ICU 机械通气患者的早期积极活动
Early Active Mobilization during Mechanical Ventilation in the ICU.
机构信息
From the Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine (C.L.H., M.B., R.B., T.B., A.M.H., A.S.N., A.D.N., J.J.P., J.S., S.W., P.J.Y.), School of Public Health and Preventive Medicine (B.J.G.), Monash University, the Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital (R.B., A.S.N.), the Department of Critical Care (C.L.H., R.B., A.S.N., J.J.P., P.J.Y.) and the School of Medicine (J.J.P.), University of Melbourne, the Department of Intensive Care (A.D.N.) and the Intensive Care Unit and Physiotherapy Department (C.L.H., C.J.T.), Alfred Hospital, and the Department of Intensive Care, Royal Melbourne Hospital (R.B., J.J.P.), Melbourne, VIC, the Critical Care Division, the George Institute for Global Health (C.L.H., A.M.H.), and Intensive Care Services, Royal Prince Alfred Hospital (H.B.), Sydney, the Curtin School of Allied Health, Curtin University, Bentley, WA (M.H.), and the Department of Physiotherapy, Royal Perth Hospital (M.H.), and the Intensive Care Unit, St. John of God Subiaco Hospital (S.W.), Perth, WA - all in Australia; the Intensive Care Unit, Wellington Hospital (P.J.Y.), and the Medical Research Institute of New Zealand (S.H., P.J.Y.) - both in Wellington, New Zealand; the Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, and the Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin - both in Germany (S.J.S); the Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor (T.J.I.); the Department of Medicine Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore (T.J.I.); the Clinical Trials Unit, Intensive Care National Audit and Research Centre, London (D.W.G.); the Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo (A.S.N.); and University College Dublin-Clinical Research Centre at St. Vincent's University Hospital, Dublin (K.B., A.D.N.).
出版信息
N Engl J Med. 2022 Nov 10;387(19):1747-1758. doi: 10.1056/NEJMoa2209083. Epub 2022 Oct 26.
BACKGROUND
Intensive care unit (ICU)-acquired weakness often develops in patients who are undergoing invasive mechanical ventilation. Early active mobilization may mitigate ICU-acquired weakness, increase survival, and reduce disability.
METHODS
We randomly assigned 750 adult patients in the ICU who were undergoing invasive mechanical ventilation to receive increased early mobilization (sedation minimization and daily physiotherapy) or usual care (the level of mobilization that was normally provided in each ICU). The primary outcome was the number of days that the patients were alive and out of the hospital at 180 days after randomization.
RESULTS
The median number of days that patients were alive and out of the hospital was 143 (interquartile range, 21 to 161) in the early-mobilization group and 145 days (interquartile range, 51 to 164) in the usual-care group (absolute difference, -2.0 days; 95% confidence interval [CI], -10 to 6; P = 0.62). The mean (±SD) daily duration of active mobilization was 20.8±14.6 minutes and 8.8±9.0 minutes in the two groups, respectively (difference, 12.0 minutes per day; 95% CI, 10.4 to 13.6). A total of 77% of the patients in both groups were able to stand by a median interval of 3 days and 5 days, respectively (difference, -2 days; 95% CI, -3.4 to -0.6). By day 180, death had occurred in 22.5% of the patients in the early-mobilization group and in 19.5% of those in the usual-care group (odds ratio, 1.15; 95% CI, 0.81 to 1.65). Among survivors, quality of life, activities of daily living, disability, cognitive function, and psychological function were similar in the two groups. Serious adverse events were reported in 7 patients in the early-mobilization group and in 1 patient in the usual-care group. Adverse events that were potentially due to mobilization (arrhythmias, altered blood pressure, and desaturation) were reported in 34 of 371 patients (9.2%) in the early-mobilization group and in 15 of 370 patients (4.1%) in the usual-care group (P = 0.005).
CONCLUSIONS
Among adults undergoing mechanical ventilation in the ICU, an increase in early active mobilization did not result in a significantly greater number of days that patients were alive and out of the hospital than did the usual level of mobilization in the ICU. The intervention was associated with increased adverse events. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; TEAM ClinicalTrials.gov number, NCT03133377.).
背景
在接受有创机械通气的患者中，经常会出现重症加强治疗病房（ICU）获得性肌无力。早期积极的活动可能会减轻 ICU 获得性肌无力，提高生存率，并降低残疾程度。
方法
我们随机分配了 750 名正在接受有创机械通气的 ICU 中的成年患者，分别接受增加的早期活动（镇静最小化和每日物理治疗）或常规护理（每个 ICU 通常提供的活动水平）。主要结局是随机分组后 180 天时患者存活且出院的天数。
结果
早期活动组中，患者存活且出院的中位数天数为 143 天（四分位距，21 至 161 天），常规护理组为 145 天（四分位距，51 至 164 天）（绝对差值，-2.0 天；95%置信区间 [CI]，-10 至 6；P=0.62）。两组中患者平均（±SD）每日主动活动时间分别为 20.8±14.6 分钟和 8.8±9.0 分钟（差异为每天 12.0 分钟；95%CI，10.4 至 13.6）。两组分别有 77%的患者在中位数间隔 3 天和 5 天可以站立（差异，-2 天；95%CI，-3.4 至 -0.6）。到第 180 天，早期活动组有 22.5%的患者死亡，常规护理组有 19.5%的患者死亡（比值比，1.15；95%CI，0.81 至 1.65）。在幸存者中，两组的生活质量、日常生活活动、残疾、认知功能和心理功能相似。早期活动组有 7 名患者和常规护理组有 1 名患者报告了严重不良事件。早期活动组有 34 名（9.2%）患者和常规护理组有 15 名（4.1%）患者报告了可能与活动相关的不良事件（心律失常、血压变化和血氧饱和度下降）（P=0.005）。
结论
在 ICU 中接受机械通气的成年人中，与 ICU 常规活动水平相比，增加早期主动活动并没有显著增加患者存活且出院的天数。该干预措施与不良事件增加有关。（由澳大利亚国家卫生和医学研究委员会以及新西兰健康研究委员会资助；TEAM 临床试验.gov 编号，NCT03133377。）
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