early rehabilitation in intensive care unit ( icu ) patients helps to prevent and minimize the deleterious effects of immobility , to improve functional capacity , and to reduce the duration of mechanical ventilation and length of hospital stay , as well as improving the quality of life of such patients . 1 
 4 
  however , the literature describes some barriers that limit or preclude this rehabilitation . some examples are disease severity , level of sedation , use of vasoactive drugs , and presence of catheters , whether central or peripheral . 5 
 6 
  the use of central or peripheral catheters for drug administration and monitoring in critically ill patients is common . in patients with difficult access , with multiple access sites , or with a bleeding disorder , partial or total confinement to bed to prevent catheter dislodgement or loss is still common . in addition , there is the concern about maintaining blood flow in patients undergoing continuous renal replacement therapy . 7 
  recent studies have shown that mobilization of patients with catheters is safe and is not associated with access - related or catheter - related adverse events . 6 
 8 
 9 
  however , some centers still consider the presence of catheters a barrier to mobilization , delaying the start of rehabilitation . 5 
 10 
  given that the literature on this topic is controversial and that most studies were conducted in centers in the united states and australia , all of which provide physical therapy that is different from that provided in brazil , the objective of the present study is to determine whether mobility therapy is associated with central or peripheral catheter - related adverse events in critically ill patients in an icu in brazil . our hypothesis is that there is no association between mobility therapy and central or peripheral catheter - related adverse events such as accidental dislodgement or removal and infection . this study was approved by the human research ethics committee of the faculdade de medicina da universidade de so paulo ( fmusp , university of so paulo school of medicine ) . we performed a retrospective analysis of the daily medical and physical therapy records of patients admitted to the 6-bed icu of the department of clinical emergencies of the fmusp instituto central do hospital das clnicas ( ichc , hospital das clnicas central institute ) between december of 2009 and april of 2011 . the daily record forms were developed prior to the study , were completed electronically , and had been in use for at least one year in the icu . therefore , data on all study variables were available through an electronic medical records system . physical therapy in the icu was characterized by respiratory therapy and by mobility therapy . in brief , respiratory therapy was based on airway clearance maneuvers ( including aspiration ) , lung expansion techniques , adjustment of oxygen therapy , and inhalation therapy ( the last of these being administered as medically prescribed ) . in addition , if the patient was mechanically ventilated , the physical therapist also assisted in adjustment of ventilator settings and in patient extubation . mobility therapy consisted of upper limb , lower limb , and trunk exercises , in passive , active , and resistive modes . exercise was performed with the patient lying on the bed , sitting on the bed , or sitting in an armchair , depending on the ability of the patient and at the discretion of the physical therapist . in addition , exercise in the standing position and ambulation around the bed and in the hallway was recommended . the icu multidisciplinary team comprised 1:6 nurse / patient , 1:2 nursing technician / patient , 1:6 resident in physical therapy / patient , and 1:10 senior physical therapist / patient . physical therapy was available 12 hours a day ( from 7:00 a.m. to 7:00 p.m. ) , and , during that period , each patient usually received two visits , which were tailored to the needs of each individual . data collection included demographic characteristics and clinical data , such as age , gender , clinical admission diagnosis , simplified acute physiology score ( saps ) 3 , site of admission , duration of mechanical ventilation , length of icu stay , and mortality . in addition , we collected data related to central venous catheters ( cvcs ) , hemodialysis ( hd ) catheters , and indwelling arterial catheters ( iacs ) : insertion site ; number of catheter days ; and number of mobility therapy sessions conducted with a catheter in situ . the catheter - related adverse events considered were obstruction , accidental dislodgement or removal , and infection . the data we collected on mobility therapy included the frequency and level of each activity ( in - bed