Effects of the High-Intensity Early Mobilization on Long-Term Functional Status of Patients with Mechanical Ventilation in the Intensive Care Unit
Chuanlin Zhang, Xueqin Wang, Jie Mi, Zeju Zhang, Xinyi Luo, Ruiying Gan, Shaoyu Mu
Critical Care Research and Practice, doi:10.1155/2024/4118896
Objective. Intensive care unit (ICU)-acquired weakness often occurs in patients with invasive mechanical ventilation (IMV). Early active mobility may reduce ICU-acquired weakness, improve functional status, and reduce disability. Te aim of this study was to investigate whether high-intensity early mobility improves post-ICU discharge functional status of IMV patients. Methods. 132 adult patients in the ICU who were undergoing IMV were randomly assigned into two groups with a ratio of 1 : 1, with one group received high-intensity early mobility (intervention group, IG), while the other group received conventional treatment (control group, CG). Te functional status (Barthel Index (BI)), capacity of mobility (Perme score and ICU Mobility Scale (IMS)), muscle strength (Medical Research Council sum scores (MRC-SS)), mortality, complication, length of ICU stay, and duration of IMV were evaluated at ICU discharge or after 3-month of ICU discharge. Results. Te patient's functional status was improved (BI scores 90.6 ± 18.0 in IG vs. 77.7 ± 27.9 in CG; p � 0.005), and capacity of mobility was increased (Perme score 17.6 ± 7.1 in IG vs. 12.2 ± 8.5 in CG, p < 0.001; IMS 4.7 ± 2.6 in IG vs. 3.0 ± 2.6 in CG, p < 0.001). Te IG had a higher muscle strength and lower incidence of ICU-acquired weakness (ICUAW) than that in the CG. Te incidence of mortality and delirium was also lower than CG at ICU discharge. However, there were no diferences in terms of length of ICU stay, duration of IMV, ventilator-associated pneumonia, and venous thrombosis. Conclusions. High-intensity early mobility improved the patient's functional status and increased capacity of mobility with IMV. Te benefts to functional status remained after 3 month of ICU discharge. Other benefts included higher muscle strength, lower incidence of ICUAW, mortality, and delirium in IG.
Ethical Approval Te studies involving human participants were reviewed and approved by the Ethics Committee of the First Afliated Hospital of Chongqing Medical University (Document No. 2018-015).
Consent Te patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any identifable images or data included in this article.
Conflicts of Interest Te authors declare that they have no conficts of interest.
Authors' Contributions MI J and ZHANG CL were involved in the study design and critical revision of the manuscript. WANG XQ, ZHANG ZJ, GAN RY, LUO XY, and MU SY were involved in drafting of the manuscript. All the authors approved the fnal version of the manuscript, including the authorship list.
References
Ali, O'brien Jr, Hofmann, Acquired weakness, handgrip strength, and mortality in critically ill patients, American Journal of Respiratory and Critical Care Medicine
Anekwe, Biswas, Bussières, Spahija, Early rehabilitation reduces the likelihood of developing intensive care unit-acquired weakness: a systematic review and metaanalysis, Physiotherapy
Bailey, Bellomo, Brickell, Early active mobilization during mechanical ventilation in the ICU, New England Journal of Medicine
Chillura, Bramanti, Tartamella, Advances in the rehabilitation of intensive care unit acquired weakness: a case report on the promising use of robotics and virtual reality coupled to physiotherapy, Medicine (Baltimore)
Devlin, Skrobik, Gélinas, Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU, Critical Care Medicine
Ding, Zhang, Zhang, What is the optimum time for initiation of early mobilization in mechanically ventilated patients? A network meta-analysis, PLoS One
Fan, Cheek, Chlan, An ofcial American Toracic Society Clinical Practice guideline: the diagnosis of intensive care unit-acquired weakness in adults, American Journal of Respiratory and Critical Care Medicine
