Mobilisation in the ICU

Ronel Roos (PhD)University of the Witwatersrand,

School of Therapeutic Sciences,

Department of Physiotherapy

What is meant by ‘mobilisation’?“Mobilisation refers to physical activity sufficient to elicit acute physiological effects that enhance ventilation, central and peripheral perfusion, circulation, muscle metabolism and alertness and are countermeasures for venous stasis and deep vein thrombosis”

(Gosselink et al., 2008)

‘Early mobilisation’ implies that mobilisation activities start immediately after physiological stabilisation of the patient.

(Korupolu et al., 2009)

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Aims of early mobilisationThe aims of early mobilisation in the ICU is to maintain or enhance:

• Patient’s joint range of motion

• Patient’s muscle strength

• Patient’s physical function

• Oxygenation and lung volumes

• Improve sputum clearance

• Influence health-related quality of life(Korupolu et al., 2009; Stiller and Phillips, 2003)

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Contextual background • Critical illness has many devastating consequences including

profound neuromuscular weakness, psychological and cognitive disturbances that may result in long-term functional impairments and reduction in quality of life (Jackson et al., 2014; Fan et al., 2014; Herridge et al.,

2011; Cuthbertson et al., 2010;).

• Poor muscle strength negatively influences patients’ mortality rates, time on ventilation, ICU and hospital length of stay (Cottereau et al., 2015;

Lee et al., 2012; Ali et al., 2008)

• Loss of cross-sectional area in rectus femoral muscle: 10.3% by day 7 and 17.7% by day 10 (Putchucheary et al., 2013)

• ICU-acquired weakness is independently associated with post-ICU mortality and poorer functional outcomes (Wieske et al., 2015)

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Contextual background… • Common symptoms experienced by critical care

survivors: weakness, fatigue, disturbed sleep, painand shortness of breath (Choi et al., 2014)

• Challenges identified in caregivers of critical care survivors include fatigue and depression (Choi et al., 2014;

Choi et al., 2012)

• Initiating early mobilisation in ICU might be a potential strategy for influencing some of the impairments present in survivors of critical care and lessening strain on patients and caregivers later on.

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Patient’s view"Then I had to try to get up with a walker and I just couldn’t. I couldn’t even hold my head. I wasn’t able to do anything.“ (67 year

old male)

"You know what, I don’t want to go home and have my wife help me get to bed and help me go to the bathroom — and if I fall — I just don’t want to be a burden to her. That’s it! When I can walk again it will be different.“ (64 year old male)

"In the beginning when I came home and wanted to go upstairs, I sat on my behind and went up and down the stairs. It took a while before I could get around.“ (45 year old female)

(Agard et al., 2012)

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Benefits of early mobilisation

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• Systematic review reviewing early mobilisation in the ICU programmes

• 15 studies included in review

• Findings

o Improvement in peripheral and respiratory muscle strength

o Improvement in physical function e.g. out-of-bed activities

o Reduction in shortness of breath experienced

o Improvement in QOL by hospital discharge(Adler and Malone, 2012)

Benefits of early mobilisation…

• Shorter duration of delirium and more ventilator free days (Schweickert et al., 2009)

• ICU and hospital length of stay shorter (Morris et al., 2008)

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(Korupolu et al., 2009)

Barriers• Inadequate staffing numbers

• Not enough time

• Lack of equipment

• Concerns regarding patient safety and stability

• Fear of dislodging lines

• Sedation practices

• Inadequate pain management

• Poor identification of delirium

• Risk of self-injury and elevated work stress(Jolley et al., 2014; Hodgson et al., 2013)

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Facilitators• Creating an early mobilisation culture among staff in the ICU (Mendez-

Tellez et al., 2012; Bailey et al., 2007).

• Physiotherapy evidenced-based protocol care (Hanekom, Louw and Coetzee,

2012).

• Early mobility programme lead by nursing staff “Move to improve” (Drolet et al., 2013).

