Sturgeon Community Hospital Mobilization in the Intensive Care Unit 02 Sept 2015 Sturgeon Community Hospital Rehab Services

THE PLAN (TY FOR JOINING!): Introduction THE PLAN (TY FOR JOINING!): AHS Mentorship Program Running Simulations – Continued Education for the Department: Reviewing Code Blue Ventilator Settings & RRT Weaning Protocol at the SCH Mobilizing with arterial lines & CRRT Mobilization Guidelines in the ICU Progressing the PT role in an ICU setting

A new initiative available to any physical therapist in Alberta AHS Mentorship Program A new initiative available to any physical therapist in Alberta MENTOR ROLE Facilitate the development and achievement of goals in conjunction with the mentee; Assist in developing skills relevant to the practice area in question;

A new initiative available to any physical therapist in Alberta AHS Mentorship Program A new initiative available to any physical therapist in Alberta MENTOR ROLE Facilitate the development and achievement of goals in conjunction with the mentee; Assist in developing skills relevant to the practice area in question; MENTEE ROLE Develop goals to progress knowledge in your area; Utilize resources of the mentor to progress your professional development (e.g. networking, technical skills)

A new initiative available to any physical therapist in Alberta AHS Mentorship Program A new initiative available to any physical therapist in Alberta BENEFITS OF PROGRAM: As a mentor: Feel good helping out the less experienced folk; Update knowledge to current standards; Improve standards of care for PT; Cross-site communication; As a mentee: Education in an area of your preference; Facilitation of professional goals; Networking & cross-site communication; Professional development;

A new initiative available to any physical therapist in Alberta AHS Mentorship Program A new initiative available to any physical therapist in Alberta BENEFITS OF PROGRAM: CONTACT INFORMATION: June Norris (E) june.norris@albertahealthservices.ca (P) 780-735-3481 As a mentor: Feel good helping out the less experienced folk; Update knowledge to current standards; Improve standards of care for PT; Cross-site communication; As a mentee: Education in an area of your preference; Facilitation of professional goals; Networking & cross-site communication; Professional development;

CODE BLUE Designate a leader Utilize your working surface Running Simulations: Continued Education for the Department CODE BLUE Designate a leader Utilize your working surface Closed loop instructions Appoint clear tasks

CODE BLUE Designate a leader Utilize your working surface Running Simulations: Continued Education for the Department CODE BLUE Designate a leader Utilize your working surface Closed loop instructions CPR Release Handle Appoint clear tasks Raise height for the level of the bagger Check on GOC Timekeeping Call a code blue (33#) Remove headboard and place under patient (prn) Assist with CPR Page the responsible physician Move the bed into an open position Gather additional equipment

CODE BLUE Applying O2 Communicating with the code team Relax! Running Simulations: Continued Education for the Department CODE BLUE Applying O2 Communicating with the code team Relax! 5LPM or less: More than 5LPM:

CODE BLUE Applying O2 Communicating with the code team Relax! Running Simulations: Continued Education for the Department CODE BLUE Applying O2 Communicating with the code team Relax! 5LPM or less: SBAR: 1) Situation 2) Background 3) Assessment 4) Recommendation Utilize nasal cannula More than 5LPM: Apply NRBM. RRTs will apply at 10LPM

PaO2 < 60mmHg on FiO2 > 50% PaCO2 > 50mmHg (norm: 35-45) Ventilator Settings: Indications PaO2 < 60mmHg on FiO2 > 50% PaCO2 > 50mmHg (norm: 35-45) pH < 7.20 (norm: 7.35-7.45) PaO2/FIO2 < 200 (norm: ~400) After major surgery Impending respiratory failure

Basic components of Ventilation Ventilator Settings: Basic Components Basic components of Ventilation • Respiratory rate (determined by ventilator or patient) • Tidal volume (determined with volume and pressure settings) PEEP (barotrauma can result with PEEP > ~12) FiO2 (0.2-1.0) (can be a measure of the severity of illness)

Ventilator Settings: PEEP -- Barotrauma A – shunt B - good C – dead space

All modes have set Fi02 and PEEP Ventilator Settings: Modes of Ventilation 3 Primary Types: Controlled All the work is done by the ventilator Patient has no control over any aspect Patient is normally heavily sedated and perhaps paralysed so as not to fight the ventilator Assisted Some spontaneous breathing Patient may initiate some breaths and assumes some WOB, how much depends on mode used. Assist-Control a mixture of both, synchronised but no spontaneous breathing – better tolerated All modes have set Fi02 and PEEP

Will deliver a set volume Does not take pressures into account Ventilator Settings: Modes of Ventilation Volume Controlled Pressure Controlled Assist-Controlled Will deliver a set rate Will deliver a set volume Does not take pressures into account Pressure will depend on resistance and compliance Will deliver a set rate Ventilator will deliver a breath until a preset pressure is reached. The volume delivered will depend on the resistance and compliance (note: high resistance will mean preset pressures are reached sooner, so volume may not be that big) Ventilation is preset, however the ventilator will attempt to synchronise with patients breathing if they are able. Patient can trigger extra breaths but variables remains the same If patient does not take a breath within preset time period, will take over control of breathing rate/volume at preset RR.

