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Early Active Mobilization in Critically Ill Patients on Vasopressor or Inotropic Support: A Prospective Cohort Study
*Corresponding author: Andres Mauricio Enriquez Popayan, Department of Physiotherapy in Intensive Care, SES Hospital Universitario del Caldas, Manizales, Colombia. Research Group GIHORO, Hospital Regional de la Orinoquia, Yopal, Colombia. andresmauricioenriquezp@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Enriquez Popayan AM, Gutierrez-Arias R. Early Active Mobilization in Critically Ill Patients on Vasopressor or Inotropic Support: A Prospective Cohort Study. J Card Crit Care TSS. 2025;9:211-8. doi: 10.25259/JCCC_40_2025
Abstract
Objectives:
The objective of this study was to assess the safety of early active mobilization (EAM) in critically ill adults receiving vasopressor or inotropic support.
Material and Methods:
We conducted a prospective cohort study in a 10-bed intensive care unit in Colombia between September 2023 and November 2024. Eligible patients were adults ≥18 years with vasopressor or inotropic support for ≥2 h, stable dosing for ≥30 min, and the ability to follow simple commands (Glasgow Coma Scale score ≥13 or Richmond Agitation-Sedation Scale −2 to +1). Exclusion criteria were inability to perform active or assisted movement, severe hypoperfusion (lactate >6 mmol/L), prone positioning, multiple-organ failure, uncontrolled bleeding, post-cardiac arrest status, or recent cerebral/cardiac ischemic events. Interventions followed the frequency, intensity, time, and type of exercise principle and included EAM activities based on individual clinical assessment. We evaluated patients using standardized scales and monitored cardiorespiratory responses. The primary outcome was safety, defined as the absence of adverse events during or immediately after EAM.
Results:
We included 24 patients (mean age 66.5 ± 13.5 years, 62.5% male). Primary diagnoses were septic shock (29%) and cardiogenic shock (29%). Norepinephrine was required in 75% of patients (median dose 0.13 μg/kg/min). During EAM, 50% received supplemental oxygen and 25% required mechanical ventilation. Mobilization activities included sitting at the edge of the bed (46%), standing (29%), sitting in a chair (17%), and remaining semi-Fowler (8%). No adverse events occurred during any session. Only minimal, clinically non-significant increases in diastolic blood pressure (P < 0.05) and mean arterial pressure (P < 0.05) were observed.
Conclusions:
EAM in patients appears safe in critically ill adults receiving vasopressor or inotropic support when guided by structured assessment protocols. These findings challenge current restrictive mobility practices and suggest potential benefits for patient recovery. Larger studies are needed to confirm safety and establish evidence-based mobilization guidelines for hemodynamically supported patients.
Keywords
Adverse events
Critical care
Early ambulation
Early mobilization
Physical therapy
Vasoconstrictor agent
INTRODUCTION
Patients in the intensive care units (ICU) frequently require vasopressor or inotropic support to maintain adequate hemodynamic stability.[1,2] These drugs help ensure tissue perfusion and stabilize critically ill patients.[3,4] However, their use traditionally restricts patient mobility due to safety concerns.
Current practice commonly places patients on bed rest during the initial ICU period.[5-7] This approach varies based on factors including level of consciousness, clinical stability, drugs dosage, and baseline mobility status.[8-10] While early active mobilization (EAM) effectively and safely reduces complications associated with prolonged bed rest,[11-14] patients receiving vasopressor or inotropic support typically receive only passive interventions.[15-18] This limitation stems from concerns about potential safety incidents and hesitancy to initiate active movement.
Evidence regarding mobilization in patients receiving vasopressor or inotropic support remains limited, particularly in Latin American populations. Most existing studies focus on passive interventions or exclude patients with hemodynamic support. This knowledge gap creates uncertainty about optimal mobilization strategies for this population.
