Mobilising the Critically Ill, an emerging Concept Shaju Kareem Hassan Senior Physiotherapist Dubai Hospital International Partner, American Physical Therapy Association

New technologies in critical care and mechanical ventilation leads to long term survival of critically ill patients and a dramatic increase in the number of ventilator dependent patients Recently there is being an increased interest in early rehabilitation of the critically ill patient. The recent articles published demonstrates the effectiveness of early rehab efforts in the short and long term functional outcome.

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

Implementation of early rehabilitation programme is associated with Minimizing complication of bed rest Facilitating the weaning from ventillatory support Reduced ICU length of stay Reduced hospital length of stay Promoting improved function Improving patients quality of life Cost saving No adverse outcomes Morris PE, et al. Crit Care Med, 2008;36:2238-2243

Immobility associated complication Respiratory Decreased respiratory motion Abdomen influence on the diaphragm motion Increased depended edema Fluid accumulation in the dependent region / compression atelectasis Impaired ability to clear the tracheo bronchial secretions Increased risk of atelectasis and development of ventilator associated pneumonia Increased risk of pulmonary embolism Weak respiratory muscles due to prolonged mechanical ventilation

Skeletal muscle deconditioning Skeletal muscle strength reduces 20% every week of bed rest. Weak muscles generate an increased oxygen demand. Healthy individuals on 5 days of strict bed rest develop insulin resistance and microvascular dysfunction Rapid muscle atrophy Primary: bed rest, limb casting Secondary to critically illness polyneuropathy and critical illness myopathy Muscle groups that lose strength most quickly are those that maintain posture, and ambulation One day of bed rest requires two weeks of reconditioning to restore baseline muscle strength Topp R et al. Am J of Crit Care, 2002;13(2):263 263-76 Candow DG, Chilibick PD. Differences in size, strength, & power of upper & lower body muscle groups in young & older men. J Gerontol Gerontol, 2005:60A:148 , 148-155 Homburg NM,. Arterioscler Thrombo Vasc Biol Biol, 2007;27(12):2650 , 2650-2656

Critical Illness Neuromyopathy Critical illness polyneuropathy (CIP) Critical Illness myopathy (CIM) Hypotension Microthrombi Endoneural edema Mitochondrial dysfunction Factors that decrease the availability of nutrients Sepsis Administration of corticosteroids Elevated resting metabolism Increased protein degradation Two hit hypothesis

Immobility associated complication Cardiovascular Reduced stroke volume and Cardiac output, heart muscle atrophy, increased heart rate, Hypovolemia, Orthostatic hypotension Deep vein thrombosis Other musculoskeletal problems Bone demineralization Joint contractures Endocrine Hyperglycemia Insuline resistance Skin Decubitus ulcers Psychosocial Depression Decreased functional capacity Gastrointestinal constipation Renal Renal calculi Urinary stasis The elderly are more vulnerable

Immobility = deconditioning Multiple changes in the organ system physiology that are induced by inactivity are reversed by activity ( Siebens H, et al, J Am Geriatr Soc 2000;48:1545-52)

Acute care rehabilitation Upper extremity muscle strength correlates with early weaning and extubations Martin et al,Crit Care Med 2005;33:2259 -2265 Elderly patients responded well with physical therapy programmes including strengthening exercises , ambulation and functional training.

Can we safely mobilize and ambulate mechanically intubated patients ?

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

Early Activity is safe & feasible in mechanically intubated patient Results Activity 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

3 Main criteria for early activity initiation “Early” -- time period beginning after initial physiological stabilization Neurologic (responding to verbal stimulus), Respiratory (FiO2 < 60% & PEEP < 10cm of H2O) Circulatory (absence of orthostatic hypotension and ionotrops drips) Thomsen GE, et al. CCM 2008;36;1119-1124

Step by step mobility process The ultimate goal is to promote maximum level of independence before hospital discharge. For patient’s not actively participating Maintain HOB of mechanically ventilated patients > 30 degrees unless contraindicated Perform PROM exercises while in bed rest and Phase 1 Restricted to bed rest, can progress to sitting on bed and standing Phase 2 Progress to transfer training and walking assisted inside the room Phase 3 Progressive walking Phase 4 Care of patient transferred out of ICU and planning for discharge

Progressive UPRIGHT mobility process Elevate the head of bed to 45 deg (consider large abdomen) Elevate the HOB to 45 deg plus legs in dependent position (partial chair) Elevate HOB to 65 deg plus legs in full dependent ( full chair position ) Sitting in bedside chair using a mechanical hoist Use a tilt table (optional)

Progressive 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

Progressive upright mobility process Walk with assistance Walk independently

Exclusion criteria Cardiovascular instability Respiratory instability Hypotension SBP <90 mmHg Tachycardia HR >130 beats/ min Unstable cardiac rhythm Two or more vasopressors / ionotrops or frequent upward titration Respiratory instability FiO2 > 0.60 PEEP > +10 cm H2O Resp rate >35 bpm Requirement of neuromuscular blockade Pressure 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 pump Active bleeding

Screening Algorithm

Early mobility process Prolonged complete bed rest is rare and questioned Early mobility can be considered for patients Deconditioned by >3 days of immobility Require orthostatic training to upright positioning Ready to begin ventilator weaning Check readiness for and progression of activity on each day / each shift Customizing the plan Incorporating in multi disciplinary rounds Communicating the mobility plan to the concerned staff at the follow up wards

Skiller K, et al Physiother Theroy Pract ,2003,;19(4):239-257 Safety Issues Review medical background Is their sufficient CV reserve? Discuss with team to evaluate Are all other factors or conditions favorable? Labs values ,Electrolytes etc Review with team Select appropriate mode and intensity of mobilization Skiller K, et al Physiother Theroy Pract ,2003,;19(4):239-257

Safety Issues Use a protocol that work well with other ICU interventions i.e. sedation, weaning etc. Dedicated trained team (Morris PE, et al 2008) Physical therapist, nursing, respiratory therapist, Intensivist etc. Provide detailed patient information to all team members Sort out any expected problems and precaution

Barriers to Mobility Strategies Sedation Use sedation protocols and goal directed sedation Human & Technological Resources Personnel Need for leadership and coordination Cross training of ICU staff Time management Education and training of all staff involved for efficient fearless effort Saftey,feasibilty,and potential benefits of mobilization Safe lifting and transfer techniques to prevent injuries Management of lines and tubes Use of proper lifting equipments Managing problems with obese patients Morris PE Crit Care Clin, 2007;23:1-20

Change in ICU culture is important Transferring patient to the unit with an early mobility protocol, significantly increased the probability of ambulation ( p < .0001) The increase in the ambulation was not explained by the improvement in patient’s underlying pathophysiology Thomsen GE, et al. CCM 2008;36;1119-1124 Supports the importance of an ICU culture

All hospitalized patients should have a detailed and specific activity program initiated on admission and followed up Getting Them Moving Makes a Difference

Thank you