Surgical Intensive Care Unit Optimal Mobilisation Score (SOMS) trial: a protocol for an international, multicentre, randomised controlled trial focused on goal-directed early mobilisation of surgical ICU patients.

INTRODUCTION: Immobilisation in the intensive care unit (ICU) leads to muscle weakness and is associated with increased costs and long-term functional disability. Previous studies showed early mobilisation of medical ICU patients improves clinical outcomes. The Surgical ICU Optimal Mobilisation Score (SOMS) trial aims to test whether a budget-neutral intervention to facilitate goal-directed early mobilisation in the surgical ICU improves participant mobilisation and associated clinical outcomes. METHODS AND ANALYSIS: The SOMS trial is an international, multicentre, randomised clinical study being conducted in the USA and Europe. We are targeting 200 patients. The primary outcome is average daily SOMS level and key secondary outcomes are ICU length of stay until discharge readiness and 'mini' modified Functional Independence Measure (mmFIM) at hospital discharge. Additional secondary outcomes include quality of life assessed at 3 months after hospital discharge and global muscle strength at ICU discharge. Exploratory outcomes will include: ventilator-free days, ICU and hospital length of stay and 3-month mortality. We will explore genetic influences on the effectiveness of early mobilisation and centre-specific effects of early mobilisation on outcomes. ETHICS AND DISSEMINATION: Following Institutional Review Board (IRB) approval in three institutions, we started study recruitment and plan to expand to additional centres in Germany and Italy. Safety monitoring will be the domain of the Data and Safety Monitoring Board (DSMB). The SOMS trial will also explore the feasibility of a transcontinental study on early mobilisation in the surgical ICU. RESULTS: The results of this study, along with those of ancillary studies, will be made available in the form of manuscripts and presentations at national and international meetings. REGISTRATION: This study has been registered at clinicaltrials.gov (NCT01363102).

Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions.

PURPOSE: Persistent low-level hypotension represents a barrier to discharging patients from the intensive care unit (ICU). Midodrine may be an effective adjunct to wean intravenous (IV) vasopressors and permit ICU discharge. We tested the hypothesis that midodrine, given to patients on IV vasopressors who otherwise met ICU discharge criteria, increased the magnitude of change in IV vasopressor rate. MATERIALS AND METHODS: This was a prospective, observational study in 20 adult surgical ICU patients who met ICU discharge criteria except for an IV vasopressor requirement. We compared the change in phenylephrine equivalent rates during the day before midodrine to the change in phenylephrine equivalent rates after midodrine initiation and analyzed changes in total body fluid balance, heart rate, mean arterial pressure, and white blood cell count during this period. RESULTS: Patients received 41.0±33.4 µg/min of phenylephrine equivalents and the change in IV vasopressor rate (slope) decreased significantly from -0.62 µg/min per hour of phenylephrine equivalents before midodrine to -2.20 µg/min per hour following the initiation of midodrine treatment (P=.012). Change in total body fluid balance, heart rate, mean arterial pressure, and white blood cell count did not correlate with change in IV vasopressor rate. CONCLUSION: Midodrine treatment was associated with an increase in the magnitude of decline of the IV vasopressor rate. Oral midodrine may facilitate liberation of surgical ICU patients from an IV vasopressor infusion, and this may affect discharge readiness of patients from the ICU.

Global muscle strength but not grip strength predicts mortality and length of stay in a general population in a surgical intensive care unit.

BACKGROUND: Paresis acquired in the intensive care unit (ICU) is common in patients who are critically ill and independently predicts mortality and morbidity. Manual muscle testing (MMT) and handgrip dynamometry assessments have been used to evaluate muscle weakness in patients in a medical ICU, but similar data for patients in a surgical ICU (SICU) are limited. OBJECTIVE: The purpose of this study was to evaluate the predictive value of strength measured by MMT and handgrip dynamometry at ICU admission for in-hospital mortality, SICU length of stay (LOS), hospital LOS, and duration of mechanical ventilation. DESIGN: This investigation was a prospective, observational study. METHODS: One hundred ten patients were screened for eligibility for testing in the SICU of a large, academic medical center. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, diagnoses, and laboratory data were collected. Measurements were obtained by MMT quantified with the sum (total) score on the Medical Research Council Scale and by handgrip dynamometry. Outcome data, including in-hospital mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation, were collected for all participants. RESULTS: One hundred seven participants were eligible for testing; 89% were tested successfully at a median of 3 days (25th-75th percentiles=3-6 days) after admission. Sedation was the most frequent barrier to testing (70.6%). Manual muscle testing was identified as an independent predictor of mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation. Grip strength was not independently associated with these outcomes. LIMITATIONS: This study did not address whether muscle weakness translates to functional outcome impairment. CONCLUSIONS: In contrast to handgrip strength, MMT reliably predicted in-hospital mortality, duration of mechanical ventilation, SICU LOS, and hospital LOS.

