Critical Care Medical & Rehab Management

Question 1

what is the aim of ICU liberation?

Answer 1

liberate patients from the harmful effects of an ICU stay and provides evidence-based strategies in a comprehensive “bundle” for the entire interdisciplinary team

Question 2

since ICU liberation in 2013, the bundle has decreased what 3 things?

Answer 2

• likelihood of hospital death with 7 days of ICU admisssion by 68%
• delirium days by 25-50%
  -ICU readmissions by half

Question 3

list the ICU liberation bundle: (A-F)

Answer 3

A= assess, prevent, manage pain
B= both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)
C= choice of analgesia and sedation
D= delirium assessment, prevention, & management
E= early mobility and exercise
F= family engagement and empowerment

Question 4

true or false. early mobility in the ICU has been proven to be safe and feasible in both adult and pediatric populations

Answer 4

true

Question 5

what are the benefits of early mobility in the ICU?

Answer 5

• decreases/prevents delirium
• improves functional outcomes
• cost effective by decreasing length of stay

Question 6

in order to be successful with early mobility in the ICU these 3 things are required:

Answer 6

1. interdisciplinary teamwork/communication
2. staff who understand critical care physiology & pt response to exercise
3. support medical teams

Question 7

what is one big difference between acute care PT eval/treats and ICU PT eval/treats?

Answer 7

pt may not be able or stable enough to get out of bed in ICU

Question 8

Barriers to ICU mobility/rehab:

Answer 8

patients too sick and sedated
medical equipment limits mobility
limited or under-qualified staffing
prioritization of ICU patients for follow up intervention along the continuum of care
ICU medical staff have limited knowledge of benefits of PT in ICU

Question 9

what is the stop light system used for in ICU?

Answer 9

grade various clinical considerations and what is considered safe for in-bed and out-of-bed activities

Question 10

Stop light system meanings:
– Green:
– yellow:
– Red:

Answer 10

– low risk of adverse event, proceed as usual according to each ICU’s protocols & procedures
– potential risk & consequences of an adverse event are higher than green, but may be outweighed by potential benefits of mobilization
– significant potential risk or consequences of an adverse event. Active mobilization should not occur unless specifically authorized

Question 11

specific examples for indications for mechanical ventilation:
– acute respiratory failure:
– compromised lung function:
– breathing difficulties:
– inability to maintain airway:

Answer 11

– hypoxemic vs. hypercapnic respiratory failure
– PNA, COVID, CF, pleural effusions, aspiration
– rib fractures, neurologic insults, phrenic nerve injuries
– trauma, severe AMS, ETOH/substance abuse, airway swelling

Question 12

is it within PT scope of practice to make changes on a mechanical vent?

Answer 12

no

Question 13

what is a tracheostomy?

Answer 13

surgical opening into the trachea to create an artificial airway

Question 14

a trach eliminates the need for _______ and makes weaning from MV _____

Answer 14

oral endotracheal tube ; easier

Question 15

what is a Passy-Muir Valve (PMV)?

Answer 15

external speaking valve (one way valve) that creates a closed pressure system for the creation of sound by vocal cords

Question 16

MV settings normal values:
– RR:
– Tidal volume:
– fraction of inspired O2 (FiO2):
– positive end expiratory pressure (PEEP):
– Minute volume (MV or VE):
– pressure support (PS):

Answer 16

– 10-16 ; can be adjusted depending on goal
– 4-8 mL/kg of body weight
– atmospheric is 21%, can go up to 100% w/ MV
– Atmospheric is 3-5 cmH2O, can go up as high as 20 cmH2O depending on goal of MV
– averages 4-6 L/min
– ranges from 5-30 cmH2O (higher # = higher work of vent)

Question 17

what is positive end expiratory pressure (PEEP)?

Answer 17

amount of pressure at the end of expiration that keeps alveoli open to allow for gas exchange and prevent collapse

Question 18

what is minute volume?

Answer 18

total amount of air moved in and out of the lungs in 1 minute
Rate x volume (RRxTV=MV)

Question 19

what is pressure support?

Answer 19

pressure delivered by vent to overcome airway resistance and open airways

Question 20

explain the MV mode:
– assisted:

Answer 20

vent starts and stops the breath
vent does most of the work
referred to as non-weaning modes

Question 21

explain the MV mode:
– spontaneous:

Answer 21

patients starts and stops the breath
patient does all or some of the work
vent will provide volume or pressure only AFTER the pt initiates their own breath
referred to as weaning modes

Question 22

assist control MV:
– ____ mode of MV
– can provide:
– used if patient is:
– if patient can generate inhalation:
– if patient can NOT generate a breath:
– provides the ability to keep pts:
– benefit of this type for PT:

Answer 22

non-weaning
– full ventilatory support, but doesn’t have to depending on situation
– unconscious, sedated, and can’t generate breath on their own
– triggers ventilator to provide a pre-set pressure or volume
– the vent will provide a breath based on pre-set parameters
– work of breathing very low
– can tolerate increased demands if medically stable and working with PT since the vent can provide so much more support

Question 23

pressure support MV:
– type:
– pt must generate ____ of own breaths
– pre-set pressure is given during _____ only
– the _____ the pressure is set –> easier it is for pt to generate ______
– settings range between _____
– may need _______ to tolerate additional exertion

Answer 23

– spontaneous, weaning mode
– 100%
– inhalation
– higher –> inhalation
– 5-30 cmH2O
– higher PS

Question 24

what is spontaneous breathing trial (SBT)?

