Establishing an Awake and Walking ICU: Fundamental Concepts and a Case Report

Immobilism Syndrome is an often neglected disorder in the critical care setting. The repercussions of this condition are frequently detrimental and enduring, leading to a significant decline in patients' overall ability to operate. Enabling the movement of patients, even when they are undergoing mechanical ventilation and other artificial organ supports, is not only feasible but also advantageous. This article provides a comprehensive examination of the fundamental components of an Awake and Walking Intensive Care Unit and the burden caused by excessive sedation and immobilism.

Introduction

Immobilism Syndrome is a disorder that is often overlooked by most doctors and other health professionals, despite its potential to cause harmful consequences. Many experts acknowledge that prolonged durations of bed rest have detrimental effects, although the full degree of the injury is frequently disregarded. Immobilism is a sickness that gradually causes damage to many organs and systems. These patients have cardiovascular, pulmonary, gastrointestinal, musculoskeletal, neuroendocrine, urinary, and psychological harm, which can result in long-term effects. A significant number of patients who were confined to bed for an extended period of time describe a permanent decrease in their cognitive and physical abilities following a severe illness that rendered them immobile. Multiple organic dysfunctions can result in detrimental consequences due to a lack of exercise and immobility. Many patients are unable to regain the functionality they lost as a result of a protracted period of bed rest.

Prolonged immobility experienced during hospitalisation can lead to functional impairment lasting for a year, resulting in individuals being unable to resume employment due to persistent debility and exhaustion (Zhang et al. 2019). The documented effects of weightlessness on astronauts produce similar repercussions to those experienced during prolonged periods of lying down, as observed in the field of aerospace medicine (Sprague 2004). While the negative effects of excessive rest have been recognised since the era of Hippocrates (1984), it was not until the latter part of the 20th century, with advancements in military medicine, that the practice of early mobilisation of patients was initiated. The recognition of immobilism syndrome as a significant contributor to lifelong functional impairment, with the possibility for fatality, is of utmost importance and requires urgent attention. Mobilising critically ill patients is an even greater challenge, as they present several barriers intrinsic to their severity. It is necessary to change the local culture and develop well-established protocols so that this task can be performed satisfactorily.

Causes and Consequences Associated With Extended Periods of Immobility

Diverse ailments can lead to prolonged periods of immobility, affecting individuals across various age groups. Patients in advanced stages of dementia often suffer from immobility, as do individuals who have had a stroke. As individuals grow older, they commonly undergo a decline in physical vitality, leading to an inclination towards reduced activity and more sedentary behaviour. Psychiatric patients, especially those suffering from depression or requiring high doses of sedative medications, may encounter immobility. Young patients who suffer from several traumatic events and endure diverse orthopaedic injuries may require extended periods of immobilisation. Severely malnourished patients may experience immobility as a result of significant muscle loss or neurological issues resulting from famine. Common joint problems, such as osteoarthritis or arthritis, have the potential to extend the duration of time that a patient is confined to bed. Septic patients and others experiencing other types of haemodynamic shock may also experience an extended period of immobility. These patients often require the use of mechanical breathing and vasoactive medications, which pose considerable challenges to mobilisation. The increasing prevalence of morbid obesity poses a challenge for the multidisciplinary team in terms of mobilisation. Neuroendocrine diseases, such as myxoedema coma, can lead to extended periods of bedridden immobility. 

