Post on 28-Aug-2018
Professionals should be knowledgeable of their institutions policies and procedures. This course will contain Florida Hospital established clinical practice guidelines associated with lab values, mobilization and intervention.
Clinical judgement should be based upon patient presentation, signs and symptoms, and communication with health care professionals to provide safe and effective care.
Identify information through the lens of each discipline when conducting a medical record review
Identify and understand the effects of lines and attachments
To understand lab values: How to provide safe intervention
To understand the positive and negative effects of medication on therapeutic intervention
To understand delirium: How it affects patient interaction and performance
Learn how to mobilize patient from supine to stride
To understand the importance of caregiver and staff education
Patient (Pt) has a resting Heart Rate of 150.
Pt has a femoral line, can you help them get out of bed?
Pt’s blood pressure (BP) is 205/110.
Pt has an arterial line, it is safe to perform grooming tasks and brush teeth?
Pt has a Doppler ultrasound ordered to rule out deep vein thrombosis (DVT) in the Lower Extremity. Pt is currently on Coumadin. Is therapy intervention appropriate?
Pt has an INR (international normalized ratio) of 4.
Pt with Respiratory Rate of 37 on vent with FiO2 of 75; PEEP of 10.
Handout!
Cost Between 2000 and 2005, annual critical care medicine costs increased from $56.6
billion to $81.7 billion, representing 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of gross domestic product
Hospital stays that involved intensive care unit (ICU) services were two and half times more costly than other hospital stays
In 2011, 26.9 percent of hospital stays in 29 States involved ICU charges, accounting for 47.5 percent of aggregate total hospital charges
Hospitalization More than 5.7 million patients are admitted annually to intensive care units in the
United States
All acute care hospitals have at least one intensive care unit and approximately 55,000 critically ill patients are cared for each day
Cardiac, respiratory, and neurologic conditions dominated stays with high ICU utilization
Length of Stay
Intensive care unit length of stay (LOS) has been estimated at 3.8 days in the United States
Adherence to Surviving Sepsis Campaign performance bundles, early patient mobilization, use of high-intensity ICU physician staffing, and enhanced staff and family communication all improve LOS
From 2002 through 2009, ICU stays rose at three times the rate of general hospital stays without an increase in severity of illness
Delirium
Pressure ulcers
Malnutrition
Deconditioning
Weakness
Joint contractures
Isolation
Depression
EARLY INTERVENTION IS KEY!
Systemic• Acute respiratory failure (ARF)
• Acute kidney injury (AKI)
• Sepsis
Cardiac• Acute myocardial infarction (AMI)
• Myocardial Infarction (MI)
Neurological• Intracranial hemorrhage (ICH); Cerebral Vascular Accident (CVA)
• Progressive diseases (Parkinson’s ; amyotrophic lateral sclerosis)
Oncology• Leukemia
Post surgical• Liver, kidney, lung, or heart transplant
• Coronary artery bypass grafting (CABG)
• Mitral valve replacement (MVR); Aortic valve replacement (AVR)
Arterial lines (radial, brachial, femoral)
Central venous catheters
Intravenous catheters
Swan Ganz
Chest tubes
Feeding tubes: nasogastric (NG), percutaneous endoscopic gastrostomy (PEG) , gastro-jejunal (GJ), jejunal (J)
Drains (Jackson-Pratt; Hemovac; External Ventricular Drain)
Shunt
Electrocardiography (EKG) leads/Telemetry monitor
Foley catheter
Fecal management system (Flexi-Seal)
Sequential Compression Devices (SCD’s)
Nasal cannula
High flow nasal cannula
CPAP - Continuous positive airway pressure
BiPAP - Bilevel positive airway pressure
Mechanical Ventilator• Endotracheal tubes
Orotracheal - through the mouth
Nasotracheal - through the nose
• Tracheostomy tube -through trachea
T-piece
Why is patient in the hospital?
