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Mobilising the Critically Ill, an emerging Mobilising the Critically Ill, an emerging ConceptConcept

Shaju Kareem HassanShaju Kareem HassanSenior Physiotherapist Senior Physiotherapist

Dubai HospitalDubai Hospital

International Partner, American Physical Therapy AssociationInternational Partner, American Physical Therapy Association

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New technologies in critical care New technologies in critical care and mechanical ventilation leads and mechanical ventilation leads to long term survival of critically ill to long term survival of critically ill patients and a dramatic increase patients and a dramatic increase in the number of ventilator in the number of ventilator dependent patientsdependent patients

Recently there is being an Recently there is being an increased interest in early increased interest in early rehabilitation of the critically ill rehabilitation of the critically ill patient.patient.

The recent articles published The recent articles published demonstrates the effectiveness of demonstrates the effectiveness of early rehab efforts in the short and early rehab efforts in the short and long term functional outcome.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 – 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 Implementation of early rehabilitation programme is associated withassociated with

Minimizing complication of bed restMinimizing complication of bed restFacilitating the weaning from ventillatory supportFacilitating the weaning from ventillatory supportReduced ICU length of stayReduced ICU length of stayReduced hospital length of stay Reduced hospital length of stay Promoting improved functionPromoting improved functionImproving patients quality of lifeImproving patients quality of lifeCost savingCost savingNo adverse outcomesNo adverse outcomes

Morris PE, et al. Morris PE, et al. Crit Care MedCrit Care Med, 2008;36:2238-2243, 2008;36:2238-2243

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Immobility associated complicationImmobility associated complication

RespiratoryRespiratory

– Decreased respiratory motionDecreased respiratory motionAbdomen influence on the diaphragm motionAbdomen influence on the diaphragm motion

– Increased depended edemaIncreased depended edemaFluid accumulation in the dependent region / compression Fluid accumulation in the dependent region / compression atelectasisatelectasis

– Impaired ability to clear the tracheo bronchial Impaired ability to clear the tracheo bronchial secretionssecretions

– Increased risk of atelectasis and development of Increased risk of atelectasis and development of ventilator associated pneumoniaventilator associated pneumonia

– Increased risk of pulmonary embolismIncreased risk of pulmonary embolism– Weak respiratory muscles due to prolonged Weak respiratory muscles due to prolonged

mechanical ventilationmechanical ventilation

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Skeletal muscle deconditioningSkeletal muscle deconditioning

Skeletal muscle strength reduces 20% every week of bed rest. Weak Skeletal muscle strength reduces 20% every week of bed rest. Weak muscles generate an increased oxygen demand.muscles generate an increased oxygen demand.

Healthy individuals on 5 days of strict bed rest develop insulin resistance and Healthy individuals on 5 days of strict bed rest develop insulin resistance and microvascular dysfunctionmicrovascular dysfunction

Rapid muscle atrophyRapid muscle atrophy– Primary: bed rest, limb castingPrimary: bed rest, limb casting– Secondary to critically illness polyneuropathy and critical illness Secondary to critically illness polyneuropathy and critical illness

myopathymyopathy

Muscle groups that lose strength most quickly are those that maintain Muscle groups that lose strength most quickly are those that maintain posture, and ambulationposture, and ambulation

One day of bed rest requires two weeks of reconditioning to restore baseline One day of bed rest requires two weeks of reconditioning to restore baseline muscle strengthmuscle strength

Topp R et al. Am J of Crit Care, 2002;13(2):263 263-76Topp R et al. Am J of Crit Care, 2002;13(2):263 263-76Candow DG, Chilibick PD. Differences in size, strength, & power of upper & lower body muscle groups in young & older men. Candow DG, Chilibick PD. Differences in size, strength, & power of upper & lower body muscle groups in young & older men. J Gerontol Gerontol, J Gerontol Gerontol, 2005:60A:148 , 148-1552005:60A:148 , 148-155Homburg NM,. Arterioscler Thrombo Vasc Biol Biol, 2007;27(12):2650 , 2650-2656Homburg NM,. Arterioscler Thrombo Vasc Biol Biol, 2007;27(12):2650 , 2650-2656

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Critical Illness NeuromyopathyCritical Illness Neuromyopathy

Critical illness polyneuropathy (CIP)Critical illness polyneuropathy (CIP)

Critical Illness myopathy (CIM)Critical Illness myopathy (CIM)

– HypotensionHypotension

– MicrothrombiMicrothrombi

– Endoneural edemaEndoneural edema

– Mitochondrial dysfunctionMitochondrial dysfunction

– Factors that decrease the availability Factors that decrease the availability of nutrientsof nutrients

