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

2. 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

3. 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;

4. 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)

5. 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;

6. 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)
(P)
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;

7. 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

8. 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

9. 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:

10. 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

11. 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: )
PaO2/FIO2 < 200 (norm: ~400)
After major surgery
Impending respiratory failure

12. 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 ( )
(can be a measure of the severity of illness)

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

14. 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

15. 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.

16. 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)

17. Ventilator Settings: Identifying Settings on the Ventilator

18. Ventilator Settings: Weaning Protocol

19. Ventilator Settings: Weaning Protocol

20. 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.

21. 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)

22. 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)

23. 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

24. 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

25. 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.

26. 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

27. Resources
G DRIVE