Faul, Erdfelder, Buchner, Lang, Statistical power analyses using G * Power 3.1: tests for correlation and regression analyses, Behavior Research Methods
Gosselink, Bott, Johnson, Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on physiotherapy for critically ill patients, Intensive Care Medicine
Hill, Fowler, Pinto, Herridge, Cuthbertson et al., Long-term outcomes and healthcare utilization following critical illnessa population-based study, Critical Care
Hodgson, Bailey, Bellomo, A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in the ICU, Critical Care Medicine
Hodgson, Bellomo, Berney, Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study, Critical Care
Hodgson, Needham, Haines, Feasibility and inter-rater reliability of the ICU mobility scale, Heart & Lung
Hodgson, Stiller, Needham, Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults, Critical Care
Jarman, Chapman, Vollam, Stiger, Williams et al., Investigating the impact of physical activity interventions on delirium outcomes in intensive care unit patients: a systematic review and meta-analysis, Journal of the Intensive Care Society
Lang, Paykel, Haines, Hodgson, Clinical practice guidelines for early mobilization in the ICU: a systematic review, Critical Care Medicine
Liu, Shibata, Fukuchi, Optimal timing of introducing mobilization therapy for ICU patients with sepsis, Journal of intensive care
Liu, Tian, Jiang, Song, Du et al., Early mobilisation practice in intensive care units: a large-scale cross-sectional survey in China, Nursing in Critical Care
Mahoney, Barthel, funcional evaluation: the barthel index, Maryland State Medical Journal
Mcwilliams, Jones, Atkins, Earlier and enhanced rehabilitation of mechanically ventilated patients in critical care: a feasibility randomised controlled trial, Journal of Critical Care
Mehta, Cook, Devlin, Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults, Critical Care Medicine
Menges, Seiler, Tomonaga, Schwenkglenks, Puhan et al., Systematic early versus late mobilization or standard early mobilization in mechanically ventilated adult ICU patients: systematic review and metaanalysis, Critical Care
Mirzakhani, Williams, Mello, Muscle weakness predicts pharyngeal dysfunction and symptomatic aspiration in long-term ventilated patients, Anesthesiology
Morris, Berry, Files, Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: a randomized clinical trial, JAMA
Moss, Nordon-Craft, Malone, A randomized trial of an intensive physical therapy program for patients with acute respiratory failure, American Journal of Respiratory and Critical Care Medicine
Nanas, Kritikos, Angelopoulos, Predisposing factors for critical illness polyneuromyopathy in a multidisciplinary intensive care unit, Acta Neurologica Scandinavica
Nydahl, Jeitziner, Vater, Early mobilisation for prevention and treatment of delirium in critically ill patients: systematic review and meta-analysis, Intensive and Critical Care Nursing
Nydahl, Mcwilliams, Weiler, Mobilization in the evening to prevent delirium: a pilot randomized trial, Nursing in Critical Care
Patel, Wolfe, Patel, Efect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial, Te Lancet Respiratory Medicine
Perme, Chandrashekar, Early mobility and walking program for patients in intensive care units: creating a standard of care, American Journal of Critical Care
Popoola, Dingle, Maclaren, Dyson, What are the barriers to nurses mobilising adult patients in intensive care units? An integrative review, Australian Critical Care
Puthucheary, Rawal, Mcphail, Acute skeletal muscle wasting in critical illness, Survey of Anesthesiology
Raurell-Torredà, Arias-Rivera, Martí, Care and treatments related to intensive care unit-acquired muscle weakness: a cohort study, Australian Critical Care
Reis, Figueiredo, Biscaro, Lunardelli, Maurici, Psychometric properties of the Barthel Index used at intensive care unit discharge, American Journal of Critical Care