What series of events led to admission?• Surgery (Elective or Emergent)
• Cardiac
• Fever (Sepsis)
• Pulmonary
• Neurological Event
• Trauma
• Oncology
What is patients prior level of function?
What diagnostic tests have been completed?
Chest X-ray
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Angiogram (MRA)
Computed Tomography Scan (CT)
Computed Tomography Angiography (CTA)
Electrocardiogram (EKG)
Venous Ultrasound and/or Arterial Doppler Scan
Electroencephalogram (EEG)
Ultrasound
Lumbar Puncture
Is Patient on oxygen?• Nasal cannula
• Heated high flow: added humidification will assist to overcome the negative impact of dry air on lung tissue
• BIPAP
• Mechanical Ventilator
What type of ventilator and settings?
Respiratory Rate:
• Number of breaths per minute that the Ventilator delivers
FiO2:
• Fraction of inspired oxygen or percentage of O2 delivered
Volume Control:
• Preset to deliver volume of O2 and air
PEEP:
• Positive end-expiratory pressure
• Increase oxygenation in either AC or SIMV mode
• Positive pressure applied at end of exhalation
Pressure Support:
• Used in SIMV, provides small amount of pressure during inspiration
Mode of Mechanical Ventilation
Assisted-Control (AC)
Synchronized Intermittent Mandatory Ventilation (SIMV)
Blood Pressure (BP)• 60/90 mmHg – 90/150 mmHg
Respiration Rate• 14-20 breaths/min
Heart Rate• 60-100 beats per minute
Temperature• 96.4 – 99.1 degrees Fahrenheit
What is mean arterial pressure (MAP)?
• Indication of blood perfusion
• 70-110mmHg
• Minimum 60 to nourish body
• DPx2+SP
3
MAP= Heart disease, Heart attack, stroke
MAP= possible sepsis
Antihypertensives
Anticonvulsants
Ca Channel blockers
Vasopressors (Pressors)
Diuretics
Paralytics
Anticoagulants
Narcotic analgesics
Analgesic sedatives
Opioid Analgesics • Fentanyl
• Morphine
• Meperidine
Benzodiazepines• Lorazepam
• Midazolam
• Diazepam
White blood cells (WBC)• Body ability to fight infections
• (4.4 - 10.5 x 103
mm3)
Platelets• Hemostasis – clotting
• (139 - 361x103mm
3)
Hemoglobin• Blood’s capacity to carry O2
• (12.6 - 16.7gm/dL males)
• (11.4 - 14.7gm/dL females)
Hematocrit: • Red Blood Cell (RBC)
• (36.9 – 48.5 % males)
• (34.3 – 45.5% females)
INR (International Normalized Ratio)• (0.8 - 1.2)
INR= Increased risk of bleeding
INR= Increased risk of clotting
Sodium (Na)• Determinant of extracellular fluid volume
• 136 - 145 MMOL/L
Potassium (K)• Important for function of excitable cells such as nerves,
muscles, and heart
• 3.5 - 5.0 MMOL/L
Calcium (Ca)
• Important for bone formation• 8.5 - 10.5 mg/dL
Chloride (Cl)
• Important for fluid balance and acid base status.• 98 – 110 MMOL/L
Blood Urea Nitrogen (BUN)• Elevates kidney function
• 5 - 25mg/dL
Serum Creatinine• Evaluates kidney function
• 0.6 - 1.20 mg/dL
Glucose• Measures blood glucose at time sample is obtained.
• 70 - 100 mg/dL
Measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery
pH
• 7.35-7.45
PaCO2- Partial Pressure Carbon Dioxide
• 35-45 mmHg
PaO2- Partial Pressure Oxygen
• 80-105 mmHg
HCO3- Bicarbonate
• 22-26mEq/L
O2 Saturation
• 92-100%
Respiratory Therapeutic Intervention ?
Endotracheal tube
Tracheostomy tube
O2 saturation: >90%<90%
Respiratory rate: <30bpm>30bpm
Ventilation: HFOVInverse ratioAMV
PEEP: <10cm H2O
Break
Occupational Therapy Assessment
Are there any orders that would impact therapy intervention?