exercise , sitting on the edge of the bed or out of bed , standing , and walking ) . statistical analysis was performed with statistical package for the social sciences , version 15.0 ( spss inc . , descriptive analysis was performed using frequency of each event ( percentage ) , mean ( sd ) , or median ( interquartile range [ iqr ] ) , when appropriate . for each catheter type ( cvc , hd catheter , and iac ) , we determined the number of patients who experienced a catheter - related adverse event and the number of those who did not . therefore , the patients were divided into two groups on the basis of presence or absence of catheter - related adverse events . we used the nonparametric mann - whitney test to compare the adverse event and non - adverse event groups in terms of number of catheter days and number of mobility therapy sessions , for each catheter type . logistic regression analysis ( including ors and their 95% cis ) was performed to determine the association between adverse events and number of mobility therapy sessions . the association analysis was adjusted for number of catheter days ( confounding variable ) . for statistical analysis , during the study period , 275 patients were admitted to the clinical emergency icu of the ichc - fmusp , all of whom were included in the analysis . the mean age of the patients was 48  18 years , and most patients ( 84% ) were admitted for clinical decompensation . in addition , of the 275 patients , 82 ( 30% ) were admitted with a diagnosis of sepsis . the major source of origin was the emergency room ( in 53% ) , followed by the ward because of clinical worsening ( in 26% ) . the length of icu stay was 5 [ iqr : 7 ] days , and 44% of the patients required invasive mechanical ventilation during that period . table 1.patient demographic characteristics.avariable(n = 275)age , years48  18male gender , n ( % ) 135 ( 49)saps338  19diagnosis , n ( % ) 
 clinical229 ( 84)surgical45 ( 16)site of admission , n ( % ) 

 emergency room145 ( 53)ward ( clinical worsening)72 ( 26)operating room ( po)45 ( 16)others12 ( 4)mechanically ventilated patients , n ( % ) 122 ( 44)duration of mechanical ventilation , days 
 3 length of icu stay , days 
 5 mortality , n ( % ) 47 ( 17)saps : simplified acute physiology score ; and po : postoperative period . of the 275 patients , 82% ( n = 225 ) received at least one mobility therapy session ( a total of 2,638 sessions ) and 94% ( n = 258 ) received at least one respiratory therapy session throughout their icu stay . in addition , of those 275 patients , 31% ( n = 86 ) sat in an armchair ( i.e. , out of bed ) and 29% ( n = 80 ) walked at least once during their icu stay . patients with orotracheal tubes ( orotracheal intubation ) or tracheostomy tubes ( with or without mechanical ventilation ) underwent a total of 1,428 mobility therapy sessions , in which the main activity was ambulation , in 237 sessions ; orthostasis , in 161 sessions ; sitting in an armchair , in 91 sessions ; sitting on the edge of the bed , in 60 sessions ; and in - bed exercise , in 879 sessions . during those sessions table 2 shows the frequency of patients who experienced catheter - related adverse events by catheter type , as well as the number of catheter days , the frequency of mobility therapy sessions conducted with a catheter in situ , and the most successfully accomplished activity in those sessions , by catheter type and by absence or presence of catheter - related adverse events . among the 275 patients evaluated , cvcs were used in 49% , hd catheters were used in 26% , and iacs were used in 29% . the main insertion sites were the jugular and subclavian veins , for cvcs and hd catheters , and the radial artery , for iacs . a total of 1,268 mobility therapy sessions were conducted with a catheter in situ , and the most prevalent activity was in - bed limb mobilization ( in passive , active , and resistive modes ) . catheter - related adverse events occurred in 20 patients , and , in two of those 20 patients , there were two adverse events ( a total of 22 catheter - related adverse events ) . the adverse events were as follows : infection ( n = 5 , cvc ; n = 2 , hd catheter ) ; obstruction ( n = 5 , hd catheter ; n = 2 , iac ) ; and accidental dislodgement or removal ( n = 4 , cvc ; n = 1 , hd catheter ; n = 2 , iac ) . in one case , table 2.characteristics of the catheters used and of the mobility therapy provided.variablecvchd catheteriacadverse eventadverse eventadverse eventabsentpresentabsentpresentabsentpresentpatients , n ( % ) 126 ( 94)8 ( 6)63 ( 89)8 ( 11)75 ( 95)4 ( 5)catheter days , median [ iqr]5 8 * 6 9 3 7 * mobility therapy sessions ( n ) , median [ iqr ] 
 4 6 4 12 * 2 10 main insertion site 






