title: Early Mobilization in the Intensive Care Unit: A Systematic Review Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up Predictors of mortality and short-term physical and cognitive dependence in critically ill persons 75 years and older: a prospective cohort study Muscle thickness, measured with ultrasound, may be an indicator of lean tissue wasting in multiple organ failure in the presence of edema. Bioelectrical impedance assessment of nutritional status in critically ill patients. Effect of nutritional support on routine nutrition assessment parameters and body composition in intensive care unit patients. Critically ill elderly patients in a developing world--mortality and functional outcome at 1 year: a prospective single-center study. Inter-rater reliability of manual muscle strength testing in ICU survivors and simulated patients Muscle wasting in intensive care patients: ultrasound observation of the M. quadriceps femoris muscle layer. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments Disability in activities of daily living, depression, and quality of life among older medical ICU survivors: a prospective cohort study Effects of Physical Training on Functional Status in Patients With Prolonged Mechanical Ventilation Measuring change in disability after inpatient rehabilitation: comparison of the responsiveness of the Barthel Index and the Functional Independence Measure Initial interrater reliability for a novel measure of patient mobility in a cardiovascular intensive care unit. Outcome of older patients requiring ventilatory support in intensive care: impact of nutritional status. Presence and severity of intensive care unit-acquired paresis at time of awakening are associated with increased intensive care unit and hospital mortality* The interobserver agreement of handheld dynamometry for muscle strength assessment in critically ill patients Mortality in healthy elderly patients after ICU admission Alterations in Respiratory and Limb Muscle Strength and Size in Patients With Sepsis Who Are Mechanically Ventilated Physical Complications in Acute Lung Injury Survivors: A Two-Year Longitudinal Prospective Study The Clinical Utility of the Functional Status Score for the Intensive Care Unit (FSS-ICU) at a Long-Term Acute Care Hospital: A Prospective Cohort Study Usefulness of a clinical diagnosis of ICU-acquired paresis to predict outcome in patients with SIRS and acute respiratory failure Assessment of body cell mass at bedside in critically ill patients. Functional Recovery Following Physical Training in Tracheotomized and Chronically Ventilated Patients Predictive factors of in-hospital mortality in older patients admitted to a medical intensive care unit. Body composition analysis in critically ill survivors: a comparison of bioelectrical impedance spectroscopy devices. Interest of conventional clinical, biochemical and bioimpedance measurements as indicators of mortality risk in critical patients. The surgical intensive care unit optimal mobility score predicts mortality and length of stay* Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. Acute skeletal muscle wasting in critical illness. Poor functional status immediately after discharge from an intensive care unit The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. Association between ultrasound measurements of muscle thickness, pennation angle, echogenicity and skeletal muscle strength in the elderly Global Muscle Strength But Not Grip Strength Predicts Mortality and Length of Stay in a General Population in a Surgical Intensive Care Unit The Physical Function Intensive Care Test: Implementation in Survivors of Critical Illness Acquired weakness, handgrip strength, and mortality in critically ill patients.
abstract: Purpose : The purpose of this review is to evaluate the literature related to mobilization of the critically ill patient with an emphasis on functional outcomes and patient safety . Methods : We search ed the electronic data bases of PubMed , CINAHL , Medline ( Ovid ) , and The Cochrane Library for a period spanning 2000‐2011 . Articles used in this review included r and omized and nonr and omized clinical trials , prospect i ve and retrospective analyses , and case series in peer review ed journals . Sackett 's Levels of Evidence were used to classify the current literature to evaluate the strength of the outcomes reported . Results : Fifteen studies met inclusion criteria and were review ed . According to Sackett 's Levels of Evidence , 9 studies were level 4 evidence , one study was level 3 , 4 studies were level 2 , and one study was level one evidence . Ten studies pertained to patient safety/feasibility and 10 studies pertained to functional outcomes with 5 fitting into both categories . Conclusion : A search of the scientific literature revealed a limited number of studies that examined the mobilization of critically ill patients in the intensive care unit . However , literature that does exist supports early mobilization and physical therapy as a safe and effective intervention that can have a significant impact on functional outcomes Introduction The purpose of this trial was to investigate the effectiveness of an exercise rehabilitation program commencing during ICU admission and continuing into the outpatient setting compared with usual care on physical function and health-related quality of life in ICU survivors . Methods We conducted a single-center , assessor-blinded , r and omized controlled trial . One hundred and fifty participants were stratified and r and omized to receive usual care or intervention if they were in the ICU for 5 days or more and had no permanent neurological insult . The intervention group received intensive exercises in the ICU and the ward and as out patients . Participants were assessed at recruitment , ICU admission , hospital discharge and at 3- , 6- and 12-month follow-up . Physical function was evaluated using the Six-Minute Walk Test ( 6MWT ) ( primary outcome ) , the Timed Up and Go Test and the Physical Function in ICU Test . Patient-reported outcomes were measured using the Short Form 36 Health Survey , version 2 ( SF-36v2 ) and Assessment of Quality of Life ( AQoL ) Instrument . Data were analyzed using mixed models . Results The a priori enrollment goal was not reached . There were no between-group differences in demographic and hospital data , including acuity and length of acute hospital stay ( LOS ) ( Acute Physiology and Chronic Health Evaluation II score : 21 vs 19 ; hospital LOS : 20 vs 24 days ) . No significant differences were found for the primary outcome of 6MWT or any other outcomes at 12 months after ICU discharge . However , exploratory analyses showed the rate of change over time and mean between-group differences in 6MWT from first assessment were greater in the intervention group . Conclusions Further research examining the trajectory of improvement with rehabilitation is warranted in this population .Trial registration The trial was registered with the Australian New Zeal and Clinical Trials Registry ACTRN12605000776606 Background The purpose of this study was to identify predictors of 3-month mortality in critically ill older persons under medical care and to assess the clinical impact of an ICU stay on physical and cognitive dependence and subjective health status in survivors . Methods We conducted a prospect i ve observational cohort study including all older persons 75 years and older consecutively admitted into ICU during a one-year period , except those admitted after cardiac arrest , All patients were followed for 3 months or until death . Comorbidities were assessed using the Charlson index and physical dependence was evaluated using the  Katz index of Activity of Daily Living ( ADL ) .  Cognitive dependence was determined by a score based on the individual components of the Lawton index of Daily Living and subjective health status was evaluated using the Nottingham  Health Profile ( NHP ) score . Results One hundred patients were included in the analysis . The mean age was 79.3 ± 3.4 years .  