Physician notes/Consults
Any recent or planned surgeries/procedures?
Where would you find “Weight Bearing” precautions?
Status Review • Mode of Ventilation
• Imaging
• Tubes and attachments
• Critical lab values
Handout!
Handout!
What does the patient look like? • Positioning
What equipment is in the room?• Line attachments
What are current vital signs?
Is the patient in pain?
Does the patient have any precautions?• Are there weight bearing precautions or range of motion
restrictions before you start mobilizing?
Borg Scale
MoCA: Montreal Cognitive Assessment
MMSE: Mini-Mental Status Examination
HADS: Hospital Anxiety and Depression Scale
RASS: Richmond Agitation and Sedation Scale
Pain Scale: Faces Pain Scale
Assessment of Pitting Edema
• The most common assessment of symptoms of breathlessness
Borg Scale
MoCA• Purpose: Measure of
cognition including orientation, short term memory, executive function, language, and attention
• Time: 10-12 minutes
MMSE
• Purpose: Assess problems with memory and other cognitive functions
• Time: 10 minutes
HADS• Purpose: Self-rating
scale to measure anxiety and depression a patient may be experiencing during their stay in the hospital
• 14 questions
• Time: >10 mins
RASS• Purpose: assess the patient’s level of sedation in the ICU
Pain Scale• Visual/Verbal Scale:
Assessment of Pitting Edema • Purpose: Subjective and qualitative measure of depth and rate
of pitting
Occupational Profile:Prior Level of Function Was the patient a caregiver to other people? Pets?
Did the patient drive?
Was the patient employed?
Was the patient attending school?
Did the patient perform household management tasks?
Did the patient attend religious services and activities?
What are the patients leisure activities? • Cook
• Gardener
• Singer
ST Assessments
Speech-language Evaluations (motor speech, language, cognition)
• Optimize functional communication
Swallow Evaluations (clinical bedside and instrumental evaluations)
• Optimize toleration of safest and least restrictive diets
Passy-Muir Speaking Valve and Voice Evaluations• Optimize functional communication
Pertinent Information
Prior level of functioning
Imaging
Lab values
Tubes, lines
Medications
Interdisciplinary consults/progress notes
Medical course
Recent admissions
Diet
Prior Level of Function
• Before admission, what was the patient’s most functional mode of communication?
• What technologies did the patient have available? (ie: glasses, dentures, communication device, etc)
• Has the patient had recent hospitalizations? Why?
• Does the patient have a history of requiring ST services? What for?
• What is the patient’s baseline diet?
• What modifications or assistance does the patient require during meals?
Imaging
• Infiltrates seen on a chest x-ray may reflect presence of aspiration pneumonia
• Infiltrates new or chronic? How do findings compare to prior radiographs?
• Location of infiltrates related to patient’s positioning
X-rays
• Important to identify presence and locations of neurologic injuries
• Locations of and types of neuro injuries/CVAs may indicate higher risks of cognitive-linguistic deficits, dysphagia/silent aspiration
CT/MRI
Lab Values
Leukocytosis (elevated WBC) can indicate developing infection, like pneumonia from aspiration, may be accompanied by fever
White blood cells (WBC)
Red Blood Cells (RBC), Hematocrit (HCT), Hemoglobin (Hgb)Red Blood Cell indices
Protein status indicator used to examine nutritional status; potential indicator of malnutrition
Pre-albumin lab values
Ammonia levels can indicate significant mental status changes; hypokalemia can cause weakness and fatigue r/t dysphagia; hypocalcemia can cause mental status changes, depression, extrapyramidal symptoms, neuromuscular irritability r/t dysphagia
Electrolytes
Tubes and Attachments
Tubes and Attachments
PICTURES
Medications
Central nervous system side effects• Decreased level of arousal
• Suppression of brainstem swallowing regulation
• Movement disorders
Peripheral nervous system side effects• Neuromuscular junction blockade
• Myopathy
• Oropharyngeal sensory impairments
• Disturbance of saliva production
Interdisciplinary Consults
ENT
GI
Internal medicine
General surgery
Neuro sx
Radiation oncology
Nutrition
Psychiatry
Medical Course Intubations (one vs. multiple, emergent,
complications)
Procedures?