 jugular vein , n 855345 - -subclavian vein , n333111 - -femoral vein , n61172 - -radial artery , n--- 
 503dorsalis pedis artery , n----150femoral artery , n----31most successfully accomplished activity 





 ambulation , n232125030orthostasis , n513101250sitting in an armchair , n25338370sitting on the edge of the bed , n36239851limb mobilization , n533423825922720cvc : central venous catheter ; hd : hemodialysis ; iac : indwelling arterial catheter ; and iqr : interquartile range . cthe insertion site was not described on the chart in 3% ( cvc ) ; 4% ( hd catheter ) , and 9% ( iac ) of the cases . * p < 0.05 when compared with the respective non - adverse event group . cvc : central venous catheter ; hd : hemodialysis ; iac : indwelling arterial catheter ; and iqr : interquartile range . cthe insertion site was not described on the chart in 3% ( cvc ) ; 4% ( hd catheter ) , and 9% ( iac ) of the cases . when comparing the adverse event and non - adverse event groups by catheter type , we found that the number of catheter days was greater in the former than in the latter-(median [ iqr ] ) 8   vs. 5   days for cvcs ( p < 0.05 ) ; and 7   vs. 3   days for iacs ( p < 0.05)-as was the number of mobility therapy sessions per patient-(median [ iqr ] ) 12   vs. 4   for hd catheters ( p < 0.05 ) . logistic regression analysis for each catheter type , adjusted for number of catheter days , revealed that mobility therapy was not significantly associated with any catheter - related adverse event , regardless of the type of catheter employed : cvc - or = 0.862 ; 95% ci : 0.7 - 1.05 ; p = 0.146 ; hd catheter - or = 1.046 ; 95% ci : 0.898 - 1.219 ; p = 0.562 ; or iac - or = 1.746 ; 95% ci : 0.942 - 3.237 ; p = 0.077 . in the present study , we found that , of the 275 patients admitted to the clinical emergency icu of the ichc - fmusp , 82% received mobility therapy , whereas 94% received respiratory therapy . of a total of 2,638 mobility therapy sessions , 1,268 were provided to patients while they had a catheter in place ( cvc , iac , or hd catheter ) , and we found that mobility therapy was not significantly associated with any catheter - related adverse event , regardless of the type of catheter employed . in addition , in 1,428 sessions provided during orotracheal intubation or during the use of a tracheostomy tube ( with or without mechanical ventilation ) , there were no reported episodes of self - extubation or accidental extubation . recent cohort or prevalence studies have found that 34 to 62% of icu patients receive mobility therapy . 9 
 11 
 12 
  in our study , 82% of the patients received at least one mobility therapy session . this difference in the proportion of treated patients can be explained by the large number of physical therapists in our icu ( 1:10 senior physical therapist / patient and 1:6 resident in physical therapy / patient ) , unlike what occurs in icus in other countries , in which there is a strong presence of respiratory therapists . 13 
  however , the large number of physical therapists did not imply treatment aimed at more complex levels of mobilization , the most prevalent activity being in - bed exercise . one explanation for this finding is that early mobilization in icus in brazil remains unusual , despite the constant , daily presence of the physical therapist . another factor that can explain this situation is that only the activities conducted with a catheter in situ were analyzed , and patients with cvcs and iacs usually experience increased hemodynamic instability and increased disease severity . in our study , we found no association between catheter - related adverse events and mobilization ( mobility therapy ) in the icu . in addition , the incidence of catheter - related adverse events was 2% in our study ( 22 events in 1,268 sessions ) , being similar to the less than 5% incidence reported in other centers . 
 1 
 2 
 14 
 18 
  damluji et al . , 
 6 
  when evaluating 101 patients who underwent 253 physical therapy sessions with a femoral catheter in situ , found that exercise was not associated with catheter - related adverse events . , 
 8 