– SepsisSepsis

– Administration of corticosteroidsAdministration of corticosteroids

– Elevated resting metabolismElevated resting metabolism

– Increased protein degradationIncreased protein degradation

Two hit hypothesis

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Immobility associated complicationImmobility associated complication

CardiovascularCardiovascular– Reduced stroke volume

and Cardiac output, heart muscle atrophy, increased heart rate, Hypovolemia,

– Orthostatic hypotensionOrthostatic hypotension– Deep vein thrombosisDeep vein thrombosis

Other musculoskeletal Other musculoskeletal problemsproblems– Bone demineralizationBone demineralization– Joint contracturesJoint contractures

Endocrine Endocrine – HyperglycemiaHyperglycemia– Insuline resistanceInsuline resistance

SkinSkin– Decubitus ulcersDecubitus ulcers

PsychosocialPsychosocial– DepressionDepression– Decreased functional Decreased functional

capacitycapacityGastrointestinal Gastrointestinal – constipationconstipation

RenalRenal– Renal calculiRenal calculi– Urinary stasisUrinary stasis

The elderly are more vulnerable

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Immobility = deconditioningImmobility = deconditioning

Multiple changes in the organ system physiology that are Multiple changes in the organ system physiology that are induced by inactivity are reversed by activityinduced by inactivity are reversed by activity

( ( Siebens H, et al, Siebens H, et al, J Am J Am Geriatr Soc 2000;48:1545-52Geriatr 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 -2265Martin et al,Crit Care Med 2005;33:2259 -2265

Elderly patients responded well with physical therapy programmes Elderly patients responded well with physical therapy programmes including strengthening exercises , ambulation and functional including strengthening exercises , ambulation and functional training.training.

Martin et al,Crit Care Med 2005;33:2259 -2265

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Can we safely mobilize and ambulate Can we safely mobilize and ambulate mechanically intubated patients ?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:– Fall to knees, – Tube removal, – SBP > 200 mmHg, SBP < 90mmHg,– O2 desaturation < 80% & – Extubation

Bailey P, et al. Crit care Med, 2007;35:139-145

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ResultsActivity 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 initiation3 Main criteria for early activity initiation

““Early” -- time period beginning after initial physiological stabilizationEarly” -- time period beginning after initial physiological stabilization

NeurologicNeurologic– (responding to verbal stimulus),(responding to verbal stimulus),

RespiratoryRespiratory– (FiO2 < 60% & PEEP < 10cm of H2O)(FiO2 < 60% & PEEP < 10cm of H2O)

Circulatory Circulatory – (absence of orthostatic hypotension and ionotrops drips)(absence of orthostatic hypotension and ionotrops drips)

Thomsen GE, et al. CCM 2008;36;1119-1124Thomsen GE, et al. CCM 2008;36;1119-1124

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Step by step mobility processStep by step mobility process

The ultimate goalThe ultimate goal is to promote is to promote maximum level of independence maximum level of independence before hospital discharge. before hospital discharge.

For patient’s not actively participatingFor patient’s not actively participating

Maintain HOB of mechanically Maintain HOB of mechanically ventilated patients > 30 degrees ventilated patients > 30 degrees unless contraindicatedunless contraindicated

Perform PROM exercises while in Perform PROM exercises while in bed rest andbed rest and

Phase 1Phase 1 Restricted to bed rest, can Restricted to bed rest, can progress to sitting on bed progress to sitting on bed and standingand standing

Phase 2Phase 2 Progress to transfer Progress to transfer training and walking training and walking assisted inside the assisted inside the roomroom

Phase 3Phase 3 Progressive walking Progressive walking

Phase 4Phase 4 Care of patient transferred Care of patient transferred out of ICU and planning for out of ICU and planning for dischargedischarge

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Progressive Progressive UPRIGHTUPRIGHT mobility process mobility process

Elevate the head of bed to 45 deg Elevate the head of bed to 45 deg (consider large abdomen)(consider large abdomen)

Elevate the HOB to 45 deg plus legs in Elevate the HOB to 45 deg plus legs in dependent position (partial chair)dependent position (partial chair)

Elevate HOB to 65 deg plus legs in full Elevate HOB to 65 deg plus legs in full dependent ( full chair position )dependent ( full chair position )

Sitting in bedside chair using a Sitting in bedside chair using a mechanical hoistmechanical hoist

Use a tilt table (optional)Use a tilt table (optional)

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Progressive upright mobility processProgressive 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 processProgressive upright mobility process

• Walk with assistance Walk with assistance

• Walk independentlyWalk independently

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Exclusion criteriaExclusion criteria

