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18 Physical and Functional Recovery of Critically Ill Patients 199
Table 18.1 Safety consideration to perform active mobilization of mechanically ventilated ICU
patients
Risk of AE in out-of-bed
Outcome considered Risk of AE in-bed activities
activities
Artificial airway Low risk Low risk
> 60% Potential risk but overweighted
FIO
2
by the potential benefits
< 90% Potential risk but overweighted
SpO
2
by the potential benefits
Potential risk but overweighted
by the potential benefits
Significant potential risk.
Activity only performed only if
specifically authorized by
physician
PEEP >10 cmH
O Potential risk but overweighted
2
Single bicaval dual lumen
ECMO
MAP below or higher
than target causing symptoms or despite high
support
Bradycardia not requiring
treatment and not
by the potential benefits
Low risk Potential risk but overweighted
Potential risk but overweighted
by the potential benefits
Potential risk but overweighted
by the potential benefits
Potential risk but overweighted
by the potential benefits
by the potential benefits
Significant potential risk.
Activity only performed only if
specifically authorized by
physician
Potential risk but overweighted
by the potential benefits
awaiting emergency
peacemaker
Stable tachyarrhythmia Ventricular rate < 120 bpm: Low
risk
> 120 bpm: Potential risk but
overweighted
Ventricular rate < 120 bpm:
Low risk
Ventricular rate: 120–150 bpm
Potential risk but overweighted
by the potential benefits
Ventricular rate > 150 bpm:
Significant potential risk.
Activity only performed only if
specifically authorized by
physician
Shock with lactate
>4 mmol/L
RASS RASS -1 to +1: Low risk
Potential risk but overweighted
by the potential benefits
RASS <-2: Potential risk but
overweighted by the potential
benefits
RASS > +2: Significant potential risk. Activity only performed
Potential risk but overweighted
by the potential benefits
RASS -1 to +1: Low risk
RASS <-2or > +2:
Significant
potential risk.
Activity only performed only if
specifically authorized by
physician
only if specifically authorized by
physician
CAM-ICU + Low risk Potential r
ut overweighted
isk b
by the potential benefits
Adapted from “Expert
consensus and recommendations on safety criteria for active mobilization of
mechanically ventilated critically ill adults. Critical Care 2014, 18(6): 658”
FIO
fraction of inspired oxygen, SpO2 peripheral oxygen saturation, PEEP positive en-expiratory
2
pressure, ECMO extracorporeal membrane oxygenation, MAP mean arterial pressure, RASS Richmond agitation sedation scale, CAM-ICU Confusion Assessment Method for the Intensive Care
Unit
200 R. Martinez-Alejos et al.
Management and Therapies
The implementation of systematic mobilization protocols is an integral component
of the actions undertaken by multidisciplinary teams with the aim of decreasing the
incidence of ICUAW, muscle atrophy, delirium duration, and length of hospital stay.
Additionally, these protocols seek to improve muscle strength, increase venti latorfree days, enhance functional outcomes at hospital discharge, and achieve a higher
rate of patients discharged to home following a critical illness [
mobilization interventions consist of a combination of manual and mechanical
activities typically administered by physiotherapists. These interventions range
from passive and active mobilization of each limb joint to in-bed cycling, neuromuscular electrical stimulation, or orthostatic activities and walking. It should be
highlighted that all the above-cited interventions are applied as an ensemble and not
as isolated interventions. In-bed cycling involves an electromechanical cycle ergometer adaptable to the patient’s bed, offering the possibility to perform passive or
active cycling at different resistances [38]. Usually, patients undergo in-bed cycling
for 15–30 min with mixed results.
A large trial with 314 ICU patients compared in-bed cycling combined with
neuromuscular stimulation, passive and active exercises to isolated passive and
active exercises. The study failed to show any benefit on the MRC score at ICU
discharge (median difference -3.0 [95% CI, -7.0 to 2.8]; p = 0.28) or in the ICU
Mobility Scale score at ICU discharge ( p = 0.52) and in the median number of
ventilator-free days at day 28 (p = 0.24). However, 25% of the patients had an MRC
score higher than 58 at ICU discharge, suggesting a possible ceiling effect
preventing the identification of group differences. Moreover, there was no information on the MRC at baseline or sedation infusion rates in each group, which may
explain the absence of significant results.
