Early Mobilization on Continuous Renal Replacement Therapy is Safe and May Improve Filter Life
Early physical therapy interventions in critically ill patients are generally safe and improve physical functioning and patient outcomes (1–7). While the presence of vascular access catheters and the use of extracorporeal life support devices have previously been considered barriers to early physical therapy interventions in the intensive care unit (ICU), an increasing number of publications have demonstrated their safety (8–15). However, relatively few data have been reported on physical therapy interventions in the presence of continuous renal replacement therapy (CRRT), which requires both a large-bore, double-lumen central venous catheter and an extracorporeal device (16–18). Moreover, CRRT is often used in critically ill patients who demonstrate substantial hemodynamic instability with inability to tolerate traditional intermittent hemodialysis (19).
Historically, patients requiring CRRT have been restricted to bed rest or in-bed activities (16–18). There are numerous perceived risks surrounding the physical rehabilitation of patients undergoing CRRT, including hemodynamic instability, catheter dislodgement, bleeding at the catheter site, and disruption of CRRT delivery (e.g., changes in circuit pressures and/or blood flow). Given the relatively small amount of data in this area (16–18), the objective of this study was to prospectively analyze the feasibility and safety of physical therapy interventions in ICU patients undergoing CRRT. Some of the results of these studies have been reported previously in the form of an abstract (20).
Methods
Section:
Patients
This study was conducted in a medical intensive care unit (MICU) in a large tertiary care hospital setting. Data were prospectively collected over 13 months from July 1, 2013, to July 31, 2014, for all patients who received a physical therapy session while undergoing CRRT in the MICU as part of routine care. For all patients in the MICU during this time frame, we prospectively collected demographic data, MICU admission diagnosis category, living location before admission, MICU and hospital lengths of stay (LOSs), and survival to MICU discharge. For patients who received physical therapy while undergoing CRRT, we also collected the Acute Physiology and Chronic Health Evaluation II score (21) within the first 24 hours after ICU admission, as well as sedation (Richmond Agitation-Sedation Scale score [22]) and delirium (Confusion Assessment Method for the Intensive Care Unit [CAM-ICU; 23]) status on days patients performed physical therapy while receiving CRRT.
Medical stability for placing an order for physical therapy consultation was based on published criteria (24). Within 24 hours of an order for consultation, patients were evaluated by a physical therapist. Consistent with existing recommendations, physical therapists reviewed patients for medical stability before each session, including a review of trends in hemodynamics and respiratory status (24, 25). If patients did not receive a physical therapy session, the reason was prospectively recorded using the following categories: not medically appropriate; physical therapist not available; physical therapy treatment not needed; sedation; patient not available; or other. "Not medically appropriate" was coded when ICU-trained physical therapists felt that rehabilitation interventions should not occur owing to the patient's critical illness (e.g., active upward titration of vasopressors for persistent hypotension) or if MICU patients were not eligible for a physical therapy consultation owing to medical instability (24).
Physical Therapy Sessions
Before commencing therapy, the physical therapists assessed the CRRT catheter site for the presence of any preexisting bleeding or hematoma, security of the catheter (e.g., dressings and sutures intact with no signs of instability or partial removal), and catheter dysfunction (e.g., unresolved CRRT device alarms). CRRT catheters were inserted into the internal jugular, subclavian, or femoral veins. The nontunneled catheters used at our center were MAHURKAR catheters (Covidien, Mansfield, MA), and the tunneled catheters used were Palindrome (Covidien, Mansfield, MA) or HemoStar (BARD Access Systems, Salt Lake City, UT) catheters.
While patients were receiving CRRT, physical therapists provided individualized, impairment-based rehabilitation interventions. A protocol was not used for mobility; however, interventions for each patient were progressed in a stepwise fashion based on tolerance to the activity as follows: in-bed exercises (i.e., passive, active-assisted, or active range of motion in supine), supine cycle ergometry, sitting at the edge of the bed, standing, transferring to a chair, and marching in place. For example, if a patient was able to actively perform exercises in the supine position without medical instability, the therapist would progress the patient to attempt supine-to-sit transfers and so forth based on patient response and ability. Interventions could also include use of a supine cycle ergometer (MOTOmed Letto 2; RECK-Technik, Betzenweiler, Germany) for active or passive cycling based on patient strength, tolerance, and arousal. For each session, the treating physical therapist prospectively documented the patient's highest level of mobility; presence of mechanical ventilation; CRRT venous access; CRRT access/arterial, return/venous, and effluent pressures before and after the physical therapy intervention; and any potential physiological abnormalities or safety events that occurred, using preexisting definitions (6).