Sarcopenia, a condition characterised by substantial muscle loss, is a consequence of immobility (Figure 1). Immobility results in an elevation of pro-inflammatory cytokines and reactive oxygen species, leading to a decrease in muscle mass and an increase in proteolysis (Sartori et al. 2021). To mitigate this issue, it is advised to engage in resistance training and incorporate dietary protein supplements as remedies for sarcopenia resulting from bed rest. Critical illness is characterised by a state of catabolic stress, in which patients often have a systemic inflammatory response. This reaction is associated with consequences that contribute to malfunction in numerous organs, longer hospital stays, and higher rates of sickness and death (Fan et al. 2014). The condition of a severe illness is characterised by the breakdown of skeletal muscle caused by the inability to maintain a proper equilibrium between protein synthesis and degradation (Bloch et al. 2012; Rennie 2009). The breakdown of muscle proteins increases due to the activation of intracellular signalling pathways (Poulsen 2012). The ubiquitin-proteasome system is widely regarded as the primary pathway involved in the breakdown of proteins. Within this system, two specific enzymes, atrogin-1 (Muscle Atrophy F-box) and MuRF-1 (Muscle Ring Finger -1), have been identified as key players in the process of skeletal muscle atrophy. These enzymes are activated in response to both inactivity and inflammation (Teixeira et al. 2021).

Cortisol levels will increase, indicating an association with stress. Consequently, blood glucose levels rise as a result of gluconeogenesis and increased insulin resistance. In response to stress, the body breaks down skeletal muscle, which exacerbates sarcopenia (Knight et al. 2009a) (Figure 2).

The supine position also induces a redistribution of bodily fluids. The blood is redirected from the lower extremities to the torso and head, thereby enhancing the flow of deoxygenated blood back to the heart. This procedure induces significant enlargement of the right heart chambers, leading to elevated levels of atrial natriuretic peptide. Consequently, there is an elevation in diuresis, leading to a decrease in plasma volume. Over time, there will also be a decline in the volume of red blood cells. The renin-angiotensin-aldosterone system will be stimulated in an effort to maintain blood pressure despite the decrease in intravascular volume (Knight et al. 2009b).

Extended durations of immobility result in patients experiencing a deterioration in their capacity to control their torso and becoming fatigued at a faster rate. There is a reduction in aerobic capacity and VO₂Max (maximum capacity for oxygen consumption). Every day of complete inactivity leads to a decrease of 0.3% in VO₂Max (Figure 3). Plasma volume, red blood cell mass, vasodilator function, muscles, and peripheral oxygen diffusion capacity all decrease. Bed rest for a period of 72 hours results in a 30% decrease in stroke volume and an increase in resting heart rate, ultimately leading to orthostatic intolerance (Convertino et al. 1997).

From a pulmonary perspective, the reduction in tidal volume is caused by the limitation of lung expansion due to the pressure exerted by body weight on the rib cage (Figure 4). Manoeuvres can be performed to expand the lungs and reduce complications, such as atelectasis and pneumonia. Nevertheless, it is important to note that individuals who are able to breathe on their own but lack neurological interaction may pose a barrier, as they will not be able to cooperate with manoeuvres. In such instances, EPAP and breath stacking may be employed; however, there is currently insufficient scientific evidence to support their efficacy (Morais et al. 2021).

Young patients who have highly active lifestyles may undergo significant psychological distress due to immobilisation, typically induced by acute conditions such as lower limb fractures or ligament injuries. In such situations, it is crucial to develop a detailed strategy for sending patients home, as they will often attempt to resume their usual activities despite their injuries. This can result in additional injuries, hence prolonging the healing period. Moreover, it is imperative to provide psychological assistance, since the inability to work can lead to the development of depression and anxiety (Batista Filho et al. 2024). Delirium, post-traumatic stress disorder (PTSD), and chronic pain are among the most prevalent complications associated with protracted immobility in the intensive care unit (ICU).

From a gastrointestinal standpoint, prolonged bed rest in patients leads to decreased hunger and impaired movement in the gallbladder, stomach, and intestines (Figure 5). Therefore, these people are prone to developing gallstones (Hjaltadottir et al. 2020), experiencing oesophageal reflux, and suffering from constipation (Ghoshal 2007). The evacuation of the intestines is further hindered by the challenge of assuming a seated position and the insufficient consumption of water and absence of dietary fibre.

Immobility also increases the risk of developing deep vein thrombosis and pulmonary thromboembolism, as it worsens Virchow's Triad, which consists of blood flow stagnation, increased blood clotting, and damage to the inner lining of blood vessels (Knight et al. 2009a) (Figure 6).