Conversel
of in-bed cycling on the 6-minute walking distance, isometric quadriceps force, and
the subjective feeling of “Physical Functioning” item of the Short Form 36 Health
Survey questionnaire ( p < 0.05 all items) [39]. The main difference between both
studies is the time spent between ICU admission and the application of interventions.
Fossat G et al. [38] applied their first intervention approximately 30 h after admission, while Burtin C et al. [39] began interventions on the fifth day after admission,
highlighting the importance of timing to initiate early mobilization. Despite this
early recommendation, some precautions regarding respiratory, cardiovascular, and
neurological status must be considered to ensure safe intervention.
Moreover,
adherence can be disrupted by delirium and sedation status. Patients suffering from
delirium and receiving opioid boluses were significantly associated with lower levels
of participation, which is further impacted in delirium patients treated with benzodiazepine boluses [40]. However, a recent study showed that patients receiving
increased early intervention compared to usual care did not promote any benefit on
survival (OR 1.15; 95% CI 0.81–1.65) nor in quality of life, activities of daily living,
y, a s
imilar study with 90 patients showed a significant positive effect
other conditions should be assessed, as patients ’ participation and
1, 37]. The early
18 Physical and Functional Recovery of Critically Ill Patients 201
or cognitive function among survivors [41]. Additionally, patients receiving early
intervention showed a significantly higher number of adverse events during the
protocol, consisting mainly of arrhythmias, variations in blood pressure, and oxygen
desaturation. These results highlight the importance of individualizing and assessing
the right interventions for each patient [
Neuromuscular electrical
current to stimulate specific muscle groups through 3–4 channel electrodes placed in
the muscle motor points, 30–60 min once or twice per day. It seems that neuromuscular electrical stimulation combined with other interventions may lead to improved
muscle strength; decreased time spent under mechanical ventilation, ICU length of
stay, and hospital length of stay; improved activities of daily living; and increased
walking distance [42]. However, there is no evidence suggesting a reduction in
mortality. Additionally, patients in an early catabolic phase may not benefit from this
therapy, and it may be ineffective or even deleterious. An observational study
suggested that neuromuscular electrical stimulation may be beneficial in increasing
muscle layer thickness only if it is applied from the seventh day after admission
[30, 43].
There is no consensus or standardization about which exact interventions should
be applied nor a closed rule during their elaboration. Most authors aim to assess
motor and/or cardiorespiratory outcomes as indicators of the progression of early
mobilization processes [30]. Common criteria used to implement early mobilization
include the level of consciousness using RASS and Glasgow Coma Scale, muscular
function using the MRC score, and functional evaluation such as the ability of
patients to move upper limbs against gravity, move lower limbs against gravity, or
tolerance to sitting or standing position [31, 44]. The beneficial effects of the
different early mobilization strategies remain unclear, but a recent systematic review
associated these interventions with a decrease of ICUAW rates, a reduction of ICU
and hospitalization length of stay, and mortality during hospitalization. Other associated outcomes are the reduction of mechanical ventilation time and weaning and
the preservation of peripheral and respiratory muscle strength as previously
described. Long-term outcomes seem to highlight the beneficial impact of these
interventions with an improvement of the patients’ quality of life at 6 months and a
higher rate of reintegration to employment after hospitalization [38].
stimulation typically applies 30–50 Hz low-frequency
42].
Nutritional Therapy
Nutritional assessment is essential for critically ill patients to limit ICUAW and
promote faster recovery. Severe caloric deficit and gastrointestinal dysfunction have
been associated with muscle atrophy and ICUAW. Early enteral nutrition should be
encouraged for faster recovery. Accordingly, international guidelines suggest initiating enteral nutrition, avoiding aggressive feeding strategies, and parenteral nutrition as much as possible. Early parenteral nu trition was associated with a longer
duration of mechanical ventilation and impaired recovery of muscular function
202 R. Martinez-Alejos et al.
[45, 46]. Additionally, early parenteral nutrition to full caloric targets did not
improve muscular atrophy [46]. Glycemic control is mandatory, eventually with
the help of insulin infusion. Normal glycemic targets were associated with fewer
electrophysiological signs of critical illness polyneuropathy [2
should be carefully monitored since proteins are the main substrates implicated in
building muscle mass. However, as with other nutrients, an aggressive nutritional
strategy with high protein intake is not recommended, particularly in patients with
acute or preexisting renal disease. The amount for protein intake should be reached
once appropriate targets for carbohydrates and lipids are achieved to avoid broken
47, 48]. In summary, the targets of nutritional
amino acids triggering urogenesi
support should be slowly achieved approximately in 1 week since ICU admission,
favoring the enteral route over parenteral, and taking into consideration patients’
needs according to the severity of the actual and preexisting diseases.
