Sigfredo Aldarondo, MD, FCCP
 REST…
“In every movement, whenever one begins to endure
pain, it will be relieved by rest.”
- Hippocrates
460-371 BC
 REST…
John Hunter: “…the most powerful aid which the
surgeon could bring to disordered tissue…”
Hugh Owen Thomas: “…rest must be enforced,
uninterrupted, and prolonged.”
Until app 1939, - 10-14 days bed rest confirmed after
“major” operations, e.g.,
· appendectomy
· cholecystectomy
“It is sometimes argued that early rising is undesirable
for the tired housewife who needs nothing so much as
a good rest in bed.”
“Industry need not wish,” as Poor Richard says, and
“he that lives upon hope will die fasting. There are no
gains without pains….”
The Way to Health
Benjamin Franklin
“No pain, no gain.”
- Jane Fonda
1982

Physiologic impact of prolonged rest and
exercise in healthy subjects
◦ Muscle atrophy begins within hours of
immobilization
◦ 4-5% drop in muscle strength per week of bed rest
◦ Worse in elderly – greater loss of lean body mass
◦ Worse in critical illness
Physical Exercise
Rest / Obesity
Skeletal muscle contraction
Adipocytes
↓
Myokines
↓
↑
IL-6
↑
TNFInsulin Resistance
Modulate cytokine production
(IL-6)
↓
Anti-inflammation
(↓TNF-X)
Dyslipidemia
HTN
Inflammation

Critical Illness
◦ Acute decompensation
◦ Major physiology
derangement
◦ Organ dysfunction
◦ Need for therapeutic
interventions
◦ Obligated immobility
Critical Care – Goal
“Restoration of physiological or hemodynamic stability
and prevention of death.”
-Adler, CPT, March ‘12

◦ Improved “Survival”
◦ Survivors
Severe muscle weakness
Functional impairment
Loss of quality of life
“…The answer my friend, is blowing in the wind….”
- Bob Dylan
1962

Critical Illness and Necessary Immobilization
1) Mechanical ventilation
2) Post-op care
3) Hemodynamic Instability / Reduction of O₂
consumption
4) Need for profound analgesia / sedation /
therapeutic coma/ hypothermia
 Dynamic
Nature of Critical Care
◦ Critical Care
Recovery

Impact of Immobility – Short Term
◦ ICU-acquired weakness
◦ Increased duration of mechanical ventilation
◦ Increased ICU LOS/Cost
◦ Increased morbidity / mortality

Immobility and Critical Illness of the ICU StayThe aftermath:
◦ Mortality
◦ Weakness
◦ Functional Impairment
◦ Neurocognitive Dysfunction

NEJM: One year outcome
◦ 109 survivors of ARDS evaluated at 3, 6, 12 months
 At discharge from the ICU – 18% drop in BW; 71% returned to
baseline in 1 year.
 6% persistent pulmonary morbidity after one year
 Majority had persistent functional limitations and residual
weakness after 12 months
 49% had returned to work.

Aftermath: Neurocognitive impairment
◦ ARDS ~ 80% survivors with impaired memory, attention,
concentration , declined processing speed
◦ 25% mild cognitive impairment at 6 years
◦ 33% impaired neurophysiological testing at 6 months
 Decreased QOL
 Including depression
CCM 2003, Vol 3
Jackson, et al.

ICU – Acquired Weakness – 25-100% Prevalence
◦ Polyneuropathy
◦ Myopathy
 More common
 Higher rate of recovery

ICU Acquired Weakness: Pathophysiology
◦ Dysfunctional microcirculation → neuronal injury/axonal
degeneration
◦ Hyperglycemia → ? Neural mitochondrial dysfunction
◦ Inactivation of sodium channels
◦ Catabolic state
◦ Mitochondrial dysfunction
◦ Systemic inflammation
◦ Oxidative Stress
◦ Mechanical ventilation – diaphragmatic weakness
◦ Muscle inactivity

ICU – Acquired Weakness: Pathophysiology
…Muscle inactivity immobility –
common denominator, compounding all causes
…Need to curtail immobility…
“Less is better”

Sedation in Critical Illness
◦ Indications:
 Allow or facilitate mechanical ventilation
 Improve analgesics
 Patient comfort, decrease anxiety
 ICU staff comfort, decrease anxiety

Sedation In Critical Illness - Variables:
◦ Type
◦ Intermittent vs. continuous infusion
◦ Targeted sedation

Sedation in Critical Illness
◦ Intermittent
◦ Continuous
 Limited ability to
examine patient
 Independent
predictor of longer
mechanical ventilation

Sedation and Critical Care
◦ Important modifiable risk factor for delirium in the
ICU
 Increased mortality
 Increased long-lasting neurocognitive impairment
Stigma of
Critical Illness

“Stigma” of Critical Illness
◦ 6% 135 ICU survivors received physical therapy
◦ Over 24hr/day, 7-day/week; stable mechanically ventilated
patients
 30% - No PT
 55% - Only ROM
◦ 11 ICU’s / 3 Teaching Hospitals, 150 patients with ALI
 27% received physical therapy
 6% of all ICU days

ICU – Acquired Weakness: Early Mobility
◦ Safety concerns – Negligible adverse effects
◦ Outcomes
 Improved functional mobility
 Decreased vent days
 Decreased ICU LOS
 Improved QOL, neurocognitive function

ICU – Acquired Weakness / Ingredients of Early
Morbidity
1) Mobility Team
2) Dedicated Unit
3) Restricted sedation
4) ICU culture change to recovery & rehabilitation

Bed Rest

Bed Rest Confinement