When it comes to skin problems, it is important to mention pressure ulcers, which occur when the weight of the body puts excessive pressure on bony areas. The areas around the ankles, sacrum, and trochanters are particularly prone to pressure sores (Grey et al. 2006). Another important condition to mention is contact dermatitis, which occurs as a result of contact with sweat, bed linens, or even diapers. Fracture patients may experience an intensified immune response when in contact with plaster, potentially leading to confusion in diagnosis with other illnesses, such as angioedema and lichen planus (Li and Li 2021). Patients with atopic dermatitis have an increased likelihood of also developing contact dermatitis (Figure 7).

Immobile patients are more prone to experiencing kidney stones at a higher rate. Bedridden patients experience increasing bone demineralisation, leading to elevated levels of calcium in the blood and urine, which raises the likelihood of stone formation. Additionally, there is an increased level of urine stasis, which promotes the growth of germs and increases the likelihood of urinary tract infections. Moreover, patients who are immobilised experience heightened challenges in maintaining hygiene in the genitourinary tract, hence creating a more conducive environment for bacterial growth (Okada et al. 2008) (Figure 8).

Obstacles to Early Mobilisation of Critically Ill Patients

Implementing routine early mobilisation of patients in the hospital, especially in the intensive care environment, faces numerous obstacles. There are obstacles pertaining to patients, the infrastructure of the intensive care unit, the culture of the intensive care unit, and associated processes (Dubb et al. 2016).

Regarding the patient, we may remark the presence of haemodynamic instability, the extent of illness severity, respiratory instability, pain, malnutrition, obesity, muscle weakness, sedation, patient refusal, weariness, delirium, agitation, and cognitive impairment.

When discussing Intensive Care Unit (ICU) devices, we can identify haemodynamic monitoring equipment, bladder and venous catheters, and surgical drains as potential impediments. Structural impediments, such as insufficient personnel and resulting time constraints for team members to mobilise the patient, are limitations. This problem particularly affects developing countries (Batista Filho et al. 2022) since these nations are the most affected by the lack of labour. It is not uncommon for physiotherapists in countries with limited resources to work with extreme workload, making adequate rehabilitation work impossible. Furthermore, the absence of mobilisation guidelines and inadequate training for the interdisciplinary team also pose significant obstacles.

Nevertheless, we must emphasise that an abundance of protocols might contribute to increased complexity. In a healthcare system that is becoming more and more concerned about the availability of empty hospital beds, discharging patients prematurely before they have completed their mobilisation can disrupt their recovery process. This issue warrants significant attention when discussing the hospital release process, as patients frequently face challenges related to their socio-economic, cultural, and infrastructure circumstances, which hinder their ability to complete their recovery fully. The injury may lead to long-term repercussions, characterised by a significant impairment of functionality.

Additionally, there are also cultural obstacles that pertain to the practices of healthcare workers employed in hospitals. A significant portion of professionals lack a culture of mobilisation, and there remains a dearth of comprehensive understanding of the adverse effects of immobilism. As a consequence of a lack of comprehension of the detrimental effects on the patient, early mobilisation is not considered a priority. At times, there might be a subset of professionals that support the concept of mobilisation, but they lack the support of the rest of the team.

Regarding processes, one issue that can be highlighted is the absence of coordination among the team, resulting in misplaced expectations. The allocation of responsibilities among team members is frequently ambiguous, mostly because of insufficient interprofessional communication and collaboration. Performing daily mobilisation eligibility assessment among patients is also essential. Moreover, it is crucial to monitor the potential hazards associated with mobilisation for the professionals engaged and accurately determine the optimum team size for each specific scenario.