No preset rate or volumes Patient initiates all breaths Ventilator Settings: Modes of Ventilation Pressure Support SIMV/MMV No preset rate or volumes Patient initiates all breaths Ventilator augments breath with a top of pressure Patient does all the WOB to initiate but is supported with breath and or top up No set rate if patient stops breathing TV received is dependent on patient effort and amount of support, ie if patient takes a deep breath, will get large volume Synchronised Intermittent Mandatory Ventilation Like Assist control: Will give mandatory breaths at a preset rate and volume If patient is initiating breaths, will assist those breaths with pressure support and synchronise the machine breaths with the patient breaths (Mandatory breaths delivered when patients own breaths not reaching preset minute volume)

Ventilator Settings: Identifying Settings on the Ventilator

Ventilator Settings: Weaning Protocol

Ventilator Settings: Weaning Protocol

FEMORAL CENTRAL VENOUS BRACHIAL & RADIAL ARTERIAL DIALYSIS CATHETERS Mobilizing with arterial lines & CRRT: Types of catheters FEMORAL ARTERIAL & FEMORAL CENTRAL VENOUS BRACHIAL & RADIAL ARTERIAL DIALYSIS CATHETERS Used when access to the brachial or radial arteries is difficult, or if on higher doses of vasopressors or inotropes. Most common type seen in an ICU. Easy to monitor. BP may be inaccurate in higher doses of vasopressors/inotropes. Commonly inserted in either internal jugular or sub-clavian veins, with occasional access through femoral vein.

MOBILITY ASSESSMENT (GUIDELINES) Mobilizing with arterial lines & CRRT: Pre-screening, assessment MOBILITY ASSESSMENT (GUIDELINES) Pre-screening (must be done prior to mobilizing): Current vitals, time of ax, status of patient (e.g. RASS/GCS, mobility score, compliance) Environment & hazards; Visual assessment of lines & tubes, Assessment of arterial line site to ensure the line is secure and not at risk of being pulled out; Chest/respiratory assessment of reserve (e.g. SOB, WOB, level of oxygen needs/ventilation settings)

MOBILITY ASSESSMENT (GUIDELINES) Mobilizing with arterial lines & CRRT: Pre-screening, assessment MOBILITY ASSESSMENT (GUIDELINES) Pre-screening (must be done prior to mobilizing): Physical screening (must be done prior to disconnecting from monitor): Current vitals, time of ax, status of patient (e.g. RASS/GCS, mobility score, compliance), and current BP/heart meds Environment & hazards; Visual assessment of lines & tubes, Assessment of arterial line site to ensure the line is secure and not at risk of being pulled out; Chest/respiratory assessment of reserve (e.g. SOB, WOB, level of oxygen needs/ventilation settings) UE/LE strength/ROM/tone screen in bed Monitor BP & vitals during: Bed mobility (rolling/turning, sitting at EOB/dangle) Bed-side exercises: STS Marching on the spot x 20 steps Mini-squats x 5 Trunk control in sitting/standing Balance in sitting/standing (static & dynamic, with and/or without gait aid)

If after a pre-screen and physical screen of the patient you find: Mobilizing with arterial lines & CRRT: Guidelines for ambulation If after a pre-screen and physical screen of the patient you find: Stable BP & MAP: 90mmHg < SBP < 200mmHg and DBP < 110mmHg 55mmHg < MAP < 110mmHg (soft) Stable HR: 40 bpm < HR < 150bpm Low or no dosage of vasopressors/inotropes Arterial line is well secured No clinical s/s apparent with the patient

Mobilizing with arterial lines & CRRT: Guidelines for ambulation If after a pre-screen and physical screen of the patient you find: Stable BP & MAP: 90mmHg < SBP < 200mmHg and DBP < 110mmHg 55mmHg < MAP < 110mmHg (soft) Stable HR: 40 bpm < HR < 150bpm Low or no dosage of vasopressors/inotropes Arterial line is well secured No clinical s/s apparent with the patient AMBULATE

Mobilization Guidelines for the ICU: Present & Future CURRENT (SCH): Arterial lines must be monitored at all times during mobilization, regardless of type, or reason for usage (e.g. collection of blood gasses vs real-time BP measurement); FUTURE (PLAN): Currently, other sites do not require monitoring of radial & brachial art lines, and may mobilize these patients under similar screening assessments. A set of guidelines were drafted based off of our old guidelines and a literature review. These will be presented in the ICU meeting between intensivists, nursing, and allied health. Concerns regarding kinking/breaking the catheter, accidental loss of access, line pulled, increased occlusion/thrombosis formation, and vessel injury / pseudoaneurysm are unsubstantianted in literature. Further concerns include patient stability, which may be demonstrated through a proper physical screening. Thousands of mobility trials have been carried out safely and without adverse events.

A SPECIAL THANKS TO Jody Prohar PT Team Lead, SCH Treena Hinse Danke schoen! A SPECIAL THANKS TO Jody Prohar PT Team Lead, SCH Treena Hinse Allied Health Manager, SCH William Tung Professional Practice Lead, RAH June Norris Senior Practice Lead, Edmonton

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