Mobile, awake and critically ill

[Clavet] and colleagues showed that more than one-third of patients with a prolonged stay of 2 or more weeks in an intensive care unit (ICU) each had at least 2 functionally significant joint contractures. Furthermore, at the time of hospital discharge, 1 in 4 patients had contractures that were still present and disrupted their daily activities. The major risk factor for the development of contractures was length of ICU stay, and the odds of acquiring a contracture increased markedly between weeks 2 and 8 in the ICU. Despite the limitations of this retrospective cohort design, including chart-derived data, a single study centre and the potential for missing or absent data for other possible confounding variables, it is difficult not to be impressed by the rigor of this investigation and the magnitude of its findings. There appears to be significant potential for harm arising from the current ICU culture of patient immobility and an often excessive or unnecessary use of sedation. This is a culture that began for all the right reasons: to promote patient comfort, safety and respiratory synchrony while allowing in-tubation and mechanical ventilatory support for severe respiratory failure. But this culture has persisted despite emerging evidence that these current practices may, alone or in combination with the acute illness that precipitated the ICU admission, have important adverse consequences that may not be remediable over time. Immobility clearly plays a role in the development of contractures, and immobility is also a contributing factor to the ubiquitous finding of profound muscle wasting and weakness among patients who have long ICU stays and may contribute to their inability to regain premor-bid functional status. The current literature supports that patients in critical care settings may be mobilized without harm, even while receiving mechanical ventilation, and that wakefulness is safe and may be associated with improved neuropsychological outcomes.15-17 A recent study demonstrated how spontaneous awakening, when combined with a spontaneous breathing trial, was associated not only with a decreased duration of mechanical ventilation and ICU length of stay but also with improved survival in the first year after ICU discharge. 18 The patients in the study by Clavet and colleagues had exposure to 1.25 full-time physiotherapists, one 0.75 full-time occupational therapist and a full-time nursing staff who routinely repositioned the patients. It is not c