Data Collection
MICU physical therapists were trained in all data collection methods, including collection of real-time CRRT blood flow pressures.
The following 15 potential physiological abnormalities and safety events occurring during physical therapy were prospectively evaluated: (1) removal, dislodgement, or dysfunction of CRRT catheter or circuit; (2) bleeding at CRRT catheter site during or immediately after the session; removal, dislodgement, or dysfunction of a medical device (separately recorded for) (3) artificial airway, (4) feeding tube, (5) chest tube, (6) non-CRRT vascular access devices, (7) cardiac devices, or (8) wound/dressing; (9) hypertension or (10) hypotension requiring medical intervention or to a mean arterial pressure less than 55 or greater than 140 mm Hg; (11) oxygen desaturation requiring medical intervention or to a value less than 85%; (12) new cardiac arrhythmia; (13) cardiorespiratory arrest; (14) fall; or (15) death.
Comprehensive measures were taken to decrease the risk of error in documentation of these physiological abnormality and safety event data. These measures included (1) training for all MICU physical therapists, including training on collection of real-time CRRT blood flow pressures; (2) independent weekly review of these data by a full-time critical care rehabilitation program coordinator (E.M.) and the MICU's lead physical therapist (J.M.Z.); (3) group discussion at a weekly rehabilitation meeting with the physical therapists, program coordinator, and the medical director of the Critical Care Physical Medicine and Rehabilitation Program (D.M.N.); and (4) formal reporting and review of each documented abnormality or event at a monthly group meeting.
In addition, separate from these physiological abnormalities and safety events, the presence of CRRT device alarms during the therapy session were prospectively recorded. Due to the transient nature of the alarms, alarm types and dysfunction alerts could not feasibly be documented. At our facility, the NxStage System One CRRT device (NxStage Medical, Lawrence, MA) was used for continuous venovenous hemodialysis with the following normal pressure ranges: access/arterial pressure −50 to −200 mm Hg and return/venous and effluent pressure 20–300 mm Hg, with values outside these limits potentially leading to dysfunction or clotting of the catheter or device filter (26). Neither systemic anticoagulation (e.g., intravenous heparin) nor regional anticoagulation (e.g., citrate) was routinely used for CRRT in the MICU. Blood flow rate was 250 ml/h with dialysate flow rate typically being 20–25 ml/kg/h.
Statistical Analysis
Descriptive statistics were calculated, including count and proportion for binary or categorical variables and median and interquartile range (IQR) for continuous variables. A two-sample test of proportions was used for comparisons of proportions, and a logistic regression model, with robust variance estimation to address within-patient clustering of data, was used to calculate confidence intervals (CIs) for the physiological abnormalities and potential safety events. To compare baseline MICU demographic characteristics between patients who received physical therapy while undergoing CRRT and all other MICU patients, we used χ2 and Fisher's exact tests for categorical variables and two-sample t tests for continuous variables.
A multinomial logistic regression model with robust variance estimation was used to evaluate the association of cognitive status (Richmond Agitation-Sedation Scale and CAM-ICU delirium scores) with patients' ability to sit at the edge of the bed or greater. Statistical significance was defined as P < 0.05. Analyses were performed using Excel (Microsoft, Redmond, WA) and Stata 12.1 (StataCorp, College Station, TX) software. The institutional review board at Johns Hopkins University approved this study.
Results
Section:
From July 1, 2013, to July 31, 2014, 1,313 patients were admitted to the MICU. Of the 905 patients (69%) who received physical therapy, 57 (6%) performed at least one physical therapy session while undergoing CRRT (Figure 1 ). When we compared those who received physical therapy while undergoing CRRT with all other MICU patients, we found no significant differences in age, race, or location before admission. Those requiring CRRT were more likely to be male (P= 0.035), more frequently required mechanical ventilation (P< 0.001), and had longer MICU and hospital LOSs (P < 0.001 in both instances) (Table 1). Of the 57 MICU patients receiving CRRT during physical therapy, 95% were ambulatory before hospitalization and their median (IQR) Acute Physiology and Chronic Health Evaluation II score was 30 (23–36). A total of 23 patients (40%) died while in the hospital.
Figure 1. Patient flow diagram for 13-month evaluation period. CRRT = continuous renal replacement therapy; MICU = medical intensive care unit; PT = physical therapy.