Cardiovascular instabilityCardiovascular instability– Hypotension SBP <90 mmHgHypotension SBP <90 mmHg

– Tachycardia HR >130 beats/ minTachycardia HR >130 beats/ min

– Unstable cardiac rhythmUnstable cardiac rhythm

– Two or more vasopressors / Two or more vasopressors / ionotrops or frequent upward ionotrops or frequent upward titrationtitration

Respiratory instabilityRespiratory instability– FiO2 > 0.60FiO2 > 0.60

– PEEP > +10 cm H2OPEEP > +10 cm H2O

– Resp rate >35 bpmResp rate >35 bpm

– Requirement of neuromuscular Requirement of neuromuscular blockadeblockade

– Pressure control ventilationPressure control ventilation

• Neurological instability• Acute brain injury•ICH / SAH•ICP monitoring•Intraventricular drain•Unstable SCI •Any new neurological deterioration

• Femoral sheath / arterial line• Balanced skeletal traction• Intra aortic balloon pumpIntra aortic balloon pump• Active bleedingActive bleeding

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Screening Algorithm

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Prolonged complete bed rest is rare and questioned Prolonged complete bed rest is rare and questioned

Early mobility can be considered for patientsEarly mobility can be considered for patients

– Deconditioned by >3 days of immobilityDeconditioned by >3 days of immobility

– Require orthostatic training to upright positioningRequire orthostatic training to upright positioning

– Ready to begin ventilator weaningReady to begin ventilator weaning

Check readiness for and progression of activity on each day / each shiftCheck readiness for and progression of activity on each day / each shift

Customizing the planCustomizing the plan

Incorporating in multi disciplinary roundsIncorporating in multi disciplinary rounds

Communicating the mobility plan to the concerned staff at the follow up Communicating the mobility plan to the concerned staff at the follow up wardswards

Early mobility processEarly mobility process

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Safety IssuesSafety Issues

Review medical backgroundReview medical background

Is their sufficient CV reserve?Is their sufficient CV reserve?

Discuss with team to evaluateDiscuss with team to evaluate

Are all other factors or conditions favorable?Are all other factors or conditions favorable?

Labs values ,Electrolytes etcLabs values ,Electrolytes etc

Review with teamReview with team

Select appropriate mode and intensity of mobilizationSelect appropriate mode and intensity of mobilization

Skiller K, et al Physiother Theroy Pract ,2003,;19(4):239-257Skiller K, et al Physiother Theroy Pract ,2003,;19(4):239-257

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Safety IssuesSafety Issues

Use a protocol that work well with other ICU interventions i.e. sedation, Use a protocol that work well with other ICU interventions i.e. sedation, weaning etc.weaning etc.

Dedicated trained team Dedicated trained team (Morris PE, et al 2008(Morris PE, et al 2008))

Physical therapist, nursing, respiratory therapist, Intensivist etc.Physical therapist, nursing, respiratory therapist, Intensivist etc.

Provide detailed patient information to all team membersProvide detailed patient information to all team members

Sort out any expected problems and precaution Sort out any expected problems and precaution

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Barriers to MobilityBarriers to MobilityStrategiesStrategies

SedationSedation– Use sedation protocols and goal directed sedationUse sedation protocols and goal directed sedation

Human & Technological ResourcesHuman & Technological ResourcesPersonnel Personnel

– Need for leadership and coordination Need for leadership and coordination

– Cross training of ICU staffCross training of ICU staff

– Time managementTime management

– Education and training of all staff involved for efficient fearless Education and training of all staff involved for efficient fearless efforteffort

Saftey,feasibilty,and potential benefits of mobilizationSaftey,feasibilty,and potential benefits of mobilization

Safe lifting and transfer techniques to prevent injuriesSafe lifting and transfer techniques to prevent injuries

Management of lines and tubesManagement of lines and tubes

Use of proper lifting equipmentsUse of proper lifting equipmentsManaging problems with obese patientsManaging problems with obese patients

Morris PE Crit Care Clin, Morris PE Crit Care Clin, 2007;23:1-202007;23:1-20

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Transferring patient to the unit with an early mobility protocol, significantly Transferring patient to the unit with an early mobility protocol, significantly increased the probability of ambulation ( p < .0001)increased the probability of ambulation ( p < .0001)

The increase in the ambulation was not explained by the improvement in The increase in the ambulation was not explained by the improvement in patient’s underlying pathophysiologypatient’s underlying pathophysiology

Thomsen GE, et al. CCM 2008;36;1119-1124Thomsen GE, et al. CCM 2008;36;1119-1124

Supports the importance of an Supports the importance of an ICU cultureICU culture

Change in ICU culture is important

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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 youThank you