The median Charlson index was 6 [ IQR , 4 to 7 ] and the mean ADL and cognitive scores were 5.4 ± 1.1 and 1.2 ± 1.4 , respectively , corresponding to a population with a high level of comorbidities but low physical and cognitive dependence . Mortality was 61/100 ( 61 % ) at 3 months . In multivariate analysis only comorbidities assessed by the Charlson index [ Adjusted Odds Ratio , 1.6 ; 95 % CI , 1.2 - 2.2 ; p < 0.003 ] and the number of organ failures assessed by the SOFA score [ Adjusted Odds Ratio , 2.5 ; 95 % CI , 1.1 - 5.2 ; p < 0.02 ] were independently associated with 3-month mortality . All 22 patients needing renal support after Day 3 died . Compared with pre-admission , physical ( p = 0.04 ) , and cognitive ( p = 0.62 ) dependence in survivors had changed very little at 3 months . In addition , the mean NHP score was 213.1 ± 132.8 at 3 months , suggesting an acceptable perception of their quality of life . Conclusions In a selected population of non surgical patients 75 years and older , admission into the ICU is associated with a 3-month survival rate of 38 % with little impact on physical and cognitive dependence and subjective health status . Nevertheless , a high comorbidity level ( ie , Charlson index ) , multi-organ failure , and the need for extra-renal support at the early phase of intensive care could be considered as predictors of death Multiple organ failure ( MOF ) is accompanied by muscle wasting , but changes in body composition are frequently obscured by fluid retention ( edema ) , mainly in superficial and visceral tissue . There is a need to assess body composition and changes in body composition in these circumstances independently of edema . A relation was sought between fat-free ( lean tissue ) mass [ calculated from body weight and skinfold thicknesses and measured by using dual-energy X-ray absorptiometry ( DXA ) ] and muscle thickness ( measured using ultrasound at a variety of sites accessible in an unconscious supine subject ) to determine which sites correlated best with lean body mass . The three best sites were midbiceps , midforearm anteriorly , and midthigh anteriorly : R2 for the simple sum of the three sites correlated with fat-free mass from skinfold thicknesses was 71.1 % , and with lean tissue mass from DXA was 76.1 % . Serial measurements of both muscle thickness and midupper-arm circumference in nine patients with MOF showed a complete dissociation ; in all nine there was a significant negative correlation of muscle thickness with time ( P < 0.05 ) but changes in arm circumference were r and om . Only one patient showed a significant negative correlation with time , seven showed no change , and one other showed a significant increase . The muscle thicknesses that correlate best with lean body mass are measured over the biceps , anterior forearm , and anterior thigh . Monitoring muscle thicknesses at these three sites identifies wasting in edematous patients as it is happening The objective of this study was to assess the utility of bioelectrical impedance analysis ( BIA ) in determining nutritional status in critically ill patients in the intensive care unit ( ICU ) . Data were collected prospect ively in 33 mechanically ventilated medical and surgical ICU patients requiring nutrition as part of their care .  BIA , with subsequent calculation of body-composition indexes , was performed every other day for the duration of ICU stay . Body cell mass ( BCM ) changes correlated with energy and protein intakes ( r2 = 0.87 , P < 0.001 and r2 = 0.67 , P < 0.001 , respectively ) . Maintenance of BCM was achieved by a daily provision of 125.5 kJ.kg-1.d-1 ( 30 kcal.kg-1.d-1 ) and 1.5 g protein/kg whereas greater intakes allowed restoration of BCM . The mean ratios of exchangeable sodium to potassium ( Nae : Ke ) improved only in patients achieving positive nitrogen balance ( P = 0.013 ) . Body-composition changes determined by BIA represent a feasible adjunctive method for evaluating and monitoring nutritional status in ICU patients OBJECTIVES To determine whether routine nutrition assessment parameters and body composition change after nutritional support in intensive care unit ( ICU ) patients and whether the changes , if any , are related to cumulative energy and fluid balances . DESIGN A prospect i ve study . SETTING A university teaching hospital . PATIENTS Forty-five mechanically ventilated medical and surgical patients admitted to the ICU who received nutritional support for 7 days ( group 1 ) and 9 patients of this group who received nutritional support for 3 weeks or longer ( group 2 ) . INTERVENTIONS Enteral and parenteral nutritional support prescribed on the basis of metabolic cart measurements of energy expenditure . OUTCOME MEASURES Routine nutrition assessment , including determinations of weight , serum albumin and prealbumin , and lymphocyte count and body composition , including measurements of body cell mass , extracellular fluid and body fat , determined from bioelectric impedance analysis . RESULTS In group 1 patients , weight , albumin and prealbumin levels , and extracellular mass changed , but there was no change in lymphocyte count , body cell mass or body fat . Changes in weight and extracellular mass were slightly related to cumulative fluid balance ; changes in albumin and prealbumin levels were not related to cumulative energy or fluid balance . The findings were similar for group 2 patients . CONCLUSIONS Changes in routine nutrition assessment parameters and body composition are slightly affected by fluid balance but not by energy balance ; thus , they are not specific indicators of the adequacy of nutritional support in ICU patients . Improved nutrition assessment parameters are required to better monitor the response to nutritional support in critically ill patients PURPOSE To study the mortality and outcome of critically ill elderly patients in a developing country with focus on nutritional and socioeconomic status . METHODS A prospect i ve study of 109 patients ( 215 screened ) admitted consecutively to the intensive care unit from 2011 to 2012 .  Demographics , Acute Physiology and Chronic Health Evaluation ( APACHE ) II score , mechanical ventilation , Malnutrition Universal Screening Tool score , socioeconomic category , functional status , delirium , and length of stay were recorded . Telephonic assessment of outcome was done at 1 year . Appropriate statistical tests compared differences between subgroups . Multivariate analysis was performed on significant variables ( P<.1 ) affecting mortality . RESULTS At 12 months after discharge , 46.8 % of patients ( mean age , 76.5±9.6 years ; APACHEII , 22.7±6.4 ; and intensive care unit stay , 7.8±3.4 days ) had died . Risk factors for mortality at 12 months were APACHE II score ( P<.001 ; odds ratio [ OR ] , 1.2 ; 95 % confidence interval [ CI ] , 1.1 - 1.3 ) , severe malnutrition ( P=.006 ; OR , 0.08 ; 95 % CI , 0.01 - 0.48 ) , and delirium ( P=.03 ; OR , 0.32 ; 95 % CI , 0.11 - 0.9 ) . Risk factors for short-term mortality ( at 28 days ) were APACHE II score ( P=.02 ; OR , 1.1 [ 1.0 - 1.2 ] ) and premorbid functional status ( P=.03 ; OR , 0.2 [ 0.1 - 0.8 ] ) . Kaplan-Meier survival analysis showed a significant association with malnutrition ( log-rank test , P=.012 ) but not with socioeconomic category . Most ( 72 % ) of the survivors had a favorable functional status . CONCLUSIONS Malnutrition , delirium , and APACHEII were risk factors for long-term mortality . Survivors had a good functional outcome . Appropriate quality of life tools for this population need to be developed Objective The goal of the paper is to determine inter-rater reliability of trained examiners performing st and ardized strength assessment s using manual muscle testing ( MMT ) .  Design , subjects , and setting The authors report on 19 trainees undergoing quality assurance within a multi-site prospect i ve cohort study .InterventionInter-rater  reliability for specially trained evaluators ( “ trainees ” ) and a reference rater , performing MMT using both simulated and actual patients recovering from critical illness was evaluated . Measurements and results Across 26 muscle groups tested by 19 trainee-reference rater pairs , the median ( interquartile range ) percent agreement and intraclass correlation coefficient ( ICC ; 95 % CI ) were : 96 % ( 91 , 98 % ) and 0.98 ( 0.95 , 1.00 ) , respectively . Across all 19 pairs , the ICC ( 95 % CI ) for the overall composite MMT score was 0.99 ( 0.98–1.00 ) . When limited to actual patients , the ICC was 1.00 ( 95 % CI 0.99–1.00 ) . The agreement ( kappa ; 95 % CI ) in detecting clinical ly significant weakness was 0.88 ( 0.44–1.00 ) . Conclusions MMT has excellent inter-rater reliability in trained examiners and is a reliable method of comprehensively assessing muscle strength OBJECTIVE Patients in intensive care exhibit a high degree of loss of muscle mass . Appropriate instruments are needed to document muscle wasting in these patients . The aim of this pilot study was to describe muscle wasting in patients in the intensive care unit . DESIGN Two-fold study setting : prospect i ve longitudinal and cross-sectional single-blind . PATIENTS A total of 118 patients in the intensive care unit ( length of stay 1 - 98 days ; male : female ratio 88:30 ; age 55 + /- 17 years ) were included in a two-fold study setting . METHODS Muscle layer thickness of the M. quadriceps femoris was documented using ultrasound measurement at well-defined points . Seventeen pilot- patients were measured twice ; at baseline and after 28 days . In another group of 101 patients , muscle layer thickness was determined once after a r and om length of stay . The results of both groups were compared and correlated . RESULTS In both groups , M. quadriceps femoris thickness showed a significant negative correlation with length of stay in the intensive care unit ( p < 0.01 ) . Furthermore , muscle wasting in intensive care patients could be described using a logarithmic function . CONCLUSION Loss of muscle mass shows a negative correlation with length of stay , and seems to be higher during the first 2 - 3 weeks of immobilization/intensive care unit stay . Ultrasound is a valid and practical measurement tool for documenting muscle mass ( e.g. muscle layer thickness ) as part of the daily routine at an intensive care unit Objectives For the measurement of  patient-reported outcomes , such as ( health-related ) quality of life , often many measurement instruments exist that intend to measure the same construct . To facilitate instrument selection , our aim was to develop a highly sensitive search filter for finding studies on measurement properties of measurement instruments in PubMed and a more precise search filter that needs less abstract s to be screened , but at a higher risk of missing relevant studies . Methods A r and om sample of 10,000 PubMed records ( 01 - 01 - 1990 to 31 - 12 - 2006 ) was used as a gold st and ard . Studies on measurement properties were identified using an exclusion filter and h and search ing . Search terms were selected from the relevant records in the gold st and ard as well as from 100 systematic review s of measurement properties and combined based on sensitivity and precision . The performance of the filters was tested in the gold st and ard as well as in two validation sets , by calculating sensitivity , precision , specificity , and number needed to read . Results We identified 116 studies on measurement properties in the gold st and ard . The sensitive search filter was able to retrieve 113 of these 116 studies ( sensitivity 97.4 % , precision 4.4 % ) . The precise search filter had a sensitivity of 93.1 % and a precision of 9.4 % . Both filters performed very well in the validation sets . Conclusion The use of these search filters will contribute to evidence -based selection of measurement instruments in all medical fields Background Accurate measurement of quality of life in older ICU survivors is difficult but critical for underst and ing the long-term impact of our treatments . Activities of daily living ( ADLs ) are important components of functional status and more easily measured than quality of life ( QOL ) . We sought to determine the cross-sectional associations between disability in ADLs and QOL as measured by version one of the Short Form 12-item Health Survey ( SF-12 ) at both one month and one year post-ICU discharge . Methods Data was prospect ively collected on 309 patients over age 60 admitted to the Yale-New Haven Hospital Medical ICU between 2002 and 2004 . Among survivors an assessment of ADL 's and QOL was performed at one month and one-year post-ICU discharge . The SF-12 was scored using the version one norm based scoring with 1990 population norms . Multivariable regression was used to adjust the association between ADLs and QOL for important covariates . Results Our analysis of SF-12 data from 110 patients at one month post-ICU discharge showed that depression and ADL disability were associated with decreased QOL . Our model accounted for 17 % of variability in SF12 physical scores ( PCS ) and 20 % of variability in SF12 mental scores ( MCS ) . The mean PCS of 37 was significantly lower than the population mean whereas the mean MCS score of 51 was similar to the population mean . At one year mean PCS scores improved and ADL disability was no longer significantly associated with QOL . Mortality was 17 % ( 53 patients ) at ICU discharge , 26 % ( 79 patients ) at hospital discharge , 33 % ( 105 patients ) at one month post ICU admission , and was 45 % ( 138 patients ) at one year post ICU discharge . Conclusions In our population of older ICU survivors , disability in ADLs was associated with reduced QOL as measured by the SF-12 at one month but not at one year . Although better markers of QOL in ICU survivors are needed , ADLs are a readily observable outcome . In the meantime , clinicians must try to offer realistic estimates of prognosis based on available data and re sources are needed to assist ICU survivors with impaired ADLs who wish to maintain their independence . More aggressive diagnosis and treatment of depression in this population should also be explored as an intervention to improve quality of life Background and Purpose . Patients requiring prolonged mechanical ventilation ( PMV ) are frequently deconditioned because of respiratory failure precipitated by the underlying disease , the adverse effects of medications , and a period of prolonged immobilization . The effects of 6 weeks of physical training on the strength of respiratory and limb muscles , on ventilator-free time , and on functional status in patients requiring PMV were examined . Subjects . Thirty-nine patients with PMV were initially enrolled in the study and were assigned to either a treatment group ( n=20 ) or a control group ( n=19 ) . Three subjects in the treatment group and 4 subjects in the control group died during the 6-week intervention period and thus their data were excluded from the final analysis . Methods . Subjects in the treatment group received physical training 5 days a week for 6 weeks . Strength of respiratory and limb muscles , ventilator-free time , and functional status , which was measured by the Barthel Index of Activities of Daily Living ( BI ) and Functional Independence Measure ( FIM ) , were examined at baseline and at the third and sixth weeks of the study period . Results . Respiratory and limb muscle strength improved significantly at the third and sixth weeks in the treatment group compared with baseline measurements . Total BI and FIM scores increased significantly in the treatment group and remained unchanged in the control group . Effect sizes of the BI and FIM scores were 2.02 and 1.93 , respectively , at the sixth week . Discussion and Conclusion . The results show that a 6-week physical training program may improve limb muscle strength and ventilator-free time and thus improve functional outcomes in patients requiring PMV BACKGROUND The importance of evaluating disability outcome measures is well recognised . The Functional Independence Measure ( FIM ) was developed to be a more comprehensive and “ sensitive ” measure of disability than the Barthel Index ( BI ) . Although the FIM is widely used and has been shown to be reliable and valid , there is limited information about its responsiveness , particularly in comparison with the BI . This study compares the appropriateness and responsiveness of these two disability measures in patients with multiple sclerosis and stroke . METHODS Patients with multiple sclerosis ( n=201 ) and poststroke ( n=82 ) patients undergoing inpatient neurorehabilitation  were studied . Admission and discharge scores were generated for the BI and the three scales of the FIM ( total , motor , and cognitive ) . Appropriateness of the measures to the study sample s was determined by examining score distributions , floor and ceiling effects . Responsiveness was determined using an effect size calculation . RESULTS The BI , FIM total , and FIM motor scales show good variability and have small floor and ceiling effects in the study sample s. The FIM cognitive scale showed a notable ceiling effect in patients with multiple sclerosis . Comparable effect sizes were found for the BI , and two FIM scales ( total and motor ) in both patients with multiple sclerosis and stroke patients . CONCLUSION All measures were appropriate to the study sample . The FIM cognitive scale , however , has limited usefulness as an outcome measure in progressive multiple sclerosis . The BI , FIM total , and FIM motor scales show similar responsiveness , suggesting that both the FIM total and FIM motor scales have no advantage over the BI in evaluating change PURPOSE The purpose of this study was to determine the interrater reliability of the Perme Intensive Care Unit Mobility Score . MATERIAL S AND METHODS This was a prospect i ve observational study . Data were collected from 20 