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Intensive Early Rehabilitation in the Intensive Care Unit for Liver Transplant Recipients: A Randomized Controlled Trial

Published:March 07, 2017DOI:https://doi.org/10.1016/j.apmr.2017.01.028

      Abstract

      Objective

      To validate the feasibility and tolerance of an intensive rehabilitation protocol initiated during the postoperative period in an intensive care unit (ICU) in liver transplant recipients.

      Design

      Prospective randomized study.

      Setting

      ICU.

      Participants

      Liver transplant recipients over a period of 1 year (N=40).

      Interventions

      The “usual treatment group” (n=20), which benefited from the usual treatment applied in the ICU (based on physician prescription for the physiotherapist, with one session a day), and the experimental group (n=20), which followed a protocol of early and intensive rehabilitation (based on a written protocol validated by physicians and an evaluation by physiotherapist, with 2 sessions a day), were compared.

      Main Outcome Measures

      Our primary aims were tolerance, assessed from the number of adverse events during rehabilitation sessions, and feasibility, assessed from the number of sessions discontinued.

      Results

      The results revealed a small percentage of adverse events (1.5% in the usual treatment group vs 1.06% in the experimental group) that were considered to be of low intensity. Patients in the experimental group sat on the edge of their beds sooner (2.6 vs 9.7d; P=.048) and their intestinal transit resumed earlier (5.6 vs 3.7d; P=.015) than patients in the usual treatment group. There was no significant difference between the 2 arms regarding length of stay (LOS), despite a decrease in duration in the experimental group.

      Conclusions

      The introduction of an intensive early rehabilitation program for liver transplant recipients was well tolerated and feasible in the ICU. We noted that the different activities proposed were introduced sooner in the experimental group. Moreover, there is a tendency to decreased LOS in the ICU for the experimental group. These results now need to be confirmed by studies on a larger scale.

      Keywords

      List of abbreviations:

      AE (adverse event), ICU (intensive care unit), LOS (length of stay), LT (liver transplantation), MAP (mean arterial pressure), MRC (Medical Research Council), RR (respiratory rate)
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      References

        • Starzl T.E.
        • Groth G.
        • Brettschneider L.
        • et al.
        Orthotopic homotransplantation of the human liver.
        Ann Surg. 1968; 168: 392-415
        • Monn D.B.
        • Lee S.G.
        Liver transplantation.
        Gut Liver. 2009; 3: 145-165
      1. European Liver Transplant Registry. Overall indication and results. Available at: http://www.eltr.org/spip.php?article161. Accessed December 15, 2016.

