Why don't we mobilize our ICU patients early?

There are several questions that need answering regarding mobilization of Intensive Care Unit (ICU) patients. How do we mobilize ICU patients? Is there an internationally agreed definition? Is there an internationally agreed prescription/program for mobilizing the patients? What is considered early? Why should we mobilize our patients, and lastly, why don't we? Mobilization of ICU patients takes many different forms and views. It includes bed activities such as range of motion, turning, transferring, self-care, breathing exercises, sitting at the edge of the bed, and even stationary cycling. There are also several out of the bed activities such as sitting in a chair, standing, and walking. Although several units have their own protocols, a literature review reveals that definitions are either too broad or too narrow, subsequently challenging to transfer these results.(1) Some trials have started mobilizing patients from as early as the first day, while other trials have waited 48 hrs, 5 days, and even longer before mobilization was started. Most trials which have managed to deliver very early mobilisation have found improved outcomes up to hospital discharge, while trials which intervened later mostly found no significant effect.(2) The absence of a definition for early, very early, and late initiation of mobilization makes comparing studies very difficult. Muscle weakness that develops during the ICU stay is called ICU-acquired weakness (ICU-AW). It manifests as generalized muscle weakness that is often severe. It develops in ICU patients who receive mechanical ventilation for 24 hours or more and is associated independently with prolongation of the duration of mechanical ventilation and ICU and hospital stay. ICU-AW is associated with increased mortality in the first year following ICU discharge. Mobilizing patients at an early time point decreases invasive mechanical ventilation (MV) duration, delirium, hospital length of stay, and reduced healthcare costs.(3,4) Reported reasons for not mobilizing patients vary widely and include mechanical ventilation, catecholamine infusion, impaired consciousness, poor functional status, safety considerations, limited staff capacities, or lack of protocols. Absolute contraindications can include acute myocardial infarction, active bleeding, increased intracranial pressure with major instability, unstable pelvic fractures, therapy withdrawal, and lastly patients’ refusal.(4) Recommendations on safety criteria for early mobilization mention that vasopressor use, endotracheal intubation, renal replacement therapy, or even life support devices like ECMO should not be considered as contraindications for active mobilization. Only one study has explored the safety of very early mobilization in critically ill patients on multiple support systems.(4) Multiple QI projects have successfully implemented and sustained early mobilization projects within the ICU setting and all identified strong leadership for early mobilization. This along with the multidisciplinary team approach ensured success and sustainability of mobilizing ICU patients.(5) In conclusion, there is a lack of internationally agreed protocols or guidelines on when and how we should mobilise our patients. There are also several obstacles facing us even once achieving consensus in that. The good thing is that we are clear on why we should mobilise our patients and hopefully this will drive further research to standardize the above unanswered questions.