patients admitted in a cardiovascular intensive care unit . The interrater reliability was tested using the intraclass correlation coefficient with 95 % confidence interval and the Cohen κ coefficient of 0.9 , using a 2-tailed α of .05 to provide a 90 % power . RESULTS The 15 items of the Perme ICU Mobility Score were individually analyzed . Interrater reliability ( Cohen κ coefficient ) for items 2 , 3 , 5 , 6 , 7 , 8 , 13 , and 15 was 1.0000 ; for item 1 , 0.8276 ; item 4 , 0.8000 ; item 9 , 0.6000 ; item 10 , 0.7297 ; item 11 , 0.7260 ; item 12 , 0.7872 ; and item 14 , 0.9048 ; the intraclass correlation coefficient ( 95 % confidence interval ) was 0.9880 ( 0.97743 - 0.99859 ) . CONCLUSIONS The Perme ICU Mobility Score is a reliable tool to assess mobility status of patients admitted to the cardiovascular intensive care unit in a specific moment in time , which can be an important tool for research and clinical practice OBJECTIVES To determine predictors of mortality in the intensive care unit ( ICU ) and at 6 months after discharge ; to assess the lifestyles of survivors 6 months after discharge . DESIGN Prospect i ve cohort study of patients screened upon admission and 6 months after discharge from the ICU . SETTING The ICU of a university hospital . PARTICIPANTS One hundred sixteen consecutive patients age 70 and older admitted to the ICU and treated by mechanical ventilation for at least 24 hours . MEASUREMENTS A comprehensive medical , functional , nutritional , and social assessment  was undertaken for each patient upon admission to the ICU . Functional status and residence were recorded for patients still living 6 months after discharge from the ICU . RESULTS Mortality in the ICU and 6 months after discharge was 31 % and 52 % , respectively . The predictors of in-ICU mortality on multivariate analysis were a high omega score per day in the ICU and a high simplified acute physiologic score corrected for points related to age ( SAPS IIc ) . The predictors of mortality at 6 months were a high omega score per day in the ICU , a high SAPS IIc , and a mid-arm circumference ( MAC ) under the 10th percentile for the older French population in good health . Six months after discharge from the ICU , 91 % of the surviving patients had the same residential status and 89 % had a similar or improved functional status compared with pre-admission status . CONCLUSIONS Although severity of illness remains an important predictor of in-ICU mortality and mortality at 6 months after release from ICU , we found that impaired nutritional status upon admission was related to 6-month mortality . These results emphasize the need for a systematic nutritional assessment in older patients admitted to the ICU and treated by mechanical ventilation Objectives : To assess whether the presence and severity of intensive care unit-acquired paresis are associated with intensive care unit and in-hospital mortality . Design : Prospect i ve , observational study . Setting : Two medical , one surgical , and one medico-surgical intensive care units in two university hospitals and one university-affiliated hospital . Patients : A total of 115 consecutive patients were enrolled after > 7 days of mechanical ventilation .  Interventions : None . Measurements and Main Results : The Medical Research Council score ( from 0–60 ) was used to evaluate upper and lower limb strength at time of awakening , identified as the ability to follow five comm and s. Intensive care unit-acquired paresis was defined as a Medical Research Council score < 48 . Patients were followed-up until hospital discharge . The primary end point was hospital mortality . At awakening , median Medical Research Council score was 41 ( interquartile range , 21–52 ) , and 75 ( 65 % ) patients had intensive care unit-acquired paresis . Hospital non-survivors had a significantly lower Medical Research Council score at awakening ( 21 [ 11–43 ] ) vs. 41 [ 28–53 ] ; p = .008 ) and a significantly higher rate of intensive care unit-acquired paresis ( 85.1 % vs. 58.4 % ; p = .02 ) compared to survivors . After multivariate risk adjustment , intensive care unit-acquired paresis was independently associated with higher hospital and intensive care unit mortality ( odds ratio for hospital mortality , 2.02 ; 95 % confidence interval , 1.03–8.03 ; p = .048 ) . Each Medical Research Council point decrease was associated with a significantly higher hospital mortality ( odds ratio , 1.03 ; 95 % confidence interval , 1.01–1.05 ; p = .033 ) . Conclusions : Both the presence and severity of intensive care unit-acquired paresis at the time of awakening are associated with increased intensive care unit and hospital mortality ; the mechanisms underlying this association need further study Objective : Muscle weakness often complicates critical illness and is associated with increased risk of morbidity , mortality , and limiting functional outcome even years later . To assess the presence of muscle weakness and to examine the effects of interventions , objective and reliable muscle strength measurements are required . The first objective of this study is to determine interobserver reliability of h and held dynamometry . Secondary objectives are to quantify muscle weakness , to evaluate distribution of muscle weakness , and to evaluate gender-related differences in muscle strength . Design : Cross-sectional observational study . Setting : The surgical and medical intensive care units of a large , tertiary referral , university hospital . Patients : A cross-sectional , r and omly selected sample of awake and cooperative critically ill patients . Interventions : None . Measurements and Main Results : H and held dynamometry was performed in critically ill patients who had at least a score of 3 ( movement against gravity ) on the Medical Research Council scale . Three upper limb and three lower limb muscle groups were tested at the right-h and side . Patients were tested twice daily by two independent raters . Fifty-one test – retests were performed in 39 critically ill patients .  H and held dynamometry demonstrated good interobserver agreement with intraclass correlation coefficients > 0.90 in four of the muscle groups tested ( range , 0.91–0.96 ) and somewhat less for hip flexion ( intraclass correlation coefficient , 0.80 ) and ankle dorsiflexion ( intraclass correlation coefficient , 0.76 ) . Limb muscle strength was considerably reduced in all muscle groups as shown by the median z-score ( range , −1.08 to −3.48 sd units ) . Elbow flexors , knee extensors , and ankle dorsiflexors were the most affected muscle groups . Loss of muscle strength was comparable between men and women . Conclusions : H and held dynamometry is a tool with a very good interobserver reliability to assess limb muscle strength in awake and cooperative critically ill patients . Future studies should focus on the sensitivity of h and held dynamometry in longitudinal studies to evaluate predictive values toward patients ' functional outcome Purpose The aim of this study was to assess mortality in healthy elderly patients after non-elective medical ICU admission and to identify predictive factors of mortality in these patients . Methods Patients ≥65 years living at home and with full-autonomy ( Barthel index , BI > 60 ) , without cognitive impairment , and non-electively admitted to a medical ICU were prospect ively recruited . A full comprehensive geriatric assessment was made with vali date d scales . Results A total of 230 patients were included , 110 ( 48 % ) between 65 and 74 years and 120 ( 52 % ) ≥75 years . No significant differences were observed between the two groups in premorbid functional and cognitive status , main diagnosis at ICU admission , APACHE II and SOFA scores , use of mechanical ventilation or haemodialysis or length of ICU stay . Over a mean follow-up of 522 days ( range 20–1,170 days ) the cumulative mortality of the whole group was 55 % , being significantly higher in older subjects ( 62 vs. 47 % ; P = 0.024 ) . On multivariate analysis , only parameters related to quality of life ( QOL ) and functional status were independent predictors of cumulated mortality ( P < 0.01 , both ) . Thus , in patients with EQ-5Dvas ( < 70 ) or baseline Lawton index ( LI ) ( < 5 ) the hazard ratio for cumulated mortality was 2.45 ( 95 % CI : 1.15–5.25 ; P = 0.03 ) and 4.10 ( 95 % CI : 1.53–10.99 ; P = 0.006 ) , respectively , compared to those with better scores . Conclusions Healthy elderly non-elective medical patients admitted to the ICU have a high mortality rate related to premorbid QOL . The LI and /or EQ-5Dvas may be useful tools to identify patients with the best chance of survival Background