The ABCDEF Bundle: Powerful Ally to Create the Awake and Walking ICU

The standardised practice of restricting patients to bed rest for extended periods in the ICU is a primary modifiable risk factor for numerous iatrogenic problems that arise in this setting. The ICU emancipation initiative introduced treatment components aimed at enhancing patient outcomes and mitigating the risks associated with sedation and immobility via the ABCDEF Bundle (Ely 2017). The detrimental effects encompass diaphragm atrophy, ICU-acquired weakness, ICU delirium, post-ICU post-traumatic stress disorder (PTSD), and post-ICU cognitive deficits, all of which constitute post-ICU syndrome (PICS) (Needham et al. 2012). PICS is found in around 50% of all ICU survivors (Carel et al. 2023). The ABCDEF bundle comprises the following tools:

A: Assess, Prevent, and Manage Pain

B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)

C: Choice of Analgesia and Sedation

D: Delirium: Assess, Prevent, and Manage

E: Early Mobility and Exercise

F: Family Engagement and Empowerment

To effectively execute the ABCDEF Bundle and extend the advantages of early mobility to all eligible patients, it is crucial for ICU staff to possess a comprehensive awareness of the fundamental purpose of this bundle. The objective is to cultivate persons who demonstrate enhanced vigilance, engaged cognitive involvement, and improved physical mobility, while fostering patient autonomy and the ability to express unmet physical, emotional, and spiritual needs (Pun et al. 2019).

Before mobility can be considered, ICU teams must initially address sedation management to ensure that patients are cognitively engaged, autonomous, communicative, and cognisant. An Awake and Walking ICU is established when an ICU team achieves mastery of the ABCDEF bundle by achieving these objectives for each patient (Dayton 2020).

Notwithstanding the efficacy of the ABCDEF bundle, intensive care units frequently have difficulties in achieving 100% compliance. The 2019 ABCDEF bundle study demonstrated that outcomes from bundle adoption were assessed across 68 sites and over 15,000 patients; merely 8% of patients received the complete bundle. Merely 12% of patients were ambulating with weight-bearing capability. The advancements in administering reduced sedation, incorporating daily awakenings, breathing trials, and facilitating mobility for certain patients significantly improved patient outcomes. Seven-day mortality declined by 68%, incidence of coma and delirium reduced by 25-50%, utilisation of physical restraints diminished by 60%, ICU readmission fell by 46%, and patients exhibited a 36% increased likelihood of being released home from the hospital. Outcomes were observed to be dose-dependent (Figures 9, 10, and 11). Outcomes improved with reduced sedation and increased patient mobilisation (Pun et al. 2019). 

Despite the established correlation between patient survival and adherence to the care bundle, prevalent ICU practices continue to favour routine sedation and immobility for all intubated patients. The instruments included in the ABCDEF bundle can be manipulated to sustain longstanding cultural practices that confine patients to their beds. Obstacles to maintaining patient alertness and mobility encompass the perception that sedation equates to "sleep," is "humane," and is "indispensable for all intubated patients." The bundle is regarded as a checklist employed as a mechanism for rapid initiation and cessation of sedation during a sedation holiday. Awakening experiments are conducted solely to assess the potential for extubation and are restarted if a breathing trial is unsuccessful. Sedation is reduced sufficiently to allow occasional eye-opening, but seldom enough to facilitate communication and motion. Mobility is utilised as a rehabilitation technique post-extubation to mitigate delirium and ICU-acquired weakness, rather than being employed as a proactive rehabilitative strategy to avert these issues from arising. There exists a pervasive apprehension that permitting patients to autonomously mobilise their bodies during mechanical breathing may result in an increase in falls and inadvertent extubations. 

When patients are sedated for the purpose of tolerating mechanical ventilation and avoiding ventilator-induced lung injuries, the brain, bone, and skeletal muscle systems are depleted by sedation plus immobility; thus, accepting an unproven concept that other vital organ systems must be sacrificed to save respiratory function. Sedation medications lengthen the time patients require mechanical ventilation, need added pressor medications with harmful vasoconstricting side effects, cause delirium that leads to cognitive impairment comparable to early onset dementia, deplete skeletal muscle, which would not just allow a patient to maintain the survival skill of walking, but also reduces systemic inflammation and supports immune function. As Herridge (2008) stated in her seminal research on post-intensive care disability, "there appears to be significant potential for harm arising from the traditional ICU culture of patient immobility and an often excessive or unnecessary use of sedation”.