  when evaluating 77 patients with 92 femoral catheters ( 50 iacs , 15 cvcs , and 27 hd catheters ) , found that exercise was not associated with catheter - related thrombotic or obstructive complications . likewise , we found no association between mobility therapy and catheter - related adverse events . however , unlike in the aforementioned studies , we assessed not only the femoral site but also the jugular and subclavian sites , for cvcs and hd catheters , and the radial and dorsalis pedis arteries , for iacs . in fact , the most common catheter insertion sites were the radial and jugular sites , given that catheter insertion into the femoral site is not the primary option in our icu ( table 2 ) . therefore , even when different insertion sites were used , exercise did not imply an increase in the number of catheter - related adverse events . first , this was a single - center study - direct comparison with other hospitals in brazil should be conducted with caution . however , our findings are similar to those of studies conducted in countries where the difference in care is greater than that observed among hospitals in brazil . second , the study has a retrospective design - data were retrieved from a database and from patient charts . therefore , we can establish only an association , not a cause - and - effect relationship . in addition , information on catheter insertion site could not be obtained for all cases - that is , for 3% ( cvc ) , 4% ( hd catheter ) , and 9% ( iac)-nor was it possible to obtain information on one cvc - related adverse event . however , we believe that these factors do not alter the results of this study , because catheter insertion site was not used for analysis , being of descriptive value only . third , the only factors used in our analysis were mobility therapy and number of catheter days . thus , it was not possible to determine the effect of medical and nursing procedures ( e.g. , hygiene , transport , and tube passage ) on our results . catheter infection is known to be caused by multiple factors and can result from patient handling by healthcare workers . for this reason , the reported prevalence , which refers specifically to mobility therapy , might be overestimated relative to reality . on the basis of the present study , we conclude that , in the study population , mobility therapy is not associated with the incidence of adverse events involving cvcs , hd catheters , or iacs . verificar se a realizao de fisioterapia com foco na reabilitao motora est associada a eventos adversos em cateteres centrais e perifricos em uma uti brasileira . anlise retrospectiva das fichas de evoluo diria dos pacientes internados , de dezembro de 2009 a abril de 2011 , na uti de emergncias clnicas do instituto central do hospital das clnicas da faculdade de medicina da universidade de so paulo . alm das caractersticas clnicas e demogrficas dos pacientes , foram coletados dados referentes aos cateteres venoso central ( cvc ) , de hemodilise ( hd ) e de presso arterial invasiva ( pai ) , tais como stio de insero , tempo de permanncia e eventos adversos relacionados , bem como  caracterizao da fisioterapia motora realizada . de um total de 275 pacientes , 49% utilizaram cvc , 26% , cateter de hd e 29% , cateter de pai em algum momento da internao . um total de 1.268 sesses de fisioterapia motora ocorreu enquanto o paciente apresentava algum tipo de cateter inserido . os eventos adversos relacionados  insero dos dispositivos ocorreram em 20 pacientes , totalizando 22 ocorrncias : 32% de infeco , 32% de obstruo e 32% de retirada acidental . neste estudo , verificou - se que no existe relao entre eventos adversos nos cateteres e a realizao de fisioterapia motora : fisioterapia motora e cvc - or = 0,8 ; ic95% : 0,7 - 1,0 ; p = 0,14 ; fisioterapia motora e cateter de hd - or = 1,04 ; ic95% : 0,89 - 1,21 ; p = 0,56 ; e fisioterapia motora e cateter de pai - or = 1,74 ; ic95% : 0,94 - 3,23 ; p = 0,07 . a realizao de fisioterapia motora em pacientes crticos no est relacionada  incidncia de eventos adversos em cvc , cateteres de hd e cateteres de pai . a prtica da reabilitao precoce em pacientes internados em uma unidade de terapia intensiva ( uti ) contribui para prevenir e minimizar os efeitos deletrios do imobilismo , melhorar a capacidade funcional , reduzir o tempo de permanncia em ventilao mecnica e o tempo de internao hospitalar , alm de melhorar a qualidade de vida desses pacientes . 
 1 
 4 
  no entanto , a literatura descreve algumas barreiras que limitam ou dificultam a prtica dessa reabilitao . entre elas , podemos citar a gravidade da doena , o nvel de sedao , o uso de drogas vasoativas e a presena de cateteres , sejam eles centrais ou perifricos . 
 5 
 6 
  a utilizao de cateteres centrais ou perifricos para administrao de medicamentos e monitorizao em pacientes crticos  frequente . em pacientes com acesso difcil , com mltiplos acessos ou com coagulopatia , ainda  comum a restrio parcial ou total do paciente ao leito para prevenir o deslocamento ou a perda desses dispositivos . alm disso , existe ainda a preocupao com a manuteno do fluxo sanguneo em pacientes que realizam terapia renal contnua de substituio . 7 
  recentemente , alguns estudos tm mostrado que a mobilizao dos pacientes que possuem esses dispositivos  segura e no est associada a eventos adversos nos acessos / cateteres . 