Answer 24

“test” period to see if pt will be able to tolerate extubation

Question 25

during a SBT, the patient must generate _____ of their own breaths

Answer 25

100%

Question 26

SBT:
– vent matches:
– lasts _____ hours
– coordinated by _____
– parameters set to ____ or _____
– is mobility performed during SBT?

Answer 26

– atmospheric parameters to simulate atmospheric breathing
– 2
– RT
– pass or fail
– no

Question 27

what is extra corporeal membrane oxygenation? (ECMO)

Answer 27

heart and lung bypass for acute pulmonary and/or cardiac failure when no other form of treatment is successful

blood is removed from the venous system (deoxygenated) and oxygenated outside the body, then returned fully oxygenated

Question 28

ECMO requires _____ and is the most ______ form of life support available

Answer 28

very large cannulas and continuous attachment to ECMO machine
advanced

Question 29

indications for ECMO:

Answer 29

MSOF (multiple system organ failure)
bridge to transplant

Question 30

types of ECMO:
veno-venous (VV):
– blood removed from ___
– blood returned to _____
– ECMO supporting _______

Answer 30

– vein
– vein
– only lungs (normal cardiac function)

Question 31

types of ECMO:
veno-arterial (VA):
– blood removed from ___
– blood returned to _____
– ECMO supporting _______

Answer 31

– vein
– artery
– heart and lungs

Question 32

what is continuous renal replacement therapy (CRRT)?

Answer 32

continuous dialysis
requires large central venous catheter

Question 33

what are common veins that CRRT are placed in?

Answer 33

jugular or subclavian vein
– femoral but more safety considerations present

Question 34

what are indications for CRRT?

Answer 34

severe AKI
hyperkalemia
fluid overload
acidosis
hemodynamic instability

Question 35

when compared to iHD, CRRT:
– increases:
– greater:
– ______ management
– can dialyze at a ______ rate over longer periods of time

Answer 35

– hemodynamic stability
– solute and electrolyte control
– superior fluid balance
– slower

Question 36

what do you want to thoroughly review before working with ICU patients?

Answer 36

chart review - admission and progress notes, procedures, medications, RT documentation
team communication

Question 37

when you go into a patients room in the ICU, what are things you want to start with?

Answer 37

• get baseline vitals and vent settings at rest
• locate wires, IV lines, catheters, and determine which can be temporarily disconnected
• planning and set up (clear communication of timing, goals, plans, expectations, and roles to pt, family, nursing staff)

Question 38

what are components of an ICU eval?

Answer 38

PLOF/history
cog screen
orthostatic tolerance using bed controls
bed level ROM, strength, sensation assessment
slow progression of mobility

Question 39

what is the progression of mobility you want to assess?

Answer 39

supine > sit
sitting balance/EOB tolerance
sit > stand
standing balance
pre-gait tasks
transfers or gait

Question 40

what is the goal of an ICU eval?

Answer 40

not to return to supine if pt remains medically stable

Question 41

if after your PT session you want to keep your patient out of bed, what should you be sure to do?

Answer 41

ensure ability for other staff to return pt to supine later

Question 42

what is crucial to do while performing your ICU eval?

Answer 42

constant monitoring of vital signs and pt response to activity

Question 43

what are keys to successful mobility?

Answer 43

room set up, equipment in place, planning for all possibilities
move IV pole, lines, vent to side of bed pt will be mobilizing to
keep accessories in front of the pt to avoid dislodging
clear roles for everyone on the team
explain what is going to happen to the patient

Question 44

what are some questions to ask yourself for successful mobility?

Answer 44

what would I do if they weren’t in an ICU setting
what can i do to make sure i keep this session in my control
if something goes wrong, how will i keep the patient safe?

Question 45

true or false. mechanical ventilation, ECMO, or CRRT ARE absolute contraindications to mobility

Answer 45

false - ARE NOT
but consider why these devices are being utilized
take appropriate caution

Question 46

always monitor _____ and ______ in ICU setting

Answer 46

vitals and medications
* look at trends

Question 47

what are contraindications for PT in ICU?

Answer 47

hemodynamic instability requiring medical interventions
recent respiratory instability or increased vent settings
active bleeding
increasing trend of pressors, cardiac drugs, sedation, etc.
extreme agitation
increased intracranial pressures

Question 48

contraindications for PT - values:
– O2 sat ____
– RR ____
– FiO2 ___
– PEEP _____

Answer 48

– < 88%
– > 40
– > 60%
– > 10 cmH2O

Question 49

what is the Richmond Agitation-Sedation Scale (RASS)?

Answer 49

10 point scale used to measure agitation and sedation
– PT guidelines set parameters between +2 and -2

Question 50

what is the confusion assessment method for the intensive care unit (CAM-ICU)?

Answer 50

score for assessing severity of delirium in ICU patients
combines mentation, attention, level of alertness, and disorganized thinking

Question 51

what is activity measure for post-acute care (AMPAC 6 clicks)?

Answer 51

widely used in acute care settings to predict discharge destinations and functional impairment level
< 17/24 = might need post acute care rehab

Question 52

what is the functional status score for the intensive care unit (FSS-ICU)?

Answer 52

physical function measure specifically designed and validated to be used in ICU
scores functional ability on 5 tasks: rolling, supine to sit, EOB sitting, sit to stand, ambulation

lower score = higher impairment

Question 53

what is the Perme ICU mobility score?

Answer 53

reflects patient mobility status, scored in 7 categories
(mentation, potential mobility barriers, functional strength, bed mobility, transfers, gait, endurance)

lower score = higher impairment & higher barriers to functional mobility

Question 54

what outcome measure is the only score that incorporates barriers to mobility unique to the ICU?

Answer 54

perme ICU mobility score