Rehabilitation of Patients From the ICU to the Post-hospital Phase

Not Applicable

Not yet recruiting

• Conditions: Early Mobilization; Rehabilitation; Physiotherapy
• Interventions: Other: Early and intensive mobilization protocol at the ICU and Rehabilitation post-hospital discharge

• Registration Number: NCT06405529
• Lead Sponsor: University of Sao Paulo

Brief Summary

Introduction: Advances in knowledge have contributed to the increase in the number of patients who survive prolonged hospitalization in an Intensive Care Unit (ICU), and, among them, critically ill patients who develop acute respiratory failure and need for mechanical ventilation. These individuals have their mobility restricted to bed, and may suffer from pulmonary and systemic complications, such as ICU-Acquired Muscle Weakness, which increases the chances of resulting in reduced functional capacity or death. Early mobilization in the ICU has demonstrated benefits, but still with a low level of evidence. However, the type and intensity of exercise still need to be better defined, and previous protocols did not offer continuous monitoring from the ICU to the ward and subsequent outpatient rehabilitation for these patients, which is considered a limitation in some studies.

Objective: To investigate the effects of an early and intensive hospital mobilization and post-hospital rehabilitation program on indicators of functionality, inflammation, cost-effectiveness, and mortality in critically ill patients undergoing invasive mechanical ventilation.

Methods: This is a Blind Randomized Controlled Clinical Trial that will be conducted in the ICUs of the Hospital das Clinicas and the Emergency Unit of the Faculty of Medicine of Ribeirao Preto of the University of São Paulo. Patients of both sexes over 21 years of age who have been under invasive mechanical ventilation for at least 24 hours will be recruited. Patients will be randomized into the Intervention Group (IG), with 30 to 60 minutes of exercise per day, and the Control Group (CG), with 10 minutes of exercise per day, both with the same protocol and based on the ICU Mobility Scale - IMS, with continuity in the ward. After hospital discharge, participants will be allocated to the Guidance Group (GIor and GCor) and the Outpatient Rehabilitation Group (GIreab and GCreab), with functional exercise capacity as the main outcome, assessed by the six-minute walk test (6MWT). Volunteers will be monitored one, three, and six months after hospital discharge. The sample calculation was based on the results of the 6MWT , with a power of 80% for the assessments carried out at the proposing institution (n=206), and with a power of 90% for the multicenter project (n=275), considering a sample loss of 30%. The following will be evaluated: clinical parameters, severity indexes, functionality, lung function and mechanics, functional exercise capacity, mortality, inflammatory markers, energy expenditure, activities of daily living, quality of life, muscle assessment, adherence, barriers and facilitators and cost-effectiveness.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2024-01-07
• Status Verified: 2024-05
• Study First Submitted QC: 2024-05-06
• Last Update Submitted: 2024-05-06
• Study First Posted: 2024-05-08
• Last Update Posted: 2024-05-08
• Study Start: 2024-07-01
• Primary Completion: 2025-01-31
• Study Completion: 2027-01-31

Recruitment & Eligibility

• Status: NOT_YET_RECRUITING
• Sex: All
• Target Recruitment: 206

Inclusion Criteria

• Both sexes

• Age greater than or equal to 21 years

• Be on invasive mechanical ventilation (IMV) for at least 48 hours

• Sufficient cardiovascular stability for mobilization

  1. Absence of bradyarrhythmia (< 50 bpm);
  2. Heart rate ≥ 150 bpm;
  3. Most recent lactate measurement ≤ 4.0mmol/L;
  4. Combined adrenaline/noradrenaline infusion rate ≤ 0.2mcg/Kg/min, OR if the adrenaline/noradrenaline infusion was increased by more than 25% in the last 6 hours;
  5. Cardiac index ≥ 2.0L/min/m2; when evaluated

• Respiratory stability sufficient for mobilization f) Respiratory rate ≤ 45rpm; g) FiO2 ≤ 0.6; h) PEEP ≤ 16 cmH2O; i) No need for NO (nitric oxide), prone position, neuromuscular blocker, ECMO (extracorporeal membrane oxygenation) or HFOV (high frequency ventilation).

Read More

Exclusion Criteria

• Dependent for ADLs in the month prior to ICU admission;
• Diagnosed cognitive deficit;
• Diagnosis OR suspicion of acute primary brain disease (TBI, stroke);
• Diagnosis OR suspected spinal cord injury OR other neuromuscular disease that may result in prolonged or permanent muscle weakness (except muscle weakness acquired in the ICU);
• Need OR instructions to remain in bed OR not to bear weight on the lower limbs bilaterally;
• Life expectancy of less than 180 days due to acute or chronic clinical conditions;
• Death considered inevitable due to current clinical condition or if the patient/clinical guardian is not committed to complete active treatment (e.g. brain death);
• Inability to communicate in Portuguese;
• Readmission to the ICU of the same hospital service;
• Pregnant women;
• Patients with a permanent pacemaker.

Read More

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Rehabilitation Group	Early and intensive mobilization protocol at the ICU and Rehabilitation post-hospital discharge	After hospital discharge, this group will participate in a supervised exercise program twice a week for 8 weeks at the Rehabilitation Center.
Intervention Group	Early and intensive mobilization protocol at the ICU and Rehabilitation post-hospital discharge	During hospitalization in the ICU and ward, this group will perform 30 to 60 minutes of exercises per day, according to the IMS scale and the intensive mobilization protocol.

Primary Outcome Measures

Name	Time	Method
Functional exercise capacity	Through study completion, an average of 5 year	Assessed by the 6-minute walk test

Secondary Outcome Measures

Name	Time	Method
Pulmonary function	Through study completion, an average of 5 year	Computed tomography (CT). The high-resolution CT technique with low dose of radiation will be used, without the administration of iodinated contrast medium, scanning the entire chest in the caudocranial direction, with volumetric acquisition of 1 mm in thickness during complete inspiration. Quantitative analysis of HRCT images will be performed using the scientific program Yacta version 2.8 (Heussel et al., 2009).
Cost-effectiveness	12 months after study completion	Economic evaluation - Patient and Institution costs
Mortality	Through study completion, an average of 5 year
Clinical parameters	Through study completion, an average of 5 year	Time on mechanical ventilation (tMV)
Severity indexes	Through study completion, an average of 5 year	Sequential Organ Failure Assessment Score (SOFA Score). This tool calculates both the number and severity of organic dysfunction in six organic systems (respiratory, coagulation, hepatic, cardiovascular, renal and neurological).