Sakai, Hoshino, Okawa, Wakabayashi, Shigemitsu, Te safety and efect of early mobilization in the intensive care unit according to cancellation criteria, Progress in Rehabilitation Medicine
Santos, De Aguiar Lemos, Bianchi, Early rehabilitation using a passive cycle ergometer on muscle morphology in mechanically ventilated critically ill patients in the Intensive Care Unit (MoVe-ICU study): study protocol for a randomized controlled trial, Trials
Schaller, Anstey, Blobner, Early, goaldirected mobilisation in the surgical intensive care unit: a randomised controlled trial, Te Lancet
Schefenbichler, Teja, Wongtangman, Efects of the level and duration of mobilization therapy in the surgical ICU on the loss of the ability to live independently: an international prospective cohort study, Critical Care Medicine
Schujmann, Gomes, Lunardi, Impact of a progressive mobility program on the functional status, respiratory, and muscular systems of ICU patients: a randomized and controlled trial, Critical Care Medicine
Schujmann, Lunardi, Fu, Progressive mobility program and technology to increase the level of physical activity and its benefts in respiratory, muscular system, and functionality of ICU patients: study protocol for a randomized controlled trial, Trials
Schweickert, Pohlman, Pohlman, Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial, Te Lancet
Sibilla, Nydahl, Greco, Mobilization of mechanically ventilated patients in Switzerland, Journal of Intensive Care Medicine
Sidiras, Patsaki, Karatzanos, Long term followup of quality of life and functional ability in patients with ICU acquired Weakness-A post hoc analysis, Journal of Critical Care
Sommers, Engelbert, Dettling-Ihnenfeldt, Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations, Clinical Rehabilitation
Stevens, Dowdy, Michaels, Mendez-Tellez, Pronovost et al., Neuromuscular dysfunction acquired in critical illness: a systematic review, Intensive Care Medicine
Sulter, Steen, Keyser, Use of the Barthel index and modifed Rankin scale in acute stroke trials, Stroke
Taito, Shime, Yasuda, Out-of-bed mobilization of patients undergoing mechanical ventilation with orotracheal tubes: a survey study, Journal of Critical Care
Timenetsky, Neto, Assunção, Taniguchi, Eid et al., Mobilization practices in the ICU: a nationwide 1-day point-prevalence study in Brazil, PLoS One
Tipping, Harrold, Holland, Romero, Nisbet et al., Te efects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review, Intensive Care Medicine
Van Aerde, Meersseman, Debaveye, Five-year impact of ICU-acquired neuromuscular complications: a prospective, observational study, Intensive Care Medicine
Verceles, Wells, Sorkin, A multimodal rehabilitation program for patients with ICU acquired weakness improves ventilator weaning and discharge home, Journal of Critical Care
Wang, Lang, Haines, Skinner, Haines, Physical rehabilitation in the ICU: a systematic review and meta-analysis, Critical Care Medicine
Watanabe, Morita, Suzuki, Efects of the intensity and activity time of early rehabilitation on activities of daily living dependence in mechanically ventilated patients, Progress in Rehabilitation Medicine
Wieske, Witteveen, Verhamme, Early prediction of intensive care unit-acquired weakness using easily available parameters: a prospective observational study, PLoS One
Witteveen, Wieske, Sommers, Early prediction of intensive care unit-acquired weakness: a multicenter external validation study, Journal of Intensive Care Medicine
Wright, Tomas, Watson, Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): a multicentre, parallel-group, randomised controlled trial, Torax
Wu, Gu, Chen, Efect of early of-bed mobility on delirium in mechanical ventilated patients in intensive care unit: a prospective randomized controlled study, Zhonghua wei zhong bing ji jiu yi xue
Yang, Zhang, Cao, Ye, Song, Early mobilization for critically ill patients, Respiratory Care
Zang, Chen, Wang, Te efect of early mobilization in critically ill patients: a meta-analysis, Nursing in Critical Care
