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


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

In This Article

Future of ICU Mobilization: Robotics and Virtual Reality

Staff shortages, risk of injury for staff when supporting the patient, and fatigue in the critically ill have been named as a reason for the lack of mobilization in the ICU.[67] All of these might be reduced or eliminated if out-of-bed mobilization were supported by an exoskeleton. These systems not only reduce the burden on the staff but also allow for a gradual and patient-tailored regimen, possibly enabling earlier mobilization, as well as increasing mobilization time and distance. Research regarding ambulatory support and gait training with exoskeletons have thus far focused on patients with spinal cord injury.[88] In this patient cohort, exoskeletons have been shown to be overall feasible with minor adverse events, such as low-grade pressure ulcers.[89] The first investigations show promising data on improved gait function after completing an 8-week exoskeleton-based rehabilitation protocol.[89] The use of such devices in the ICU setting has not yet been investigated, and pilot-projects will shed more light on its feasibility, and effectiveness. Exoskeletons can only be used in patients that are sufficiently stable to be mobilized out of the bed, and although the risk of injury to the staff is reduced, it does not eliminate the need for additional staff during the mobilization periods, especially if the patient is dependent on additional devices, such as a ventilator. Nevertheless, mobilization during the early phase of the disease trajectory, as outlined above, is of key importance.

Patients in an ICU spend most of their day in bed, often 24 hours per day during the early phase of treatment. It would therefore be highly practicable to incorporate the bed into the mobilization routine. There are startup projects working on robotic ICU beds that are able to bring the patient to a standing position, without leaving the safety of the bed. The patient can then perform patient-tailored, robot-assisted leg-movement therapy, requiring a single caregiver for preparation and conduction of the entire mobilization protocol. This has the potential to reduce staff requirements and risk for staff members, provide individualized support for the patients, and possibly increased mobilization time. Thus far, there are no clinical trial results regarding the feasibility and effectiveness of these ICU beds, so it remains uncertain whether these theoretical benefits will be observed during the practical application, and what effects it will have on the short- and long-term outcome of these patients.

Motivation is also a key component of successful mobilization in the ICU. Lack of motivation has been often described as a barrier for rehabilitation in general, for example, in stroke patients.[67,90] Rehabilitation programs are repetitive in nature, and often perceived as dull, leading to effort reduction, and increased drop-out rates. After the initial release of virtual reality entertainment by the gaming industry, a swift transition into the medical field followed. It has since then been investigated in multiple cohorts and shown promising results for children with cerebral palsy, as well as stroke patients.[91,92] A initial concern regarding feasibility in older adults, who better reflect the patient cohort on ICUs, could be disproven by Huygelier et al, who showed that the attitude toward virtual reality was initially neutral but increased with a first positive experience, and furthermore that cybersickeness was not a relevant issue.[93] Gerber and colleagues showed that virtual reality itself is feasible in the ICU and decreases markers of physical stress, such as heart rate and systolic blood pressure.[94] So far, early mobilization and rehabilitation of patients with critical illness have not been investigated in conjunction with virtual reality. A pilot observation of virtual reality augmented robot-assisted gait training in patients with subacute stroke shows that the augmentation with virtual reality reduces drop-out rates, increases the time spent performing robot-assisted gait training, and improves motivation.[95] Supplementing active movement exercise or in-bed cycling during the intensive care unit stay with virtual reality might, therefore, not only improve the critically-ill patients' rehabilitation experience, but might also increase the motivation and effort, decrease the drop-out rates and ultimately lead to a beneficial impact on patient outcome.