Therefore, we aimed to evaluate the safety of EAM in critically ill adults receiving vasopressor or inotropic support. We hypothesized that structured, individualized mobilization protocols could be safely implemented without compromising hemodynamic stability.
MATERIAL AND METHODS
Study design and setting
We conducted a prospective cohort study in a 10-bed mixed medical-surgical ICU in Yopal, Colombia. The unit admits adult patients with cardiovascular, renal, respiratory, and surgical conditions. Data collection occurred between September 2023 and November 2024.
The Institutional Ethics Committee for health research of the Regional Hospital of Orinoquía approved the study (Resolution 037, September 29, 2023). The study adhered to Colombian research regulations (Resolution 8430 of 1993 by the Ministry of Health) and international standards, including the Declaration of Helsinki.
Participants
We included patients aged ≥18 years with signed informed consent who met the following criteria: (1) vasopressor or inotropic support for ≥2 h, (2) stable medication dosage for ≥30 min before EAM, (3) ability to understand and follow simple commands, and (4) Glasgow Coma Scale ≥13 or Richmond Agitation-Sedation Scale (RASS) between −2 and +1. We excluded patients who: (1) could not perform active or active-asisted movement, (2) had severe hypoperfusion (lactate >6 mmol/L), (3) were in prone position, (4) had multi-organ failure, (5) had severe electrical instability (ventricular fibrillation or tachycardia), (6) required emergency pacemaker support, (7) had unstable angina at rest, (8) had extreme bradycardia (≤40 bpm), (9) had uncontrolled active bleeding, (10) were post-cardiac arrest, or (11) had cerebral or cardiac ischemic events within 24 h.
Intervention protocol
We individualized EAM for each patient by prescribing therapeutic exercise using Frequency, Intensity, Time, and Type of Exercise (FITT) principle:[19]
Frequency: Number of sessions per day and week
Intensity: Level of effort required
Time: Duration of the intervention or therapeutic activity
Type of exercise: Aerobic or anaerobic.
The attending physiotherapist determined the initiation and prescription based on clinical judgment, considering the patient’s condition, invasive devices, muscle strength (Medical Research Council [MRC] scale), and mobility level (ICU Mobility Scale). We assessed pain using the Visual Analog Scale (VAS), perceived exertion with Borg Rating, the chronic frailty scale (Clinical Frailty Scale), and perfusion status through refill time and mottling tests.
We established the following criteria for suspending the EAM: (1) Altered consciousness (Glasgow Coma Scale ≤12 or RASS ≤−3), (2) mean arterial pressure (MAP) ≤45 mmHg, (3) chest pain, (4) oxygen desaturation ≤88%, (5) patient refusal or inability to continue, and (6) agitation.
The inotrope score was calculated using the formula: Inotrope and vasopressor doses were recorded to calculate vasopressor or inotropic support (VIS) with the following formula: Dopamin (mcg/kg/min)+dobutamine (mcg/kg/min)+100×epinephrine (mcg/kg/min) +100× norepinephrine (mcg/kg/min)+10×milrinone (mcg/kg/min)+10,000×vasopressin (units/kg/min). VIS calculation was performed with the dosage of inotropes continuing at the 24th post-operative h. VIS was calculated at the first 24th h of the post-operative ICU stay.
All interventions occurred during daytime hours (between 8:00 and 17:00) and followed the algorithm presented in Figure 1.
- Early active mobilization algorithm for patients receiving vasopressor/inotropic support. RR: Respiratory rate, HR: Heart rate, SAO2: Arterial oxygen saturation, FIO2: Fraction of inspired oxygen, PEEP: Positive end-expiratory pressure, ≥: Greater than or equal to, ≤: Less than or equal to, <: less than, MRC: Medical research council, IMS: ICU mobility scale, EAM: Early active mobilization, SBP: Systolic blood pressure, DBP: Diastolic blood pressure, MAP: Mean arterial pressure, RASS: Richmond agitation-sedation scale.