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| Characteristics | MICU Patients Who Received PT during CRRT (n =57) | All Other MICU Patients (n =1,256) | P Value |
|---|---|---|---|
| Demographic and baseline data | |||
| Males, n (%) | 32 (56) | 626 (50) | 0.035* |
| Age, yr, median (IQR) | 55 (49–64) | 57 (46–66) | 0.852 † |
| Race, n (%) | |||
| White | 25 (44) | 457 (36) | 0.368* |
| Black | 24 (42) | 649 (52) | |
| Other | 8 (14) | 150 (12) | |
| Location before admission, n (%) | |||
| Home (independent) | 36 (63) | 857 (68) | 0.650 ‡ |
| Home (with assistance) | 17 (30) | 314 (25) | |
| Other | 4 (7) | 85 (7) | |
| MICU data § | |||
| Received mechanical ventilation, n (%) | 46 (79) | 488 (39) | <0.001* |
| ICU admission diagnosis, n (%) | |||
| Respiratory failure, including pneumonia | 21 (36) | 417 (33) | 0.008* |
| Nonpulmonary sepsis | 18 (31) | 224 (18) | |
| Cardiovascular | 7 (12) | 120 (10) | |
| Other | 12 (21) | 495 (39) | |
| MICU length of stay, d, median (IQR) | 13 (7–22) | 3 (2–5) | <0.001 † |
| Hospital length of stay, d, median (IQR) | 30 (17–58) | 8 (4–15) | <0.001 † |
The 57 patients included in this study performed a total of 268 physical therapy sessions during the 13-month evaluation period. Physical therapy sessions were performed by 11 different physical therapists with experience levels ranging from 6 months to 16 years of practice. The median (IQR) MICU LOS for patients in the study was 13 (7–22) days, and the number of physical therapy sessions per patient was 3 (2–5), with 9 (6–13) days spent in the ICU without a physical therapy session. "Patient not medically appropriate" (n = 281 patient days [46%]) and "physical therapist not available" (n = 137 patient days [22%]) were the most commonly recorded reasons why a physical therapy intervention was not received while in the MICU (Table 2).
| Reason | Number of Patients (%) |
|---|---|
| Not medically appropriate* | 281 (46) |
| Physical therapist not available | 137 (22) |
| Physical therapy treatment not needed | 49 (8) |
| Sedation | 37 (6) |
| Patient not available | 33 (5) |
| Other | 78 (13) |
CRRT catheter sites during physical therapy sessions were as follows: nontunneled internal jugular (n = 171 [64%]), tunneled internal jugular (n = 92 [34%]), nontunneled femoral (n = 4 [1%]), and nontunneled subclavian (n = 1 [1%]) veins. A total of 77% of patients received mechanical ventilation at some point during their stay, with 57% of the 268 physical therapy sessions occurring while the patient was receiving mechanical ventilation.
The highest level of mobility achieved during the physical therapy sessions with CRRT included 78 (29%) in-bed exercises, 72 (27%) supine cycle ergometry, 80 (30%) sitting at the edge of the bed, 20 (7%) standing, 13 (5%) transfer to chair, and 5 (2%) marching in place. Physical therapy sessions on days when patients were less sedated and not delirious (CAM-ICU–negative status) were significantly associated with mobilization to the edge of the bed or greater (P = 0.017) (Table 3). Patients who ultimately survived to hospital discharge achieved a higher level of mobility during their ICU stay, with 62% versus 33% (P = 0.05) able to sit at the edge of the bed or greater while receiving CRRT.
| Sedation and Delirium Status | Sat at Edge of Bed or Greater (n [%]) | P Value | |
|---|---|---|---|
| Yes | No | ||
| RASS | n = 119 | n = 149 | <0.001* |
| Restless/agitated (RASS score >0) | 7 (6) | 13 (9) | |
| Alert and calm (RASS score 0) | 75 (63) | 44 (30) | |
| Lightly sedated (RASS score −1 or −2) | 37 (31) | 61 (41) | |
| Moderated/deeply sedated (RASS score −3, −4, or −5) | 0 (0) | 31 (21) | |
| CAM-ICU † | n = 110 | n = 120 | 0.017* |
| Positive (delirious) | 49 (45) | 78 (65) | |
| Negative (not delirious) | 61 (55) | 42 (35) | |
No CRRT-specific safety events occurred (0%; 95% upper CI, 6.3%). Apart from CRRT-specific events, a total of six physiological abnormalities or potential safety events occurred, representing 2.2% (95% CI, 0.6–8.2%) of all 268 physical therapy sessions. All six events were hypotension (mean arterial pressure, <55 mm Hg). A single event occurred in two patients, and the remaining four events occurred in one patient. The latter patient was chronically hypotensive, with the medical team approving physical therapy interventions despite the hypotension. In only one instance did this patient require a small increase in vasopressor dosing (norepinephrine increased from 0.23 to 0.28 μg/kg/min) to manage the hypotension.