When patients are sedated to endure mechanical ventilation and prevent ventilator-induced lung injuries, sedation combined with immobility depletes the brain, bone, and skeletal muscle systems; consequently, this supports an unverified notion that other essential organ systems must be compromised to preserve respiratory function. Sedation medications prolong the duration of mechanical ventilation, necessitate additional pressor agents with detrimental vasoconstrictive effects, induce delirium resulting in cognitive impairment akin to early-onset dementia, and diminish skeletal muscle, which is essential not only for maintaining ambulation but also for reducing systemic inflammation and bolstering immune function. According to Herridge (2008) in her pivotal study on post-intensive care impairment, "there seems to be considerable potential for harm resulting from the conventional ICU culture of patient immobility and frequently excessive or unwarranted sedation."

 At each shift, the inquiry must be posed: “Recognising that sedation is detrimental to patients, how can I reduce the cumulative dosage administered to facilitate optimal mobility, timely extubation, abbreviated ICU duration, diminished delirium, and a return to their normal lives?” To optimise early mobility, teams must recognise that the presence of an endotracheal tube and mechanical ventilation does not inherently need sedation. The C of the ABCDEF bundle necessitates the inquiry, “Is there a justification for sedation?” Indications for sedation in the ICU encompass exceptions such as refractory status epilepticus, intracranial hypertension, acute respiratory failure, and the prevention of awareness in patients receiving neuromuscular blocking medications (Reade et al. 2014).

When the culture in the ICU transitions from automatic sedation to symptom management (Eikermann et al. 2023), many patients can remain free from sedation while intubated (Strøm et al. 2010). When sedation is indicated, awakening trials should be conducted to evaluate the resolution of the condition, and sedation should be terminated when it is no longer necessary. The discontinuation of sedation shortly after ICU admission has been shown to be both safe and practical (Cuthill et al. 2020). Patients cannot attain optimal mobility when affected by ongoing or residual sedation. The E component of the ABCDEF bundle has the lowest compliance (Barr et al. 2024). The primary obstacles to mobility in the ICU are sedation and agitation. Paradoxically, sedation elevates the likelihood of delirium. Delirium subsequently elevates the likelihood of agitation by a factor of 24 (Almeida et al. 2016). Increased sedation levels may exacerbate the severity of delirium (Ortiz et al. 2022). This is an unavoidable loop that must be terminated (Figure 12).

This is probably due to patients not sleeping peacefully while sedated (Weinhouse et al. 2011). They frequently encounter alternative and vivid worlds encompassing terrible situations such as abduction (Richards et al. 2023), violence, and torture. Mobility is a primary intervention for the prevention and treatment of delirium. Mobility reduces the incidence of delirium by 23% (Duceppe et al. 2019). This likely explains why early mobility enhances patient anxiety and animosity (Klein et al. 2018). Avoiding early sedation post-intubation can mitigate two primary obstacles to mobility (Figure 13)

Practical Application: Case Report

Joan (pseudonym) is a 38-year-old female with a history of tobacco smoking, who was brought to an external hospital in September 2018 for acute respiratory failure due to influenza, which subsequently progressed to acute respiratory distress syndrome (ARDS). She was intubated and sedated at a small community hospital before being transferred to an Awake and Walking Intensive Care Unit. 

Joan states that while sedated during transport, she experienced a vivid alternate reality in which she perceived the physicians surrounding her as minors attempting to inflict harm, such as sawing off her hands at the wrists. 

Upon her arrival at the Awake and Walking ICU, the new team promptly conducted a risk-benefit analysis to address sedation and mobility management for Joan. The standard ICU protocol would maintain Joan in a sedated and immobilised state until her ventilator settings were reduced to a minimum, at which point her readiness for extubation would be assessed. 