s [
]. Protein intake
Other Supportive Therapies
Functional recovery not only consists of gaining muscle strength, but its ultimate
goal is to recover autonomy in daily life activities (i.e., eating, bathing, dressing,
communication skills, etc.). For that purpose, the ICU should have a collaborative
and integrated interdisciplinary approach, including occupational therapists and
speech-language therapists in the ICU healthcare teams. Regarding occupational
therapy, there is scant evidence about the implementation of this therapy in ICU
patients with mixed results. However, data point to occupational and speechlanguage therapies being easily and safely implemented. Moreover, some data
seems to point to a lower incidence of ICU delirium and higher scores on functional
status [49, 50].
About speech-language therapy, we similarly find a low number of studies
assessing their role in ICU, but it seems that early intervention of these healthcare
workers leads to a decrease in the dysphagia rate, days spent with tube feeding, a
lower occurrence of aspiration pneumonia, and better functional oral intake scores
[51, 52].
Patient- and Family-centered ICU Environment
Creating a patient-centered and family-inclusive ICU environment can have a
positive impact on patients’ well-being, reduce delirium rates, and promote faster
recovery [52]. Healthcare professionals should prioritize patients’ needs and wellbeing in the ICU setting and implement these changes to achieve better outcomes.
A recent
a more patient-centered and family-inclusive ICU environment may improve patient
evolution [52]. For instance, a friendlier ICU environment wi th a direct view of the
study suggested that incorporating patients’ personal needs and creating
18 Physical and Functional Recovery of Critically Ill Patients 203
outside nature could promote better regulation of the circadian rhythm, which is a
crucial aspect of patients’ recover y. Orientation aids, such as clocks and calendars,
can also reduce confusion and improve patients’ overall orientation, leading to a
better understanding of their condition and treatment plan.
Furthermore, improving the size of ICU rooms and incorporating built-in bed
ent for physical exercises, such as bikes and treadmills, can promote early
equipm
mobilization and encourage patients to be more engaged. Family participation can
also enhance patients’ motivation and engagement in physical activities. Finally,
activities should not only be focused indoors, but once patients are ready, outdoor
physical activity should be highly encouraged [
52].
Conclusions
Intensive care-acquired weakness is a common disorder in critically ill patients,
affecting muscles globally and significantly impacting muscular function, prognosis,
and functional recovery. The Medical Research Council Score is the most common
tool used to assess intensive care-acquired weakness. Additionally, other tools such
as the 6-minute walking test, imaging techniques, bioelectrical impedance analysis,
and muscle and nerve biopsy can be suitable options for implementation. Therapies
aimed at alleviating the progression of intensive care-acquired weakness and
improving recovery consist of a multidisciplinary intervention approach, including
early mobilization, nutri tional therapy, occupational therapy, and speech-language
therapy. The efficacy of these interventions may be improved with more adapte d
ICU environments.
References
1. Fan E, Cheek F, Chlan L, Gosselink R, Hart N, Herridge MS, Hopkins RO, Hough CL, Kress
JP, Latronico N, Moss M, Needham DM, Rich MM, Stevens RD, Wilson KC, Winkelman C,
Zochodne DW, Ali NA, ATS Committee on ICU-acquired Weakness in Adults, American
Thoracic Society. An official American Thoracic Society Clinical Practice guideline: the
diagnosis of intensive care unit-acquired weakness in adults. Am J Respir Crit Care Med.
2014;190(12):1437–46.
2. Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med.
2020;46(4):637–53. https://doi.org/10.1007/s00134-020-05944-4. Epub 2020 Feb 19. PMID:
32076765; PMCID: PMC7224132
3. Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in
the critical care environment. Extreme Physiol Med. 2015;4:16.
4. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in
critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–7.
5.
Tipping CJ,
mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive
Care Med. 2017;43(2):171–83.
Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active
204 R. Martinez-Alejos et al.
6. Van den Berghe G. On the neuroendocrinopathy of critical illness. Perspectives for feeding and
novel treatments. Am J Respir Crit Care Med. 2016;194(11):1337–48.
7. Friedrich O, Reid MB, Van den Berghe G, Vanhorebeek I, Hermans G, Rich MM, Larsson L.
The sick and the weak: neuropathies/myopathies in the critically ill. Physiol Rev. 2015;95
(3):1025–109.
8. Latronico N, Herridge M, Hopkins RO, Angus D, Hart N, Hermans G, Iwashyna T, Arabi Y,
Citerio G, Ely EW, Hall J, Mehta S, Puntillo K, Van den Hoeven J, Wunsch H, Cook D, Dos
Santos C, Rubenfeld G, Vincent JL, Van den Berghe G, Azoulay E, Needham DM. The ICM
research agenda on intensive care unit-acquired weakness. Intensive Care Med. 2017;43
(9):1270–81.
9. Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit
Care. 2015;19(1):274.
10. Kanova M, Kohout P. Molecular mechanisms underlying intensive care unit-acquired weakness
and sarcopenia. Int J Mol Sci. 2022;23(15):8396.
11. Supinski GS, Morris PE, Dhar S, Callahan LA. Diaphragm dysfunction in critical illness. Chest.
2018;153(4):1040–51.
12. Sutherasan Y, Vargas M, Pelosi P. Protective mechanical ventilation in the non-injured lung:
review and meta-analysis. Crit Care. 2014;18(2):211.
13. Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ, Needham DM.
Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care
Med. 2007;33(11):1876–91.
14. Garnacho-Montero J, Amaya-Villar R, Garcia-Garmendia JL, Madrazo-Osuna J, Ortix-Leyba
C. Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and
the length of stay in septic patients. Crit Care Med. 2005;33:349–54.
15. Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A, Albaladejo P, Chanques G,
Molinari N, Jaber S. Diaphragmatic dysfunction in patients with ICU-acquired weakness and its
impact on extubation failure. Intensive Care Med. 2016;42(5):853–61.
16. Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: a narrative
review. Multidiscip Respir Med. 2018;13:6.
17. Zorowitz RD. ICU-acquired weakness: a rehabilitation perspective of diagnosis, treatment, and
functional management. Chest. 2016;150(4):966–71.
18. Fazzini B, Battaglini D, Carenzo L, Pelosi P, Cecconi M, Puthucheary Z. Physical and
psychological impairment in survivors of acute respiratory distress syndrome: a systematic
review and meta-analysis. Br J Anaesth. 2022;129(5):801–14.
19. Rahiminezhad E, Zakeri MA, Dehghan M. Muscle strength/intensive care unit acquired weakness in COVID-19 and non-COVID-19 patients. Nurs Crit Care. 2022;28:1012. https://doi.org/
10.1111/nicc.12830.
20. Vanpee G, Hermans G, Segers J, Gosselink R. Assessment of limb muscle strength in critically
ill patients: a systematic review. Crit Care Med. 2014;42(3):701–11.
21. Parry SM, Berney S, Granger CL, Dunlop DL, Murphy L, El-Ansary D, Koopman R, Denehy
L. A new two-tier strength assessment approach to the diagnosis of weakness in intensive care:
an observational study. Crit Care. 2015;19(1):52.
22. O’Neill S, Jaszczak SLT, Steffensen AKS, Debrabant B. Using 4+ to grade near-normal muscle
strength does not improve agreement. Chiropr Man Therap. 2017;25:28.
23. Denehy L, de Morton NA, Skinner EH, Edbrooke L, Haines K, Warrillow S, Berney S. A
physical function test for use in the intensive care unit: validity, responsiveness, and predictive
utility of the physical function ICU test (scored). Phys Ther. 2013;93(12):1636–45.
24. Huang M, Chan KS, Zanni JM, Parry SM, Neto SG, Neto JA, da Silva VZ, Kho ME, Needham
DM. Functional status score for the ICU: an international clinimetric analysis of validity,
responsiveness, and minimal important difference. Crit Care Med. 2016;44(12):e1155–64.
