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

2. 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.

3. 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

4. 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

6. 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

7. Adverse Effects of Immobility
Cardiovascular
Decreased cardiopulmonary function
Decreased cardiac output
Reduced venous return
Decreased stroke volume
Postural hypotension
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Dermatological
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

8. Adverse Effects of Immobility
Cardiovascular
Atelectasis
Hypostatic pneumonia
Intubation
Tracheostomy
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Dermatological
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

9. Adverse Effects of Immobility
Cardiovascular
Decreased appetite/ poor nutrition
Constipation
PEG tube
Rectal trumpet
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Dermatological
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

10. Adverse Effects of Immobility
Cardiovascular
Urinary stasis
Stone formation
Infection
Foley catheter
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Dermatological
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

11. Adverse Effects of Immobility
Cardiovascular
Disuse muscle atrophy
Joint contractures
Heterotopic ossification
Decreased strength and endurance
Impaired balance
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Dermatological
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

12. Adverse Effects of Immobility
Cardiovascular
Pressure ulcers
Infection
Pain
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Dermatological
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

13. Adverse Effects of Immobility
Cardiovascular
Sensory deprivation
Disorientation and confusion
Depression and anxiety
Delirium
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Dermatological
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

14. 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
Psychological
Metabolic
Kortebein, Am J Phys Med Rehabil, 2009

15. 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

16. 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

17. 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

18. ICU-Acquired Cognitive Impairment
Wilcox, Crit Care Med, 2013
Survivors of ARDS
11 studies, n = 487
At discharge: % 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%

19. 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%

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

21. Herridge Trials

22. 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.

23. 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

24. Herridge, N Engl J Med, 2003

25. Herridge, N Engl J Med, 2003

26. 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

27. 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.”

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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

34. “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):

35. Safety and Feasibility

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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.

42. Thank You