Early Mobility in the ICU, Diaphragm muscle thinning and atrophy - PDF document

5/30/2014 Why Early ICU Patient Mobility? Early Mobility in the ICU, Diaphragm muscle thinning and atrophy begins within 18 to 48 How is It Going? hours after intubation Levine, S., T . Nguyen, et al. (2008). "Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans." N Engl J Med 358 (13): 1327-1335. Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: Diaphragm muscle thinning in patients who are mechanically ventilated. Chest 2012, 142(6):1455-1460. UCSF Critical Care & Trauma Medicine Rectus Femoris protein breakdown begins within 24 hours of ICU Conference May 29-31 2014 admission, cross sectional area declining rapidly during first week Presented by Heidi Engel, PT, DPT Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T , Sidhu PS et al: Acute Skeletal Muscle Wasting in Critical Illness. Jama 2013. heidi.engel@ucsfmedctr.org Why Early ICU Patient Mobility? Astronauts are on Bed Rest The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up. Fan E, Dowdy DW , Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N, Herridge MS They exercise for at least 2 et al: Physical Complications in Acute Lung Injury Survivors: A 2-Year Longitudinal Prospective Study. Crit Care Med 2013. hours/day to counter the Based on available evidence, early exercise/PT seems to be adverse effects to their bone the only treatment yet shown to improve long-term physical density and muscles function of ICU survivors. Calvo-Ayala E, Khan BA, Farber MO, Ely EW , Boustani MA: Interventions to improve the physical function of ICU survivors: a systematic review. Chest 2013, 144(5):1469-1480. 1

5/30/2014 An Image of ICU Delirium Delirium Prevention • We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium (+1B) • Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41(1):263-306. • Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678):1874- 1882. • Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010, 91(4):536-542. Gunther ML, Morandi A, Krauskopf E, Pandharipande P, Girard TD, Jackson JC, Thompson J, Shintani AK, Geevarghese S, Miller RR, 3rd et al: The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*. Crit Care Med 2012, 40(7):2022-2032. Page 20 ICU Liberation Proj oject of SCCM How Are We Doing? www.iculiberation.org & www.icudelirium.org Point Prevalence Studies: SYMPTOMS MONITORING CARE PAD GUIDELINES TOOLS ABCDEF BUNDLE Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende A ssess / Treat Pain H, Rothaug O, Schuchhardt D et al: Early mobilization of mechanically ventilated BPS PAIN A wakening Trials - S A Ts patients: a 1-day point-prevalence study in Germany*. Crit Care Med 2014, NPS B reathing Trials - S B Ts 42(5):1178-1186. C oordination of Care CPOT C hoice of Sedatives RASS AGITATION D elirium Reduction In this 1-day point-prevalence study conducted across Germany, only SAS 24% of all mechanically ventilated patients and only 8% of patients D iseases, D rug R emoval, with an endotracheal tube were mobilized out of bed as part of routine E nvironment DELIRIUM CAM-ICU e.g., sleep, noise, eye glasses, care. hearing aids ICDSC E arly mobility and E xercise F amily - Communication and Involvement 2

5/30/2014 How Are We Doing? How Are We Doing? Point Prevalence Studies: Point Prevalence Studies: Terri Hough University of Washington Medical Center, Presenting at The Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L: 7 th International Physical Medicine and Rehabilitation of Critically Ill Intensive care unit mobility practices in Australia and New Zealand: a point Patients Meeting 5/17/2014, Across the US: prevalence study. Crit Care Resusc 2013, 15(4):260-265. 64% of ICU patients experienced any activity, 50% of those were bed 45% were mechanically ventilated. Mobilisation activities were classified level activity, 20% of those were transfers to a chair, 10% of those were into five categories that were not mutually exclusive: 140 patients (28%) walking completed an in-bed exercise regimen, 93 (19%) sat over the side of the bed, 182 (37%) sat out of bed, 124 (25%) stood and 89 (18%) walked. Predefined adverse events occurred on 24 occasions (5%). No patient requiring mechanical ventilation sat out of bed or walked. Profoundly variable practice patterns Moving Fro rom Inf nfor ormation on to o Practice: How Exerc rcise Can n Help p You ou Live Long onger By GRETCHEN REYNOLDS, April 2, 2014, New York Times Top 10 Excuses for Keeping An ICU Patient Immobile Having unhealthy cholesterol numbers, elevated blood pressure or an expanding waistline substantially increases your chances of developing heart disease. But an encouraging new study finds that exercise may slash that risk, even if your other risk factors stay high. 3

5/30/2014 Excuse # 1. SAFETY: SAFETY : The patient is too sick, or too big Excuse: The Patient is TRUE: too…, New onset sepsis or respiratory distress (think of hours NOT days) Unstable bleeding or surgical site Terminal disease (comfort care measures), Comatose Acute unstable cardiovascular event Solution # 1. SAFETY: The patient is too sick, or too big Context Is it a beautiful sunny day Collaborate with RN,RT, MD after so much rain, or are Use Clinical judgment we in the middle of a drought? Every diagnosis in context 4

5/30/2014 Excuse # 1. SAFETY: The patient is too sick, or too big Excuse # 2. FALSE: The patient has a DVT (reference the American College of Chest Physicians 2012 guidelines: people SAFETY: with acute DVT do not need a period of bed rest) The patient is too sleepy RASS -1 to -4 FALSE: The obese patient was admitted able to walk at Hypoactive delirious home (think of how crucial prevention can be) Goal targeted sedation? FALSE: The patient is on ARDS Net Protocol FALSE: The patient is a new admit to the ICU True: Delirium is Brain Failure Solution# 2. SAFETY: Brain Failure Looks Like This The patient is too sleepy Collaborate with RN,RT, MD Use Clinical judgment Every level of delirium in context Consider the environment 5

5/30/2014 Excuse # 3. SAFETY: The patient is too agitated Solution# 2. SAFETY: The patient is too sleepy and may respond well to being up Solution # 3. SAFETY: The patient is too Excuse # 4. SAFETY: the patient has agitated challenging lines or endotracheal tube Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium “We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium” (+1B) • Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP , Joffe AM et al: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41(1):263-306. • Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678):1874-1882. • Needham DM, Korupolu R, Zanni JM, Pradhan P , Colantuoni E, Palmer JB, Brower RG, Fan E: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010, 91(4):536-542. 6

5/30/2014 What About All Those Critical Lines? What About All Those Critical Lines? Patient lines and drains can be accommodated Including Femoral Lines Mechanical ventilation and CVVH lines Damluji, A., et al. (2013). "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit." J Crit Care. Winkelman, C. (2011). "Ambulating with pulmonary artery or femoral catheters in place." Crit Care Nurse 31(5): 70-73. Lines, catheters and drains can be accommodated, secured EVD line stationary bike Solution #5 Timing: Soon to be Extubated Excuse #5 Timing: The patient is leaving Activity trumps extubation: The patient is going for: A pre- and post-activity rest period with assist-control ventilation for 30 min was employed as needed to support early activity. A procedure A CT scan If the patient was intubated and able to participate in activity, the FIO2 was increased Transferring to the floor by 0.2 before initiation of activity. We deferred ventilator weaning in support of Will be extubated soon activity, as necessary. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO: Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007, 35(1):139-145. 7