Transcript Slide 1

Mobilising the Critically Ill, an emerging
Concept
Shaju Kareem Hassan
Senior Physiotherapist
Dubai Hospital
International Partner, American Physical Therapy Association
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New technologies in critical care
and mechanical ventilation leads
to long term survival of critically ill
patients and a dramatic increase
in the number of ventilator
dependent patients
Recently there is being an
increased interest in early
rehabilitation of the critically ill
patient.
The recent articles published
demonstrates the effectiveness of
early rehab efforts in the short and
long term functional outcome.
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In ICU, patients are frequently exposed to
prolonged immobilization
ICU acquired neuromuscular complication
are common, debilitating and long lasting.
Contribution of bed rest to the development
of ICU acquired weakness is associated
with
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prolonged mechanical ventilation,
longer ICU stay and
longer recovery time
Marked decline in functional status
Steven et al, Intensive care med
2007;33(11):1876-1891
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Implementation of early rehabilitation programme is
associated with
Minimizing complication of bed rest
Facilitating the weaning from ventillatory support
Reduced ICU length of stay
Reduced hospital length of stay
Promoting improved function
Improving patients quality of life
Cost saving
No adverse outcomes
Morris PE, et al. Crit Care Med, 2008;36:2238-2243
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Immobility associated complication
Respiratory
– Decreased respiratory motion
Abdomen influence on the diaphragm motion
– Increased depended edema
Fluid accumulation in the dependent region / compression
atelectasis
– Impaired ability to clear the tracheo bronchial
secretions
– Increased risk of atelectasis and development of
ventilator associated pneumonia
– Increased risk of pulmonary embolism
– Weak respiratory muscles due to prolonged
mechanical ventilation
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Skeletal muscle deconditioning
Skeletal muscle strength reduces 20% every week of bed rest. Weak
muscles generate an increased oxygen demand.
Healthy individuals on 5 days of strict bed rest develop insulin resistance and
microvascular dysfunction
Rapid muscle atrophy
– Primary: bed rest, limb casting
– Secondary to critically illness polyneuropathy and critical illness
myopathy
Muscle groups that lose strength most quickly are those that maintain
posture, and ambulation
One day of bed rest requires two weeks of reconditioning to restore baseline
muscle strength
Topp R et al. Am J of Crit Care, 2002;13(2):263 263-76
Candow DG, Chilibick PD. Differences in size, strength, & power of upper & lower body muscle groups in young & older men. J Gerontol Gerontol,
2005:60A:148 , 148-155
Homburg NM,. Arterioscler Thrombo Vasc Biol Biol, 2007;27(12):2650 , 2650-2656
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Critical Illness Neuromyopathy
Critical illness polyneuropathy (CIP)
Critical Illness myopathy (CIM)
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Hypotension
Microthrombi
Endoneural edema
Mitochondrial dysfunction
Factors that decrease the availability
of nutrients
Sepsis
Administration of corticosteroids
Elevated resting metabolism
Increased protein degradation
Two hit hypothesis
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Immobility associated complication
Cardiovascular
– Reduced stroke volume
and Cardiac output, heart
muscle atrophy, increased
heart rate, Hypovolemia,
– Orthostatic hypotension
– Deep vein thrombosis
Other musculoskeletal
problems
– Bone demineralization
– Joint contractures
Endocrine
– Hyperglycemia
– Insuline resistance
Skin
– Decubitus ulcers
Psychosocial
– Depression
– Decreased functional
capacity
Gastrointestinal
– constipation
Renal
– Renal calculi
– Urinary stasis
The elderly are more
vulnerable
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Immobility = deconditioning
Multiple changes in the organ system physiology that are
induced by inactivity are reversed by activity
( Siebens H, et al, J Am Geriatr Soc 2000;48:1545-52)
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Acute care rehabilitation
Upper extremity muscle strength correlates with early weaning and
extubations
Martin et al,Crit Care Med 2005;33:2259 -2265
Elderly patients responded well with physical therapy programmes
including strengthening exercises , ambulation and functional
training.
Martin et al,Crit Care Med 2005;33:2259 -2265
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Can we safely mobilize and ambulate
mechanically intubated patients ?
