Physical dysfunction after discharge from the intensive care unit (ICU) is recognized as a common complication among ICU patients. Early mobilization (EM), defined as the ability to sit on the edge of the bed within 5 days, may help improve physical dysfunction. However, the barriers to, and achievement of, EM and their impact on physical dysfunction have not been fully investigated. This study aimed to investigate the achievement of EM and barriers to it and their impact on patient outcomes in mechanically ventilated ICU patients. We conducted this multicenter retrospective cohort study by collecting data from six ICUs in Japan. Consecutive patients who were admitted to the ICU between April 2019 and March 2020, were aged ≥ 18 years, and received mechanical ventilation for > 48 h were eligible. The primary outcome was the rate of independent activities of daily living (ADL), defined as a score ≥ 70 on the Barthel index at hospital discharge. Daily changes in barriers of mobilization, including consciousness, respiratory, circulatory, medical staff factors, and device factors (catheter, drain, and dialysis), along with the clinical outcomes were investigated. The association among barriers, mobilization, and Barthel index ≥ 70 was analyzed using multivariable logistic regression analysis. During the study period, 206 patients were enrolled. EM was achieved in 116 patients (68%) on the fifth ICU day. The primary outcome revealed that achieving EM was associated with a Barthel index ≥ 70 at hospital discharge [adjusted odds ratio (AOR), 3.44; 95% confidence interval (CI), 1.70–6.96]. Device factors (AOR, 0.31; 95% CI, 0.13–0.75, respectively) were significantly associated with EM achievement. EM was associated with independent ADL at hospital discharge. Time to first mobilization and barriers to achieving mobilization can be important parameters for achieving ADL independence at discharge. Further research is required to determine the most common barriers so that they can be identified and removed.

Aims: Malnutrition is prevalent among patients with heart failure (HF); however, the effects of coexisting malnutrition and frailty on prognosis are unknown. This study examines the impact of malnutrition and frailty on the prognosis of patients with HF. Methods and results: We examined 1617 patients with HF aged 65 years or older (age: 78.6 ± 7.4; 44% female) from a Japanese multicentre prospective cohort study. The nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT), and Mini Nutritional Assessment Short Form on discharge. Frailty was assessed using the criteria determined in a previous study on patients with HF. The prognostic impact of each nutrition measure on the risk of composite all-cause mortality and cardiac readmissions within 2 years of hospital discharge was assessed using Kaplan–Meier survival curves and Cox proportional hazards model analysis for non-frail and frail groups. Over 2324.2 person-years of follow-up, 88 patients died and 448 patients experienced readmission due to HF. In the non-frail group, poor nutritional status assessed using the GNRI and CONUT was associated with an increased hazard ratio (HR) of composite outcomes in the crude model; however, adjustment for potential confounders diminished the association. In the frail group, all three nutritional indicators were associated with the cumulative incidence of the study outcome (log-rank test, P < 0.05). In multivariate analysis, only the CONUT score was associated with an increased HR even after adjustment for confounders. Conclusions: The CONUT score predicted a poor prognosis in HF patients with coexisting physical frailty, highlighting the potential clinical benefit of nutritional assessment based on biochemical data for further risk stratification.

The prognostic effects of cardiac rehabilitation (CR) are inconsistent in recent reports on heart failure (HF). Generally, participants in previous trials were relatively young and had HF with reduced ejection fraction. Herein, we examined the effects of CR on HF prognosis using a nationwide cohort study. This multicenter prospective cohort study included hospitalized patients with acute HF or worsening chronic HF. Patients who underwent CR once or more times weekly for 6 months after discharge were included in the CR group. The main study end point was a composite of all-cause mortality and HF rehospitalization during a 2-year follow-up period. We performed propensity score matching to compare the survival rates between the CR and non-CR groups. Of the 2,876 enrolled patients, 313 underwent CR for 6 months. After propensity score matching using confounding factors, 626 patients (313 pairs) were included in the survival analysis (median age: 74 years). CR was associated with a reduced risk of composite outcomes (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.48 to 0.91; p = 0.011), all-cause mortality (HR 0.53; 95% CI 0.30 to 0.95; p = 0.032), and HF rehospitalization (HR 0.66; 95% CI 47 to 0.92; p = 0.012). Subgroup analysis showed similar CR effects in patients with HF with preserved ejection fraction (≥50%) and HF with reduced ejection fraction (<40%). In the landmark analysis, CR did not reduce the aforementioned end points beyond 6 months after discharge (log-rank test: composite outcomes, p = 0.943; all-cause mortality, p = 0.258; HF rehospitalization, p = 0.831). CR is a standard treatment for HF regardless of HF type; however, further challenges may affect the long-term prognostic effects of CR.

Background: Hospital-acquired disability (HAD), defined as a decline in activities of daily living (ADL) during hospitalization, is a significant component of post-intensive care syndrome (PICS) and may influence long-term outcomes in critically ill patients. Its impact on post-discharge functional recovery, especially among patients who appear ADL-independent at discharge, remains unclear. Methods: This analysis of the multicenter prospective J-RELIFE cohort included 357 ICU patients aged ≥ 40 years who required mechanical ventilation for ≥48 h. The primary outcome was global functional decline, defined as a Kihon Checklist (KCL) score ≥ 8 at 3 months after hospital discharge. Multivariable logistic regression and Cox proportional hazards models were used to identify independent predictors of functional decline, including HAD (Δ Barthel Index ≥ 5), age ≥ 65 years, and psychological distress at discharge (Hospital Anxiety and Depression Scale ≥ 8). Results: Global functional decline at three months was observed in 45% of patients. In logistic regression analysis, HAD (OR = 1.80, 95% CI: 1.00–3.24, p = 0.049), psychological distress (OR = 2.11, 95% CI: 1.27–3.49, p = 0.004), and older age (OR = 1.03 per year, p = 0.027) were independently associated with the outcome. Relative risk analysis confirmed similar associations: HAD (RR = 1.99, 95% CI: 1.71–2.31), psychological distress (RR = 1.35), and their combination significantly increased the risk of functional decline. Among patients who were ADL-independent at discharge (Barthel Index ≥ 85), those with all three risk factors had a markedly elevated risk (RR = 10.17, 95% CI: 6.46–16.00, p < 0.001). Conclusions: HAD, older age, and psychological distress at discharge are robust predictors of functional decline after ICU discharge, even in patients who appear functionally independent at discharge. These findings support comprehensive discharge planning that incorporates both physical and psychological assessments to identify high-risk individuals and improve long-term outcomes.

Skeletal Muscle Dysfunction in Critical Illness | InTechOpen, Published on: 2017-06-14. Authors: Yuki Iida and Kunihiro Sakuma