The subsequent outlines the hazards and advantages of continuous sedation and immobility for Joan. Continuous sedation will inhibit respiratory drive and enable total regulation of each breath administered to her. Implementing lung-protective methods utilising reduced tidal volume will mitigate the risk of ventilator-induced lung injury (ARDSnet 2000). Complete regulation of respiratory rate and inhibition of spontaneous breaths may alleviate concerns over self-induced lung injury (Brochard et al. 2017), although the evidence remains inconclusive (Carteaux et al. 2021).

Administering sedation to Joan may provide nurses with a sense of efficacy, as 65.7% believe sedation enhances patient comfort, while 59.2% find it facilitates the care of sedated patients (Guttormson et al. 2019). Joan will be incapable of articulating her discomfort, pain, anxiety, or terror, which may lead clinicians to be less troubled and concerned about her experience during mechanical ventilation.

HAPIS = Hospital Acquired Pressure Injuries, HAIS = Healthcare-associated infections, VAP = Ventilator-associated pneumonia, CAUTI = Catheter-associated urinary tract infections, CLABSI = Central line associated bloodstream infection

Maintaining Joan sedated may jeopardise her present and future cognitive abilities. She possessed numerous risk factors for delirium, including tobacco use (Hshieh et al. 2015), admission to the ICU, mechanical ventilation, and hypoxaemia. She faced the potential for an extended hospitalisation and sleep disturbances in the ICU, which elevate the likelihood of delirium (Ormseth et al. 2023). If Joan experienced delirium, her mortality risk in the hospital would double (Salluh et al. 2015). The probability of mortality would escalate by 10%, and the likelihood of enduring cognitive impairment would increase by 35% for each day of delirium (Ely 2004). At the age of 38, delirium can result in cognitive impairments akin to mild Alzheimer's disease and moderate traumatic brain injury (Pandharipande et al. 2013). This may result in the incapacity to work and financially support herself and her family following the ICU stay (Ahmed et al., 2021). Brain damage resulting from sedation would irrevocably alter her life.

If Joan experienced delirium, she would face an increased risk of prolonged ventilation, averaging an additional 4.47 days in the ICU and 6.67 days in the hospital (Dziegielewski et al. 2021), with ICU expenses rising by 39% (Millbrandt et al. 2004). Her risk of self-extubation would escalate by 11.6 times (Kwon and Choi 2017), the risk of falls by 2.81 times (Kalivas et al. 2023), and the likelihood of ICU readmission by 7% (Lobo-Valbuena et al. 2021). 

Sedation constitutes an independent risk factor for delirium, with an odds ratio of 2.268. If the ICU team maintained Joan in a sedated, restricted state in the ICU for more than 7 days, her risk of delirium would escalate with an odds ratio of 30.950 (Pan et al. 2019). The sole method to mitigate Joan's risk of delirium was to manage her pain, facilitate genuine interaction with her family, promote mobility, and ensure adequate sleep (Kotfis et al. 2022). Sedation would impair her capacity to communicate discomfort, interact with her family, mobilise, and achieve restorative sleep. Given her susceptibility to delirium, vigilance is important while administering deliriogenic drugs, including sedatives. 

The interdisciplinary team had to evaluate the adverse effects of sedation and immobilisation on Joan's pulmonary function. Sedation and immobility prolong ventilator duration (Strøm et al. 2010), elevate the risk of ventilator-associated events (VAE), potentially doubling mortality risk (Klompa et al. 2019), and may exacerbate existing neutrophilic lung injury (Files et al. 2015). Joan's secretion mobilisation and clearance, as well as lung aeration, would be compromised during sedation (Volpe et al. 2021). Propofol is a mitochondrial poison (Finsterer and Frank 2016) and is probably an independent risk factor for diaphragm malfunction and atrophy (Bruells et al. 2014). Maintaining Joan in a drugged and immobile state would elevate her risks of ventilator-associated events, prolonged ventilatory support, diaphragm dysfunction, tracheostomy, and maybe fatality. 