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Early Activity is Safe &
Feasible in Acute Respiratory Failure Patients
Methodology
Prospective cohort study
103 pateints/1449 activity events
Mechanically ventilated patients for > 4 days
Airway: Tracheotomy & endotracheal tube
Measured recorded activity events & adverse events
Activity events included:
Sit on bed, Sit in chair, Ambulate
Adverse events defined as:
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Fall to knees,
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Tube removal,
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SBP > 200 mmHg, SBP < 90mmHg,
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O2 desaturation < 80% &
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Extubation
Bailey P, et al. Crit care Med, 2007;35:139-145
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Results
Activity events included:
Sit on bed (233 or 16%)
Sit in chair (454 or 31%)
Ambulate (762 or 53%)
With an ET in place:
Sit on bed, chair or ambulate (593)
Ambulate (249 or 42%)
Adverse events
< 1% activity related adverse events (no extubations
occurred)
69% all to ambulate at > 100 feet at ICU discharge
Early Activity is safe &
feasible in mechanically intubated patient
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3 Main criteria for early activity initiation
“Early”
-- time period beginning after initial physiological stabilization
Neurologic
– (responding to verbal stimulus),
Respiratory
– (FiO2 < 60% & PEEP < 10cm of H2O)
Circulatory
– (absence of orthostatic hypotension and ionotrops drips)
Thomsen GE, et al. CCM 2008;36;1119-1124
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Step by step mobility process
The ultimate goal is to promote
maximum level of independence
before hospital discharge.
Phase 1
Phase 2
Progress to transfer
training and walking
assisted inside the
room
Phase 3
Progressive walking
For patient’s not actively participating
Maintain HOB of mechanically
ventilated patients > 30 degrees
unless contraindicated
Phase 4
Perform PROM exercises while in
bed rest and
Restricted to bed rest, can
progress to sitting on bed
and standing
Care of patient transferred
out of ICU and planning for
discharge
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Progressive UPRIGHT mobility process
Elevate the head of bed to 45 deg
(consider large abdomen)
Elevate the HOB to 45 deg plus legs in
dependent position (partial chair)
Elevate HOB to 65 deg plus legs in full
dependent ( full chair position )
Sitting in bedside chair using a
mechanical hoist
Use a tilt table (optional)
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Progressive upright mobility process
Once patient is conscious,
following commands
Dangle the legs in bed with
assistance (sitting at the edge
of bed )
Stand patient at bedside with
support once able to lift the leg
against gravity
Transfer to chair by pivoting or
taking 1-2 steps, sit up for 1- 2
hour
Use a bedside stationary cycle
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Progressive upright mobility process
• Walk with assistance
• Walk independently
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Exclusion criteria
Cardiovascular instability
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Hypotension SBP <90 mmHg
Tachycardia HR >130 beats/ min
Unstable cardiac rhythm
Two or more vasopressors /
ionotrops or frequent upward
titration
Respiratory instability
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FiO2 > 0.60
PEEP > +10 cm H2O
Resp rate >35 bpm
Requirement of neuromuscular
blockade
– Pressure control ventilation
• Neurological instability
• Acute brain injury
•ICH / SAH
•ICP monitoring
•Intraventricular drain
•Unstable SCI
•Any new neurological
deterioration
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Femoral sheath / arterial line
Balanced skeletal traction
Intra aortic balloon pump
Active bleeding
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Screening
Algorithm
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Early mobility process
Prolonged complete bed rest is rare and questioned
Early mobility can be considered for patients
– Deconditioned by >3 days of immobility
– Require orthostatic training to upright positioning
– Ready to begin ventilator weaning
Check readiness for and progression of activity on each day / each shift
Customizing the plan
Incorporating in multi disciplinary rounds
Communicating the mobility plan to the concerned staff at the follow up
wards
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Safety Issues
Review medical background
Is their sufficient CV reserve?
Discuss with team to evaluate
Are all other factors or conditions favorable?
Labs values ,Electrolytes etc
Review with team
Select appropriate mode and intensity of mobilization
Skiller K, et al Physiother Theroy Pract ,2003,;19(4):239-257
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Safety Issues
Use a protocol that work well with other ICU interventions i.e. sedation,
weaning etc.
Dedicated trained team (Morris PE, et al 2008)
Physical therapist, nursing, respiratory therapist, Intensivist etc.
Provide detailed patient information to all team members
Sort out any expected problems and precaution
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Barriers to Mobility
Strategies
Sedation
– Use sedation protocols and goal directed sedation
Human & Technological Resources
Personnel
– Need for leadership and coordination
– Cross training of ICU staff
– Time management
– Education and training of all staff involved for efficient fearless
effort
Saftey,feasibilty,and potential benefits of mobilization
Safe lifting and transfer techniques to prevent injuries
Management of lines and tubes
Use of proper lifting equipments
Managing problems with obese patients
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Change in ICU culture is important
Transferring patient to the unit with an early mobility protocol, significantly
increased the probability of ambulation ( p < .0001)
The increase in the ambulation was not explained by the improvement in
patient’s underlying pathophysiology
Thomsen GE, et al. CCM 2008;36;1119-1124
Supports the importance of an ICU culture
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All hospitalized patients should have a detailed and specific activity
program initiated on admission and followed up
Getting Them Moving
Makes a Difference
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Thank you
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