Zayed, Kheiri, Barbarawi, Efects of neuromuscular electrical stimulation in critically ill patients: a systematic review and meta-analysis of randomised controlled trials, Australian Critical Care
{ 'indexed': {'date-parts': [[2024, 3, 24]], 'date-time': '2024-03-24T01:01:01Z', 'timestamp': 1711242061786},
'reference-count': 60,
'publisher': 'Hindawi Limited',
'license': [ { 'start': { 'date-parts': [[2024, 3, 22]],
'date-time': '2024-03-22T00:00:00Z',
'timestamp': 1711065600000},
'content-version': 'unspecified',
'delay-in-days': 0,
'URL': 'https://creativecommons.org/licenses/by/4.0/'}],
'funder': [ { 'DOI': '10.13039/501100004374',
'name': 'Chongqing Medical University',
'doi-asserted-by': 'publisher',
'award': ['PYJJ2019-228', 'HLJJ2022-08', 'W0009', '2024WSJK029']}],
'content-domain': {'domain': [], 'crossmark-restriction': False},
'published-print': {'date-parts': [[2024, 3, 22]]},
'abstract': '<jats:p>Objective. Intensive care unit (ICU)-acquired weakness often occurs in patients with '
'invasive mechanical ventilation (IMV). Early active mobility may reduce ICU-acquired '
'weakness, improve functional status, and reduce disability. The aim of this study was to '
'investigate whether high-intensity early mobility improves post-ICU discharge functional '
'status of IMV patients. Methods. 132 adult patients in the ICU who were undergoing IMV were '
'randomly assigned into two groups with a ratio of 1\u2009:\u20091, with one group received '
'high-intensity early mobility (intervention group, IG), while the other group received '
'conventional treatment (control group, CG). The functional status (Barthel Index (BI)), '
'capacity of mobility (Perme score and ICU Mobility Scale (IMS)), muscle strength (Medical '
'Research Council sum scores (MRC-SS)), mortality, complication, length of ICU stay, and '
'duration of IMV were evaluated at ICU discharge or after 3-month of ICU discharge. Results. '
'The patient’s functional status was improved (BI scores 90.6\u2009±\u200918.0 in IG vs. '
'77.7\u2009±\u200927.9 in CG; <jats:inline-formula><math '
'xmlns="http://www.w3.org/1998/Math/MathML" '
'id="M1"><mi>p</mi><mo>=</mo><mn>0.005</mn></math></jats:inline-formula>), and capacity of '
'mobility was increased (Perme score 17.6\u2009±\u20097.1 in IG vs. 12.2\u2009±\u20098.5 in '
'CG, <jats:inline-formula><math xmlns="http://www.w3.org/1998/Math/MathML" '
'id="M2"><mi>p</mi><mo><</mo><mn>0.001</mn></math></jats:inline-formula>; IMS 4.7\u2009'
'±\u20092.6 in IG vs. 3.0\u2009±\u20092.6 in CG, <jats:inline-formula><math '
'xmlns="http://www.w3.org/1998/Math/MathML" '
'id="M3"><mi>p</mi><mo><</mo><mn>0.001</mn></math></jats:inline-formula>). The IG had a '
'higher muscle strength and lower incidence of ICU-acquired weakness (ICUAW) than that in the '
'CG. The incidence of mortality and delirium was also lower than CG at ICU discharge. However, '
'there were no differences in terms of length of ICU stay, duration of IMV, '
'ventilator-associated pneumonia, and venous thrombosis. Conclusions. High-intensity early '
'mobility improved the patient’s functional status and increased capacity of mobility with '
'IMV. The benefits to functional status remained after 3 month of ICU discharge. Other '
'benefits included higher muscle strength, lower incidence of ICUAW, mortality, and delirium '
'in IG.</jats:p>',
'DOI': '10.1155/2024/4118896',
'type': 'journal-article',
'created': {'date-parts': [[2024, 3, 23]], 'date-time': '2024-03-23T02:05:06Z', 'timestamp': 1711159506000},
'page': '1-9',
'source': 'Crossref',
'is-referenced-by-count': 0,
'title': 'Effects of the High-Intensity Early Mobilization on Long-Term Functional Status of Patients with '
'Mechanical Ventilation in the Intensive Care Unit',
'prefix': '10.1155',
'volume': '2024',
'author': [ { 'given': 'Chuanlin',
'family': 'Zhang',
'sequence': 'first',
'affiliation': [ { 'name': 'Department of Critical Care Medicine, The First Affiliated '
'Hospital of Chongqing Medical University, Chongqing, China'}]},