Respiratory needs (weaned from bipap, requiring increased support, vent settings?)
NPO status (NPO due to concerns, GI issues, prolonged NPO?)
Current nutritional means (modified diets, tubes?)
Current cognitive state (alertness, delirium, sepsis?)
Vital signs (is the patient hemodynamically stable?)
Any reasons to defer the assessment? Is the consult contraindicated?
Clinical Presentation
What are nursing observations? What is current Patient condition and medical plans?
How does the patient present clinically?• Alert? Lethargic? Tachypneic? Agitated? Combative? Calm?
Screen cognition • Can Pt state Identification information? Pt oriented?
Following directions?
ST Assessment TypesSwallow Evaluations
Begin with clinical assessment at bedside, consists of:
• oral motor exam, liquid/food trials, if appropriate
• Determine if further evaluation via instrumental assessment is indicated
• VideofluoroscopicAssessment of Swallowing (VFSS)
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Speech Evaluations (communication, cognition)
Standardized and non-standardized assessments utilized
Often limited in ICU setting d/t fatigue, reduced endurance, severity of cognitive deficits, medical instability, environment
Swallow Assessments
PICTURES
Six potential mechanisms for the development of ICU-acquired swallowing disorders
Macht, M., Wimbish, T., Bodine, C., & Moss, M. (2013). ICU-acquired swallowing disorders. Critical care medicine, 41(10), 2396-2405.
Factors that can Impact Communication and/or Swallowing Postoperative dysphagia and dysphonia◦ Surgeries involving structures of the neck
Carotid endarterectomy
Cervical fusion
Thyroidectomy
◦ Posterior fossa and skull base
surgeries
◦ Cardiothoracic surgeries
Lung/heart transplantation
Lobectomy
CABG, AVR, MVR
Factors that Impact Both Communication and Swallowing
Tracheostomy• System now open: leak under the vocal
folds, loss of subglottic pressure
• Pressure present in the trachea below a closed glottis
• Loss of physiologic PEEP
• Sensory deprivation
• Reduced tone
Risk Factors for Potential Communication and Swallowing Disorders
Preexisting dysphagia
Cancer, surgery, or radiation to head, neck, and/or esophagus
Delirium, excessive sedation, and/or dementia
Stroke or neuromuscular disease
Longer durations of mechanical ventilation
Multiple intubations
Tracheostomy
Severe gastroesophageal reflux
Paralytics and/or critical illness polyneuromyopathy
Supine bed position
SepsisMacht, M., Wimbish, T., Bodine, C., & Moss, M. (2013). ICU-acquired swallowing disorders. Critical care medicine, 41(10), 2396-2405.
ASHA. Adult Dysphagia.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA.2016;315(8):801–810. doi:10.1001/jama.2016.0287
C.G. Ravetti et al. Journal of Critical Care 30 (2015). 440.e7-440.e13
How Does Sepsis Impact Cognition?
Defined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection”
Sepsis and septic shock both associated with increased mortality in hospitalized patients
Important to dx acute brain dysfunction to initiate tx
Structural brain alterations secondary to sepsis• Temporal coordination of neuronal responses is affected,
causes desynchronization between various interconnected brain regions
Rasulo, F. A., Bellelli, G., Ely, E. W., Morandi, A., Pandharipande, P., & Latronico, N. (2017). Journal of intensive care, 5(1), 23.Iwashyna, T. J., Ely, E. W., Smith, D. M., & Langa, K. M. (2010). Jama, 304(16), 1787-1794.
Damm T, Patel JJ. Long-term outcomes after critical illness: A Concise Clinical Review. PulmCCM Journal. 2015 Jan 28.
