Innovative ICU Solutions to Prevent and Reduce Delirium and Post–Intensive Care Unit Syndrome

Alawi Luetz, MD, PhD; Julius J. Grunow; Rudolf Mörgeli, MD; Max Rosenthal, MD, PhD; Steffen Weber-Carstens, MD, PhD; Bjoern Weiss; Claudia Spies, MD, PhD

Disclosures

Semin Respir Crit Care Med. 2019;40(5):673-686. 

In This Article

Active Mobilization in Unconscious Patients

Particularly during the early stages of the disease trajectory, at the onset of pathophysiological mechanisms, physiotherapy plays a crucial role in preventing physical impairments.[68,69] While sedation and weakness can hinder voluntary participation, active mobilization is still possible through novel treatment modalities that aim at eliciting muscle contractions, regardless of the state of consciousness.

Neuromuscular electrical stimulation utilizes transcutaneous electrical impulses to trigger a muscle contraction via the corresponding nerve.[70] It has shown beneficial effects across a wide range of applications, such as athletics and conditions, associated with loss of muscle mass and strength (e.g., fractures, chronic heart failure, and chronic obstructive pulmonary disease).[71–73] It has been established as safe and feasible in critically-ill patients, and it has since been extensively investigated.[74] Neuromuscular electrical stimulation has been shown to prevent muscle atrophy via induction of protein synthesis, although a clinical outcome benefit has not yet been unequivocally established.[75,76] A differing contractile response to neuromuscular electrical stimulation has been hypothesized as a reason for that lack of clinical effectiveness, and future research into different protocols, as well as the underlying mechanisms, behind the postulated differing contractile response is still warranted. Functional electrical stimulation combines neuromuscular electrical stimulation and in-bed cycling, thus coupling the muscle stimulation with the corresponding movements. Since the method was established as feasible, multiple ongoing trials are underway to investigate any outcome effects (NCT03554811, NCT02214823).[77]

Whole-body vibration has also found its way into gyms in recent years, as it positively affects muscle strength and mass in healthy individuals.[78] It has furthermore been employed in the rehabilitation of patients with sarcopenia, and used for its beneficial effects in diseases, such as stroke or osteogenesis imperfecta.[79,80] An active reflex muscle contraction, namely, tonic vibration reflex, is elicited by whole-body vibration through activation of muscle spindles, rendering it as a suitable method for sedated patients, as no active participation is required.[81,82] Furthermore, there is evidence that whole-body vibration suppresses muscle degrading pathways involved in the development of intensive care unit–acquired weakness.[69,83] First investigations of whole-body vibration in critically-ill patients show that its application is safe and feasible, eliciting an increased energy expenditure suggestive of active muscle work.[84] Future research is necessary to refine protocols and investigate potential outcome benefits. There is currently one ongoing trial that aims to investigate a new vibration device in critically-ill patients and establish the optimal stimulation parameters in critically-ill patients (NCT03479008).

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