Dr. Sapna Kudchadkar and her pediatric anesthesia and critical care team at the Johns Hopkins University have revolutionized PICU care by establishing a structured mobilization protocol, PICU UP! to liberate pediatric ICU patients from their beds and to mobilize them early in their hospital course.[1, 2] The Liberation Bundle includes 6 elements (ABCDEF) addressing pain assessment and control, sedation management, delirium assessment and management, spontaneous awakening and breathing trials, early mobility, and family engagement.[3]
In today’s PAAD, Vanderhoek et al.[4] wondered if early mobilization in the PACU would improve oxygenation, reduce postoperative complications, decrease length of stay (LOS) and pain and fatigue as it does in adult patients.[5] But unlike the adult studies, in which patients underwent major abdominal surgery, the study pediatric population were your typical outpatients undergoing short procedures. Myron Yaster MD
Original article
Vanderhoek SM, Shoemaker L, Na YB, Prichett L, Kudchadkar SR. PACU Up!: Feasibility of an Early Mobilization Program for Children After Surgery and Anesthesia. Anesth Analg. 2025 Apr 25. doi: 10.1213/ANE.0000000000007525. Epub ahead of print. PMID: 40279266.
“The objective of this quality improvement (QI) project was to evaluate a structured early mobilization protocol, “PACU Up!,” in a pilot pediatric cohort in a large, academic post-anesthesia care unit (PACU). Specifically, we sought to assess the safety and feasibility of implementing a standardized, evidence-based early mobilization program for children recovering from anesthesia. Inclusion criteria were children aged 2 to 18 years who could ambulate unassisted, had an American Society of Anesthesiologists (ASA) physical status of I and II, and were undergoing an eligible outpatient surgery. Focus groups with nursing staff were held to educate about early mobilization, solicit feedback about the QI intervention, and facilitate program design.”[4]
“PACU Up! began in October 2024 with 3 children daily randomly assigned to walk 1 to 2 laps around the PACU before discharge. Each lap, measuring 244 feet, covered the distance from 1 end of the PACU to the other and back. Children wore hospital gowns and nonslip socks during the mobilization.”[4]
What did they find? “Median mobilization duration was 3 minutes, and PACU nurses facilitated all mobilizations. There was no difference between pre- and postimplementation groups in PACU LOS. Although mobilization typically occurred shortly after patients had met PACU discharge criteria, there was no difference between groups in the interval between meeting discharge criteria and leaving the PACU. There were no differences in pain scores or PONV before and after mobilization. Oxygen saturation increased from a median of 98% premobilization to 99% postmobilization.”[4]
From our perspective this is essentially a negative result. There really weren’t any differences between early and routine mobilization. An O2 saturation difference of 1%, particularly when both saturations were normal is hardly worth the effort. So why did we pick this for the PAAD? We think how they did this study, how they formulated a hypothesis, how they implemented the study, how they tracked their results and made changes in their protocol is a excellent example on how do a pilot/feasibility QI studies.
I (LDM) would like to discuss some specific points. Randomized controlled trials (RCT) are the most appropriate means to assess efficacy (evidence) in an ideal (controlled) world. The external validity of RCT is often poor and not generalizable to the real-world settings. Observation studies overcome some of these deficiencies recognizing the difficulty of establishing causation limits conclusions. Vanderhoek et al. [4] study is a prospective observational study comparing mobilization in ambulatory surgery patients is a prepost (before-after) design. This is a quasi-experimental design aiming to evaluate the intervention (mobilization) and outcomes without randomization to establish causality; therefore, it is more than a simple an observational study.[6] The study is small (n=60 before and n=52 after) and involved a low risk, low gain population (ambulatory patients). The study has several excellent QI highlights: (1) robust planning, (2) establishing baseline data, (3) garnering staff engagement in the planning, (4) allowing time for the staff to learn and trial the intervention (presumably with staff feedback) prior to the post data collection period. Their aim was general (safety/feasibility) more consistent with a pilot study as they state. QI projects should have SMART (specific, measurable, achievable, relevant, and time-bound) goals. They failed to state their primary and/or secondary outcomes. As they noted, the short duration (4 weeks) of intervention (ambulation) hindered data collection from more patients and barriers to compliance. For those of you who are interested in process improvement and QI initiatives, this study is well worth your time. We look eagerly forward to their next efforts looking at more complex surgery and inpatients.
Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday Reader Response.
References
1. Wieczorek B, Ascenzi J, Kim Y, Lenker H, Potter C, Shata NJ, Mitchell L, Haut C, Berkowitz I, Pidcock F et al: PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2016, 17(12):e559–e566.
2. Ista E, Redivo J, Kananur P, Choong K, Colleti J, Jr., Needham DM, Awojoodu R, Kudchadkar SR: ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries. Critical care medicine 2022, 50(1):114–125.
3. Lin JC, Srivastava A, Malone S, Jennison S, Simino M, Traube C, LaRose K, Kawai Y, Neu L, Kudchadkar S et al: Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2023, 24(8):636–651.
4. Vanderhoek SM, Shoemaker L, Na YB, Prichett L, Kudchadkar SR: PACU Up!: Feasibility of an Early Mobilization Program for Children After Surgery and Anesthesia. Anesthesia and analgesia 2025.
5. Svensson-Raskh A, Schandl AR, Ståhle A, Nygren-Bonnier M, Fagevik Olsén M: Mobilization Started Within 2 Hours After Abdominal Surgery Improves Peripheral and Arterial Oxygenation: A Single-Center Randomized Controlled Trial. Phys Ther 2021, 101(5).
6. Choi SW, Wong GTC: Quality improvement studies - pitfalls of the before and after study design. Anaesthesia 2018, 73(11):1432–1435.