation and validation of the ICU Mobility Scale in Spain. / Adaptación y validación de la ICU Mobility Scale en España.

OBJECTIVE: To adapt the ICU Mobility Scale (IMS) to the area of intensive care units (ICU) in Spain and to evaluate the metric properties of the Spanish version of the IMS (IMS-Es). METHOD: Descriptive metric study developed in two phases. Phase 1, adaptation to Spanish of the IMS by a team of nurses and physiotherapists (translation, pilot, backtranslation and agreement). Phase 2, analysis of metric properties (convergent, divergent and predictive validity, interobserver reliability, sensitivity and minimum important difference) of the IMS-Es. Patient characteristics (Barthel, Charlson, BMI, sex), sedation/agitation level (RASS), ICU and hospital stays, survival, quality of life (SF-12), muscle weakness (MRC-SS) and mobility (IMS-Es) were recorded in the patients of the MOviPre national multicentre study. RESULTS: After obtaining the IMS-Es, it was implemented in 645 patients from 80 Spanish ICUs between April and June 2017. Convergent validity: moderate correlation between IMS-Es and MRC-SS (r=.389; P<.001) and significant comparison between groups with and without ICU-acquired weakness (P<.001). Divergent validity: no correlation between IMS-Es and BMI [r (95%CI): -.112 (-.232 to .011)], weight [r (95%CI): -.098 (-.219 to .026)], Charlson [r (95%CI): -.122 (-.242 to .001)] and Barthel [r(95%CI): -.037 (-.160 to .087)] and no differences between sexes (P=.587) or BMI categories (P=.412). Predictive validity: moderate and significant correlations with post-ICU hospital stay [r (95%CI): -.442 (-.502 to -.377)] and physical component of SF-12 (PCS) [r (95%CI): .318 (.063 to .534)]; patients without active mobilisation in ICU increased risk of hospital mortality [OR (95%CI): 3.769 (1.428 to 9.947)]. Interobserver reliability: very good concordance between nurses [CCI (95%CI): .987 (.983 to .990)] and nurse-physiotherapist [CCI (95%CI): .963 (.948 to .974)]. Sensitivity to change: small effect on discharge from ICU (d=.273) and moderate effect at 3months after hospital discharge (d=.709). Minimal important difference: 2-point difference cut-off point, 91.1% sensitivity and 100.0% specificity. CONCLUSIONS: The IMS-Es is useful, valid and reliable for implementation by ICU nurses and physiotherapists in assessing the mobility of critical patients.