Skeletal muscle wasting and weakness are common in patients with sepsis in the intensive care unit , although less is known about deficits in diaphragm and limb muscles when mechanical ventilation also is required . Objective The objective of this study was to concurrently investigate relative differences in both thickness and strength of respiratory and peripheral muscles during routine care . Design A prospect i ve , cross-sectional study of 16 alert patients with sepsis and 16 people who were healthy ( control group ) was used . Methods Assessment was made of the diaphragm , upper arm , forearm , and thigh muscle thicknesses with the use of ultrasound ; respiratory muscle strength by means of maximal inspiratory pressure ; and isometric h and grip , elbow flexion , and knee extension forces with the use of portable dynamometry . To describe relative changes , data also were normalized to fat-free body mass ( FFM ) measured by bioelectrical impedance spectroscopy . Results Patients ( 9 men , 7 women ; mean age=62 years , SD=17 ) were assessed after a median of 16 days ( interquartile range=11–29 ) of intensive care unit admission . Patients ' diaphragm thickness did not differ from that of the control group , even for a given FFM . When normalized to FFM , only the difference in patients ' mid-thigh muscle size significantly deviated from that of the control group . Within the patient sample , all peripheral muscle groups were thinner compared with the diaphragm . Patients were significantly weaker than were the control group participants in all muscle groups , including for a given FFM . Within the critically ill group , limb weakness was greater than the already-significant respiratory muscle weakness . Limitations Volitional strength tests were applied such that successive measurements from earlier in the course of illness could not be reliably obtained . Conclusions When measured at bedside , survivors of sepsis and a period of mechanical ventilation may have respiratory muscle weakness without remarkable diaphragm wasting . Furthermore , deficits in peripheral muscle strength and size may exceed those in the diaphragm Objective : Survivors of severe critical illness frequently develop substantial and persistent physical complications , including muscle weakness , impaired physical function , and decreased health-related quality of life . Our objective was to determine the longitudinal epidemiology of muscle weakness , physical function , and health-related quality of life and their associations with critical illness and ICU exposures . Design : A multisite prospect i ve study with longitudinal follow-up at 3 , 6 , 12 , and 24 months after acute lung injury . Setting : Thirteen ICUs from four academic teaching hospitals . Patients : Two hundred twenty-two survivors of acute lung injury . Interventions : None . Measurements and Main Results : At each time point , patients underwent st and ardized clinical evaluations of extremity , h and grip , and respiratory muscle strength ; anthropometrics ( height , weight , mid-arm circumference , and triceps skin fold thickness ) ; 6-minute walk distance , and the Medical Outcomes Short-Form 36 health-related quality of life survey . During their hospitalization , survivors also had detailed daily evaluation of critical illness and related treatment variables . Over one third of survivors had objective evidence of muscle weakness at hospital discharge , with most improving within 12 months . This weakness was associated with substantial impairments in physical function and health-related quality of life that persisted at 24 months . The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up . The cumulative dose of systematic corticosteroids and use of neuromuscular blockers in the ICU were not associated with weakness . Conclusions : Muscle weakness is common after acute lung injury , usually recovering within 12 months . This weakness is associated with substantial impairments in physical function and health-related quality of life that continue beyond 24 months . These results provide valuable prognostic information regarding physical recovery after acute lung injury . Evidence -based methods to reduce the duration of bed rest during critical illness may be important for improving these long-term impairments Background and Purpose Long-term acute care hospitals ( LTACHs ) have emerged for patients requiring medical care beyond a short stay . Minimal data have been reported on functional outcomes in this setting . The purpose s of this study were : ( 1 ) to measure the clinical utility of the Functional Status Score for the Intensive Care Unit ( FSS-ICU ) in an LTACH setting and ( 2 ) to explore the association between FSS-ICU score and discharge setting . Participants Data were obtained from 101 patients ( median age=70 years , interquartile range [IQR]=61–78 ; 39 % female , 61 % male ) who were admitted to an LTACH . Participants were categorized into 1 of 5 groups by discharge setting : ( 1 ) home ( n=14 ) , ( 2 ) inpatient rehabilitation facility ( n=26 ) , ( 3 ) skilled nursing facility ( n=23 ) , ( 4 ) long-term care/hospice/expired ( n=13 ) , or ( 5 ) transferred to a short-stay hospital ( n=25 ) . Methods Data were prospect ively collected from a 38-bed LTACH in the United States over 8 months beginning in September 2010 .  Functional status was scored using the FSS-ICU within 4 days of admission and every 2 weeks until discharge . The FSS-ICU consists of 5 categories : rolling , supine-to-sit transfers , unsupported sitting , sit-to-st and transfers , and ambulation . Each category was rated from 0 to 7 , with a maximum cumulative FSS-ICU score of 35 . Results Cumulative FSS-ICU scores significantly improved from a median ( IQR ) of 9 ( 3–17 ) to 14 ( 5–24 ) at discharge . Median ( IQR ) cumulative discharge FSS-ICU scores were significantly different among the discharge categories : home=28 ( 22–32 ) , inpatient rehabilitation facility=21 ( 15–24 ) , skilled nursing facility=14 ( 8–21 ) , long-term care/hospice/expired=5 ( 0–11 ) , and transfer to a short-stay hospital=4 ( 0–7 ) . Discussion and Conclusions Patients receiving therapy at an LTACH demonstrate significant improvements from admission to discharge using the FSS-ICU . This outcome tool discriminates among discharge setting s and successfully documents functional improvements of patients in an LTACH setting Purpose Neuromuscular abnormalities are common in ICU patients . We aim ed to assess the incidence of clinical ly diagnosed ICU-acquired paresis ( ICUAP ) and its impact on outcome . Methods Forty-two patients with systemic inflammatory response syndrome on mechanical ventilation for ≥48 h were prospect ively studied . Diagnosis of ICUAP was defined as symmetric limb muscle weakness in at least two muscle groups at ICU discharge without other explanation . The threshold Medical Research Council ( MRC ) Score was set at 35 ( of 50 ) points . Activities in daily living were scored using the Barthel Index 28 and 180 days after ICU discharge . Results Three patients died before sedation was stopped . ICUAP was diagnosed in 13 of the 39 patients ( 33 % ) . Multivariate regression analysis yielded five ICUAP-predicting variables ( P < 0.05 ) : SAPS II at ICU admission , treatment with steroids , muscle relaxants or norepinephrine , and days with sepsis . Patients with ICUAP had lower admission SAPS II scores [ 37 ± 13 vs. 49 ± 15 ( P = 0.018 ) ] , lower Barthel Index at 28 days and lower survival at 180 days after ICU discharge ( 38 vs. 77 % , P = 0.033 ) than patients without ICUAP . Daily TISS-28 scores were similar but cumulative TISS-28 scores were higher in patients with ICUAP ( 664 ± 275 ) than in patients without ICUAP ( 417 ± 236 ; P = 0.008 ) . The only independent risk factor for death before day 180 was the presence of ICUAP . Conclusions A clinical diagnosis of ICUAP was frequently established in this patient group . Despite lower SAPS II scores , these patients needed more re sources and had high mortality and prolonged recovery periods after ICU discharge Critical illness affects body composition profoundly , especially body cell mass ( BCM ) . BCM loss reflects lean tissue wasting and could be a nutritional marker in critically ill patients . However , BCM assessment with usual isotopic or tracer methods is impractical in intensive care units ( ICUs ) . We aim ed to modelize the BCM of critically ill patients using variables available at bedside . Fat-free mass ( FFM ) , bone mineral ( Mo ) , and extracellular water ( ECW ) of 49 critically ill patients were measured prospect ively by dual-energy X-ray absorptiometry and multifrequency bioimpedance .  