25.
Parry SM,
Assessment of impairment and activity limitations in the critically ill: a systematic review of
Granger CL, Berney S, Jones J, Beach L, El-Ansary D, Koopman R, Denehy L.
18 Physical and Functional Recovery of Critically Ill Patients 205
measurement instruments and their clinimetric properties. Intensive Care Med. 2015;41
(5):744–62.
26. Needham DM, Sepulveda KA, Dinglas VD, Chessare CM, Friedman LA, Bingham CO 3rd,
Turnbull AE.
An international modified Delphi consensus study. Am J Respir Crit Care Med. 2017;196
(9):1122–30.
27. Moore JL, Potter K, Blankshain K, Kaplan SL, OʼDwyer LC, Sullivan JE. A core set of
outcome measures for adults with neurologic conditions undergoing rehabilitation: a clinical
practice guideline. J Neurol Phys Ther. 2018;42(3):174–220.
28. O’Grady HK, Edbrooke L, Farley C, Berney S, Denehy L, Puthucheary Z, Kho ME, International METRIC Critical Care Data Group. The sit-to-stand test as a patient-centered functional
outcome for critical care research: a pooled analysis of five international rehabilitation studies.
Crit Care. 2022;26(1):175.
29. de Melo TA, Silva Guimarães F, Silva LE, JR. The five times sit-to-stand test: safety, validity
and reliability with critical care survivors’ s at ICU discharge. Arch Physiother. 2022;13(1):2.
30. Hickmann CE, Castanares-Zapatero D, Bialais E, Dugernier J, Tordeur A, Colmant L,
Wittebole X, Tirone G, Roeseler J, Laterre PF. Teamwork enables high level of early mobilization in critically ill patients. Ann Intensive Care. 2016;6(1):80.
31. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker
S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early
intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med.
2008;36(8):2238–43.
32. Formenti P, Umbrello M, Coppola S, Froio S, Chiumello D. Clinical review: peripheral
muscular ultrasound in the ICU. Ann Intensive Care. 2019;9(1):57.
33. De Rosa S, Umbrello M, Pelosi P, Battaglini D. Update on lean body mass diagnostic
assessment in critical illness. Diagnostics (Basel). 2023;13(5):888.
34. Zuccarelli L, Baldassarre G, Magnesa B, Degano C, Comelli M, Gasparini M, Manferdelli G,
Marzorati M, Mavelli I, Pilotto A, Porcelli S, Rasica L, Šimunič B, Pišot R, Narici M, Grassi B.
Peripheral impairments of oxidative metabolism after a 10-day bed rest are upstream of
mitochondrial respiration. J Physiol. 2021;599(21):4813–29.
35. Yoshimatsu T, Yoshida D, Shimada H, Komatsu T, Harada A, Suzuki T. Relationship between
near-infrared spectroscopy, and subcutaneous fat and muscle thickness measured by ultrasonography in Japanese community-dwelling elderly. Geriatr Gerontol Int. 2013;13(2):351–7.
36. Latronico N, Bertolini G, Guarneri B, Botteri M, Peli E, Andreoletti S, Bera P, Luciani D,
Nardella A, Vittorielli E, Simini B, Candiani A. Simplified electrophysiological evaluation of
peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study. Crit Care.
2007;11(1):R11.
37. Vollenweider R, Manettas AI, Häni N, de Bruin ED, Knols RH. Passive motion of the lower
extremities in sedated and ventilated patients in the ICU – a systematic review of early effects
and replicability of interventions. PLoS One. 2022;17(5):e0267255.
38. Fossat G, Baudin F, Courtes L, Bobet S, Dupont A, Bretagnol A, Benzekri-Lefèvre D, Kamel T,
Muller G, Bercault N, Barbier F, Runge I, Nay MA, Skarzynski M, Mathonnet A, Boulain T.
Effect of in-bed leg cycling and electrical stimulation of the quadriceps on global muscle
strength in critically ill adults: a randomized clinical trial. JAMA. 2018;320(4):368–78.
39. 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(9):2499–505.