Lunch Break
Just 4 hours of immobility and disuse can initiate the process of decline in cell diameter,
number of muscle fibers, muscle mass, and endurance, particularly in LE.
Appleton, R., & Kinsella, J. (2012). Intensive care unit-acquired weakness. British Journal of Anesthesia, 1-5. doi:10.1093/bjaceaccp/mkr057
Consequences of Bed Rest and Immobility
How Mobility Decreases Ventilator Days
In a supine position, lung volumes are reduced
Risk of atelectasis and pneumonia increases
Muscles of respiration weaken rapidly
Knight, J. et al (2009) Effects of bedrest 1: cardiovascular,
respiratory and haematological systems. Nursing Times; 105: 21,
early online publication.
How Mobility Decreases Length Of Stay and Disability
Immobility can contribute to several complications that prolong hospital stay:
Best rest causes weakness
Bed rest causes long term disability
Bedrest causes pressure ulcers
Bedrest increases risk of DVT
Bed rest results in orthostatic hypotension
Wick, J.Y. (2011). Bedrest: Implications for the Aging Population. Retrieved from
http://www.pharmacytimes.com/publications/issue/2011/January2011/FeatureBedrest-0111
Early and Progressive Mobility *Levels of Therapy
1. Dangling
2. Standing at bedside
Early and Progressive Mobility *Levels of Therapy
3. Transfer to chair (active), includes standing without marching in place
4. Ambulation (marching in place, walking in room or hall)
*All may be done with assistance
Determining Readiness
How do you know if the patient is too sick for mobility?
We use the MOVE criteria
M: myocardial stability; no ongoing myocardial ischemia; no ventricular arrhythmias requiring initiation of IV
antiarrhythmic
O: oxygenation </= 0.8, PEEP </= 12
V: vasopressors; no increase dose of any vasopressor infusion for at least 2 hours
E: Pt engages upon verbal stimulation with staff (RASS of >/=
-3 or better to be successful
N: (New for Neuro Patients ONLY) neurologic stability (ICP < 20mm and no active seizures)
Mobility is Safe
Multiple research studies have been conducted on this topic in the past several years. A sample follows:
Of 498 patients, 1 adverse event (arterial line)1
Of 176 interventions, 2 adverse events (both hypotensive)2
Of 424 interventions, 1 adverse event (self extubation)3
1: Schweichert, W.D. & Hall, J. (2007). ICU-acquired weakness. Chest, 131 (5):1541-1549
2: Leditschke, A. et al. (Mar 2012). What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J., 23(1):26-29
3: Bourdin, G. et al. (Apr 2010). The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care. 55(4) 400-7
ABCDE Bundle
What is it?
Coordination between multiple disciplines
Management of critically ill patient
Goal: Prevent over sedation
Decrease immobility
Decrease development of delirium
ABCDE
Motomed
Physical Therapy Interventions
Positioning Exercises• Muscle strengthening• Breathing
Bed Mobility Activities• Rolling• Sitting edge of bed• Trunk control• Unsupported sitting• ADL • Turning side to side
PT intervention continued
Transfer from bed• Sit to stand
• Commode transfer
• Chair transfer
Gait• Pre-gait activities
• Weight shifting activities
• Stepping in place
• Gait training with walker
Stop, Look and Question
Symptomatic drop in BP
HR <50 or >130 for 5 minutes
RR <5 or >20 above baseline for 5 minutes
O2 sat <88% for 5 minutes with O2 supplement
Significant pain/distress
Profound fatigue
Pt requests to stop Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., & ...Hopkins, R. (2007). Early activity is feasible and safe in respiratory failurepatients. Critical Care Medicine, 35(1), 139-145.
“Barriers?”
Fears based upon “what if?”
