Comment on Early versus delayed mobilization for in-hospital mortality and health-related quality of life among critically ill patients: a systematic review and meta-analysis (Okada et al., Journal of Intensive Care 2019)

Abstract

Critical comment on the review by Okada et al. on the effect of early versus delayed mobilization because of their definition of early mobilization as mobilization within a week of ICU admission in contrast to current evidence.

Comment

In their systematic review and meta-analysis, Okada et al. investigate the impact of early versus delayed mobilization for in-hospital mortality and health-related quality of life among critically ill patients, including 11 studies in their meta-analysis [1]. They compared randomized controlled trials (RCTs) starting mobilization within 1 week of ICU admission to those initiating mobilization later than 1 week.

Aware that there is no uniform definition of “early mobilization” in the ICU yet, to use 1 week as cut-off point seems unreasonable for various reasons. So far, only studies starting early mobilization within 72 h have been able to improve patient outcomes, as summarized in published narrative reviews [2] with adoption in practice guidelines [3]. Schweickert et al. applied physical therapy and interruption of sedation within 72 h of ICU admission causing higher independent functionality at hospital discharge, shorter duration of delirium, and more ventilator-free days [4]. In another single-center RCT, the effect of standardized rehabilitation therapy in patients with acute respiratory failure leads to functional results at 6 months after hospital discharge [5]. [6]. And the just published study of an early mobility program started within 48 h confirmed improvement in function and increased functional independence [6]. In contrast, studies starting mobilization later had no beneficial effect [2].

Another current meta-analysis using different definitions was able to show an effect of early mobilization [7]. Finally, Ding et al. showed in their network meta-analysis that initiation of mobilization within 48–72 h in mechanical ventilation patients may be optimal to improve intensive care unit-acquired weakness [8].

In conclusion, as timing seems crucial for patient-centered outcomes, early mobilization should be consistently defined as mobilization within 72 h of ICU admission.