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• W2892843899 abstract "See related article, p 25 See related article, p 25 “It means a great deal…to be put on their own feet in a short time, rather than be confined to bed, having their weak backs and general debility increase rather than disappear after the operation which was to cure them.”—Dr Emil Ries, JAMA 18991Ries E. Some radical changes in the after-treatment of celiotomy cases.J Am Med Assoc. 1899; XXXIII: 454-456Crossref Scopus (19) Google Scholar The concept of early mobilization is not new—it was introduced more than a century ago. An editorial in JAMA written 4 decades after Dr Ries's first report discussed the benefits of “early rising” after surgery, including the “a more rapid return to normal strength and activity and a better outlook and morale in the patient”.2Ashkins J. Early rising after surgical operations.N Engl J Med. 1945; 233: 33-37Crossref Google Scholar As early as 1944, a controlled clinical trial to test the effectiveness of early mobilization after major surgery found less surgical and organ-specific complications in the group that sat in a chair and walked on the day after surgery compared with bedrest for 10-15 days.3Hashem M.D. Nelliot A. Needham D.M. Early mobilization and rehabilitation in the ICU: moving back to the future.Respir Care. 2016; 61: 971-979Crossref PubMed Scopus (50) Google Scholar, 4Powers J.H. The abuse of rest as a therapeutic measure in surgery: early postoperative activity and rehabilitation.J Am Med Assoc. 1944; 125: 1079Crossref Scopus (15) Google Scholar Early rising after major surgery became a popular dialogue in the 1940s, with “the evil sequelae” and “abuse” of bedrest being commonly discussed and documented,5Dock W. The evil sequelae of complete bed rest.J Am Med Assoc. 1944; 125: 1083-1085Crossref Scopus (85) Google Scholar, 6Ghormley R.K. The abuse of rest in bed in orthopedic surgery.J Am Med Assoc. 1944; 125: 1085-1087Crossref Scopus (4) Google Scholar and even an entire conference dedicated to the topic.7Keys A. Introduction to the symposium on convalescence and rehabilitation.Federation Proc. 1944; 3: 189Google Scholar In the intensive care unit (ICU), however, a primary focus on resuscitation and maintaining physiologic stability propagated the notion that bedrest could minimize metabolic demand and facilitate healing and recovery. That approach, compounded by the use of continuous sedative infusions and neuromuscular blockade to ensure patient safety and amnesia, led to an ICU culture of immobility. In 1998, Petty compared his rounds in the ICU with those at the start of his career in 1964 and was troubled by the patients who were “sedated and lying without motion, appearing to be dead, except for the monitors that tell me otherwise.”8Petty T.L. Suspended life or extending death?.Chest. 1998; 114: 360-361Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Fast-forward 20 years and the pendulum is still swinging. There is burgeoning research on the impact of early mobilization in critically ill adults, including strategies for decreasing the risk of postintensive care syndrome.9Needham D.M. Davidson J. Cohen H. Hopkins R.O. Weinert C. Wunsch H. et al.Improving long-term outcomes after discharge from intensive care unit: report from a stakeholdersʼ conference.Crit Care Med. 2012; 40: 502-509Crossref PubMed Scopus (1304) Google Scholar, 10Tipping C.J. Harrold M. Holland A. Romero L. Nisbet T. Hodgson C.L. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review.Intensive Care Med. 2017; 43: 171-183Crossref PubMed Scopus (277) Google Scholar Although awareness about the benefits of early mobilization has increased, so too has the knowledge that optimizing mobility requires modifying our approach to other aspects of care, including choice of sedation, sleep hygiene, and recognition of delirium.11Hopkins R.O. Choong K. Zebuhr C.A. Kudchadkar S.R. Transforming PICU culture to facilitate early rehabilitation.J Pediatr Intensive Care. 2015; 4: 204-211Crossref PubMed Google Scholar, 12Devlin J.W. Skrobik Y. Gélinas C. Needham D.M. Slooter A.J.C. Pandharipande P.P. et al.Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.Crit Care Med. 2018; 46: e825-e873Crossref PubMed Scopus (1276) Google Scholar As such, the Society of Critical Care Medicine (SCCM) has forged an “ICU Liberation” Collaborative, of which the core is the “ABCDEF” bundle.13Ely E.W. The ABCDEF bundle: science and philosophy of how ICU liberation serves patients and families.Crit Care Med. 2017; 45: 321-330Crossref PubMed Scopus (222) Google Scholar This multifaceted approach to improving outcomes in survivors of critical illness incorporates these important elements into routine ICU care: “A,” Assessment of pain; “B,” Both spontaneous awakening and breathing trials; “C,” Choice of sedation and analgesia; “D,” Delirium monitoring and management; “E,” Early mobility and exercise; and “F,” Family engagement. Of specific interest to us in pediatrics, 10% of the 76 ICUs participating in the SCCM Collaborative were pediatric intensive care units (PICUs). In this volume of The Journal, Cuello-Garcia et al report their systematic review of early mobilization in critically ill children.14Cuello-Garcia C.A. Chuen S.H. Simpson R. Al-Harbi S. Choong K. Early mobilization in the critically ill children: a systemic review.J Pediatr. 2018; 203: 25-33Scopus (36) Google Scholar After screening 1199 abstracts, the authors identified 11 studies and 1 clinical practice guideline focused on early mobilization in the PICU setting. The studies encompassed 2 pilot randomized controlled trials, with the remaining studies encompassing prospective studies, before–after studies, and retrospective cohort studies. The authors divided the review into 3 categories: (1) definition; (2) safety and feasibility; and (3) efficacy. With regard to defining early mobility, they found there was marked variability in the definition of both the terms “early” and “mobilization.” Contraindications to mobilization across studies often included cardiorespiratory instability; however, the threshold for what constituted “instability” was not consistently defined. Eleven of the studies demonstrated the common theme that early mobilization was safe with no increase in adverse events and was feasible when the appropriate resources and support from the care team were available. Across the board, the implementation of early-mobilization programs led to an increase in the frequency of rehabilitation consults and reduced time to mobilization. However, the authors report that efficacy outcomes, including duration of mechanical ventilation, length of stay, and morbidities, were most often chosen as secondary endpoints and that the certainty of this evidence was low. The authors conclude that current evidence suggests interdisciplinary collaboration to increase mobilization is feasible. However, they state the challenges of ongoing patient, family, and resource barriers in combination and a lack of efficacy outcomes as areas of needed attention. Cuello-Garcia et al are to be congratulated for synthesizing the available data on an important and timely area in pediatric critical care. Particularly helpful is the comprehensive listing of excluded studies in the supplemental content, which provides the reader with an overview of the breadth of literature surrounding the topic of acute rehabilitation in children. The authors have included 4 abstracts in the 11 studies discussed, which highlights the limited amount of evidence available to meet the author's criteria for inclusion. It is also notable that 5 of the 11 included studies were conducted by the senior author of the systematic review, suggesting that at the present time, research in PICU early mobilization is still in its infancy, with a small pool of engaged investigators. However, that pool is growing, with new publications focused on quality-improvement initiatives and establishment of medical criteria for PICU mobilization.15Van Damme D. Flori H. Owens T. Development of medical criteria for mobilizing a pediatric patient in the PICU.Crit Care Nurs Q. 2018; 41: 323-329Crossref PubMed Scopus (4) Google Scholar, 16Betters K.A. Hebbar K.B. Farthing D. Griego B. Easley T. Turman H. et al.Development and implementation of an early mobility program for mechanically ventilated pediatric patients.J Crit Care. 2017; 41: 303-308Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar It is important to point out that this is not the first systematic review conducted on pediatric acute rehabilitation—in fact, it is the third in 4 years.17Cameron S. Ball I. Cepinskas G. Choong K. Doherty T.J. Ellis C.G. et al.Early mobilization in the critical care unit: a review of adult and pediatric literature.J Crit Care. 2015; 30: 664-672Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 18Wieczorek B. Burke C. Al-Harbi A. Kudchadkar S.R. Early mobilization in the pediatric intensive care unit: a systematic review.J Pediatr Intensive Care. 2015; 2015: 129-170PubMed Google Scholar The take-home from all of these reviews has been consistent—it's time to study the outcomes. Early mobilization in the PICU is safe and feasible when approached systematically. However, we still don't know how it changes the short- and long-term trajectory of pediatric survivors of critical illness. This aspect is critically important, given the current landscape