• The Awakening and Breathing Coordination, Delirium monitoring/management and Early exercise/mobility (ABCDE) bundle is an evidence-based, inter-professional, multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation and managing intensive care unit (ICU) acquired delirium and weakness (Balas et al., 2013).

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Methods of implementing early mobilisation in ICU

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Equipment• Standing hoist or tilt table

• Rolling IV poles with infusion pumps

• Rolling walking (rollator) frames

• Wheelchairs

• Portable ventilator or traditional ventilator on battery power

• Cardiac monitor and pulse oxymeter

• Ambubag with PEEP valve and O2 cylinder

• Neuromuscular electrical stimulation

• Passive cycling/Cycle Ergometry

• Inspiratory Muscle Trainer Device(Mendez-Tellez et al 2012; Gosselink et al., 2011)

Passive and active cycling (Gosselink et al., 2011)

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Mobility aids to promote walking

Custom-made walking frame (Hodgson et al., 2013)

Custom-made walking frame (Drolet et al., 2013)

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Functional activities

Standing hoist https://www.youtube.com

Balance in sitting http://physical-

therapy.advanceweb.com/Archives/Article-Archives/Early-Mobilization.aspx

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Physiotherapy in ICU(Lottering and Van Aswegen, under review)

Physiotherapy Technique Never Almost Never Sometimes Fairly Often Very Often

Manual chest clearance techniques (percussions, vibrations, shaking) 2 0 1 4 101

Postural drainage/modified postural drainage 2 2 12 25 67

Airway suctioning 1 0 2 16 89

Manual hyperinflation (ambubagging) 14 26 33 20 15

Intermittent positive pressure breathing (IPPB) 27 19 28 21 13

Incentive spirometery 19 7 24 21 37

Active cycle of breathing techniques 5 6 15 26 56

Inspiratory muscle training (threshold device/ devices by other manufacturers) 31 23 23 15 16

Flutter device 46 31 17 11 3

Blow bottle 20 11 16 30 31

Blowing up a glove 33 6 31 18 20

Deep breathing exercises 2 0 2 21 83

Nebulization 2 4 7 43 52

Mobilizing a patient in bed 0 1 0 16 91

Mobilizing a patient out of bed 0 2 6 16 84

Positioning a patient in bed 0 0 5 12 91

Positioning a patient out of bed 0 3 8 18 79

Peripheral muscle strengthening exercises 2 0 5 29 72

Adjustment of mechanical ventilation settings for respiratory muscle training 53 23 15 13 4

Active involvement in weaning a patient from mechanical ventilation 39 24 16 16 13

Implementation and supervision of non-invasive ventilator support (CPAP,

BiPAP)*55 22 13 15 3

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Safety recommendations

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Is early mobilisation in ICU safe?• Yes - very few untoward events occur < 4%

(Adler and Malone, 2012)

Examples of untoward events included:o Desaturation < 88% (but patients responded to increasing FiO2)

o Removal of nasogastric tube (n=1), radial arterial line (n=1)

o Heart rate increases more than 20% from baseline

o Respiratory rate increases above 40 breaths per minute

• Safety can be ensured byo Careful patient screening

o Trained staff who carefully evaluate patients’ physiological changes during graded mobilisation.

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Safety recommendations

Reference Categories

Hodgson et al. (2014) In-bed or out-of-bed activities/ potential for risk

Hanekom et al. (2011) Three categories: unconscious, awake, deconditioned patient

Gosselink et al. (2011) Five levels dependent on cooperation

Korupolu et al. (2009) Intrinsic factors

Perme et al. (2009) Four phases

Stiller and Phillips (2003) Medical background and intrinsic factors

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Start to Move protocol – Gosselink et al 2011 Neth J Crit Care 15 (2)

When to discontinue activity?(Adler and Malone, 2012)

Conclusion• Early mobilisation should form part of the every

patient’s ICU care plan and is essential for improving patient outcome after ICU discharge.

• Overcome perceived barriers by addressing

o Unit specific barriers

o Multidisciplinary team related barriers

o Patient related barriers

• Don’t forget critical care survivors following

discharge.

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