40. Kamdar BB, Combs MP, Colantuoni E, King LM, Niessen T, Neufeld KJ, Collop NA,
Needham DM. The association of sleep quality, delirium, and sedation status with daily
participation in physical therapy in the ICU. Crit Care. 2016;19:261.
41.
TEAM Study
Bellomo R, Brickell K, Broadley T, Buhr H, Gabbe BJ, Gould DW, Harrold M, Higgins AM,
Hurford S, Iwashyna TJ, Serpa Neto A, Nichol AD, Presneill JJ, Schaller SJ, Sivasuthan J,
Core outcome measures for clinical research in acute respiratory failure survivors.
Investigators and the ANZICS Clinical Trials Group, Hodgson CL, Bailey M,
206 R. Martinez-Alejos et al.
Tipping CJ, Webb S, Young PJ. Early active mobilization during mechanical ventilation in the
ICU. N Engl J Med. 2022;387(19):1747–58.
42. Liu M, Luo J, Zhou J, Zhu X. Intervention effect of neuromuscular electrical stimulation on ICU
acquired weakness: a meta-analysis. Int J Nurs Sci. 2020;7(2):228–37.
43. Gruther W, Kainberger F, Fialka-Moser V, Paternostro-Sluga T, Quittan M, Spiss C, Crevenna
R. Effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor
muscles in intensive care unit patients: a pilot study. J Rehabil Med. 2010;42(6):593–7.
44. Latronico N, Friedrich O. Electrophysiological investigations of peripheral nerves and muscles:
a method for looking at cell dysfunction in the critically ill patients. Crit Care. 2019;23(1):33.
45. Hermans G, Casaer MP, Clerckx B, Güiza F, Vanhullebusch T, Derde S, Meersseman P, Derese
I, Mesotten D, Wouters PJ, Van Cromphaut S, Debaveye Y, Gosselink R, Gunst J, Wilmer A,
Van den Berghe G, Vanhorebeek I. Effect of tolerating macronutrient deficit on the development of intensive-care unit acquired weakness: a subanalysis of the EPaNIC trial. Lancet Respir
Med. 2013;1(8):621–9. https://doi.org/10.1016/S2213-2600(13)70183-8.
46. Van den Berghe G, Schoonheydt K, Becx P, Bruyninckx F, Wouters PJ. Insulin therapy protects
the central and peripheral nervous system of intensive care patients. Neurology. 2005;64
(8):1348–53.
47. Thiessen SE, Derde S, Derese I, Dufour T, Vega CA, Langouche L, Goossens C, Peersman N,
Vermeersch P, Vander Perre S, Holst JJ, Wouters PJ, Vanhorebeek I, Van den Berghe G. Role
of glucagon in catabolism and muscle wasting of critical illness and modulation by nutrition.
Am J Respir Crit Care Med. 2017;196(9):1131–43.
48. Álvarez EA, Garrido MA, Tobar EA, Prieto SA, Vergara SO, Briceño CD, González FJ.
Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: a pilot randomized clinical trial. J Crit Care. 2017;37:85–90.
49. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L,
Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB,
Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill
patients: a randomized controlled trial. Lancet. 2009;373(9678):1874–82.
50. Hongo T, Yamamoto R, Liu K, Yaguchi T, Dote H, Saito R, Masuyama T, Nakatsuka K,
Watanabe S, Kanaya T, Yamaguchi T, Yumoto T, Naito H, Nakao A. Association between
timing of speech and language therapy initiation and outcomes among post-extubation dysphagia patients: a multicenter retrospective cohort study. Crit Care. 2022;26(1):98.
51. Turra GS, Schwartz IVD, Almeida ST, Martinez CC, Bridi M, Barreto SSM. Efficacy of speech
therapy in post-intubation patients with oropharyngeal dysphagia: a randomized controlled trial.
Codas. 2021;33(2):e20190246.
52. Kotfis K, van Diem-Zaal I, Williams Roberson S, Sietnicki M, van den Boogaard M, Shehabi Y,
Ely EW. Correction to: the future of intensive care: delirium should no longer be an issue. Crit
Care. 2022;26(1):285.