 6 
 8 
 9 
  entretanto , alguns centros ainda consideram a presena desses dispositivos como barreiras para a mobilizao , retardando o incio da reabilitao . 5 
 10 
  tendo em vista que a literatura sobre esse tpico ainda  controversa e que a maior parte dos estudos foi realizada em centros americanos e australianos que possuem assistncia fisioteraputica diferente da realidade brasileira , o objetivo do presente estudo  verificar se a realizao de fisioterapia com foco na reabilitao motora est associada a eventos adversos em cateteres centrais e perifricos em uma uti brasileira . nossa hiptese  que no existe associao entre fisioterapia com foco em reabilitao motora e eventos adversos tais como deslocamento / retirada acidental e quadros infecciosos nos cateteres centrais e perifricos . este estudo foi aprovado pela comisso de tica para anlise de projetos de pesquisa em humanos da faculdade de medicina da universidade de so paulo ( fmusp ) . foi realizada uma anlise retrospectiva das fichas de evoluo diria dos pronturios mdicos e fisioteraputicos de todos os pacientes internados , de dezembro de 2009 a abril de 2011 , na uti da disciplina de emergncias clnicas do instituto central do hospital das clnicas ( ichc ) da fmusp , que possui 6 leitos . as fichas de evoluo diria foram elaboradas previamente ao estudo , eram preenchidas eletronicamente e j vinham sendo utilizadas h pelo menos um ano na unidade . o atendimento fisioteraputico na unidade era caracterizado tanto pela assistncia respiratria quanto pela reabilitao motora . brevemente , a assistncia respiratria era baseada em manobras de desobstruo das vias areas ( incluindo aspirao ) , tcnicas de expanso pulmonar , ajuste da oxigenoterapia e inaloterapia ( esta de acordo com a prescrio mdica ) . alm disso , se o paciente estivesse sob assistncia ventilatria mecnica , o fisioterapeuta tambm auxiliava nos ajustes de parmetros ventilatrios e na extubao do paciente . a reabilitao motora consistia na prtica de exerccios de membros superiores e inferiores e de tronco , nas modalidades passiva , ativa e resistida . os exerccios eram realizados com o paciente deitado no leito , em sedestao no leito ou em sedestao na poltrona , de acordo com a capacidade do indivduo e a critrio do fisioterapeuta . alm disso , exerccios em ortostatismo e deambulao ao redor do leito e no corredor tambm eram preconizados . a equipe multiprofissional dessa unidade era composta de 1:6 enfermeira / paciente , 1:2 tcnico em enfermagem / paciente , 1:6 residente em fisioterapia / paciente e 1:10 fisioterapeuta snior / paciente . a assistncia fisioteraputica estava presente 12 horas por dia ( das 7h s 19h ) e , normalmente , cada indivduo recebia dois atendimentos durante esse perodo , direcionados  necessidade de cada paciente . a coleta de dados incluiu caractersticas demogrficas e dados clnicos , tais como idade , sexo , diagnstico de internao clnica , simplified acute physiology score ( saps ) 3 , local de admisso , tempo de ventilao mecnica , tempo de internao e mortalidade . alm disso , foram coletados dados referentes aos cateteres venosos centrais ( cvc ) , cateteres para a realizao de hemodilise ( hd ) e cateteres para a mensurao de presso arterial invasiva ( pai ) , tais como stio de insero do cateter , tempo de permanncia ( em dias ) e nmero de sesses de fisioterapia motora realizada com cateter in situ . finalmente , os dados de fisioterapia coletados foram frequncia e nvel de cada atividade ( exerccios no leito , sentar - se na beira da cama ou fora do leito , levantar - se e deambular ) . a anlise estatstica foi realizada utilizando - se o software statistical package for the social sciences , verso 15.0 ( spss inc . , chicago , il , eua ) . a anlise descritiva foi realizada atravs da frequncia de cada evento ( porcentagem ) , mdia ( dp ) ou mediana ( intervalo interquartlico [ iiq ] ) , quando apropriado . para cada tipo de cateter ( cvc , cateter de hd e cateter de pai ) , verificou - se o nmero de pacientes que apresentaram ou no algum tipo de evento adverso relacionado ao cateter . dessa forma , os pacientes foram divididos em dois grupos de acordo com a presena ou ausncia de evento adverso . o teste no paramtrico de mann - whitney foi utilizado para comparar o tempo de permanncia do cateter e o nmero de sesses de fisioterapia