Sedation and immobility would place Joan at a heightened risk for ICU-acquired weakness and diaphragm dysfunction, potentially reducing her two-year survival probability by 43% (Saccheri et al. 2020) and escalating expenses by 30.5% (Hermans and Van den Berghe 2015).

Patients in the ICU typically have a daily loss of 2% of muscle mass (Fazzini et al. 2023). Sedation induces the most rapid and significant muscular atrophy relative to other primary causes of muscle loss (Parry and Puthucheary 2015). Consequently, 40% of muscle strength may be diminished within the initial week of immobilisation (Topp et al. 2002). If Joan continues to receive propofol, she will experience diminished muscle excitability due to the disruption of sodium channels in the muscles (Trapani et al. 2000) and decreased glucose utilisation, as propofol elevates insulin resistance in cardiac and skeletal muscle (Yasuda et al. 2012). 

The administration of sedation and the resultant immobility may profoundly affect Joan's psychological safety. During sedation, she would be incapable of expressing her needs, desires, preferences, and inquiries. She would become wholly vulnerable and reliant on the ICU care, thereby exacerbating panic and trauma. If she develops ICU-acquired frailty, she will become physically reliant on others for fundamental life functions. Physical reliance elevates the likelihood of anxiety, depression, and PTSD during ICU admission (Teixeira et al. 2021). 

Delirium constitutes a risk factor for post-ICU PTSD (Girard et al. 2007). If Joan is sedated and experiences delirium, she risks becoming ensnared in a vivid, violent, and horrific alternate reality sometimes referred to as "hallucinations" (Richards et al. 2023). Ambiguity and indistinct recollections heighten the risk and intensity of PTSD (Ehlers et al. 2000). 

Joan's team had to evaluate the alternatives to sedation and immobility, weighing the associated dangers against the benefits of maintaining her consciousness and movement. The incidence of adverse events during early mobility is 0.6%, encompassing falls, extubation, removal or malfunction of intravascular catheters, removal of other tubes, cardiac arrest, haemodynamic fluctuations, and desaturation (Nydahl et al. 2017), despite patients exhibiting a median PF ratio of 89 (Bailey et al. 2007). 

Safeguarding Joan from delirium will preserve her cognitive function both in the ICU and beyond. ICU mobility reduces the risk of delirium by 23% according to one study (Duceppe et al. 2019) and by 95% in another (Bersaneti and Whitaker 2022). If Joan develops delirium, mobility will reduce the length by two days (Schweikert et al. 2009). Mobilising within 48 hours post-intubation, as opposed to delaying for many days (Patel et al. 2023), can enhance cognitive performance by 20% one year following discharge (Figure 14).

Permitting Joan to remain awake and seated will enable her to cough, mobilise, clear her secretions, and enhance lung aeration (Hickmann et al. 2021). Enabling her to assume an upright posture will reduce alveolar strain and enhance ventilation-perfusion mismatch. Engaging in active mobility, including sitting, standing, and walking, will stimulate her diaphragm and mitigate the risk of diaphragm dysfunction and atrophy (Dong et al. 2021). With each day of enhancement in mobility, her chance of ventilator-associated pneumonia diminishes by 40% (Qi et al. 2023). Absence of sedation will reduce her ventilator duration by an average of 4.2 days (Strøm et al. 2010). For each day of movement out of bed, her ventilator time will diminish by 10% (Fazio et al. 2024), possibly due to the preservation of muscular strength and cognitive function necessary for independent respiration, efficient coughing, and airway protection post-extubation.

 If Joan awakens immediately, she is likely to retain her cognitive and fine motor skills, enabling her to write with a pen and paper or text on her cell phone, thereby providing her a voice during a vital and vulnerable period in her life. She will be able to communicate her pain management requirements and preferences to her ICU team, as well as connect with her husband and children. She will maintain the physical ability to manage her own oral hygiene, dressing, toileting, etc., so as to preserve her dignity, identity, and autonomy. Access to communication, control, and effective pain treatment can safeguard her against PTSD (Myhren et al. 2009). Joan's lack of sedation will not elevate her risk of PTSD (Strøm et al. 2011), since less sedation has been demonstrated to diminish PTSD risks (Kress et al. 2003). Authentic recollection of her ICU experience may safeguard her against PTSD (Jones et al. 2001).