The surgical intensive care unit optimal mobility score predicts mortality and length of stay.

OBJECTIVES: To test if the surgical intensive care unit optimal mobility score predicts mortality and intensive care unit and hospital length of stay. DESIGN: Prospective single-center cohort study. SETTING: Surgical intensive care unit of the Massachusetts General Hospital. PATIENTS: One hundred thirteen consecutive patients admitted to the surgical intensive care unit. INVESTIGATIONS: We tested the hypotheses that the surgical intensive care unit optimal mobility score independent of comorbidity index, Acute Physiology and Chronic Health Evaluation II, creatinine, hypotension, hypernatremia, acidosis, hypoxia, and hypercarbia predicts hospital mortality, surgical intensive care unit and total hospital length of stay. MEASUREMENTS AND MAIN RESULTS: Two nurses independently predicted the patients' mobilization capacity by using the surgical intensive care unit optimal mobility score the morning after admission, whereas a third nurse recorded the achieved mobilization levels of patients at the end of the day. A multidisciplinary expert team measured patients' grip strength and assessed their predicted mobilization capacity independently. Multivariate analysis revealed that the surgical intensive care unit optimal mobility score was the only independent predictor of mortality. Surgical intensive care unit optimal mobility score, hypotension, and hypernatremia (>144 mmol/L) independently predicted intensive care unit length of stay, whereas the surgical intensive care unit optimal mobility score and hypernatremia predicted total hospital length of stay. The Acute Physiology and Chronic Health Evaluation II score was not identified in the multivariate analysis. The surgical intensive care unit optimal mobility score was also a reliable and valid instrument in predicting achieved mobilization levels of patients. CONCLUSIONS: In surgical critically ill patients presenting without preexisting impairment of functional mobility, the surgical intensive care unit optimal mobility score is a reliable and valid tool to predict mortality and intensive care unit and hospital length of stay.

Septicemia due to Capnocytophaga canimorsus following dog bite in an elderly male.

A previously healthy, 67-year-old, man with past medical history of myocardial infarction and hypertension was rushed to the emergency room after sudden onset of fever, chills, severe rigors, hypotension, tachycardia and vomiting. The patient was diagnosed as being in septic shock, and investigations revealed intracellular gram-negative bacilli in polymorphonuclear leukocytes in the peripheral smear. A history of dog contact was elicited after this very unusual and rare finding. Cultures confirmed septicemia due to Capnocytophaga canimorsus, a normal oral and nasal flora inhabitant of cats and dogs that can cause severe and sometimes fatal septicemia in humans. We report this very interesting case because of the common prevalence of dog homeownership and the rarity of C. canimorsus inducing sepsis.

Early mobilization in critically ill patients: patients' mobilization level depends on health care provider's profession.

OBJECTIVE: To evaluate whether the level of mobilization achieved and the barriers for progressing to the next mobilization level differ between nurses and physical therapists. DESIGN: Prospective, observational study. SETTING: Twenty-bed surgical intensive care unit (SICU) of the Massachusetts General Hospital. PARTICIPANTS: Sixty-three critically ill patients. METHODS: Physical therapists and nurses performed 179 mobilization therapies with 63 patients. OUTCOME MEASUREMENT: Mobilization was defined as the process of enhancing mobility in the SICU, including bed mobility, edge of bed activities, transfers out of bed to a chair, and gait training; the mobilization level was measured on the SICU optimal mobilization scale, a 5-point (0-4) numerical rating scale. RESULTS: Patients' level of mobilization achieved by physical therapists was significantly higher compared with that achieved by nurses (2.3 ± 1.2 mean ± SD versus 1.2 ± 1.2, respectively P < .0001). Different barriers for mobilization were identified by physical therapists and nurses: hemodynamic instability (26% versus 12%, P = .03) and renal replacement therapy (12% versus 1%, P = .03) were barriers rated higher by nurses, whereas neurologic impairment was rated higher by physical therapists providers (18% versus 38%, P = .002). No mobilization-associated adverse events were observed in this study. CONCLUSIONS: This study showed that physical therapists mobilize their critically ill patients to higher levels compared with nurses. Nurse and physical therapists identify different barriers for mobilization. Routine involvement of physical therapists in directing mobilization treatment may promote early mobilization of critically ill patients.