entre os grupos ( evento adverso presente ou ausente ) para cada tipo de cateter . uma anlise de regresso logstica ( considerando - se or e ic95% ) foi realizada para verificar a associao entre a presena de eventos adversos e o nmero de sesses de fisioterapia . essa anlise de associao foi ajustada pela varivel tempo de permanncia do cateter ( varivel de confuso ) . para a anlise estatstica , adotamos o nvel de significncia de 5% ( p < 0,05 ) . no perodo estudado , foram admitidos 275 pacientes na uti de emergncias clnicas do ichc - fmusp , todos os quais foram includos na anlise . as caractersticas demogrficas e os dados clnicos dos pacientes esto contidos na tabela 1 . a idade mdia dos pacientes foi de 48  18 anos , e a maioria dos pacientes ( 84% ) foi internada por descompensao clnica alm disso , dentre os 275 pacientes , 82 ( 30% ) foram internados com diagnstico de sepse . a principal fonte de origem foi o pronto socorro ( 53% ) , seguida pela enfermaria por motivo de piora clnica ( 26% ) . o tempo de internao na unidade foi de 5 [ iiq : 7 ] dias , e 44% dos pacientes necessitaram de assistncia ventilatria mecnica invasiva durante esse perodo . a mortalidade geral da unidade foi de 17% . tabela 1.caracterizao demogrfica dos pacientes.avariveis(n = 275)idade , anos48  18gnero masculino , n ( % ) 135 ( 49)saps338  19diagnstico , n ( % ) 
 clnico229 ( 84)cirrgico45 ( 16)local de admisso , n ( % ) 

 pronto socorro145 ( 53)enfermaria ( piora clnica)72 ( 26)centro cirrgico ( po)45 ( 16)outros12 ( 4)pacientes em ventilao mecnica , n ( % ) 122 ( 44)tempo de ventilao mecnica , dias 
 3 tempo de internao , dias 
 5 mortalidade , n ( % ) 47 ( 17)saps : simplified acute physiology score ; e po : ps - operatrio em relao  assistncia fisioteraputica , 82% dos 275 pacientes ( n = 225 ) receberam pelo menos uma sesso de fisioterapia relacionada  reabilitao motora ( totalizando 2.638 sesses ) , e 94% dos 275 pacientes ( n = 258 ) receberam pelo menos um atendimento de assistncia respiratria durante todo o tempo de internao na uti . alm disso , 31% dos 275 pacientes ( n = 86 ) se sentaram em poltrona ( fora do leito ) e 29% ( n = 80 ) andaram pelo menos uma vez durante a sua internao na uti . com relao  presena de cnulas orotraqueais ( intubao orotraqueal ) e cnulas de traqueostomia ( em assistncia ventilatria mecnica ou no ) , foram realizadas 1.428 sesses de fisioterapia motora , nas quais a principal atividade realizada foi deambulao , em 237 sesses ; ortostatismo , em 161 sesses ; sedestao em poltrona , em 91 sesses ; sedestao a beira do leito , em 60 sesses ; e exerccios em leito , em 879 sesses . a tabela 2 mostra a frequncia de pacientes que apresentaram eventos adversos relacionados a cada tipo de cateter , o tempo de permanncia de cada cateter em cada grupo de pacientes , a frequncia de sesses de fisioterapia realizadas com cada cateter in situ e a melhor atividade realizada nessas sesses . do total de 275 pacientes , 49% utilizaram cvc , 26% , cateter de hd e 29% , cateter de pai em algum momento durante o perodo de internao . alm disso , 86 pacientes ( 31% ) apresentaram mais de um tipo de cateter inserido ao mesmo tempo . os principais stios de insero foram as veias jugular e subclvia , para cvc e cateter de hd , e a artria radial , para cateter de pai . na presena de cateteres , foram realizadas 1.268 sesses , sendo que a atividade mais prevalente foi a mobilizao geral de membros no leito ( incluindo as modalidades passiva , ativa e resistida ) . eventos adversos relacionados aos cateteres ocorreram em 20 pacientes , sendo que em dois pacientes houve a ocorrncia de dois eventos adversos ( totalizando 22 eventos adversos relacionados aos cateteres ) . os eventos ocorridos foram : infeco ( n = 5 , cvc ; n = 2 , cateter de hd ) ; obstruo ( n = 5 , cateter de hd ; n = 2 , cateter de pai ) ; e deslocamento ou retirada acidental ( n = 4 , cvc ; n = 1 , cateter de hd ; n = 2 , cateter de pai ) . em um caso , no houve registro da causa do evento adverso em pronturio . de hdcateter de paievento adversoausentepresenteausentepresenteausentepresentepacientes , n ( % ) 126 ( 94)8 ( 6)63 ( 89)8 ( 11)75 ( 95)4 ( 5)tempo de cateter ( dias ) , mediana [ iiq]5 8 * 6 9 3 7 * sesses de fisioterapia motora ( n ) , mediana [ iiq ] 
 4 6 4 12 * 2 10 principais stios de insero 






