Early Mobilization in an Oncology Intensive Care Unit

Introduction: Quality of life and functionality of critically ill cancer patients are significantly affected after ICU admission, with changes due to immobility, hemodynamic instability, muscular atrophy, cognitive deficits, psychological difficulties, decreased cardiovascular functional capacity, neurological deleterious effects on the respiratory system. The physiotherapeutic intervention is effective in preventing and reducing the deleterious dysfunctions of immobility, as well as improving the quality of life of the patient during his / her stay in the ICU. Objective: To carry out a systematic review of literature seeking the benefits of early mobilization in intensive care patients. Methodology: Refers to a systematic literature review, approaching the PRISMA methodology, with two independent examiners who analyzed the quality of the study. We selected as inclusion criteria articles in Portuguese, English and Spanish that refer to the topic of early mobilization in intensive care oncology. Documents that do not associate with the proposed theme were excluded from the search. The articles were searched in the databases: VHL, PUBMED, COCHRANE, PEDRO and EBSCO. Results: For the elaboration of the study, 66 articles were found in the total, where only 8 articles were used because they refer to the use of early mobilization in intensive oncologic therapy. Final considerations: Early mobilization in the ICU is essential in the intervention of the multidisciplinary team on the cognitive, physical and functional aspects along with the kinesiotherapeutic progressivity adequate to the individual needs of each patient, providing significant benefits in the prevention of dysfunctions caused by the immobilism syndrome, resulting in the best quality of life for the patient.


Introduction
Cancer patient has specific pathophysiological and clinical characteristics, most often needing support in the ICU sometime during disease progression, in order to bring therapeutic support to the patient in periods of greater severity or risk. According to the world health organization, cancer is the concepto given to the set of diseases in which cells grow and spread wildly, can reach any part of the body. In 2018, presented a occurrence of more than 596 thousand cases of the disease in Brazil [1,2].
In the ICU, critically ill patients who need to monitor and stabilize their hemodynamic condition are admitted in a sophisticated way, being possible a greater attention of the multidisciplinary team [2]. Quality of life and functionality of critically ill cancer patients are considerably affected after ICU admission with alterations caused by immobility, hemodynamic instability, muscle atrophy, cognitive impairment, psychological difficulties, decreased cardiovascular, neurological alteration, deleterious effects on the respiratory system, functional decline, delirium and others [1,2,3].
Studies show that the occurrence of dysfunctions in the patient's homeostasis begins after 72 hours of admission to the ICU, and its consequences can last up to five years after hospital discharge, thus reducing the quality of life, generating a biopsychosocial imbalance and consequently generating a higher incidence of depression and anxiety [4].
The most favorable way for the prevention of these alterations is the physical therapy action through early mobilization in the ICU [5,6].
Early mobilization consists of the initiation of physical therapy and cognitive activities in patients with mechanical ventilation within 48-72 hours of intubation onset, which begins with a multidisciplinary assessment to analyze the cognitive, physical and functional state of the patient, thus identifying and intervening according to the needs of each [1]. Activities such as stretching, positioning, use of the cycle ergometer, breathing exercises, assisted active exercises, transfer exercises, active range of motion exercises, bed mobility activities, walking, walking and others can be performed for a functional activity of the patient [1,2,6,7,8]. For early mobilization to be efficient, it is important to consider the type of exercise, the intensity, frequency, dose and duration, promoting a progressive kinesiotherapy according to the patient's evolution [2,5,7].
Often the patient may experience devastating fatigue, anxiety, fear, pain, boredom, insomnia (due to the turbulent environment), and most often lack motivation. This can have a negative impact on adherence to the therapist's proposed treatment, often becoming a reason for stopping early mobilization. The trust and involvement between therapist and patient is very important, as soon as you are able to establish this bond, it will begin to progress and evolve in the recovery stages, as time has come to realize and measure the functional gains that are being made [9].
The benefits of mobilization include decreased ICU stay, cardiopulmonary improvement, reduced fatigue symptoms, improved quality of life, increased muscle strength, weakness prevention, improved gastrointestinal function, pain control, decreased incidence of clot formation, pneumonia, promotion of clearance of secretions, pressure ulcers, also improving perfusion and muscle metabolismo [1,2,3,7,9,10,11]. The mobilization has been increasingly used as a nonpharmacological technique for pain relief, is associated with decreased sedation depth, with an excellent result, causing an increase in the number of days without mechanical ventilation. In addition, it decreases the time by 48 hours hospitalization, thus reducing hospital costs [5,12]. Therefore, the physical therapy intervention is highly effective in preventing and reducing deleterious dysfunctions of immobility, as well as improving the patient's quality of life during their ICU stay, thus enhancing their rehabilitation in the post-hospitalization period [2,5].

