What are the recommendations for initiating mobility protocols in the Cardiovascular Intensive Care Unit (CVICU) to improve coordination and mobility in patients?

Early Mobilization in the Cardiovascular ICU

Implement a protocol-based early mobilization program within 72 hours of CVICU admission that combines both passive and active components, progressing stepwise to the highest tolerable level for each patient. 1

Timing of Initiation

• Start early mobilization within 72 hours of ICU admission for all functionally independent patients without contraindications 1
• Median time to first mobilization activity can be as early as 19 hours from admission in well-organized programs 2
• Previously functionally dependent patients should also receive early mobilization, though evidence is less robust (Level of Evidence 3) 1

Protocol Implementation

Use a structured protocol that includes both passive and active mobilization components (Level of Evidence 1) 1

The protocol should incorporate:

• Passive mobilization (range of motion, positioning, muscle stretching) when consciousness, cognition, or hemodynamics prevent active participation 1, 3
• Active mobilization progressing through bed exercises, sitting, standing, to ambulation based on patient tolerance 1, 3
• Stepwise progression to the highest possible level at each session rather than aggressive maximal mobilization from the start 1

This approach is superior to protocols using only active mobilization, as the TEAM trial showed that pushing patients to maximum activity levels provided no benefit 1

Safety Criteria and Cardiovascular Considerations

Assess adequate respiratory and cardiovascular reserve before each session, though no absolute parameter cutoffs exist 1

Discontinuation Criteria

Stop mobilization if any of the following occur 1:

• Oxygen saturation < 86%
• Heart rate increase > 30% from baseline
• Systolic blood pressure rise ≥ 40 mmHg from baseline
• Diastolic blood pressure rise ≥ 20 mmHg from baseline
• Mean arterial pressure < 60 mmHg
• New or worsened cardiac arrhythmia requiring treatment
• Deterioration in level of consciousness
• Uncontrolled pain despite adequate analgesia

Special CVICU Populations

Patients on ECMO or CRRT can be mobilized after interprofessional consultation when no contraindications exist 1

• ECMO mobilization carries 3.4-3.6% adverse event rate (mostly self-limiting low flow alarms) with only one reported cannula displacement 1
• CRRT mobilization has only 1.8% adverse event rate 1
• These interventions require centers with appropriate expertise 1

Session Preparation

Before each mobilization session 1:

• Inform the patient about the planned activity
• Ensure sufficient staff are available (typically requires multidisciplinary team)
• Secure and extend all artificial airways, intravenous lines, and drains
• Adjust alarm limits appropriately
• Monitor vital functions continuously throughout the intervention 3

Integration with Comprehensive Care

Integrate early mobilization into the ABCDEF bundle (Assess pain, Both SAT/SBT, Choice of sedation, Delirium management, Early mobility, Family engagement) 1

This bundled approach consistently improves patient outcomes and creates synergistic effects 1

Dosing and Intensity

• Higher mobilization doses (≥30 minutes daily) improve quality of life at 6 months and reduce mortality 1
• Mobilization duration >40 minutes positively impacts functional outcomes at ICU discharge 1
• Use low-resistance multiple repetitions (3 sets of 8-10 repetitions at 50-70% of 1 repetition maximum) for strength training 3
• Reduce metabolic demands by decreasing active muscle mass, exercise duration, or repetitions when cardiovascular reserve is limited 3

Common Pitfalls

Avoid these errors:

• Waiting for "perfect" hemodynamic stability—patients on vasopressors can be mobilized safely (35% of mobilized patients in one study required vasopressors) 2
• Excluding mechanically ventilated patients—51% of successfully mobilized patients were ventilated 2
• Using immobilization as default—immobilization should require explicit medical prescription 1
• Insufficient staffing or equipment—hospital management must provide necessary resources 1

Outcomes

Early mobilization in the ICU reduces:

• Duration of mechanical ventilation 4, 5
• ICU length of stay 1, 4, 5
• Hospital length of stay 1
• ICU-acquired weakness 1
• Ventilator-associated pneumonia 1

Adverse events occur in only 2.6-3.9% of mobilization sessions, with hemodynamic instability causing interruption in just 0.8% of activities 1, 2