Alarms on the CRRT machine occurred in 36 physical therapy sessions (13%). The median (IQR) differences in pressure values before and after each physical therapy session were 0 (−4 to 5) mm Hg for access/arterial, 0 (−6 to 4) mm Hg for return/venous, and 0.5 (−9 to 7) mm Hg for effluent (Table 4). Of note, 33 (12%) of the physical therapy sessions did not have reported pre- or post-session pressure values, owing to data omission or intentional cessation of CRRT by the medical team at the end of the physical therapy session in preparation for patient transport. No physical therapy session resulted in discontinuation of CRRT or loss of catheter patency.
| Minimum | Maximum | Median | 25th Percentile | 75th Percentile | |
|---|---|---|---|---|---|
| Access/arterial | 0 | 68 | 0 | −4 | 5 |
| Return/venous | 0 | 56 | 0 | −6 | 4 |
| Effluent | 0 | 51 | 0.5 | −9 | 7 |
Discussion
Section:
We performed a prospective evaluation of the feasibility and safety of physical therapy in MICU patients undergoing CRRT. The numerous treatment sessions performed with ICU patients undergoing CRRT, as reported in our data, demonstrate that it is feasible to perform rehabilitation therapy with these patients. Moreover, no CRRT-related safety events occurred. Other reports of physiological abnormalities or potential safety events were rare (2.2%). All such reports were related to hypotension (six occasions), with only a single instance requiring an intervention as a result of hypotension (i.e., a small increase in vasopressor dose). Thus, these data suggest that physical therapy with patients undergoing CRRT is feasible and appears safe as part of routine care in the ICU.
Clinical studies have repeatedly shown that physical therapy is feasible, safe, and beneficial for improving physical function and outcomes in ICU patients (1–7). Acute renal failure can affect as many as 25% of ICU patients (27). With CRRT being a common treatment for acute renal failure in the ICU, the perception that CRRT is a barrier to receiving physical therapy may compromise efforts to improve patients' physical recovery.
Although this analysis was based on a single-center evaluation of 57 MICU patients with 268 physical therapy sessions, it represents an important addition to the existing literature, which includes two other clinical studies and one case report (16–18). Wang and colleagues (17) performed a study in two medical-surgical ICUs in which they evaluated 34 patients with 67% mobilized to the edge of the bed or greater. They reported no physiological abnormalities or catheter-related safety events. Moreover, they reported increased CRRT filter life with physical therapy sessions, as well as decreased access pressures with sitting at the edge of the bed and increased access pressures with marching on the spot that returned to preintervention levels once the patient was returned to supine position. Talley and colleagues (16) described a single-center analysis of 104 medical-surgical ICU patients with no CRRT catheter dislodgements, falls, or other serious adverse events. In their study, 89% of patients performed only range of motion in supine position, with 9% sitting at the edge of the bed and 2% standing and walking. They did not evaluate circuit pressures, but they did volitionally decrease the blood flow rate by 25% during activity to account for possible increases in CRRT circuit pressures.
In our study, during 30% of physical therapy sessions, the highest level of mobility achieved was sitting at the edge of the bed. Ambulation is not possible at our facility, owing to our CRRT units not being portable. However, the relatively low frequency of transfer to chair (5%) and standing or marching in place (9%) may be due to these CRRT patients' high severity of illness and sedation and delirium status, as indicated in our analyses. It is important to note that researchers in other clinical studies have also reported a limited number of patients who were able to participate in higher levels of mobility, with Wang and colleagues (17) not able to recruit a full cohort of patients in their standing and marching group and Talley and colleagues (16) reporting only 2% of patients standing or walking.
Limitations
This study had several potential limitations. The prospective reporting of potential physiological abnormalities or safety events was reliant upon documentation by the treating physical therapists, and instances may have been omitted. However, as described in the Methods section, comprehensive measures were taken to help decrease this potential limitation, and such reporting does not have punitive implications for the physical therapists.