BCM was estimated according to the four-compartment cellular level : BCM = FFM - ( ECW/0.98 ) - ( 0.73 × Mo ) . Variables that might influence the BCM were assessed , and multivariable analysis using fractional polynomials was conducted to determine the relations between BCM and these data . Bootstrap resampling was then used to estimate the most stable model predicting BCM . BCM was 22.7 ± 5.4 kg . The most frequent model included height ( cm ) , leg circumference ( cm ) , weight shift ( Δ ) between ICU admission and body composition assessment ( kg ) , and trunk length ( cm ) as a linear function : BCM ( kg ) = 0.266 × height + 0.287 × leg circumference + 0.305 × Δweight - 0.406 × trunk length - 13.52 . The fraction of variance explained by this model ( adjusted r(2 ) ) was 46 % . Including bioelectrical impedance analysis variables in the model did not improve BCM prediction . In summary , our results suggest that BCM can be estimated at bedside , with an error lower than ±20 % in 90 % subjects , on the basis of static ( height , trunk length ) , less stable ( leg circumference ) , and dynamic biometric variables ( Δweight ) for critically ill patients BACKGROUND : Rehabilitation is a non-pharmacologic therapy that can restore health and reverse the patient 's disability , but the efficacy of rehabilitation in critically ill patients is not well documented . METHODS : In a prospect i ve cohort study , we assessed whether the degree of change in functional status after comprehensive rehabilitation influenced clinical outcomes in 77 tracheotomized patients ( mean ± SD age 75 ± 7 y ) admitted for difficult weaning to our regional weaning center . The care plan , including peripheral muscle training , was delivered daily . We recorded admission demographic , anthropometric , and functional characteristics . We measured the change in basic activities of daily living score ( ΔBADL ) , survival , and weaning success rate as clinical outcomes . We performed the Pearson correlation analysis and linear regression , with ΔBADL as the dependent variable , to test the predictive power of the baseline measurements . RESULTS : Sixty-seven patients ( 87 % ) survived , and 55 of them ( 74 % ) succeeded in weaning during their stay in the weaning center . The mean ± SD ΔBADL improvement was 2.5 ± 2.0 points ( median 2 points ) . Baseline performance of the latissimus dorsi predicted ΔBADL ( β = 0.388 , 95 % CI 0.111–1,664 , P = .03 ) . The probability of remaining ventilator-free ( P = .043 ) and survival ( P = .001 ) differed across the 4 ΔBADL categories ( 0 = no change , 1–2 = least improvement , and > 2 = improvement above median change ) . CONCLUSIONS : Mortality rate and weaning success differ according to ΔBADL following active rehabilitation/training in tracheotomized , ventilated , difficult-to-wean patients . The performance of the latissimus dorsi was the only significant predictor of change OBJECTIVES To identify prognostic factors that are independently predictive of in-hospital mortality in older patients hospitalized in a medical intensive care unit ( MICU ) . DESIGN Prospect i ve cohort study . SETTING A MICU in an Italian university hospital . PARTICIPANTS Patients aged 65 and older consecutively admitted to the MICU directly from the first-aid unit . MEASUREMENTS Upon admission , the following variables were examined : demographics , clinical history ( diabetes mellitus , active neoplasm , cognitive impairment , immobilization , pressure ulcers , use of nutritional support , home oxygen therapy ) , physiopathology ( Acute Physiology and Chronic Health Evaluation ( APACHE ) II ) , and cognition/function ( activity of daily living ( ADL ) , instrumental activity of daily living ( IADL ) , Short Portable Mental Status Question naire ( SPMSQ ) ) . The vital status of the patient at the end of hospitalization was recorded . RESULTS Over a period of 10 months , 659 patients were recruited ( mean age + /- st and ard deviation = 76.6 + /- 7.5 ; 352 men and 307 women ) . There were 97 deaths ( 14.71 % ) . The following factors proved to be significantly associated with in-hospital mortality : old age , low body mass index ( BMI ) values , low values of albumin , high scores on APACHE II , functional impairment ( ADL , IADL ) , cognitive impairment ( SPMSQ ) , history of cognitive deterioration , history of confinement to bed , and presence of pressure ulcers . Using multivariate analysis , the following variables were independently predictive of in-hospital mortality : lack of independence in ADLs ( P < .001 ) , moderate-to-severe cognitive impairment on SPMSQ ( P < .001 ) , score on APACHE II ( P = .002 ) , and low BMI values ( P = .031 ) . CONCLUSION The prognosis of older patients hospitalized in medical intensive care units depends not only on the acute physiological impairments , but also on a series of preexisting conditions , such as loss of functional independence , severe and moderate cognitive impairment , and low BMI BACKGROUND Body composition is commonly altered in response to critical illness and can be estimated at the bedside with bioelectrical impedance spectroscopy ( BIS ) . Different electrode configurations may be used to mitigate assumptions of the technique , but the reliability of tetra-polar and octo-polar arrangements has yet to be established . This study aim ed to compare both configurations , in a prospect i ve observational study of 17 critically ill survivors and 12 healthy controls . METHODS  Weight , supine body length , and BIS on both tetra-polar and octo-polar configured devices were recorded , then repeated 2 days later . Bioelectrical impedance vector analysis  was subsequently performed using data from the tetra-polar device at a frequency of 50 kHz . RESULTS Test-retest agreement was acceptable for the tetra-polar device ( intraclass correlation coefficient range , patients : 0.876 - 0.988 vs controls : 0.983 - 0.998 , P ≤ 0.001 ) . However , lower and wider ranging test-retest intraclass correlation coefficients were obtained with the octo-polar instrument in both groups . Furthermore , there was a difference in the mass/volume of body compartments measured on each device in both patients ( P ≤ .017 ) and controls ( P ≤ .045 ) . A change in the composition profile of critically ill males  was evident between measurement occasions , which was reflected by a reduction in body weight of 1.6 ( 1.5 ) kg ( P ≤ 0.001 ) across the sample over the same period . CONCLUSIONS BIS devices should not be used interchangeably in the clinical setting . The reliability of the tetra-polar instrument was good , but daily fluctuations in body weight may have affected the results Risk assessment is nowadays an essential part of the management of seriously ill subjects , and multiple scoring methods are available , based on single or preferably multiple determinations . Some of these protocol s have been successfully used around the world , and they permit the prediction of outcomes in different clinical population s. However , many indices are labor-intensive or dem and an exp and ed set of biochemical determinations , thus representing an economical burden . Aim ing to evaluate the prognostic value of ordinary variables that are already present in the clinical observation , 50 consecutive patients admitted at the intensive care unit were prospect ively documented . Methods included clinical ( age , sex , stay in ICU , FIO2 ) , biochemical ( serum albumin , hemoglobin , glucose , creatinine , WBC count ) , and bioimpedance variables ( resistance , reactance , body impedance coefficient ) . All these values were registered at admission and before discharge or death , and compared with survival rate . Initially only WBC count was significantly different in survivors , but ongoing documentation revealed that later on , four indices were endowed with prognostic impact : serum album , glucose levels , WBC count and FIO2 requirements . Organ or function-sustaining procedures were also associated with outcome , nominally mechanical ventilation , vasoactive drugs , and enteral/parenteral nutrition . Furthermore , patients su bmi tted to two or three of these methods exhibited higher mortality than those receiving just one , with even better result for those not requiring any . It is concluded that observation of ongoing changes in conventional clinical variables available in the clinical chart are a valid means of estimating the mortality risk in critical cases Objectives : To test if the surgical intensive care unit optimal mobility score predicts mortality and intensive care unit and hospital length of stay . Design : Prospect i ve single-center cohort study . Setting : Surgical intensive care unit of the Massachusetts General Hospital . Patients : One hundred thirteen consecutive patients admitted to the surgical intensive care unit . Investigations : We tested the hypotheses that the surgical intensive care unit optimal mobility score independent of comorbidity index , Acute Physiology and Chronic Health Evaluation II , creatinine , hypotension , hypernatremia , acidosis , hypoxia , and hypercarbia predicts hospital mortality , surgical intensive care unit and total hospital length of stay . Measurements and Main Results : Two nurses independently predicted the patients ’ mobilization capacity by using the surgical intensive care unit optimal mobility score the morning after admission , whereas a third nurse recorded the achieved mobilization levels of patients at the end of the day . A multidisciplinary expert team measured patients ’ grip strength and assessed their predicted mobilization capacity independently . Multivariate analysis revealed that the surgical intensive care unit optimal mobility score was the only independent predictor of mortality . Surgical intensive care unit optimal mobility score , hypotension , and hypernatremia ( > 144 mmol/L ) independently predicted intensive care unit length of stay , whereas the surgical intensive care unit optimal mobility score and hypernatremia predicted total hospital length of stay . The Acute Physiology and Chronic Health Evaluation II score was not identified in the multivariate analysis . The surgical intensive care unit optimal mobility score  was also a reliable and valid instrument in predicting achieved mobilization levels of patients . Conclusions : In surgical critically ill patients presenting without preexisting impairment of functional mobility , the surgical intensive care unit optimal mobility score is a reliable and valid tool to predict mortality and intensive care unit and hospital length of stay . ( Crit Care Med 2012 ; 40:–1128 PURPOSE The aim of this study was to describe the frequency , physiologic effects , safety , and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation . MATERIAL S AND METHODS Prospect i ve observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit ( ICU ) during a 13-week period was conducted . RESULTS Of the 32 patients who met the inclusion criteria , only 21 ( 66 % ) received physician orders for evaluation by rehabilitation services ( physical and /or occupational therapy ) . Fifty rehabilitation treatments were provided to 19 patients on a median of 12 % of medical ICU days per patient , with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment . Physiologic changes during rehabilitation therapy were minimal . Joint contractures were frequent in the lower extremities and did not improve during hospitalization . In 53 % and 79 % of initial ICU assessment s , muscle weakness was present in upper and lower extremities , respectively , with a decreased prevalence of 19 % and 43 % at hospital discharge , respectively . New impairments in physical function were common at hospital discharge . CONCLUSIONS This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength , range of motion , and functional outcomes at hospital discharge IMPORTANCE Survivors of critical illness demonstrate skeletal muscle wasting with associated functional impairment . OBJECTIVE To perform a comprehensive prospect i ve characterization of skeletal muscle wasting , defining the pathogenic roles of altered protein synthesis and breakdown . DESIGN , SETTING , AND PARTICIPANTS Sixty-three critically ill patients ( 59 % male ; mean age : 54.7 years [ 95 % CI , 50.0 - 59.6 years ] ) with an Acute Physiology and Chronic Health Evaluation II score of 23.5 ( 95 % CI , 21.9 - 25.2 ) were prospect ively recruited within 24 hours following intensive care unit ( ICU ) admission from August 2009 to April 2011 at a university teaching and a community hospital in Engl and . Patients were recruited if older than 18 years and were anticipated to be intubated for longer than 48 hours , to spend more than 7 days in critical care , and to survive ICU stay . MAIN OUTCOMES AND MEASURES Muscle loss was determined through serial ultrasound measurement of the rectus femoris cross-sectional area ( CSA ) on days 1 , 3 , 7 , and 10 . In a subset of patients , the fiber CSA area was quantified along with the ratio of protein to DNA on days 1 and 7 . Histopathological analysis was performed . In addition , muscle protein synthesis , breakdown rates , and respective signaling pathways were characterized . RESULTS There were significant reductions in the rectus femoris CSA observed at day 10 ( −17.7 % [ 95 % CI , −25.9 % to 8.1 % ] ; P < .001 ) . In the 28 patients assessed by all 3 measurement methods on days 1 and 7 , the rectus femoris CSA decreased by 10.3 % ( 95 % CI , 6.1 % to 14.5 % ) , the fiber CSA by 17.5 % ( 95 % CI , 5.8 % to 29.3 % ) , and the ratio of protein to DNA by 29.5 % ( 95 % CI , 13.4 % to 45.6 % ) . Decrease in the rectus femoris CSA was greater in patients who experienced multiorgan failure by day 7 ( −15.7 % ; 95 % CI , −27.7 % to 11.4 % ) compared with single organ failure ( −3.0 % ; 95 % CI , −5.3 % to 2.1 % ) ( P < .001 ) , even by day 3 ( −8.7 % [ 95 % CI , −59.3 % to 50.6 % ] vs −1.8 % [ 95 % CI , −12.3 % to 10.5 % ] , respectively ; P = .03 ) . Myofiber necrosis occurred in 20 of 37 patients ( 54.1 % ) . Protein synthesis measured by the muscle protein fractional synthetic rate was depressed in patients on day 1 ( 0.035%/hour ; 95 % CI , 0.023 % to 0.047%/hour ) compared with rates observed in fasted healthy controls ( 0.039%/hour ; 95 % CI , 0.029 % to 0.048%/hour ) ( P = .57 ) and increased by day 7 ( 0.076 % [ 95 % CI , 0.032%-0.120%/hour ] ; P = .03 ) to rates associated with fed controls ( 0.065%/hour [ 95 % CI , 0.049 % to 0.080%/hour ] ; P = .30 ) , independent of nutritional load . Leg protein breakdown remained elevated throughout the study ( 8.5 [ 95 % CI , 4.7 to 12.3 ] to 10.6 [ 95 % CI , 6.8 to 14.4 ] μmol of phenylalanine/min/ideal body weight × 100 ; P = .40 ) . The pattern of intracellular signaling supported increased breakdown ( n = 9 , r = −0.83 , P = .005 ) and decreased synthesis ( n = 9 , r = −0.69 , P = .04 ) . CONCLUSIONS AND RELEVANCE Among these critically ill patients  , muscle wasting occurred early and rapidly during the first week of critical illness and was more severe among those with multiorgan failure compared with single organ failure . These findings may provide insights into skeletal muscle wasting in critical illness Purpose . To evaluate the functional status of patients within the first week of discharge from an intensive care unit ( ICU ) , and to identify predictors and explanatory factors of functional status . Methods . A prospect i ve , observational , cohort study was conducted with consecutive ICU patients who had stayed in a mixed , closed-format , university-level ICU for longer than 48 h. Results . Between 3 and 7 days of discharge from the ICU , functional status ( as primary outcome ) , walking ability , muscle strength , and sensory and cognitive functioning were assessed in 69 survivors . The overall functional status was poor ( median Barthel Index 6 ) . In their ability to perform basic activities of daily living , 67 % percent were severely dependent , 15 % were moderately dependent , and 9 % were slightly dependent on other people . Independent walking was impossible for 73 % of participants , grip strength was reduced for 50 % , and 30 % had cognitive impairments . Duration of ventilation was associated with functional status after ICU discharge . Reduced grip strength and walking ability were identified as explanatory factors for poorer functional status shortly after discharge from the ICU . Conclusion . In the first week after discharge from the ICU , the majority of the patients had substantial functional disabilities in activities of daily living . These disabilities were more severe in patients who experienced ventilation for a longer period of time . There is a need for prospect i ve studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge PURPOSE To determine whether frailty can be measured within 4 days prior to hospital discharge in older intensive care unit ( ICU ) survivors of respiratory failure and whether it is associated with post-discharge disability and mortality . MATERIAL S AND METHODS We performed a single-center prospect i ve cohort study of 22 medical ICU survivors age 65 years or older who had received noninvasive or invasive mechanical ventilation for at least 24 hours . Frailty was defined as a score of ≥3 using Fried 's 5-point scale . We measured disability