Illness severity
Sedation
Perceived lack of benefit
Equipment
Unit culture
How to Overcome Barriers
Education
Discussion
Training
Demonstration of How to Mobilize a Critically Ill Patient
VIDEO
Interventions ADL/IADL re-training• Toileting, grooming, dressing
Leisure participation • Play sports, garden
Social participation • Face to face interaction, phone call, text message
Relaxation/coping strategies• Deep breathing
Vision• High contrast colors
Cognition • Compensatory memory techniques
Interventions
Fall prevention and safety education• Preventative care to prevent risk of readmission
Edema management • Proper positioning, elevation extremities
Pain management• Proper positioning and use of external items
Bracing and splinting• Static or dynamic splints
Therapeutic exercises
Therapeutic activities
ICU Diary
Holistic, client-centered approach
Promotes: sensory integration through auditory and visual stimulation, cognitive engagement, reorientation, awareness to reality, fine-motor coordination.
A journal that can include notes from physicians, interdisciplinary staff in order to best communicate with patient and family in a chronological order
Identified for patients with: ICU length of stay grater than 48 hours, have experienced mechanical ventilation and sedation, who are experiencing or at high risk of delirium.
Goal of Interventions
Prevent social isolation
Increase quality of life
Improve occupational independence
Improve strength and range of motion
Promote psychological/spiritual health
Diagnosis: acute lung injury, COPD exacerbation, acute exacerbation of asthma, sepsis, hemorrhage
Acuity: in intervention group, patients received therapy 87% of days
Interventions: unresponsive patients PROM for all limbs, responsive A/AAROM, bed mobility activities, sitting balance activities and participation in ADLs and exercise, transfer training, pre-gait exercises, walking
Results: 59% of intervention group returned to independent functional status at hospital discharge compared to 35% of control group, shorter duration of delirium, and more ventilator-free days
Purpose: implement OT services in the ICU and report the awareness and perception of OT services by the ICU staff (including physicians, psychologists, nurses, social workers, STs, and PTs)
OT interventions: reception, coping, communication, functionality, and family involvement; weekly participation in clinical case discussions and contributing to the holistic vision of care
Results: the ICU team manifested an understanding of OT intervention possibilities and reports that OT can to the quality of care and more humanized care for pts
Intervention Illustration
Patient education
Lower body dressing
Toilet transfer
Grooming
Therapeutic exercises
VIDEO
Break
ICU Environment
VIDEO
Impact of Impaired Swallowing and Communication
Lack of participation in decision making, limited personal interaction• Motivation
• Misunderstandings
• Increased anxiety, increased likelihood of delirium
Over-medication and sedation• Increased likelihood of delirium
• Reduced mobility and positioning
• Increased risk for aspiration and subsequent complications
• Nutritional compromises
• Increased risk of reflux
• Dependent oral care
Dysphagia s/p Prolonged Orotracheal Intubation
ICU Delirium Prevalence 40-60% of Non-ventilated and 60-80% in
mechanically ventilated critical care patients
Results in hypoperfusion in frontal, temporal, and subcortical regions of the brain
Lasting cognitive deficits associated with reduced quality of life post discharge
Sedation and analgesia practices impact delirium; prevalent in ICU settings
Prevention strategies are more effective than treatment strategies
Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews. Neurology, 5(4), 210–220.
Clinical Features of Delirium
Hyperactive
Features of restlessness, agitation, hypervigilance
Often experience hallucinations, delusions
Hypoactive
Most common in elderly patients
Lethargy, sedation
Respond slowly to questioning
Frequently overlooked, dx as having depression or dementia
Frequent reorientation
Cognitive stimulation
Early mobilization (PT, OT)
Timely removal of physical restraints
Vision and hearing assistive devices, if needed
Meeting needs for nutrition, fluids, and sleep
Modify environment• Noise
• Lighting
• Sleep/wake cycles
• Family presence
Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009).
Communication in the intensive care unit is a necessity—not a luxury
ASHA 2010 Acute Care/AAC Garrett Baumann Downey
What are the benefits of using a “speaking” valve?