 To avert post-ICU syndrome, Joan must be mobilised within 72 hours following intubation (Matsuoka et al. 2023). Timely mobilisation will facilitate prehabilitation to avert delirium and ICU-acquired weakness, rather than rehabilitating post-complication (Topp et al. 2002). Each 10-minute increment of early movement in the ICU will reduce her hospital stay by 1.2 days (Jenkins et al. 2024). An early mobility programme in the ICU reduced hospital-acquired pressure injuries by 77.2% (Vollman et al. 2024) (Figure 15).

Awake and Walking

Joan entered the hospital exhibiting dyspnoea and hypoxia the day before her admission to the Awake and Walking ICU. With her oxygen levels stabilised and respiratory support in place, there was no longer a contraindication for Joan to engage in her maximum movement (Figures 16, 17 and Table 1):

• Sat in a chair during the day
• Walked around the ICU 3 times a day
• Showered while intubated
• Texted/wrote on clipboard
• Helped daughter with homework
• Connected with husband 
• Extubated and discharged home
• Resumed running her own business afterward

Joan's hospitalisation and life were significantly influenced by her early awakening and mobility following intubation. She may have easily become chronically crippled, akin to 50% of ICU survivors (Geense et al. 2021). Among ARDS survivors, 73% experience delirium (Hsieh et al. 2015), 60% develop ICU-acquired weakness (Fan et al. 2014), 70-100% exhibit severe cognitive impairments upon hospital discharge (Herridge et al. 2016), 39% are diagnosed with PTSD (Mikkelsen et al. 2012), and merely 49% return to work within the first year post-discharge (Kamdar et al. 2018). Prompt ambulation safeguarded Joan from delirium, ICU-acquired frailty, elevated mortality risk, and post-ICU syndrome. Six years post-discharge, Joan has a fulfilling life with her expanding family, which now includes three additional grandkids.

Conclusion

Mobilising patients in critical condition is a recurring difficulty. The successful execution of this task requires a high level of determination from the multidisciplinary team, as well as a thorough understanding of the adverse effects that can result from extended sedation and immobilisation. While the primary objective of an ICU is to sustain the patient's life, it is equally crucial to prioritise the patient's post-ICU quality of life and level of functionality. Patients sometimes suffer lasting consequences following a severe illness and protracted hospital stay, which might be significantly minimised with more proactive rehabilitation interventions. An Awake and Walking Intensive Care Unit specifically deals with the challenges posed by profound sedation and immobility in patients who require mechanical ventilation. It is important to implement research findings on the treatment of ICU delirium, ICU-acquired weakness, post-ICU PTSD, post-ICU dementia, prolonged time on the ventilator, and mortality associated with sedation and immobility practices to improve outcomes in both the short and long term. Full recovery is not impossible. This study serves as a rallying cry and a movement to prevent the occurrence of disability through the excessive use of sedation and immobilisation.The multidisciplinary team should consider adopting an F-to-A bundle. If there are family members who are motivated and early mobility is the most compliant part of the ICU liberation bundle, patients must also have the other criteria satisfied. Patients initiate ambulation when their pain is managed (A), they are conscious, and the ventilator is adjusted to their requirements (B and C), while delirium is evaluated and adjusted (D). It is essential to provide exercise-based therapy to all ICU survivors to achieve full recovery. However, it is important to first allow them the chance to maintain as much physical and cognitive ability as they can. Implement an F to A ICU liberation package strategy to effectively avert the significant physical handicap caused by the ICU, as evidenced by the care Joan received in the Awake and Walking ICU (Bailey et al. 2007). 

Conflict of Interest

None.