with the Katz Activities of Daily Living . We estimated unadjusted associations between Fried 's frailty score and incident disability at 1-month and 6-month mortality using Cox proportional hazard models . RESULTS The mean ( SD ) age was 77 ( 9 ) years , mean Acute Physiology and Chronic Health Evaluation II score was 27 ( 9.7 ) , mean frailty score was 3.4 ( 1.3 ) , and 18 ( 82 % ) were frail . Nine subjects ( 41 % ) died within 6 months , and all were frail . Each 1-point increase in frailty score was associated with a 90 % increased rate of incident disability at 1-month ( rate ratio : 1.9 , 95 % CI 0.7 - 4.9 ) and a threefold increase in 6-month mortality ( rate ratio : 3.0 , 95 % CI 1.4 - 6.3 ) . CONCLUSIONS Frailty can be measured in older ICU survivors near hospital discharge and is associated with 6-month mortality in unadjusted analysis . Larger studies to determine if frailty independently predicts outcomes are warranted The increase of elderly in our society requires simple tools for quantification of sarcopenia in inpatient and outpatient setting s. The aim of this study was to compare parameters determined with musculoskeletal ultrasound ( M-US ) with muscle strength in young and elderly patients . In this prospect i ve , r and omised and observer blind study , 26 young ( 24.2 ± 3.7 years ) and 26 old ( age 67.8 ± 4.8 years ) patients were included . Muscle thickness , pennation angle and echogenicity of all muscles of musculus quadriceps were measured by M-US and correlated with isometric maximum voluntary contraction force ( MVC ) of musculus quadriceps . Reproducibility of M-US measurements as well as simple and multiple regression models were calculated . Of all measured M-US variables the highest reproducibility was found for measurements of thickness ( intraclass correlation coefficients , 85–97 % ) . Simple regression analysis showed a highly significant correlation of thickness measurements of all muscles of musculus quadriceps with MVC in the elderly and in the young . Multiple regression analysis revealed that thickness of musculus vastus medialis had the best correlation with MVC in the elderly . This study showed that measurement of muscle thickness , especially of musculus vastus medialis , by M-US is a reliable , bedside method for monitoring the extent of sarcopenia Background Paresis acquired in the intensive care unit ( ICU ) is common in patients who are critically ill and independently predicts mortality and morbidity . Manual muscle testing ( MMT ) and h and grip dynamometry assessment s have been used to evaluate muscle weakness in patients in a medical ICU , but similar data for patients in a surgical ICU ( SICU ) are limited . Objective The purpose of this study was to evaluate the predictive value of strength measured by MMT and h and grip dynamometry at ICU admission for in-hospital mortality , SICU length of stay ( LOS ) , hospital LOS , and duration of mechanical ventilation . Design This investigation was a prospect i ve , observational study . Methods One hundred ten patients were screened for eligibility for testing in the SICU of a large , academic medical center . The Acute Physiology and Chronic Health Evaluation ( APACHE ) II score , diagnoses , and laboratory data were collected . Measurements were obtained by MMT quantified with the sum ( total ) score on the Medical Research Council Scale and by h and grip dynamometry . Outcome data , including in-hospital mortality , SICU LOS , hospital LOS , and duration of mechanical ventilation , were collected for all participants . Results One hundred seven participants were eligible for testing ; 89 % were tested successfully at a median of 3 days ( 25th–75th percentiles=3–6 days ) after admission . Sedation was the most frequent barrier to testing ( 70.6 % ) . Manual muscle testing  was identified as an independent predictor of mortality , SICU LOS , hospital LOS , and duration of mechanical ventilation . Grip strength was not independently associated with these outcomes . Limitations This study did not address whether muscle weakness translates to functional outcome impairment . Conclusions In contrast to h and grip strength , MMT reliably predicted in-hospital mortality , duration of mechanical ventilation , SICU LOS , and hospital LOS Background Recent studies have demonstrated safety , feasibility , and decreased hospital length of stay for patients with weakness acquired in the intensive care unit ( ICU ) who receive early physical rehabilitation . The scored Physical Function in Intensive Care Test ( PFIT-s ) was specifically design ed for this population and demonstrated excellent psychometrics in an Australian ICU population . Objective The purpose of this study was to determine the responsiveness and predictive capabilities of the PFIT-s in patients in the United States admitted to the ICU who required mechanical ventilation ( MV ) for 4 days or longer . Methods This nested study within a r and omized trial administered the PFIT-s ,  Medical Research Council ( MRC ) sum score  , and grip strength test at ICU recruitment and then weekly until hospital discharge , including at ICU discharge . Spearman rho was used to determine validity . The effect size index was used to calculate measurement responsiveness for the PFIT-s . The receiver operating characteristic curve was used in predicting participants ' ability to perform functional components of the PFIT-s . Results From August 2009 to July 2012 , 51 patients were recruited from 4 ICUs in the Denver , Colorado , metro area . At ICU discharge , PFIT-s scores were highly correlated to MRC sum scores ( rho=.923 ) and grip strength ( rho=.763 ) ( P<.0005 ) . Using baseline test with ICU discharge ( 26 pairs ) , test responsiveness was large ( 1.14 ) . At ICU discharge , an MRC sum score cut-point of 41.5 predicted participants ' ability to perform the st and ing components of the PFIT-s . Limitations The small sample size was a limitation . However , the findings are consistent with those in a larger sample from Australia . Conclusions The PFIT-s is a feasible and valid measure of function for individuals who require MV for 4 days or longer and who are alert , able to follow comm and s , and have sufficient strength to participate RATIONALE ICU-acquired paresis ( ICUAP ) is common in survivors of critical illness . There is significant associated morbidity , including prolonged time on the ventilator and longer hospital stay . However , it is unclear whether ICUAP is independently associated with mortality , as sicker patients are more prone and existing studies have not adjusted for this . OBJECTIVES To test the hypothesis that ICUAP is independently associated with increased mortality . Secondarily , to determine if h and grip dynamometry is a concise measure of global strength and is independently associated with mortality . METHODS A prospect i ve multicenter cohort study was conducted in intensive care units ( ICU ) of five academic medical centers . Adults requiring at least 5 days of mechanical ventilation without evidence of preexisting neuromuscular disease were followed until awakening and were then examined for strength . MEASUREMENTS AND MAIN RESULTS We measured global strength and h and grip dynamometry . The primary outcome was in-hospital mortality and secondary outcomes were hospital and ICU-free days , ICU readmission , and recurrent respiratory failure .  Subjects with ICUAP ( average MRC score of < 4 ) had longer hospital stays and required mechanical ventilation longer . H and grip strength was lower in subjects with ICUAP and had good test performance for diagnosing ICUAP . After adjustment for severity of illness , ICUAP was independently associated with hospital mortality ( odds ratio [ OR ] , 7.8 ; 95 % confidence interval [ CI ] , 2.4 - 25.3 ; P = 0.001 ) . Separately , h and grip strength was independently associated with hospital mortality ( OR , 4.5 ; 95 % CI , 1.5 - 13.6 ; P = 0.007 ) . CONCLUSIONS ICUAP is independently associated with increased hospital mortality . H and grip strength is also independently associated with poor hospital outcome and may serve as a simple test to identify ICUAP . Clinical trial registered with www . clinical trials.gov ( NCT00106665 )
target: Conclusions There is considerable variability in the type of measures utilized to measure physical impairments and limitations in survivors of critical illness .
background: Purpose To identify measures used to evaluate the broad constructs of functional impairment and limitations in the critically ill across the continuum of recovery , and to evaluate , synthesis e and compare the clinimetric properties of the measures identified .