Chapter 19
Ethical Considerations in Critical Care
Nutrition
Giorgio Fullin, Eugenia Magnanimi, Michela Zardin, and Andrej Michalsen
Bioethics in Clinical Practices
Medical ethics provides clinicians with a framework to navigate intricate ethical
dilemmas, offering a comprehensive perspective to consider relationships, responsibilities, and nuances inherent in clinical practice, particularly in decisions
pertaining to human life. Within the realm of medical science, various technologies
dictate what can be technically achieved in specific cases. In contrast, medical ethics
directs attention to what should be done.
Bioethics, as a subset, involves the application of appropriate measures, consid-
patients’ wishes, values, and preferences. It promotes shared decision-making
ering
and addresses challenging issues. The ethical complexities in medicine can subject
clinicians to stress and decision-making fatigue, underscoring the need for a clear
path in clinical reasoning.
Since 1979, Tom L. Beauchamp and James F. Childress have developed the
Principlism ethical model. This practical approach facilitates the analysis and
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-66541-7_19.
G. Fullin (
Department of Anesthesia and Intensive Care, Ca’ Foncello Hospital, Treviso, Italy
E. Magnanimi
Department of Emergency, Critical Care Medicine and Trauma, Eugenia Magnanimi,
Policlinico Umberto I, Rome, Italy
M. Zardin
Anesthesia, and Intensive Care, Valli del Noce Hospital, Cles, Trento, Italy
A. Michalsen
Department of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Konstanz
Hospital, Constance, Germany
© The
A. Cotoia et al. (eds.), Nutrition, Metabolism and Kidney Support,
https://doi.org/10.1007/978-3-031-66541-7_19
✉)
Author(s), under exclusive license to Springer Nature Switzerland AG 2024
207
208 G. Fullin et al.
resolution of complex cases where determining the most appropriate choice is
challenging. Grounded in widely accepted principles—respect for autonomy, beneficence, non-maleficence, and distributive justice—this model provides a structured
framework.
Autonomy, or self-governance, und
erscores a competent patient’s right to refuse
treatment after receiving adequate information, even if this refusal may lead to their
own death. It emphasizes individual freedom in healthcare decision-making,
acknowledging the right to self-determination. Importantly, autonomy extends to
situations where patients are unable to fully express their will, a common scenario in
critical illness.
Beneficence obligates healthcare providers to act in the patient’s best interests,
promoting what is good for them. The principle of non-maleficence, encapsulated in
“Primum non nocere,” mandates the avoidance of causing harm to others. Justice, in
the context of medical ethics, ensures equal access to healthcare for all, advocating
for fair resource distribution without discrimination, guided by ethically appropriate
and transparent criteria.
These ethical principles are integral to medical decision-making, extending their
relevance to nutritional therapy. In the realm of nutritional choices, careful consideration is essential to determine the treatment that is most beneficial and least
harmful, with a primary focus on respecting human dignity and considering the
overall clinical condition and prospects of the individual.
al et
Medic
hics offers a framework for clinicians to navigate complex ethical
dilemmas; it provides a lens to thoughtfully consider all the relationships, responsibilities, and nuances involved in clinical practice, especially when it comes to
decisions concerning human life. Bioethics, among others, involves the application
of appropriate measures considering the patents’ wishes, values, and preferences.
Medical science is applied through a variety of technologies, which determine what
we can technically do in any given case. Medical ethics, on the other hand, focuses
on what we should do.
Furthermore,
challenging issues [
bioethics encourages shared decision-making and the resolution of
1, 2]. The ethical complexities in medicine can subject clinicians
to stress and decision-making fatigue unless they follow a clear path in clinical
reasoning. Starting from 1979, Tom L. Beauchamp and James F. Childress developed the Principlism ethical model, a practical approach to facilitate the analysis and
resolution of complex cases, where it is difficult to understand which the most
appropriate choice is is under the respective circumstances [
This model is
3].
grounded on the adoption of some widely accepted principles, namely, the principle
of respect for autonomy, the principle of beneficence, the principle of
non-maleficence, and the principle of distributive justice. Autonomy, quite literally,
means self-governance. A competent patient has the right to refuse a treatment after
receiving adequate information, even if this refusal would result in their own death.
Autonomy provides us with the idea that individual patients should have the freedom
to make their own decisions about healthcare [
3].
This means recognizing the
individual’s right for self-determination, their ability to make independent decisions.
Autonomy does not imply that a patient must receive any treatment they wish or