Awaking, exercising, sitting, walking and extubating: moving on the paradigms for mechanically ventilated patients

In the intensive care unit (ICU) patients are exposed to catheters, tubes, alarms and noise, and they experience thirst, hunger, immobility and several other sources of discomfort. How hostile is the ICU environment to patients and to caregivers? It is intuitive to put patients to sleep while they stay in this inhospitable place for life support. Moreover, during sleep, respiration is controllable, oxygen consumption may be reduced, and patients’ appearances are placid to observers. Hibernation during critical illness was the gold standard of care for a long time. In 2000, Kress et al. showed that daily interruption of continuous sedation was associated with less time spent on mechanical ventilation and less time needing ICU support.(1) However, critics questioned whether the price of sleep deprivation, pain, anxiety, depression, agitation, and delirium paid by those patients was really worth the benefit.(2) The authors’ response came three years later with a long-term follow-up of those patients, evaluating the psychological impact of daily sedative interruption as positive.(3) Afterwards, these same findings were replicated in other studies.(4,5) In one such study, daily sedative interruption was substituted with a no-sedation protocol, resulting in a reduction in the time needed for critical care support and no long-term psychological negative impact.(6) Ultimately, the reduction of sedation levels associated with early passive and active mobilization was coupled with a more precocious functional independence.(7) Patients were incentivized to early mobilization using a cycle ergometer and had high satisfaction in doing so.(8) Currently, some ICUs propose the judicious early mobilization of critically ill patients. They consider progressive levels of mobilization, from active on-bed mobilization to exercising while sitting, exercising while standing, and ambulating. All of these levels could be offered to the patient regardless of the need for mechanical ventilation.(9) During the last 10 years, the paradigm of sedation in critically ill patients has changed greatly worldwide, and ICUs are working even more with awake patients who are able to contribute to their own care. In Brazil, one trial comparing a no-sedation protocol with daily interruption showed the feasibility of using very small amounts of sedatives in a lower nurse staffing level ICU compared to the ICUs in which the previous studies were conducted. Moreover, there was not any associated harm in either group in which patients were kept awake.(10) Furthermore, the use of deeper sedation on ICU admission was associated with a higher mortality in another Brazilian study.(11) Similar results were also found in Australian ICUs.(12) Still, in Brazil Camargo Pires-Neto et al. showed the metabolic safety of early passive mobilization(13) and the feasibility, safety and Marcelo Park1, Ruy Camargo Pires-Neto1,2, Antonio Paulo Nassar Junior1,3