        • Griffiths R.
        • Hall J.
        Intensive care unit-acquired weakness.
        Crit Care Med. 2010; 38: 779-787
        • Chambers M.
        • Moylan J.
        • Reid M.
        Physical inactivity and muscle weakness in the critically ill.
        Crit Care Med. 2009; 37: S337-S346
        • De Jonghe B.
        • Sharshar T.
        • Lefaucheur J.P.
        Paresis acquired in the intensive care: a prospective multicenter study.
        JAMA. 2002; 288: 2859-2867
        • De Jonghe B.
        • Lacherade J.C.
        • Sharshar T.
        Intensive care unit acquired weakness: risk factors and factors and prevention.
        Crit Care Med. 2009; 37: S309-S315
        • Dres M.
        • Dubé B.P.
        • Mayaux J.
        • et al.
        Coexistence and impact of limb muscle and diaphragm weakness at time of liberation from mechanical ventilation in medical intensive care unit patients.
        Am J Respir Crit Care Med. 2017; 195: 57-66
        • Herridge M.S.
        • Cheung A.M.
        • Tansey C.M.
        • et al.
        One year outcomes in survivors of the acute respiratory distress syndrome.
        N Engl J Med. 2003; 348: 683-693
        • Hofhuis J.G.
        • Van Stel H.F.
        • Schrijvers A.J.
        Health related quality of life in critically ill patients: how to score and what is the clinical impact?.
        Curr Opinion Crit Care. 2009; 15: 1-6
        • Burtin C.
        • Clerckx B.
        • Robbeets C.
        • et al.
        Early exercise in critically ill patients: a randomized controlled trial.
        Crit Care Med. 2009; 37: 2499-2505
        • Needham D.
        Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function.
        JAMA. 2008; 300: 1685-1691
        • Pohlman M.
        • Schweickert W.
        • Polhman A.
        • et al.
        Feasability of physical and occupational therapy beginning from initiation of mechanical ventilation.
        Crit Care Med. 2010; 38: 2089-2094
        • Morris P.E.
        • Goad A.
        • Thompson G.
        • et al.
        Early intensive care unit mobility in the treatment of acute respiratory failure.
        Crit Care Med. 2008; 36: 2238-2243
        • Perme C.
        • Chandrashekar R.
        Early mobility and walking program for patients in ICU: creating a standard of care.
        Am J Crit Care. 2009; 18: 212-221
        • Gosselink R.
        • Clerckx B.
        • Robbeets C.
        • Vanhullebusch T.
        • Vanpee G.
        • Segers J.
        Netherlands physiotherapy in the intensive care unit.
        J Crit Care. 2011; 15: 66-75
        • Bailey P.
        • Thomsen G.E.
        • Spulher V.J.
        • et al.
        Early activity is feasible and safe in respiratory failure patients.
        Crit Care Med. 2007; 35: 139-145
        • Schweickert W.D.
        • Pohlman M.C.
        • Pohlman A.S.
        • et al.
        Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial.
        Lancet. 2009; 373: 1874-1882
        • Needham D.M.
        • Korupolu R.
        • Zanni J.
        • et al.
        Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.
        Arch Phys Med Rehabil. 2010; 91: 536-542
        • Bourdin G.
        • Barbier J.
        • Burle J.F.
        • et al.
        The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study.
        Respir Care. 2010; 55: 400-407
        • Winkellman C.
        • Johnson K.
        • Hejal R.
        • et al.
        Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study.
        Intensive Crit Care Nurs. 2012; 28: 307-318
        • Kayambu G.
        • Boots R.
        • Paratz J.
        Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomised controlled trial.
        Intensive Care Med. 2015; 41: 865-874
        • De Jonghe B.
        • Lacherade J.C.
        • Durand M.C.
        • Sharshar T.
        Critical illness neuromuscular syndromes.
        Neurol Clin. 2008; 26: 507-520
        • Fan E.
        • Ciesla N.
        • Truong A.
        • Boopathi V.
        • Zeger S.
        • Needham D.
        Inter-rate reliability of manual muscle strength testing in ICU survivors and simulated patients.
        Intensive Care Med. 2010; 36: 1038-1043
        • Leditschke A.
        • Green M.
        • Irvine J.
        • Bisset B.
        • Mitchell I.A.
        What are the barriers to mobilizing intensive care patients?.
        Cardiopulm Phys Ther J. 2012; 23: 26-29
        • Hopkins R.O.
        • Miller R.R.
        • Rodriguez L.
        • Spuhler V.
        • Thomsen G.E.
        Physical therapy on the wards after early physical activity and mobility in the ICU.
        Phys Ther. 2012; 92: 1518-1523
        • Li Zhigiang
        • Xiaoxia
        • Bo Z.
        • Zhang Y.
        • Xi X.
        Active mobilization for mechanically ventilated patients: a systematic review.
        Arch Phys Med Rehabil. 2012; 94: 551-561
        • Rongies W.
        • Stepnewska S.
        • Pyzynska E.
        • et al.
        Rehabilitation principles in patients after orthotopic liver transplantation.
        Hepatology. 2005; 1: 41-44
        • Mor E.
        • Cohen J.
        • Erez E.
        • et al.
        Short intensive care unit stay reduces septic complications and improve outcome after liver transplantation.
        Transplant Proc. 2001; 33: 2939-2940
        • Mandell
        • Lezott D.
        • Kam I.
        • Zamudio S.
        Reduced use of intensive care after liver transplantation: Influence of early extubation.
        Liver Transplant. 2002; 8: 676-681
        • Delaney C.
        • Zutshi M.
        • Senagore
        • Remzi F.
        • Hammel J.
        • Fazio V.
        Prospective randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection.
        Dis Colon Rectum. 2003; 46: 851-859
        • Browning L.
        • Denehy L.
        • Scholes R.
        The quantity of early upright mobilization performed following upper abdominal surgery is low: an observational study.
        Aust J Physiother. 2007; 53: 47-52
        • Richard J.C.
        • Maggiore S.M.
        • Mancebo J.
        • Lemaire F.
        • Jonson B.
        • Brochard L.
        Effects of vertical positioning on gas exchange and lung volumes in acute respiratory distress syndrome.
        Intensive Care Med. 2006; 32: 1623-1626
        • Deye N.
        • Lellouche F.
        • Maggiore S.
        • et al.
        The semi-seated position slightly reduces the effort to breathe during difficult weaning.
        Intensive Care Med. 2013; 39: 85-92
        • Rongies W.
        • Stepniewska B.
        • Golinska B.
        • et al.
        An attempt to assess the influence of primary desease on the results of therapeutic rehabilitation in an early post-operative period of orthotopic liver transplant recipients.
        Ann Transplant. 2008; 13: 40-43
        • Rongies W.
        • Stepniewska B.
        • Golinska B.
        • et al.
        Influence of the primary disease on rehabilitation results in the early postoperative period in patients after orthotopic liver transplantation.
        Transplant Proc. 2009; 41: 3119-3122
        • Beyer N.
        • Aadahl M.
        • Strange B.
        • et al.
        Improved physical performance after orthotopic liver transplantation.
        Liver Transplant Surg. 1999; 5: 301-309
        • Epstein S.K.
        • Freeman R.
        • Khayat A.
        • Unterborn J.
        • Pratt D.
        • Kaplan M.
        Aerobic capacity is associated with 100 day outcome after hepatic transplantation.
        Liver Transplant. 2004; 10: 418-424
        • Lemyze M.
        • Dharancy S.
        • Nevière R.
        • Pruvot F.R.
        • Declerck N.
        • Wallaert B.
        Aerobic capacity in patients with chronic liver disease: very modest effect of liver transplantation.
        Presse Med. 2010; 39: 174-181
        • Senduran M.
        • Yurdalan S.U.
        • Karadibak
        • Gunerli A.
        Haemodynamic effects of physiotherapy programme in intensive care unit after liver transplantation.
        Disabil Rehabil. 2010; 32: 1461-1466
        • Stiller K.
        • Phillips A.
        • Lambert P.
        The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients.
        Physiother Theory Pract. 2004; 20: 175-185
        • Zafiropoulos B.
        • Alison J.A.
        • McCarren B.
        Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient.
        Aust J Physiother. 2004; 50: 95-100
        • Adler J.
        • Malone D.
        Early mobilization in the intensive care unit: a systematic review.
        Cardiopulm Phys Ther J. 2012; 23: 5-13
        • Lord R.
        • Mayhew C.
        • Korupolu R.
        • Needham D.
        ICU early physical rehabilitation programs: financial modeling of cost savings.
        Crit Care Med. 2013; 41: 717-724
        • Morris P.E.
        • Berry M.J.
        • Files D.C.
        • et al.
        Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: a randomized clinical trial.
        JAMA. 2016; 315: 2694-2702