Mobilization in the Critical Care Unit

(How It Works)

Craig Moreland, PT, MSDirector of Physical Therapy, UPMC

Presbyterian, Montefiore, and Western Psychiatric Institute & Clinic

Annual PM&R Assembly

The Physical Therapist’s Role in the ICU

• 3 main goals:1.Optimize oxygen transport and the

function of its supporting systems2.Reduce multi-system complications3.Maximize functional recovery

and minimize diffuse atrophy

What we, as therapists, need to know…

• Basic cardiopulmonary pathophysiology• Complications of bedrest and physiologic

change associated with deconditioning• Common ICU medications• Emergency procedures• Role of the other ICU team members• All monitoring equipment• Ventilator and respiratory equipment

The Physical Therapist Evaluation

• Previous Level of Function• Mental Status• Time of DIS (Daily Interruption of

Sedation)• Assessment of Lines, Tubes,

and Drains

What We Need to Coordinate to Set Us Up to

Succeed!• Timing is Everything!!Medications (pain, anxiety)Sedation InterruptionWeaning TrialsRespiratory TherapyOccupational TherapyNursing

~The Mobility Team~• Physician• Nursing Staff• Pharmacist• Occupational Therapist• Speech Therapist • Physical Therapist• Respiratory Therapist• Rehabilitation Aides

The Action! What Can We Do?

• Positioning• Postural Drainage• Cough Assist• Splinting• Exercise • Transfer, ADL, and Balance Training• Ambulation• Education (invaluable)

Therapy ICU Intervention:

Positioning and Postural Drainage: Position the patient for respiratory success (eg. Anterior vs. Posterior Pelvic Tilt)Postural drainage is accomplished by positioning the patient so that the position of the lung segment to be drained allows gravity to have its greatest effectWe to remember to write signs in the patient’s rooms to increase communication…

Patient is in semi-left-sidelying to drain the right middle lobe for 30-45 minutes for optimal respiratory mobilization; patient positioned at 10:30am

Therapy ICU Intervention

Exercise:Get Family InvolvedEducate NursingStrengthen Respiratory Musculature

Primary: Diaphragm, IntercostalsAccessory: Sternocleidomastoid,

Scalene

Therapy ICU Intervention

Cough Assist:Asthma Patient:

~teach a “pump cough”~a forceful prolonged exhalation can lead to distress

COPD Patient:~difficulty with expiration~do not teach “take a deep breath”~controlled small breaths

Neuromuscular Paralysis:~maximize airway clearance~make sure the patient can swallow safely~position for success, couple extension & inhalation, couple flexion &

exhalation

Therapy ICU Intervention

Prior to initiating our mobility project, we needed to train all staff in…•Body Mechanics•Proper Lifting•Safety with Functional Transfers•Proper Guarding Techniques

Therapy ICU Intervention

Transfer and Balance Training:Monitor the Ventilator and Vital SignsBlood Pressure with Change in PositionTransfers are the mainstay of our ICU treatment sessionsWho is doing what to ensure safety???ONE PERSON IN CHARGEWe always try incorporate quality of life into our treatment sessions!!

Safe Mobilization with Multiple Lines, Tubes, and

DrainsArterial Line EVD

Central Line IABP

Chest Tube Licox Monitor

Dialysis Catheter Sheath

ECMO Swan-Ganz Catheter

Who Does What?

• Setting Up the Room• Scanning the Lines, Tubes,

Drains• Scanning the Ventilator• Inspecting the Patient• Who Holds What Line?• What is each healthcare worker’s

role?

Therapy ICU Intervention

Ambulation is Our Ultimate Goal!!•Preparation•Multi-disciplinary Approach•Portable Ventilator Available?Education is Invaluable!!•Patient, Family Member, Health Care Team

Therapy ICU InterventionWhat Equipment will the mobility team need?Ventilator, Ambu Bag, or Portable OxygenPortable Monitor or Pulse OximeterIV poleLines, tubes, drainsAssistive Devices Chairs

When Does the Therapist Modify Activity???

1. FiO2 greater than 60%2. PEEP greater than 10 cm H20 pressure3. Consistent O2 Saturations less than 92%4. Hx of desaturations with positional changes5. Unstable Blood Pressure6. Severe Acidosis with pH less than 7.30~~~While many of these may not be absolute

contraindications to mobilization, they should be cause to stop and discuss with the medical and nursing team prior to continuing~~~

Just Remember…

~~~The most important skill for a therapist to

develop in the Critical Care Unit is to recognize when to initiate, delay, progress, and

terminate treatment~~~