Early Mobility in the ICU Peter Hurh, MD Assistant Professor University of Pittsburgh Medical Center Medical Director UPMC Rehabilitation Institute at East

I have no conflicts of interest to report I have no conflicts of interest to report. I do not endorse any products that may be pictured in any photos.

Objectives Understand the complications secondary to immobility in the ICU. Understand short-term and long-term effects of critical illness and immobility. Understand that therapy in the ICU is safe, feasible, and effective. Reword, expand

NG tube, probably foley catheter, rectal trumpet, dialysis catheters, intubated or trach, PEG, blood pressure cuff, IV bags, central lines, peripheral lines, continuous monitors, laying supine all day

Metabolic Cardiovascular Psychological Pulmonary Dermatological Renal Gastrointestinal NG tube, probably foley catheter, rectal trumpet, dialysis catheters, intubated or trach, PEG, blood pressure cuff, IV bags, central lines, peripheral lines, continuous monitors, laying supine all day Genitourinary Musculoskeletal

Adverse Effects of Immobility Cardiovascular Decreased cardiopulmonary function Decreased cardiac output Reduced venous return Decreased stroke volume Postural hypotension Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://exercisephysiologist.files.wordpress.com/2012/02/cardiovascular_system2.jpg Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

Adverse Effects of Immobility Cardiovascular Atelectasis Hypostatic pneumonia Intubation Tracheostomy Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://static-img-a.hgcdn.net/Media/_640x360/HG201_lungs-emphysema-chronic-pulmonary_FS.jpg Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

Adverse Effects of Immobility Cardiovascular Decreased appetite/ poor nutrition Constipation PEG tube Rectal trumpet Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://www.dasilvainstitute.com/wp-content/uploads/2014/01/Gastrointestinal-Disorders.jpg Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

Adverse Effects of Immobility Cardiovascular Urinary stasis Stone formation Infection Foley catheter Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://ce.pharmacy.wisc.edu/images_webpages/UrinaryTract33673135.jpg Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

Adverse Effects of Immobility Cardiovascular Disuse muscle atrophy Joint contractures Heterotopic ossification Decreased strength and endurance Impaired balance Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://cdn.mindnutrition.com/images/articles/how-not-to-get-old-part-iii-musculoskeletal-system.png Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

Adverse Effects of Immobility Cardiovascular Pressure ulcers Infection Pain Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://www.spinal-injury.net/spinal-injury-network/images/progression-pressure-sore.jpg Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

Adverse Effects of Immobility Cardiovascular Sensory deprivation Disorientation and confusion Depression and anxiety Delirium Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://www.jhartfound.org/blog/wp-content/upLoads/2013/09/TS177524905_delirium350.jpg Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

Adverse Effects of Immobility Cardiovascular Insulin resistance Decreased muscle protein synthesis Myosin changes from slow to fast twitch fibers Change from fatty acid to less efficient glucose metabolism Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological http://runnernurse.com/?p=241 Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

ICU-Acquired Weakness Critical Illness Polyneuropathy Clinical findings Distal sensory and motor deficits, i.e. foot drop Normal deep tendon reflexes Electrodiagnostic findings Symmetric, sensorimotor, axonal polyneuropathy Decreased SNAP and CMAP amplitudes Reduced motor recruitment UPDATE WITH NEW ARTICLE Korupolu, Contemporary Critical Care, 2009 Hough, Clin Chest Med, 2006 Kress, N Engl J Med, 2014

ICU-Acquired Weakness Critical Illness Myopathy Clinical findings Proximal muscle weakness without sensory deficits Decreased deep tendon reflexes Electrodiagnostic findings Preserved SNAP amplitudes; decreased CMAP amplitudes; increased CMAP duration Small and short motor unit action potentials UPDATE WITH NEW ARTICLE Korupolu, Contemporary Critical Care, 2009 Hough, Clin Chest Med, 2006 Kress, N Engl J Med, 2014

ICU-Acquired Weakness Critical Illness Polyneuropathy and Myopathy Acquired neuromuscular disorder Difficult to differentiate in the ICU due to factors such as sedation and patient cooperation Coexist in critically ill patients

ICU-Acquired Cognitive Impairment Wilcox, Crit Care Med, 2013 Survivors of ARDS 11 studies, n = 487 At discharge: 70-100% of patients with cognitive impairments Most common deficits: attention, concentration, memory, executive function 1 year follow up: 46-78% 2 year follow up: 25-47%

ICU-Acquired Cognitive Impairment Wilcox, Crit Care Med, 2013 (con’t) Mixed populations of medical and surgical ICU patients At discharge: 39-51% with cognitive impairments 3-6 month follow up: 13-79% 12 month follow up: 10-71%

“As the population ages and mortality from critical illness declines, the number of ICU survivors is growing.” Needham, Arch Phys Med Rehabil, 2010

Herridge Trials

Herridge, N Engl J Med, 2003 Evaluated 109 survivors of ARDS 3, 6, and 12 months post-discharge from ICU Median age: 45 years Median duration of ICU admission: 25 days Physical exam, pulmonary function testing, six-minute walk test, quality-of-life evaluation QOL measures: physical functioning, social functioning, physical role, emotional role, mental health, pain, vitality, general health Margaret Herridge, Toronto General Hospital QOL measured with Medical Outcomes Study 36-item Short-Form General Health Survey, or the SF-36; 8 multiple-item scales that assess physical functioning, social functioning, physical role, emotional role, mental health, pain, vitality, general health.