Data collection
We collected sociodemographic characteristics, diagnoses, hemodynamic status, vasopressor/inotropic support and dosage, and EAM prescriptions at 2 time points: Before intervention (identification, assessment, and planning) and after intervention (condition at completion, adverse events).
Safety outcomes
We recorded all patient safety-related events during the EAM, categorized as follows: (1) Hemodynamic and respiratory events: Clinical instability preventing EAM continuation; (2) patient integrity events: Falls or physical trauma; and (3) invasive device events: Unintentional removal or malfunction.
Statistical analysis
We described continuous quantitative variables using the mean ± standard deviation or median with interquartile range (IQR), depending on distribution. Categorical variables were presented as absolute and relative frequencies (%). We assessed normality using the Shapiro-Wilk test.
We compared cardiorespiratory responses before and after the EAM intervention using paired Student’s t-test or Wilcoxon signed-rank test. We performed statistical analyses using JASP software (JASP Team, 2024. JASP Version 0.19.3 [Computer software]), with a significance set at <0.05. We created the radar chart using RAWGraphs (© 2013–2021, Apache License 2.0).
RESULTS
Patient characteristics
Twenty-four patients participated in our study. The mean age was 66.46 ± 13.5 years, with 62.5% being male. The most common admission diagnoses were septic shock (29.17%) and cardiogenic shock (29.17%). One vasopressor or inotropic drug was required in 75% of participants, with norepinephrine being the most frequently used (75%) followed by dobutamine (19.17%) [Table 1].
| Characteristic | Number |
|---|---|
| Admission diagnosis, n(%) | |
| Septic shock | 7 (29.17) |
| Surgery | 3 (12.5) |
| Emergency dialysis | 3 (12.5) |
| Cardiogenic shock | 7 (29.17) |
| Septic and cardiogenic shock | 2 (8.32) |
| Neurological | 1 (4.17) |
| Metabolic | 1 (4.17) |
| Number of vasoactive/ionotropic drugs, n(%) | |
| 1 | 18 (75) |
| 2 | 5 (20.83) |
| 3 | 1 (4.17) |
| Norepinephrine, n(%) | 18 (75) |
| Dose norepinephrine (ug/kg/min), median (p25–p75) | 0.13 (0.09–0.19) |
| Dobutamine, n(%) | 7 (29.17) |
| Dose dobutamine (ug/kg/min), median (p25–p75) | 2.75 (2.5–3.5) |
| Dopamine, n(%) | 1 (95.83) |
| Dose dopamine (ug/kg/min) | 7.6 |
| Vasopressin, n(%) | 2 (8.32) |
| Dose vasopressin (uh), median (p25–p75) | 2 (2–2) |
| Levosimendam, n(%) | 1 (95.83) |
| Dose levosimendam (mL/h) | 10 |
| Milrinone, n(%) | 2 (8.32) |
| Dose milrinone (ug/kg/min), median (p25–p75) | 0.27 (0.27–0.27) |
kg: Kilogram, min: Minute, h: Hour, mL: Milliliter, ug: Microgram, n: Number, %: Percentage
Mobilization assessment
At EAM time, the median muscle strength measured using the MRC-sum score scale was 51.5 points (IQR 47.75–59). The most frequent frailty level was 5, with mobility levels 8 and 10 being most common [Table 2]. Most patients (62.5%) reported no pain before the intervention, with a maximum pain level of 3. In addition, 58.33% reported a maximum resting dyspnea score of 1 on the modified Borg scale. All patients had a capillary refill time <3 s, and two patients (8.33%) had a Mottling Score of 1.
