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Mobilising the Critically Ill, an emergingMobilising the Critically Ill, an emerging

ConceptConcept

Shaju Kareem HassanShaju Kareem HassanSenior Physiotherapist Senior Physiotherapist

Dubai Hospital Dubai Hospital

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



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New technologies in critical careNew technologies in critical care

and mechanical ventilation leadsand mechanical ventilation leadsto long term survival of critically illto long term survival of critically illpatients and a dramatic increasepatients and a dramatic increasein the number of ventilator in the number of ventilator dependent patientsdependent patients

Recently there is being anRecently there is being anincreased interest in earlyincreased interest in earlyrehabilitation of the critically illrehabilitation of the critically illpatient.patient.

The recent articles publishedThe recent articles publisheddemonstrates the effectiveness of demonstrates the effectiveness of early rehab efforts in the short andearly rehab efforts in the short andlong term functional outcome.long term functional outcome.



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In ICU, patients are frequently exposed toprolonged immobilization

ICU acquired neuromuscular complicationare common, debilitating and long lasting.

Contribution of bed rest to the developmentof ICU acquired weakness is associatedwith

± 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 isImplementation of early rehabilitation programme isassociated withassociated with

Minimizing complication of bed restMinimizing complication of bed rest

Facilitating the weaning from ventillatory supportFacilitating the weaning from ventillatory support

Reduced ICU length of stayReduced ICU length of stay

Reduced hospital length of stayReduced hospital length of stay

Promoting improved functionPromoting improved function

Improving patients quality of lifeImproving patients quality of life

Cost savingCost saving

No adverse outcomesNo adverse outcomes

Morris PE, et al.Morris PE, et al. C rit C are Med C rit C are Med , 2008;36:2238, 2008;36:2238--22432243



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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 / compressionFluid accumulation in the dependent region / compressionatelectasisatelectasis

±± Impaired ability to clear the tracheo bronchialImpaired ability to clear the tracheo bronchialsecretionssecretions

±± 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 prolongedWeak respiratory muscles due to prolongedmechanical ventilationmechanical ventilation



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Skeletal muscle deconditioningSkeletal muscle deconditioning

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

Healthy individuals on 5 days of strict bed rest develop insulin resistance andHealthy individuals on 5 days of strict bed rest develop insulin resistance andmicrovascular dysfunctionmicrovascular dysfunction

Rapid muscle atrophyRapid muscle atrophy±± Primary: bed rest, limb castingPrimary: bed rest, limb casting

±± Secondary to critically illness polyneuropathy and critical illnessSecondary to critically illness polyneuropathy and critical illnessmyopathymyopathy

Muscle groups that lose strength most quickly are those that maintainMuscle groups that lose strength most quickly are those that maintainposture, and ambulationposture, and ambulation

One day of bed rest requires two weeks of reconditioning to restore baselineOne day of bed rest requires two weeks of reconditioning to restore baselinemuscle strengthmuscle strength

Topp R et al. Am J of Crit Care, 2002;13(2):263 263Topp R et al. Am J of Crit Care, 2002;13(2):263 263--7676

Candow 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 2005:60A:148 , 148--155 155

Homburg NM,. Arterioscler Thrombo Vasc Biol Biol, 2007;27(12):2650 , 2650Homburg NM,. Arterioscler Thrombo Vasc Biol Biol, 2007;27(12):2650 , 2650--26562656



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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 availabilityFactors 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

Cardiovascular Cardiovascular

± Reduced stroke volumeand Cardiac output, heartmuscle atrophy, increasedheart rate, Hypovolemia,

±± Orthostatic hypotensionOrthostatic hypotension±± Deep vein thrombosisDeep vein thrombosis

Other musculoskeletalOther musculoskeletalproblemsproblems

±± Bone demineralizationBone demineralization

±± Joint contracturesJoint contractures

EndocrineEndocrine

±± HyperglycemiaHyperglycemia

±± Insuline resistanceInsuline resistance

SkinSkin

±± Decubitus ulcersDecubitus ulcersPsychosocialPsychosocial

±± DepressionDepression

±± Decreased functionalDecreased functionalcapacitycapacity

GastrointestinalGastrointestinal

±± constipationconstipationRenalRenal±± 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 areMultiple 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 AmJ Am Geriatr Soc 2000;48:1545Geriatr Soc 2000;48:1545--5252))



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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 Martin et al,Crit Care Med 2005;33:2259 --22652265

Elderly patients responded well with physical therapy programmesElderly patients responded well with physical therapy programmes

including strengthening exercises , ambulation and functionalincluding 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 ambulateCan we safely mobilize and ambulatemechanically 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 eventsActivity 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

³³Early´Early´ ---- time period beginning after initial physiological stabilizationtime 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)

CirculatoryCirculatory

±± (absence of orthostatic hypotension and ionotrops drips)(absence of orthostatic hypotension and ionotrops drips)

Thomsen GE, et al. CCM 2008;36;1119Thomsen GE, et al. CCM 2008;36;1119--11241124



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Step by step mobility processStep by step mobility process

T he ultimate goal T he ultimate goal is to promoteis to promote

maximum level of independencemaximum level of independence

before hospital discharge.before hospital discharge.

For patient¶s not actively participatingFor patient¶s not actively participating

Maintain HOB of mechanicallyMaintain HOB of mechanically

ventilated patients > 30 degreesventilated patients > 30 degrees

unless contraindicatedunless contraindicated

Perform PROM exercises while inPerform PROM exercises while in

bed rest andbed rest and

Phase 1Phase 1 Restricted to bed rest, canRestricted to bed rest, can

progress to sitting on bedprogress to sitting on bed

and standingand standing

Phase 2Phase 2 Progress to transfer Progress to transfer

training and walkingtraining and walking

assisted inside theassisted inside the

roomroom

Phase 3Phase 3 Progressive walkingProgressive walking

Phase 4Phase 4 Care of patient transferredCare of patient transferred

out of ICU and planning for out of ICU and planning for

dischargedischarge



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Progressive UPRIGHT mobility processProgressive UPRIGHT mobility process

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

Elevate the HOB to 45 deg plus legs inElevate the HOB to 45 deg plus legs in

dependent position (partial chair )dependent position (partial chair )

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

Sitting in bedside chair using aSitting 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 withassistance (sitting at the edge

of bed )

Stand patient at bedside withsupport once able to lift the legagainst 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 assistanceWalk 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 upwardionotrops or frequent upwardtitrationtitration

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 questionedProlonged 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 upCommunicating 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):239Skiller K, et al Physiother Theroy Pract ,2003,;19(4):239--257257



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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 teamDedicated 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 precautionSort out any expected problems and precaution



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Barriers to MobilityBarriers to Mobility

StrategiesStrategies

SedationSedation

±± Use sedation protocols and goal directed sedationUse sedation protocols and goal directed sedation

Human & Technological ResourcesHuman & Technological Resources

PersonnelPersonnel

±± Need for leadership and coordinationNeed for leadership and coordination

±± Cross training of ICU staff Cross training of ICU staff

±± Time managementTime management

±± Education and training of all staff involved for efficient fearlessEducation 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 equipments

Managing problems with obese patientsManaging problems with obese patients

Morris PE Crit Care Clin 2007 23:1Morris PE Crit Care Clin 2007 23:1--2020



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Transferring patient to the unit with an early mobility protocol, significantlyTransferring 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 inThe 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;1119Thomsen GE, et al. CCM 2008;36;1119--11241124

Supports the importance of anSupports 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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T hank youT hank you

shaju kareem

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