{ 'given': 'Xueqin',
'family': 'Wang',
'sequence': 'additional',
'affiliation': [ { 'name': 'Department of Critical Care Medicine, The First Affiliated '
'Hospital of Chongqing Medical University, Chongqing, China'}]},
{ 'ORCID': 'http://orcid.org/0000-0001-8283-2051',
'authenticated-orcid': True,
'given': 'Jie',
'family': 'Mi',
'sequence': 'additional',
'affiliation': [ { 'name': 'Department of Critical Care Medicine, The First Affiliated '
'Hospital of Chongqing Medical University, Chongqing, China'},
{ 'name': 'School of Nursing, Chongqing Medical University, Chongqing, '
'China'}]},
{ 'given': 'Zeju',
'family': 'Zhang',
'sequence': 'additional',
'affiliation': [ { 'name': 'School of Nursing, Chongqing Medical and Pharmaceutical College, '
'Chongqing, China'}]},
{ 'given': 'Xinyi',
'family': 'Luo',
'sequence': 'additional',
'affiliation': [ { 'name': 'Department of Critical Care Medicine, The First Affiliated '
'Hospital of Chongqing Medical University, Chongqing, China'}]},
{ 'given': 'Ruiying',
'family': 'Gan',
'sequence': 'additional',
'affiliation': [ { 'name': 'Department of Critical Care Medicine, The First Affiliated '
'Hospital of Chongqing Medical University, Chongqing, China'}]},
{ 'given': 'Shaoyu',
'family': 'Mu',
'sequence': 'additional',
'affiliation': [ { 'name': 'School of Nursing, Chongqing Medical University, Chongqing, '
'China'}]}],
'member': '98',
'reference': [ {'key': '1', 'doi-asserted-by': 'publisher', 'DOI': '10.1186/s13054-014-0658-y'},
{'key': '2', 'doi-asserted-by': 'publisher', 'DOI': '10.1186/s13063-015-0914-8'},
{'key': '3', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/ccm.0000000000005285'},
{'key': '4', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.aucc.2021.09.002'},
{'key': '5', 'doi-asserted-by': 'publisher', 'DOI': '10.1111/nicc.12896'},
{'key': '6', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/01.sa.0000450914.29374.55'},
{'key': '7', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/ccm.0000000000003299'},
{'key': '8', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.physio.2019.12.004'},
{'key': '9', 'doi-asserted-by': 'publisher', 'DOI': '10.1164/rccm.200712-1829oc'},
{'key': '10', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/aln.0b013e31829373fe'},
{'key': '11', 'doi-asserted-by': 'publisher', 'DOI': '10.1007/s00134-020-05927-5'},
{'key': '12', 'doi-asserted-by': 'publisher', 'DOI': '10.1186/s13054-016-1248-y'},
{'key': '13', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/ccm.0000000000004574'},
{'key': '14', 'doi-asserted-by': 'publisher', 'DOI': '10.1177/0269215514567156'},
{'key': '15', 'doi-asserted-by': 'publisher', 'DOI': '10.1007/s00134-008-1026-7'},
{'key': '16', 'doi-asserted-by': 'publisher', 'DOI': '10.2490/prm.20200016'},
{'key': '17', 'doi-asserted-by': 'publisher', 'DOI': '10.1186/s13054-015-0765-4'},
{'key': '18', 'doi-asserted-by': 'publisher', 'DOI': '10.1371/journal.pone.0230971'},
{'key': '19', 'doi-asserted-by': 'publisher', 'DOI': '10.1177/0885066617728486'},
{'key': '20', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.jcrc.2018.06.022'},
{'key': '21', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/ccm.0000000000004181'},
{'key': '22', 'doi-asserted-by': 'publisher', 'DOI': '10.1136/thoraxjnl-2016-209858'},
{'key': '23', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/s0140-6736(16)31637-3'},
{'key': '24', 'doi-asserted-by': 'publisher', 'DOI': '10.1164/rccm.201505-1039oc'},
{'key': '25', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/s2213-2600(22)00489-1'},
{'key': '26', 'doi-asserted-by': 'publisher', 'DOI': '10.1056/nejmoa2209083'},
{'key': '27', 'doi-asserted-by': 'publisher', 'DOI': '10.1001/jama.2016.7201'},
{'key': '28', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/ccm.0000000000001643'},
{'key': '29', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/s0140-6736(09)60658-9'},
{'key': '30', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.aucc.2020.12.005'},