| Characteristic | Number |
|---|---|
| Frailty, n(%) | |
| 1 | 0 (0) |
| 2 | 2 (8.33) |
| 3 | 1 (4.17) |
| 4 | 7 (29.17) |
| 5 | 8 (33.33) |
| 6 | 3 (12.5) |
| 7 | 1 (4.17) |
| 8 | 2 (8.33) |
| IMS, n(%) | |
| 0 | 0 (0) |
| 1 | 0 (0) |
| 2 | 4 (16.66) |
| 3 | 3 (12.5) |
| 4 | 0 (0) |
| 5 | 0 (0) |
| 6 | 0 (0) |
| 7 | 0 (0) |
| 8 | 7 (29.17) |
| 9 | 3 (12.5) |
| 10 | 7 (29.17) |
| Upper limb edema, n(%) | |
| 0 | 10 (41.68) |
| 1 | 2 (8.33) |
| 2 | 2 (8.33) |
| 3 | 8 (33.33) |
| 4 | 2 (8.33) |
| Lower limb edema, n(%) | |
| 0 | 3 (12.5) |
| 1 | 8 (33.33) |
| 3 | 4 (16.67) |
| 2 | 5 (20.83) |
| 4 | 4 (16.67) |
n: Number, %: Percentage, IMS: ICU mobility scale
Mobilization activities
Before EAM, all patients were in a semi-Fowler position. Median session duration was 20 min (IQR 15–20). Intensity was prescribed based on dyspnea perception in 18 patients (75%); the remaining used the target heart rate. Mobilization activities achieved included: (1) sitting at the bed edge: 11 patients (45.83%), standing: 7 patients (29.17%), sitting in a chair: 4 patients (16.67%), and remaining in semi-Fowler position: 2 patients (8.33%).
Most patients performed functional training in transitions to sitting at the bed edge (91.67%), upper limb exercises (54.17%), and sit-to-stand transitions (50%) [Figures 2 and 3]. Six patients (25%) received invasive mechanical ventilation during the intervention, while 12 (50%) received supplemental oxygen through low- and high-flow systems. Three patients (12.5%) underwent renal replacement therapy during EAM.
- Types of exercises performed during the early active mobilization intervention. BST: Bedside sitting transition, CST: Chair sitting transition, BST: Bipedal sitting transition, SG: Stationary gait, SSG: Stationary stair gait, HN: Head-neck, UL: Upper limbs, LL: Lower limbs, NE: Neuromuscular electrostimulation.
- Early mobilization active activities in patients receiving vasoporessor or inotropic support. (a) Patient in a sitting position with invasive ventilatory support and receiving norepinephrine drug. (b) Patient in a sitting position with invasive ventilatory support and receiving dobutamine drug. (c) Patient in a biped position performing resistive exercises and receiving dobutamine drug. (d) Patient performing stair marching with oxygen support and receiving dobutamine drug.
Safety outcomes
No patients experienced adverse events during or after EAM sessions. The cardiorespiratory response was minimal. Only diastolic blood pressure and MAP showed a statistically significant increase (P < 0.05) [Figure 4], but these changes were clinically non-significant and did not require intervention cessation.
- Cardiorespiratory response to the early active mobilization intervention. (a) Heart rate (HR), bpm: Beats per minute, (b) Peripheral oxygen saturation (SpO2), (c) Respiratory rate (RR), bpm: Breaths per minute, (d) Systolic blood pressure (SBP), mmHg: Millimeter of mercury, (e) Diastolic blood pressure (DBP), and (f) Mean arterial pressure (MAP). Green: Before early active mobilization, Orange: After active mobilization, (*): Statistically significant difference (P-value ≤ 0.05).
DISCUSSION
EAM represents an intervention that facilitates recovery during hospitalization and positively impacts patient discharge.[20] Although research has increased over recent decades,[21] significant knowledge gaps remain, especially regarding EAM in patients receiving vasopressor or inotropic support in Latin America. This is the first study in Colombia and only the second involving a South American population.[22] Our main finding suggests that EAM may be safe in this patient population; however, this should be interpreted cautiously due to our study design and sample size.