of pediatric critical care, where decreased mortality has been exchanged for increased short- and long-term morbidities.19Heneghan J.A. Pollack M.M. Morbidity.Pediatr Clin North Am. 2017; 64: 1147-1165Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar We also have not determined the optimal timing, dose, or duration of rehabilitation interventions in critically ill children. How much is too much? Or too often? Is there a threshold where the risk–benefit actually weighs heavier toward risk? There are few places in the hospital that rival the heterogeneity of the PICU, where the same nurse may be assigned to care for a 1-month-old cardiac surgery patient and a 17-year-old patient with diabetic ketoacidosis during the same shift. That same variability poses unique challenges for transdisciplinary rehabilitation research, including the need for both age- and size-specific equipment and standard pediatric tools for evaluating functional outcomes across the age and developmental spectrum. Indeed, a lack of efficacy data makes it difficult to overcome the inertia of PICU immobility culture. However, the promising effects of early mobilization in adults should be the impetus for large-scale pediatric studies evaluating not only its efficacy but the mechanisms by which early mobilization makes a difference. The opportunities for discovery as a pediatric critical care community are expansive. Data on the baseline acute rehabilitation practices in PICUs internationally will likely illuminate specific areas for targeted research.20PARK-PICU Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU) [Internet].https://park.web.jhu.eduDate: 2018Google Scholar Building on the ABCDEF bundle, we are learning that optimizing sedation, integrating sleep promotion, and preventing delirium go hand in hand with creating healing environments for infants and children too,21Simone S. Edwards S. Lardieri A. Walker L.K. Graciano A.L. Kishk O.A. et al.Implementation of an ICU bundle: an interprofessional quality improvement project to enhance delirium management and monitor delirium prevalence in a single PICU.Pediatr Crit Care Med. 2017; 18: 531-540Crossref PubMed Scopus (59) Google Scholar, 22Kudchadkar S.R. Shata N. Aljohani O.A. Alharbi A. Jastaniah E. Nadkarni A. et al.Day-night activity rhythms are disrupted in children admitted to the pediatric ICU after major surgery.Am J Respir Crit Care Med. 2016; 193: A3096Google Scholar, 23Kawai Y., Weatherhead J.R., Traube C., Owens T.A., Shaw B.E., Fraser E.J., et al. Quality improvement initiative to reduce pediatric intensive care unit noise pollution with the use of a pediatric delirium bundle. J Intensive Care Med, in press.Google Scholar and the SCCM Pediatric Collaborative data are forthcoming. We are investigating ICU-acquired weakness in children and modalities for monitoring and diagnosis,24Valla F.V. Young D.K. Rabilloud M. Periasami U. John M. Baudin F. et al.Thigh ultrasound monitoring identifies decreases in quadriceps femoris thickness as a frequent observation in critically ill children.Pediatr Crit Care Med. 2017; 18: e339-e347Crossref PubMed Scopus (25) Google Scholar, 25Glau C.L. Conlon T.W. Himebauch A.S. Yehya N. Weiss S.L. Berg R.A. et al.Progressive diaphragm atrophy in pediatric acute respiratory failure.Pediatr Crit Care Med. 2018; 19: 406-411Crossref PubMed Scopus (45) Google Scholar, 26Williams S. Horrocks I.A. Ouvrier R.A. Gillis J. Ryan M.M. Critical illness polyneuropathy and myopathy in pediatric intensive care: a review.Pediatr Crit Care Med. 2007; 8: 18-22Crossref PubMed Scopus (63) Google Scholar and have established the PICU framework for postintensive care syndrome.27Manning J.C. Pinto N.P. Rennick J.E. Colville G. Curley M.A.Q. Conceptualizing post intensive care syndrome in children—the PICS-p framework.Pediatr Crit Care Med. 2018; 19: 298-300Crossref PubMed Scopus (158) Google Scholar It is crucial to establish the safety and feasibility of early mobilization in the PICU setting. Now we need to focus not on the “if” but instead sharpen our focus on the “how” and “why.” How should we approach it? Why does it work? Why should we do it? How does it improve outcomes? It's time to move on. Early Mobilization in Critically Ill Children: A Systematic ReviewThe Journal of PediatricsVol. 203PreviewTo characterize how early mobilization is defined in the published literature and describe the evidence on safety and efficacy on early mobilization in critically ill children. Full-Text PDF" @default.
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• W2892843899 title "Early Mobility in the Pediatric Intensive Care Unit: Can We Move On?" @default.
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