This evaluation was performed in a single medical ICU, and therefore the results may not be generalizable to other ICUs or patient populations. However, 11 different physical therapists with a wide range of experience levels provided sessions as part of routine practice during the study's 13-month evaluation period, which may help support the study's generalizability. This study was performed as part of routine care and did not include any protocol for delivery of the physical therapy sessions, which may limit its replication but adds to its generalizability to the clinical environment.
Data regarding active versus passive activity during bed exercises and supine cycle ergometry are not available. There were only four physical therapy sessions with a femoral hemodialysis catheter, and conclusions regarding safety of activity with CRRT femoral catheters are limited in our report. Of note, our facility avoids placement of femoral catheters in an effort to decrease catheter-associated infections as per the International Society of Nephrology's "Kidney Disease: Improving Global Outcomes Clinical Practice Guideline for Acute Kidney Injury" (28).
Finally, we did not evaluate CRRT filter life and had limited data on the type of alarms associated with mobility. Additional studies addressing physical therapy with CRRT femoral catheters, as well as higher levels of mobility such as standing or marching in place, are important to advancing this research. Studies evaluating level of mobility as a prognostic factor for ICU survival may also be beneficial.
Conclusions
This report describes our prospective analysis of the feasibility and safety of 268 physical therapy sessions in 57 adult patients undergoing CRRT in a single MICU. Physical therapy sessions included in-bed exercises, supine cycle ergometry, sitting, standing, transfer to a chair, and marching in place. No CRRT-related events occurred, and only six transient episodes of hypotension occurred, without any patient harm. Thus, in the context of careful clinical judgment, physical therapy interventions are feasible and appear to be safe in ICU patients who are undergoing CRRT.
The authors thank Minxuan Huang for his assistance with statistical analysis, Aparna Nallagangula for her assistance with data collection and entry, and the following physical therapists for their assistance with data collection: Melanie Asefa, Steve Crandall, Lauren Gornoski, Amy Hall, Paul Ricard, Jessica Rossi, Jennifer Sahm, Jason Seltzer, and Julie Skrzat.
References
Section:
| 1 . | Burtin C , Clerckx B , Robbeets C , Ferdinande P , Langer D , Troosters T , Hermans G , Decramer M , Gosselink R . Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009;37:2499–2505. Crossref, Medline, Google Scholar |
| 2 . | Morris PE , Griffin L , Berry M , Thompson C , Hite RD , Winkelman C , Hopkins RO , Ross A , Dixon L , Leach S , et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011;341:373–377. Crossref, Medline, Google Scholar |
| 3 . | Bailey P , Thomsen GE , Spuhler VJ , Blair R , Jewkes J , Bezdjian L , Veale K , Rodriquez L , Hopkins RO . Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007;35:139–145. Crossref, Medline, Google Scholar |
| 4 . | Schweickert WD , Pohlman MC , Pohlman AS , Nigos C , Pawlik AJ , Esbrook CL , Spears L , Miller M , Franczyk M , Deprizio D , et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373:1874–1882. Crossref, Medline, Google Scholar |
| 5 . | Needham DM , Korupolu R , Zanni JM , Pradhan P , Colantuoni E , Palmer JB , Brower RG , Fan E . Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010;91:536–542. Crossref, Medline, Google Scholar |
| 6 . | Sricharoenchai T , Parker AM , Zanni JM , Nelliot A , Dinglas VD , Needham DM . Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care 2014;29:395–400. Crossref, Medline, Google Scholar |
| 7 . | Kayambu G , Boots R , Paratz J . Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med 2013;41:1543–1554. Crossref, Medline, Google Scholar |
| 8 . | Leditschke IA , Green M , Irvine J , Bissett B , Mitchell IA . What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J 2012;23:26–29. Crossref, Medline, Google Scholar |
| 9 . | Damluji A , Zanni JM , Mantheiy E , Colantuoni E , Kho ME , Needham DM . Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit. J Crit Care 2013;28:535.e9–535.e15. Crossref, Medline, Google Scholar |
| 10 . | Perme C , Nalty T , Winkelman C , Nawa RK , Masud F . Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: a prospective observational study. Cardiopulm Phys Ther J 2013;24:12–17. Crossref, Medline, Google Scholar |