EAM remains limited in patients receiving vasopressor or inotropic support for several reasons. Healthcare professionals often hesitate to mobilize patients on vasopressor support due to safety concerns.[23] The ICU culture may also create barriers, as units not prioritizing mobilization may hinder implementation.[24] Clinical instability is a significant factor contributing to the infrequent application of EAM, with passive interventions often favoured.[25,26]
Our findings align with previous research demonstrating mobilization safety in this population. Borges et al. conducted a study in Brazil where only two of 150 mobilizations resulted in non-serious, easily reversible adverse events.[22] Similarly, Lindholz et al. reported that active mobilization is feasible and safe in patients receiving norepinephrine infusions.[27] Our study extends these findings by examining patients receiving dual or even triple vasopressor/inotropic support, without observing adverse events. While the utilization of vasopressor or inotropic agents may potentially heighten risks, thorough patient assessment coupled with tailored EAM prescriptions can aid in alleviating these risks. To ensure patient safety, we used a structured algorithm to facilitate appropriate patient selection. In addition, we employed the “FITT” mnemonic to individualize the exercise prescription.[19]
Regarding vasopressor/inotropic dosing, Jacob et al. noted no consensus on the safe dosage threshold for initiating EAM.[28] We observed significant variability in medication doses, supporting the need for comprehensive clinical assessment rather than rigid dosage cutoffs. We recommend adherence to established safety protocols and guidelines.[29,30]
An “ideal” inotrope score for early mobilization in cardiogenic shock does not exist; instead, mobilization is guided by overall hemodynamic stability and safety criteria. The VIS helps assess the degree of hemodynamic support needed, but mobilization readiness also depends on the patient’s individual response and clinical condition. The VIS is a tool for quantifying the amount of cardiovascular drug support a patient which is receiving. Higher scores indicate more severe shock and greater instability, which typically prevent or limit mobilization. Patients with low VIS are more likely to be stable enough for mobilization. One study found that patients receiving low-dose vasopressor were mobilized more frequently than those on moderate or high doses:
Moderate VIS: Mobilization in this range requires greater caution and monitoring. Out-of-bed mobilization was safe with norepinephrine doses up to 0.20 mcg/kg/min, and in-bed mobilization was safe up to 0.33 mcg/kg/min.
High VIS: These patients are often too unstable for anything beyond passive or minimal in-bed movement. The rate of early mobilization decreases significantly as inotrope doses and VIS increase.
Mobilization safety criteria
Instead of a fixed inotrope score, clinical decisions to mobilize a patient in cardiogenic shock rely on strict safety criteria.[27]
Our study has several limitations. Specific inclusion criteria influenced the very small sample size, as we aimed to evaluate the safety of EAM, not passive mobilization. Patients lacking adequate levels of consciousness were excluded, reducing the eligible population. In addition, the ICU’s location serves a smaller population than major urban centers, with limited admissions. Many complex patients were also referred to larger hospitals. Another limitation was at all times, being vigilant of the inotropic score of the inotropes, though we stuck to mobilize only those with a VIS of two or less.
Despite these limitations, our study provides valuable clinical knowledge in a field with limited evidence. This finding challenges traditional clinical paradigms by demonstrating that EAM is both feasible and safe, without compromising clinical or hemodynamic stability. It represents a transformative contribution with the potential to become a turning point in current practice, encouraging earlier interventions. Its timely implementation could optimize functional recovery, improve hospital discharge outcomes, and reduce the sequelae associated with ICU stays.
CONCLUSION
EAM in patients receiving vasopressor or inotropic support appears safe when implemented with structured assessment protocols and individualized interventions. These findings challenge current restrictive mobility practices and suggest potential benefits for patient recovery without compromising hemodynamic stability.
Future research should focus on larger multicenter studies to confirm our findings and establish evidence-based guidelines for mobilization in hemodynamically supported patients. Such studies may help reduce hospital-associated complications and improve functional outcomes in this population.
Ethical approval:
The research/study approved by the Institutional Ethics Committee at Hospital Regional de la Orinoquía, number Resolution 037, dated 29th September 2023.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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