1. Role of physiotherapists in ICU Care with bed ridden patients
Professor of Anaesthesia
MRI Alex. University
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2. Role of physiotherapist in ICU
They are responsible for providing patients with rehabilitation regimens.
Decrease incidence of complications.
Decrease ICU stay.
Decrease cost.

3. Objectives Risk factor for immobilisation in ICU
Disadvantages of immobility
Pressure sores in critically ill patients
Prevention of bed sores
Treatment of bed sores

4. Immobilisation and muscle weakness
The musculoskeletal system is designed to keep moving; it takes only seven days of bed rest to reduce muscle bulk by up to 30%.

5. Causes of immobilisation in ICU
Any serious problems:
Neurological deficit, and general debilitation and weakness.
Polyneuropathy or myopathy after the acute phase of multiple organ dysfunction.
Patients with severe congestive heart failure.
Respiratory faliure.
Myocardial infarction
Controlled ventilation and administration of sedative and neuromuscular blocking agents.

6. Disadvantages of immobility
Cardiovascular
Venous stasis
Increased risk of venous thrombosis
pulmonary embolism
Respiratory
Decreased functional residual capacity
Decreased lung compliance
Retained secretions
Atelectasis

7. Disadvantages of immobility
Metabolic
Increased excretion of nitrogen, calcium, potassium, magnesium, and phosphorus
Osteoporosis
Kidney stones
Gastrointestinal tract
Lack of digestion
constipation

8. Disadvantages of immobility
Musculoskeletal
Decrease in muscle bulk
Loss of bone density
Decreased range of joints movement
Pressure sores

9. Role of physiotherapists
Encourage active movement in the bed.
active assisted movement
passive movements (shoulders, hands, hips, and ankles ) to avoid contractures.

10. Bed sores
Patients do not move regularly develop pressure sores on dependent areas.
The most vulnerable areas are the tissues over bony prominences.
The cost to heal a single full-thickness pressure sore may be as high as 70,000 dollars.

11. Pathophysiology
Pressure is exerted on surface beneath ( pressure points).
These pressures are often in excess of capillary filling pressure (approximately 32 mm Hg).
prolonged exposure to pressures just slightly above capillary filling pressure initiates a series leads to tissue necrosis and ulceration.

12. Pathophysiology
Shear forces and friction aggravate the effects of pressure and are important components of the mechanism of injury
Maceration may occur in a patient who has incontinence, predisposing the skin to injury

13. Stages of bed sores Suspected Tissue Injury:
This stage is described as a "purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear."

14. Stages of bed sores Stage I:
intact skin with signs of impending ulceration.
Initially there is blanchable erythema indicating reactive hyperemia.
Reactive hyperemia should resolve within 24 hours of the relief of pressure.
Finally, the skin may appear white from ischemia.

15. Stages of bed sores Stage II:
A partial-thickness loss of skin involving epidermis and dermis that appears as an open shallow ulcer with a pink wound bed.

16. Stages of bed sores Stage III:
A full-thickness loss of skin with extension into subcutaneous tissue but not through the underlying fascia. This lesion presents as an ulcer that may include undermining and tunneling of adjacent tissue. Bone, tendon, and fascia are not exposed.

17. Stages of bed sores Stage IV:
full-thickness tissue loss with extension into muscle, bone, tendon, or joint capsule. Slough or eschar may be present in the wound. Osteomyelitis with bone destruction and dislocations or pathologic fractures may be present.

18. Factors increase developing pressure sores in critically ill patients
Inability to move
Muscle wasting
Depressed cardiac function
Malnutrition, hypoproteinemia
Incontinence or presence of a fistula contributes to ulceration in several ways.

19. Prevention of bed sores
Turn or ask patients to turn every 2 hours.
Skin lubricant
Avoid hypoxia
Active or passive exercise to enhance blood supply
good nutrition.

20. Management of bed sores
Management of pressure ulcers relies on key principles, including:
pressure reduction,
adequate debridement of necrotic and devitalized tissue,
control of infection, and meticulous wound care.

21. management Pressure reduction
Turning and repositioning the patient remains the cornerstone of prevention and treatment through pressure relief.
Repositioning should be performed every 2 hours, even in the presence of a specialty surface or bed.
Patients who are bed ridden should be positioned at a 30 degree angle when lying on their side to minimise pressure over the ischial tuberosity and greater trochanter.

22. Give over care for pressure points of the body
Use specialized surfaces for bed and wheelchair; foam mattress, air- filled mattress, water-filled mattress, gel-filled mattress.

23. RELIEVE SKIN PRESSURE FROM THE FOOT
Relieve skin pressure by changing position or being positioned so that pressure is taken off a bony area.

24. Side Position Padding Head: Small, foam support under head.
Hips: Pad placed above and below the hip joint. When pads are placed correctly, a flat hand can be slid between the body and the bed to be certain that pressure has been relieved.
Ankle: Pad placed above the ankle joint
Between Lower Legs: Pillow placed lengthwise between legs to prevent pressure on the knees and ankle joint.

25. Supine (Back) Position Padding
Head: Small, foam support under the head.
Back: Place pad under lower back to provide elevation of the sacrum
Knees: The bend at the knee is a natural curvature. Use a pad above the area behind the knee.
Ankles: A small pad is necessary at the back of the heel to relieve tension on the calf of the leg.
Heels must be off the bed to prevent skin breakdown.
Between Lower Legs: Foam pad or pillow placed between the knees to present possible breakdown at the knee and ankle joints.

26. Prone Position Padding
Head: Small, foam support under head.
Chest: Use one or more pillows according to comfort.
Thighs: Foam pads placed above the knees to prevent redness of knees
Between Knees: Pads placed between knees to keep knees and ankles apart so pressure sores do not develop.

27. RELIEVE SKIN PRESSURE IN A WHEEL CHAIR
Weight reduction is the most essential technique for preventing pressure on the skin and muscle of the sacrum and each hip
Cushions: Air, foam, gel or fluid
A cushion for wheelchair is essential. Cushions provide pressure relief and weight distribution and thus aid in the prevention of pressure sores

28. Take Routine Care of Your Skin
The third way to prevent skin sores, the most serious problem in SCI, is to keep skin healthy.
Health skin is skin which is intact, well lubricated with natural oils, and nourished by a good blood supply.
Skin stays healthy with good diet, good hygiene, regular skin inspection, and regular pressure relief.

29. Other treatment
Nutritional status should be evaluated and optimized to ensure adequate intake of calories, proteins, and vitamins.
Cessation of smoking, adequate pain control, maintenance of adequate blood volume, and correction of anemia.
The wound must be kept clean and free of urine and feces

30. Other treatment
Bacterial contamination must be assessed and treated appropriately.
Wound dressings:
the goal is to achieve a clean, healing wound with granulation tissue. A stage I lesion may not require dressing.
Wound debridement

31. References
Christian N Kirman, Lars M Vistnes Pressure Ulcers, Nonsurgical Treatment and Principles Treatment & Management. Medscape 2010
Sheila Adam, Sally Forrest Clinical Review
ABC of intensive care, Other supportive care BMJ 319 : 175 (Published 17 July 1999)

32. Thank you