Methodology
Refers to a systematic literature review performed according to the PRISMA protocol (PreferredReportItems for SystematicaReviewsand Meta-Analyses) with two independent examiners who assessed the quality of the study. In the first stage, searches were performed in five electronic databases: BVS, PUBMED, COCHRANE, PEDRO and EBSCO. The searches were performed in the English, Portuguese and Spanish languages, without starting date filter and until May 28, 2019. The search strategy given by the combination of the following keywords: "Early Mobilization, Intensive Care Unit, Oncology".
Then, there was a preliminary evaluation of titles and abstracts only, and duplicate articles that did not correspond to early mobilization in intensive cancer therapy were previously excluded. Later in the third stage, the selected studies were read in full and all those that met the inclusion criteria were included in this systematic review. Thus, any documents that do not associate with the proposed theme, and which are not of English, Portuguese or Spanish were excluded from the search (figure 1).

Results
To prepare the study, 66 articles were found, in which only 15 articles were used (Table 1), because they refer to the use of early mobilization in intensive cancer therapy. The incidence of pneumonia was 30.6%. Longer stay in the intensive care unit, tracheostomy decannulation after 10 days and longer operative times. Were significantly associated with pneumonia. Delayed mobilization (after day 4 postoperatively) was an independent risk factor for pneumonia. A questionnaire included questions on demographic data, assessment scales for delirium, sedation and pain, as well as pharmacological agents and methods of practice.
Most respondents were aware of the benefits of early mobilization, but lack of support staff and security concerns were major obstacles to their implementation. Systematize the knowledge about PM in the intensive care environment and its repercussion, especially on the functional and permanence aspects of mechanical ventilation (MV) and the ICU.

Systematic review
Only clinical trials with Control Group (CG) and full access availability were included, which evaluated the effect of PM on the ICU in adult humans over 18 years.
Early mobilization in the Intensive Care Unit had a significantly positive impact on patients' functional outcomes.

Study Systematic Reviews
Data collection and analysis Two researchers independently selected titles and abstracts and evaluated full-text articles based on the inclusion criteria of this review. We resolve any disagreement by discussing with a third reviewer as needed.
There were mixed results on the effect of early movement or exercise on function.
One study found that in some measures of physical function, participants who received the intervention could get out of bed earlier and walk greater distances. Early movement or exercise seems safe because the number of adverse events was very low. There was no difference between the groups. time spent in hospital, muscle strength or mortality rates

Discussion
According to Murakami FM et al, technological advances and care for critically ill patients contribute to a high prevalence of patients who responded to early mobilization, and the clinical or surgical diagnosis does not interfere with the response of these patients, significantly contributing to decreased mortality, increased patient survival, which is of interest in always improving the adverse effects of immobility [2]. According to De Matos CA et al, there is a positive response related to patient survival and lower mortality rate with early mobilization interventions in intensive care units [1].
From Almeida EPM et al and Shouhed D et al, evidence that a postoperative early mobilization program seems to be safe and viable, working with exercises that improve fatigue, improve quality of life, increase muscle strength and decrease the incidence of clot formation.
Therefore in his study no clear clinical results were found [6,10]. As stated by Thomas AJ et al, that physiotherapy conducts early rehabilitation as a component of ICU management, shows concern about the effectiveness of interventions provided beyond routine care, with this as a significantly positive response [7].
Silva VS et al, show that the frequency and severity of neuromuscular weakness and its clinical manifestations can be minimized by the application of early mobilization (MP) that acts in the prevention and treatment of these complications. Early physical therapy, even during the time of intubation and ventilatory support, can be safely practiced, improving patient functional outcomes [13].
Corner EJ et al, concluded through a survey of the patient's experience of early mobilization in the ICU that patients agreed with the relevance of early mobilization but found it difficult, tiring and uncomfortable [3].
Warren ML et al and Haren RMV et al present that mobilization activities performed by physiotherapists have increased, bringing the benefit of reduced time in an intensive care unit [4,8]. For Weeks A et al, evidence that the functionality and quality of life of critically ill patients worsen when admitted to the ICU, but the study indicates that there must be cognitive and physical interventions as they are potentially viable in cancer patients to treat the limitation of functional performance [5].
Chawla R et al stated that most physicians are aware of the gains that mobilization brings to the patient, but their implementation is still limited due to lack of support and concern for their safety, and that mobilization depends on sedation-analgesia and ICU muscle rest [12]. Already Yeung JK et al, reported that several microsurgeons resist adopting mobilization protocols due to possible complications such as graft loss and skin discontinuation, so prefer to avoid [11].
For Silva AP et al, the exercises have well-stipulated physical and psychological gains, also reduce oxidative stress and inflammation, by providing the growth of anti-inflammatory cytokines production [14].
According to Doiron KA et al, patients admitted to the intensive care unit require greater stabilization and monitoring attention, however, to be effective early mobilization has to take into account the type of exercise, frequency that is applied and dose and duration in these critically ill patients [15]. However, Engel HJ et al, says how favorable is the role of the physiotherapist in this early intervention in patient health, preventing changes and improving quality of life while in the ICU, thus promoting the rehabilitation of cancer patients [9].

Final Considerations
According to the analysis of the data obtained through this systematic literature review, it is noted that early ICU mobilization is highly effective in addressing the multidisciplinary team on cognitive, physical and functional aspects along with kinesio therapeutic progressivity appropriate to the individual needs of patients, providing significant benefits in preventing dysfunctions caused by the immobility syndrome, resulting in a better quality of life for the patient.