| 11 . | Perme C , Lettvin C , Throckmorton TA , Mitchell K , Masud F . Early mobility and walking for patients with femoral arterial catheters in intensive care unit: a case series. J Acute Care Phys Ther 2011;2:30–34. Crossref, Google Scholar |
| 12 . | Nydahl P , Ruhl AP , Bartoszek G , Dubb R , Filipovic S , Flohr HJ , Kaltwasser A , Mende H , Rothaug O , Schuchhardt D , et al. Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany. Crit Care Med 2014;42:1178–1186. Crossref, Medline, Google Scholar |
| 13 . | Berney SC , Harrold M , Webb SA , Seppelt I , Patman S , Thomas PJ , Denehy L . Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Crit Care Resusc 2013;15:260–265. Medline, Google Scholar |
| 14 . | Rahimi RA , Skrzat J , Reddy DR , Zanni JM , Fan E , Stephens RS , Needham DM . Physical rehabilitation of patients in the intensive care unit requiring extracorporeal membrane oxygenation: a small case series. Phys Ther 2013;93:248–255. Crossref, Medline, Google Scholar |
| 15 . | Turner DA , Cheifetz IM , Rehder KJ , Williford WL , Bonadonna D , Banuelos SJ , Peterson-Carmichael S , Lin SS , Davis RD , Zaas D . Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach. Crit Care Med 2011;39:2593–2598. Crossref, Medline, Google Scholar |
| 16 . | Talley CL , Wonnacott RO , Schuette JK , Jamieson J , Heung M . Extending the benefits of early mobility to critically ill patients undergoing continuous renal replacement therapy: the Michigan experience. Crit Care Nurs Q 2013;36:89–100. Crossref, Medline, Google Scholar |
| 17 . | Wang YT , Haines TP , Ritchie P , Walker C , Ansell TA , Ryan DT , Lim PS , Vij S , Acs R , Fealy N , et al. Early mobilization on continuous renal replacement therapy is safe and may improve filter life. Crit Care 2014;18:R161. Crossref, Medline, Google Scholar |
| 18 . | Brownback CA , Fletcher P , Pierce LN , Klaus S . Early mobility activities during continuous renal replacement therapy. Am J Crit Care 2014;23:348–351, quiz 352. Crossref, Medline, Google Scholar |
| 19 . | Patel P , Nandwani V , McCarthy PJ , Conrad SA , Keith Scott L . Continuous renal replacement therapies: a brief primer for the neurointensivist. Neurocrit Care 2010;13:286–294. Crossref, Medline, Google Scholar |
| 20 . | Toonstra AL , Zanni JM , Nelliot A , Needham DM . Safety and feasibility of rehabilitation for patients with critical illness undergoing continuous renal replacement therapy (CRRT) [abstract]. J Acute Care Phys Ther 2013;4:114. Google Scholar |
| 21 . | Knaus WA , Draper EA , Wagner DP , Zimmerman JE . APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818–829. Crossref, Medline, Google Scholar |
| 22 . | Ely EW , Truman B , Shintani A , Thomason JW , Wheeler AP , Gordon S , Francis J , Speroff T , Gautam S , Margolin R , et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003;289:2983–2991. Crossref, Medline, Google Scholar |
| 23 . | Ely EW , Inouye SK , Bernard GR , Gordon S , Francis J , May L , Truman B , Speroff T , Gautam S , Margolin R , et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703–2710. Crossref, Medline, Google Scholar |
| 24 . | Korupolu R , Chandolu S , Needham D . Series on early mobilisation of critically ill patients. Part one: Screen and safety issues. ICU Manage 2009;9:27–29. Google Scholar |
| 25 . | Hodgson CL , Stiller K , Needham DM , Tipping CJ , Harrold M , Baldwin CE , Bradley S , Berney S , Caruana LR , Elliott D , et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 2014;18:658. Crossref, Medline, Google Scholar |
| 26 . | NxStage Medical, Inc. NxStage system one user's guide: chapter 4.22. Lawrence, MA; 2009. Google Scholar |
| 27 . | Singbartl K , Kellum JA . AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int 2012;81:819–825. Crossref, Medline, Google Scholar |
| 28 . | International Society of Nephrology. KDIGO clinical practice guideline for acute kidney injury: chapters 5.4–5.6. Kidney Int 2012;2(Suppl 1):101–110. Google Scholar |
Author Contributions: A.L.T., J.M.Z., and D.M.N. contributed to the conception and design of the manuscript. A.L.T., J.M.Z., C.J.S., A.N., E.M., E.H.S., and D.M.N. contributed to the analysis and interpretation of data. A.L.T. drafted the manuscript and all other authors critically revised it for important intellectual content. All authors gave final approval of the manuscript version to be published. Author disclosures are available with the text of this article at www.atsjournals.org.
Source: https://www.atsjournals.org/doi/10.1513/AnnalsATS.201506-359OC
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