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Use of physical restraints in adult ICU patients to prevent patient-initiated device removal: a systematic review

Erika Bassi, Marilena Ceresola


Review Question/Objective: 
The aim of the systematic review is to present the best available evidence on the use of physical restraint to prevent patient-initiated device removal in adult ICUs patients.
The review question is: what is the effectiveness of physical restraints on prevention of patient-initiated device removal in adult ICU patients?

Inclusion Criteria: 
Types of Participants: 
All adult (>18 years old) ICU patients:
- with all types of devices (for example -but not limited to- endotracheal tube, IABP, lung drainage, CVC, indwelling bladder catheter, arterial catheter, feeding tube, etc)
- with any kind of pathology, at any degree of severity and any kind of co-morbidity.

Types of interventions: 
Physical restraints intended as any kind of device, material, or equipment that is attached (not only “adjacent”: bed rails in ICU cannot be considered physical restraints) to a person’s body and deliberately prevents the person’s free bodily movement.
- All types of sedation at any dosage are accepted in light of the current sedation trends including daily wakening protocols1 and a patient’s activity level scored as calm and cooperative
- Patient treated with neuromuscular blocking agent (NMBAs) are excluded from this systematic review; neuromuscular blocking drugs block neuromuscular transmission at the neuromuscular junction, causing paralysis of the affected skeletal muscles. Their use in ICUs is usually limited to patients affected by severe acute respiratory distress syndrome (ARDS)23 because they require a deep sedation and could be implicated in lung atelectasis24,25, ICU-acquired myopathies and prolonged duration of mechanical ventilation26,27. Patients treated with NMBAs can’t make any movement -restrained or not- and they are not subjected to self-removal of therapeutic devices.

Types of outcomes: 
- Frequency of patient-initiated device removal.
- Complications related to patient-initiated device removal (for example -but not limited to- bleeding/haemorrhage, respiratory failure/failure, delay in therapy, pneumothorax, urinary retention, aspiration, hypotension, ect)
- Complications related to the use of physical restraints in terms of direct injury (for example -but not limited to- lacerations, bruising, development of pressure sores, ischaemia, nerve compression, etc)


physical restraints; chemical restraint; unplanned extubation; self-extubation; device removal; treatment interference; therapy disruption; agitation; intensive care unit; critical care; harm; injury

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