 veia jugular , n 855345 - -veia subclvia , n333111 - -veia femoral , n61172 - -artria radial , n--- 
 503artria dorsal do p , n----150artria femoral , n----31melhor atividade realizada 





 deambulao , n232125030ortostatismo , n513101250sentar na poltrona , n25338370sentar na beira do leito , n36239851mobilizao geral de membros , n533423825922720cvc : cateter venoso central ; hd : hemodilise ; pai : presso arterial invasiva ; e iiq : intervalo interquartlico . . csitio de insero no estava descrito no pronturio em 3% ( cvc ) ; 4% ( cateter de hd ) e 9% ( cateter de pai ) . cvc : cateter venoso central ; hd : hemodilise ; pai : presso arterial invasiva ; e iiq : intervalo interquartlico . asesses de fisioterapia motora em cada paciente , realizadas com dispositivos in situ . csitio de insero no estava descrito no pronturio em 3% ( cvc ) ; 4% ( cateter de hd ) e 9% ( cateter de pai ) . * comparando - se os grupos presena e ausncia de eventos adversos em cada tipo de cateter , verificamos que o grupo com evento adverso presente apresentou maior tempo de permanncia do cateter quando comparado ao grupo com evento adverso ausente - ( mediana [ iiq ] ) 8   vs. 5   dias para cvc ( p < 0,05 ) ; e 7   vs. 3   dias para cateter de pai ( p < 0,05 ) - e maior nmero de sesses de fisioterapia por paciente - ( mediana [ iiq ] ) 12   vs. 4   para cateter de hd ( p < 0,05 ) . na anlise de regresso logstica de cada tipo de cateter , ajustada para o tempo de permanncia ( em dias ) , verificamos que no existe relao entre a presena de eventos adversos nos cateteres e a realizao de fisioterapia motora : fisioterapia motora e cvc - or = 0,862 ; ic95% : 0,7 - 1,05 ; p = 0,146 ; fisioterapia motora e cateter de hd - or = 1,046 ; ic95% : 0,898 - 1,219 ; p = 0,562 ; e fisioterapia motora e cateter de pai - or = 1,746 ; ic95% : no presente estudo , verificamos que 82% dos 275 pacientes internados na uti de emergncias clnicas do ichc - fmusp receberam algum tipo de fisioterapia motora , ao passo que 94% dos pacientes receberam algum tipo de assistncia respiratria . de um total de 2.638 sesses de fisioterapia motora , 1.268 sesses ocorreram enquanto o paciente apresentava algum tipo de cateter inserido ( cvc , cateter de pai ou cateter de hd ) , no sendo encontrada relao entre a presena de eventos adversos relacionados aos cateteres e a realizao de fisioterapia motora . alm disso , em 1.428 sesses realizadas durante o perodo de intubao orotraqueal ou o uso da cnula de traqueostomia ( com ou sem assistncia ventilatria ) , no foi relatado nenhum episdio de autoextubao ou extubao acidental das cnulas . estudos de coorte recentes ou de prevalncia verificaram que 34 a 62% dos pacientes internados em uti realizam algum tipo de fisioterapia relacionada  parte motora . 
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  em nosso estudo , 82% dos pacientes receberam pelo menos uma sesso de fisioterapia motora . essa diferena em relao  proporo de pacientes atendidos pode ser explicada pela maior quantidade de fisioterapeutas disponveis em nossa unidade ( 1:10 fisioterapeuta snior / paciente e 1:6 residente em fisioterapia / paciente ) , diferentemente do que ocorre nas utis de outros pases , onde a presena do terapeuta respiratrio  mais marcante . 
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  entretanto , a maior proporo de fisioterapeutas no implicou atendimento visando nveis mais complexos de mobilizao , sendo os exerccios realizados no leito os de maior prevalncia . uma explicao para este achado  ainda a falta de cultura da mobilizao precoce em utis brasileiras apesar da presena constante e diria do fisioterapeuta na unidade . outro fator ainda que pode explicar essa situao  que apenas as atividades realizadas durante a presena dos cateteres foram analisadas e pacientes com cvc e cateteres de pai normalmente apresentam maior instabilidade hemodinmica e gravidade . em nosso estudo no encontramos associao entre a presena de eventos adversos nos dispositivos e a mobilizao ( fisioterapia motora ) realizada em uti . alm disso , a incidncia de eventos adversos relacionados aos cateteres foi de 2% em nosso estudo ( 22 eventos em 1.268 sesses ) , sendo similar  incidncia < 5% relatada em outros centros . 
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  damluji et al . 
