Mobilization in Indian intensive care units: Where do we stand?

Sir,

We read with the great interest the article by Rajesh Chawla et al. (2014) surveying the mobilization, analgesic, and sedative practises in Indian intensive care units (ICUs).[1] We appreciate the authors for the greater efforts in evaluating the intensive care practises at a larger scale. Though the response rate was poor(11%), the study paves way for utilization of several standardization procedures including therapeutic practises in ICUs. Especially the study has demonstrated mobilization practices in Indian ICUs.

Mobilization is a standard practice in western ICUs. Earlier research had elaborated effects of early mobilization in maintenance of muscle mass, thus preventing critical illness myoneuropathy, increasing functional capacity, early functional independence, early weaning, reduction of ventilator-associated pneumonia and critical illness, reduction of intensive care, and hospital stay, improving neuropsychiatric outcomes such as ICU delirium, reduction of caregiver stress, and health resource utilization.[2,3,4,5,6,7] Western literature including meta-analysis and systematic reviews are available stating significant evidence in mobilization of critically ill patients.[2,5,7]

In the article by Rajesh Chawla (2014), we are not surprised by the fact that out of 94% (614 physician responders), only 13% (90 physicians) were in favor of mobilizing critically ill patients with equipments (ventilators and tubes).[1] Western literature supports mobilization of intensive care patients with ventilators and assistive devices.[8,9] Safety in mobilizing intensive care patients with ventilators and tubes are proved earlier.[10,11] We disagree the author in holding only physician apprehension as responsible for poor mobilization practises in Indian ICUs. This may be due to lack of infrastructure, expertise training in handling mobile ventilators, and mobilizing aids, such as mechanical hoists (passive transfer using mechanical aids),[12] lack of therapist's and nurse's knowledge of initiating and progressing early mobilization in ICU, criteria for termination of mobilization, screening for risk stratification during mobilization, knowledge about mobility aids, and safe handling techniques.[10,11] New promising researches are put forward depicting the positive attitude of mobilizing patients in Indian ICUs in past few years.[13,14,15] We recommend future trials in elucidating the effects of early mobilization in intensive care outcomes in Indian medical pitch.

Apart from the study mentioned, limitation, such as the poor response rate poor responders, few other setbacks prevent from generalization of the study results in Indian clinical arena.[1] First, majority of the responders are age below 40 (59%) and ICU practising experience below 5 years (41%). Since this survey partially depends on the experience of the practising intensivists, the practise patterns elaborated in the study are questionable to certain extent. Second, the majority of the responders are from institutions with less than 20 ICU beds (77%). Though the bed strength falls within the standardization of Indian Society for Critical care medicine (ISCCM), the systematic mobilization program may not be implemented at ease within the constrained perimeter of the ICUS included in the present study. Further, the current survey could have inclusions of various ICUs such as cardiology, neurology, post-surgical and traumatic practice patterns differing between ICUs within an Insitution itself which may question the applicability of the results in Indian clinical arena.

Other than the above limitations, the study adds evidence to the current therapeutic practises, newer association between sedation and mobilization and neuropsychiatric outcomes such as delirium in Indian intensive care settings. We appreciate once again the authors for demonstrating lag of current ICU practices behind the standard guidelines of therapeutic applications in Indian ICUs.