Restores• Communication of wants/needs, ability to express oneself
• Participation in care and therapy
• Improve patient cognitive and physiological status
• Reduce delirium and anxiety
• Laryngeal/pharyngeal sensation and tone
• Improve swallowing for secretion management and potentially PO
• Reduces tracheal secretions and need for suctioning
• Allows for coughing and clearance of material in the airway
• Physiological PEEP
• Reduces atelectasis, improves weaning from ventilator support
• Improves balance/support for sitting/dangling/ambulation
• Improve upper extremity force
• Improve bowel/bladder emptying
Therapy using PMV
ST/RT collaboration
Co-treating with PT/OT
Focus/goals• Pt/caregiver training
• Improve toleration
• Coordination of exhalation/voicing
• Speech/language/cognitive tx goals
• Using PMV to enhance swallow tx
• Resistive breathing training (ie: EMST)
• Oral motor exercises
• Laryngeal elevation exercises
• Oral sensory stimulation
VIDEO of in-line PMV placement
Second half of video starting at 1:44
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Appleton, R., & Kinsella, J. (2012). Intensive care unit-acquired weakness. British Journal of Anesthesia, 1-5. doi:10.1093/bjaceaccp/mkr057
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Bombarda, T. B., Lanza, A. L., Santos, C.A.V., & Joaquim, R.H.V.T. (2016). The occupational therapy in adult intensive care unit(ICU) and team perceptions. Cadernos De Terapia Ocupacional, 24(4), 827-835. doi:10.4322/0104-4931.ctoRE0861
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Evangelist, M., & Gartenberg, A. (2016). Toolkit for developing an occupational therapy program in the ICU. OT Practice, 1(1), 20.
Go AS, Mozaffarian D, Roger VL, et al. Heart Disease and stroke statics—2013 update: a report from the American Heart Association. Circulation. Jan 1 2013:127(1)e6-e245.
Haft, J. & Bartlett, R. (2016). Extracorporeal membrane oxygenation (ECMO) in adults. 2014 Intra-abdominal balloon pump. WebMD. <http://www.webmd.com/heart-disease/tc/intra-aortic-balloon-pump-topic-overview.>
Barrett, M., Smith, M., Elixhauser, A., Honigman, L., & Pines, J. (2014). HCUP Statistical brief #185: Utilization of intensive care services, 2011. Agency for Healthcare Research and Quality. Retrieved from https://hcup-us.ahrq.gov/reports/statbriefs/sb185-Hospital-Intensive-Care-Units-2011.jsp
References Götz, T., Günther, A., Witte, O. W., Brunkhorst, F. M., Seidel, G., & Hamzei, F. (2014). Long-term sequelae of severe sepsis:
cognitive impairment and structural brain alterations–an MRI study (LossCog MRI). BMC neurology, 14(1), 145.
Rasulo, F. A., Bellelli, G., Ely, E. W., Morandi, A., Pandharipande, P., & Latronico, N. (2017). Are you Ernest Shackleton, the polar explorer? Refining the criteria for delirium and brain dysfunction in sepsis. Journal of intensive care, 5(1), 23.
Patel, M. B., Morandi, A., & Pandharipande, P. P. (2015). What’s new in post-ICU cognitive impairment?. Intensive care medicine, 41(4), 708-711.
Maley, J. H., & Mikkelsen, M. E. (2016). Short-term gains with long-term consequences: the evolving story of sepsis survivorship. Clinics in chest medicine, 37(2), 367-380.
Sonneville, R., Verdonk, F., Rauturier, C., Klein, I. F., Wolff, M., Annane, D., ... & Sharshar, T. (2013). Understanding brain dysfunction in sepsis. Annals of intensive care, 3(1), 15.
Annane, D., & Sharshar, T. (2015). Cognitive decline after sepsis. The Lancet Respiratory Medicine, 3(1), 61-69.
Widmann, C. N., & Heneka, M. T. (2014). Long-term cerebral consequences of sepsis. The Lancet Neurology, 13(6), 630-636.
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