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  verificaram , em 253 sesses de fisioterapia realizadas em 101 pacientes com cateteres inseridos na via femoral , que a realizao de exerccios no estava relacionada a eventos adversos nesses dispositivos . em outro estudo , perme et al . 
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  verificaram , em 77 pacientes com 92 dispositivos femorais ( 50 cateteres de pai , 15 cvc e 27 cateteres de hd ) , que a realizao de exerccios no estava relacionada a complicaes de trombose / obstruo nesses dispositivos . da mesma forma , tambm no encontramos associao entre a realizao de fisioterapia e eventos adversos nos dispositivos . entretanto , ao contrrio dos estudos citados , nossa avaliao no se restringiu ao stio femoral , sendo tambm considerados os stios jugular e subclvio , para cvc e cateteres de hd , e as artrias radial e dorsal do p , para os dispositivos de pai . de fato , os stios mais incidentes para insero dos dispositivos foram os stios radial e jugular , tendo em vista que a insero de dispositivos no stio femoral no  a opo primria em nossa unidade ( tabela 2 ) . dessa forma , mesmo quando inseridos em stios diferentes , a realizao de exerccios no implicou aumento de eventos adversos nos cateteres inseridos . primeiro , o estudo foi realizado em um nico centro - a comparao direta com outros hospitais nacionais deve ser realizada com cautela . entretanto , nossos achados so similares aos de estudos realizados em outros pases onde a diferena de assistncia  maior quando comparada  diferena na assistncia existente entre os hospitais nacionais . segundo , o estudo tem um desenho retrospectivo - os dados foram retirados de um banco de dados e do pronturio de pacientes . dessa forma , no podemos estabelecer uma relao de causa - efeito e sim apenas de associao . alm disso , os dados referentes ao stio de insero dos cateteres no puderam ser inteiramente reportados ( ausncia de 3% para cvc , de 4% para cateter de hd e de 9% para cateter de pai ) , bem como a descrio de um evento adverso para cvc . entretanto , acreditamos que esses fatores no alteram o resultado do nosso estudo , pois o stio de insero dos cateteres no foi utilizado para anlise , tendo valor apenas descritivo de caracterizao . utilizados em nossa anlise foram a realizao de fisioterapia motora e o tempo de permanncia de cada cateter ( em dias ) . assim , no foi possvel verificar a interferncia dos procedimentos mdicos e da equipe de enfermagem ( por exemplo , higienizao , transporte e passagens de sondas ) em nossos resultados . com relao s infeces dos cateteres , sabe - se que as mesmas possuem causa multifatorial e podem ser decorrentes da manipulao do paciente por qualquer profissional . nesse sentido , a prevalncia reportada , relacionada especificamente  fisioterapia , pode estar superestimada em relao  realidade . dessa forma , conclumos por meio do presente estudo que a prtica de mobilizao na populao estudada no est relacionada  presena de eventos adversos nos cvc , cateteres de hd e cateteres de pai .
objective : to determine whether mobility therapy is associated with central or peripheral catheter - related adverse events in critically ill patients in an icu in brazil . methods : a retrospective analysis of the daily medical records of patients admitted to the clinical emergency icu of the university of so paulo school of medicine hospital das clnicas central institute between december of 2009 and april of 2011 . 
 in addition to the demographic and clinical characteristics of the patients , we collected data related to central venous catheters ( cvcs ) , hemodialysis ( hd ) catheters and indwelling arterial catheters ( iacs ) : insertion site ; number of catheter days ; and types of adverse events . 
 we also characterized the mobility therapy provided . 
 results : among the 275 patients evaluated , cvcs were used in 49% , hd catheters were used in 26% , and iacs were used in 29% . 
 a total of 1,268 mobility therapy sessions were provided to patients while they had a catheter in place . 
 catheter - related adverse events occurred in 20 patients ( a total of 22 adverse events ) : 32% , infection ; 32% , obstruction ; and 32% , accidental dislodgement . 
 we found that mobility therapy was not significantly associated with any catheter - related adverse event , regardless of the type of catheter employed : cvc - or = 0.8 ; 95% ci : 0.7 - 1.0 ; p = 0.14 ; hd catheter - or = 1.04 ; 95% ci : 0.89 - 1.21 ; p = 0.56 ; or iac - or = 1.74 ; 95% ci : 0.94 - 3.23 ; p = 0.07 . conclusions : in critically ill patients , mobility therapy is not associated with the incidence of adverse events involving cvcs , hd catheters , or iacs .