What are the recommendations for early mobilization in critically ill patients in the Intensive Care Unit (ICU) setting?

ICU Early Mobilization

Direct Recommendation

Early mobilization should be initiated within 72 hours of ICU admission using a protocol-based, stepwise approach that progresses from passive to active exercises, integrated into the ABCDEF bundle, with sessions lasting ≥30-40 minutes daily when tolerated. 1, 2, 3

Timing of Initiation

• Start mobilization within 72 hours (ideally within the first few days) of ICU admission for all functionally independent patients after initial cardiorespiratory and neurological stabilization 1, 2, 3
• Previously functionally dependent patients should also receive early mobilization, though the evidence base is less robust 3
• The critical intervention window is early in the ICU course, as electrophysiological changes occur within 48 hours and muscle loss is rapid 4

Protocol-Based Implementation

A structured, protocol-based approach is essential and must include both passive and active components: 1, 2

Stepwise Progression Hierarchy

The mobilization protocol should follow this hierarchical progression based on patient tolerance: 1, 2, 3

1. Passive interventions (for unconscious/sedated patients):

   • Positioning upright ≥40° upper body elevation when hemodynamically stable 2, 4
   • Passive range of motion exercises 2
   • Neuromuscular electrical stimulation (NMES) for patients unable to move voluntarily 2, 4
   • Muscle stretching and splinting 2, 4

2. Assisted exercises:

   • Bed cycling using bedside ergometers 2, 4
   • Functional exercises with assistance 2

3. Active exercises (for alert, cooperative patients):

   • Active exercises in bed 2
   • Sitting at edge of bed 4
   • Bed-to-chair transfers 4
   • Standing 4
   • Walking with aids 2, 4

4. Resistance training:

   • 3 sets of 8-10 repetitions at 50-70% of 1 repetition maximum 2, 4
   • Target large muscle groups 4

Dosing and Duration

• Mobilization sessions should last ≥30-40 minutes daily to achieve optimal outcomes 1, 3
• Higher doses (≥30 minutes/day) improve quality of life at 6 months and reduce mortality 3
• Duration >40 minutes positively impacts functional outcomes at ICU discharge 1, 3
• Progress stepwise to the highest possible level at each session rather than attempting maximal mobilization from the start 1, 3

Safety Criteria and Contraindications

Pre-Session Assessment Requirements

Before each mobilization session, ensure: 1, 3

• Patient is informed about planned activity
• Sufficient staff is available
• All artificial airways, IV lines, and drains are secured and extended
• Alarm limits are adjusted appropriately
• Continuous vital function monitoring is in place

Absolute Contraindications to Mobilization

Do not mobilize patients with: 1, 4

• Hemodynamic instability or active resuscitation
• Uncontrolled cardiac arrhythmias
• Active myocardial ischemia
• Increased intracranial pressure
• Intravenous antihypertensive therapy for hypertensive emergency 1

Stop Mobilization Immediately If:

Terminate the session if any of the following occur: 1, 3

• 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 onset or worsened cardiac arrhythmia requiring treatment
• Deterioration in level of consciousness
• Uncontrolled pain despite adequate analgesia

Relative Considerations

• Patients with high FiO₂ requirements (>0.6), high ventilatory support, or hemodynamic instability are not candidates for aggressive mobilization 2, 4
• Endotracheal intubation is NOT a contraindication to early mobilization 1, 3
• FiO₂ < 0.6 with SpO₂ > 90% and respiratory rate < 30 breaths/minute are considered safe for in-bed and out-of-bed mobilization 1

Special Populations

ECMO and CRRT Patients

• Patients on ECMO or CRRT can be mobilized after interprofessional consultation when no contraindications exist 3
• ECMO mobilization carries 3.4-3.6% adverse event rate (mostly self-limiting low flow alarms) with only one reported cannula displacement 3
• CRRT mobilization has only 1.8% adverse event rate 3

Mechanically Ventilated Patients

• Mechanical ventilation is not a contraindication to mobilization 1, 3
• Mobilization is well tolerated even in intubated patients 5
• Ensure adequate respiratory reserve before each session 1, 3

Integration with Comprehensive Care

Early mobilization must be integrated into the ABCDEF bundle: 1, 3

• Assess, prevent, and manage pain
• Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
• Choice of analgesia and sedation
• Delirium: assess, prevent, and manage
• Early mobility and exercise
• Family engagement and empowerment

Expected Outcomes

Early mobilization in the ICU: 3

• Reduces duration of mechanical ventilation
• Decreases ICU length of stay by 1.82 days 4
• Reduces hospital length of stay by 3.90 days 4
• Reduces ICU-acquired weakness by 51% (RR = 0.49) 4
• Decreases ventilator-associated pneumonia
• Improves functional outcomes at discharge

Safety Profile

• Adverse events occur in only 2.6-3.9% of mobilization sessions 3
• Hemodynamic instability causes interruption in just 0.8% of activities 3
• Early mobilization is safe and feasible when appropriate safety criteria are followed 1, 6

Common Pitfalls to Avoid

• Do not delay mobilization waiting for complete resolution of all abnormalities—the risks of immobility outweigh the risks of mobilization when safety criteria are met 3, 4
• Do not attempt maximal mobilization immediately—use stepwise progression to avoid overburdening patients 1, 3
• Do not mobilize without adequate staffing and equipment—early mobilization is labor-intensive and requires appropriate resources 6
• Do not ignore the critical early window—mobilization programs beginning after ICU discharge have limited impact on mitigating weakness 4
• Immobilization should be the exception, not the rule 1