Herridge, N Engl J Med, 2003 Global assessment At discharge, patients lost average of 18% of body weight All patients reported poor function due to loss of muscle bulk, proximal muscle weakness, and fatigue 12% had persistent pain at chest tube insertion sites at 1 year 7% had entrapment neuropathies 5% had large joint immobility due to heterotopic ossification 4% had contractured fingers or frozen shoulders

Herridge, N Engl J Med, 2003

Herridge, N Engl J Med, 2003

Herridge, N Engl J Med, 2003 Discussion Persistent functional limitation at one year mainly due to muscle wasting and weakness Multifactorial including corticosteroid-induced and critical-illness-associated myopathy Six-minute walk test and quality-of-life assessments are correlated Impaired muscle function -> compromised functional ability -> compromised quality of life Findings consistent with previous published reports

Herridge, N Engl J Med, 2003 Conclusion “…survivors of the acute respiratory distress syndrome continue to have functional limitations one year after their discharge from the ICU.” “…still do not know how long it takes for these patients to recover fully from their critical illness or whether complete recovery is possible in every case.”

Herridge, N Engl J Med, 2011 Continued follow up of same patients at 2, 3, 4, and 5 years after discharge from ICU

Herridge, N Engl J Med, 2011 Six minute walk test significant correlated with physical component score of the SF-36 at 3, 6, 12 month, 2, 3, 4, 5 years (p<0.01). PCS: physical-component score MCS: mental-component score Physical component of the SF-36 at 5 years remained ~1 SD below the mean score for age- and sex-matched control.

Herridge, N Engl J Med, 2011 Six minute walk test significant correlated with physical component score of the SF-36 at 3, 6, 12 month, 2, 3, 4, 5 years (p<0.01). PCS: physical-component score MCS: mental-component score Physical component of the SF-36 at 5 years remained ~1 SD below the mean score for age- and sex-matched control.

Herridge, N Engl J Med, 2011 Six minute walk test significant correlated with physical component score of the SF-36 at 3, 6, 12 month, 2, 3, 4, 5 years (p<0.01). PCS: physical-component score MCS: mental-component score Physical component of the SF-36 at 5 years remained ~1 SD below the mean score for age- and sex-matched control.

Herridge, N Engl J Med, 2011 Six minute walk test significant correlated with physical component score of the SF-36 at 3, 6, 12 month, 2, 3, 4, 5 years (p<0.01). PCS: physical-component score MCS: mental-component score Physical component of the SF-36 at 5 years remained ~1 SD below the mean score for age- and sex-matched control.

Herridge, N Engl J Med, 2011 Conclusions Persistent exercise limitations and reduced physical quality of life 5 years after critical illness Quality of life and exercise capacity may have resulted from combination of persistent weakness, and other physical and neuropsychological impairments Depression, anxiety, PTSD, agitation, family/caregiver mental health problems, social isolation, sexual dysfunction, job loss, dispute with insurance claims

“When we started our ICU in 1964, patients who required mechanical ventilation were awake and alert and often sitting in a chair…” “…what I see these days are paralyzed, sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise.” Petty T. Chest. 1998; 114(2): 361-363

Safety and Feasibility

Bailey, Crit Care Med, 2007 103 mechanically ventilated patients >4 days 1,449 activity events Sit on edge of bed, sit in chair, ambulation Adverse events Fall to knees, tube removal, systolic blood pressure >200mmHg or <90 mmHg, O2 sat <80%, extubation

Bailey, Crit Care Med, 2007 Total of 14 adverse events in 1449 activity events (0.96%) Fall to knees, orthostatic hypotension, O2 desaturation, nasal feeding tube removal, hypertension No adverse event resulted in extubation, complications requiring additional intervention, additional cost, longer hospital stay

Morris, Crit Care Med, 2008 280 mechanically ventilated patients 135 patients in control group, 145 patients in protocol Protocol initiated within 48 hours of mechanical ventilation Activity ranged from PROM, AAROM, AROM, sit edge of bed, transfers, standing, ambulation

Morris, Crit Care Med, 2008 No adverse events Deaths, near-deaths, cardiopulmonary resuscitation, removal of device No difference in numbers of arterial catheters, venous devices, need for re-intubation between control and protocol groups

Pohlman, Crit Care Med, 2010 49 mechanically ventilated patients 498 activity sessions Time from intubation to initial therapy = 1.5 days Adverse events in 16% of all sessions (80/498) Desaturation (6%), tachycardia (4.2%), tachypnea (4%), agitation/ discomfort (2%), device removal (0.8%) No serious consequences noted for any adverse event

Conclusion Immobility and critical illness can affect every organ system, leading to significant functional impairments. These impairments, both physical and psychological, can be long lasting. Early intervention in the ICU is safe and feasible, and may prove to prevent the risk of ICU-acquired impairments and disabilities.

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