{'key': '31', 'doi-asserted-by': 'publisher', 'DOI': '10.1177/0885066618771001'},
{'key': '32', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/md.0000000000020939'},
{'key': '33', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.jcrc.2018.07.006'},
{'key': '34', 'doi-asserted-by': 'publisher', 'DOI': '10.1111/nicc.12455'},
{'key': '35', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/ccm.0000000000004808'},
{'key': '36', 'doi-asserted-by': 'publisher', 'DOI': '10.4187/respcare.10481'},
{'key': '37', 'doi-asserted-by': 'publisher', 'DOI': '10.2490/prm.20210054'},
{ 'key': '38',
'first-page': '61',
'article-title': 'Barthel, funcional evaluation: the barthel index',
'volume': '14',
'author': 'F. I. Mahoney',
'year': '1965',
'journal-title': 'Maryland State Medical Journal'},
{'key': '39', 'doi-asserted-by': 'publisher', 'DOI': '10.1186/s13063-018-2641-4'},
{'key': '40', 'doi-asserted-by': 'publisher', 'DOI': '10.1161/01.str.30.8.1538'},
{'key': '41', 'doi-asserted-by': 'publisher', 'DOI': '10.4037/ajcc2022732'},
{'key': '42', 'doi-asserted-by': 'publisher', 'DOI': '10.4037/ajcc2009598'},
{'key': '43', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.hrtlng.2013.11.003'},
{'key': '44', 'doi-asserted-by': 'publisher', 'DOI': '10.1371/journal.pone.0111259'},
{'key': '45', 'doi-asserted-by': 'publisher', 'DOI': '10.1164/rccm.201411-2011st'},
{'key': '46', 'doi-asserted-by': 'publisher', 'DOI': '10.1111/nicc.12638'},
{'key': '47', 'doi-asserted-by': 'publisher', 'DOI': '10.3758/brm.41.4.1149'},
{'key': '48', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.jcrc.2018.01.001'},
{'key': '49', 'doi-asserted-by': 'publisher', 'DOI': '10.1186/s40560-022-00613-8'},
{'key': '50', 'doi-asserted-by': 'publisher', 'DOI': '10.1371/journal.pone.0223151'},
{'key': '51', 'doi-asserted-by': 'publisher', 'DOI': '10.1186/s13054-020-03446-9'},
{'key': '52', 'doi-asserted-by': 'publisher', 'DOI': '10.1007/s00134-016-4612-0'},
{'key': '53', 'doi-asserted-by': 'publisher', 'DOI': '10.1111/j.1600-0404.2008.00996.x'},
{'key': '54', 'doi-asserted-by': 'publisher', 'DOI': '10.1007/s00134-007-0772-2'},
{'key': '55', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.jcrc.2019.06.022'},
{'key': '56', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.aucc.2019.04.003'},
{'key': '57', 'doi-asserted-by': 'publisher', 'DOI': '10.1097/ccm.0000000000000727'},
{'key': '58', 'doi-asserted-by': 'publisher', 'DOI': '10.1016/j.iccn.2022.103334'},
{'key': '59', 'doi-asserted-by': 'publisher', 'DOI': '10.1177/17511437221103689'},
{ 'key': '60',
'doi-asserted-by': 'publisher',
'DOI': '10.3760/cma.j.cn121430-20210209-00238'}],
'container-title': 'Critical Care Research and Practice',
'original-title': [],
'language': 'en',
'link': [ { 'URL': 'http://downloads.hindawi.com/journals/ccrp/2024/4118896.pdf',
'content-type': 'application/pdf',
'content-version': 'vor',
'intended-application': 'text-mining'},
{ 'URL': 'http://downloads.hindawi.com/journals/ccrp/2024/4118896.xml',
'content-type': 'application/xml',
'content-version': 'vor',
'intended-application': 'text-mining'},
{ 'URL': 'http://downloads.hindawi.com/journals/ccrp/2024/4118896.pdf',
'content-type': 'unspecified',
'content-version': 'vor',
'intended-application': 'similarity-checking'}],
'deposited': { 'date-parts': [[2024, 3, 23]],
'date-time': '2024-03-23T02:05:13Z',
'timestamp': 1711159513000},
'score': 1,
'resource': {'primary': {'URL': 'https://www.hindawi.com/journals/ccrp/2024/4118896/'}},
'subtitle': [],
'editor': [{'given': 'Thomas', 'family': 'Spentzas', 'sequence': 'additional', 'affiliation': []}],
'short-title': [],
'issued': {'date-parts': [[2024, 3, 22]]},
'references-count': 60,
'alternative-id': ['4118896', '4118896'],
'URL': 'http://dx.doi.org/10.1155/2024/4118896',
'relation': {},
'ISSN': ['2090-1313', '2090-1305'],
'subject': ['Critical Care and Intensive Care Medicine'],
'container-title-short': 'Critical Care Research and Practice',
'published': {'date-parts': [[2024, 3, 22]]}}
