Early Mobilisation & Rehab in ICU Flashcards
What systems are affected by bed rest?
- Musculoskeletal
- Pulmonary
- CV
- Integumentary
- Endocrine
- Immunological
- Gastrointestinal
- Haematological
- Psychological
What is the relationship between muscle wastage in ICU and organ failure?
Muscle wastage gets worse with increasing organ failure
What effects does bed rest have on the pulmonary system?
- Increased RR
- Increased V/Q mismatch
- Increased risk atelectasis & pneumonia
- Decreased MIP
- Decreased FVC
What effects does bed rest have on the immune & endocrine systems?
- Proinflammatory (decreased production of cellular antioxidants, production of cytokines)
- Impaired glucose tolerance
- Decreased vitamin D levels
What effects does bed rest have on the haematological system?
- Decreased red cell mass
- Increased risk venous thrombo-embolism
What effects does bed rest have on the GI system?
- Anorexia & constipation
- Overfeeding is deleterious: Causes accelerated muscle atrophy, increased pro inflammatory markers
What effects does bed rest have on the integumentary system?
- Pressure areas
- Contractures
What are the psychological effects of bed rest?
- Biological rhythms (loss of circadian rhythms)
- Disturbed sleep
- Mood/depression
What does evidence show regarding depression in ICU survivors?
- Davydow et al 2012
- 28% had clinically significant depression after sepsis
What did Pandharipande et al 2013 find regarding cognitive outcomes after critical illness?
- 821 patients with high severity of illness
- 74% had delirium (mean duration 4 days)
- Duration associated with worse cognition at 12 months
- High use of sedatives
What did Morris et al 2008 find regarding early mobilisation in ICU?
Improves
- Functional status at hospital discharge
- Muscle strength
- 6MWT distance
- Subjective well-being
Shorter duration of delirium
Increases ventilator free days
Shorter hospital LOS
Reduced risk of death or hospital readmission within 12 months
What is the main barrier to mobilisation in ICU?
Safety concerns
What did the study of mobilisation in ICU at TCH find?
- 4 week audit of mobilisation
- 1.1% incidence of adverse outcomes
What have studies found when comparing mobilisation in & out of bed?
- Resistive exercise in bed don’t reverse vascular adaptations to bed rest
- Pulmonary effects of changing position from sitting in bed to sitting in chair (increase FRC)
- Cycle ergonometric is NWB (less effect on bone mineral density)
What did the updated systematic review by Stiller 2013 find?
Early mobilisation in ICU for adult patients was beneficial in terms of:
- Functional ability
- Potential to reduce ICU & hospital LOS
What is the “Plan B” approach to mobilisation of ICU patients?
- Preparation (discussion with MDT, communication with patient, equipment, environment)
- Leader
- Airway & emergency equipment (airway secured & cleared)
- Number of staff
- Backup plan
What equipment should be used during mobilisation for OH&S?
- Slide sheets
- Chairs
- Pat slides
- Ceiling mounted lifters
- Forearm support frames (check patient’s weight is suitable)
What are the CV CIs to mobilisation in ICU?
- Inotropes/vasopressors (not automatic, but need to consider dose)
- Arrhythmias (if output compromised, new, unstable)
- AMI (consult cardiology/ICU medical team)
- Presence of IABP/LVAD
- Presence of pulmonary artery catheter
- Any significant blood loss or new decrease in CO
What did Khan et al 2002 find regarding bed rest?
24 hours of bed rest led to a reduction in sympathetic nerve activity in response to an orthostatic stimulus
What are the neurological CIs to mobilisation in ICU?
- ICP management
- Spinal cord injury management (clear guidelines from neuro surgeons, collars/braces)
- Presence of drains
- Seizures
- Any large drop in GCS
What are the respiratory CIs to mobilisation in ICU?
- Threatened airway (awaiting ETT/trache)
- Large PTX/effusion waiting drainage
- Prone positioning
- Imminent extubation
- Dramatic change in respiratory support (e.g. escalating PEEP)
- Specific amounts of respiratory support
- Baseline RR/dyspnoea (e.g. if constantly 35)
What are some of the other CIs to mobilisation in ICU?
- Blunt trauma to abdomen (seek general surgery advice)
- Orthopaedic fracture stabilisation
- Paralysis/muscle relaxant
- High risk/evidence of bleeding (low platelets/Hb)
- Palliation
What did Morris et al 2011 find in their follow-up study of mobilisation in ICU?
Early mobilisation reduced risk of death or hospital readmission within 12 months
What did Bailey et al 2007 find regarding mobilisation in ICU?
- 1449 activity events in 103 patients
- <1% adverse effects
What did Schwieckert et al 2009 find regarding mobilisation in ICU?
- Ambulated patients out of bed within 72 hours of mechanical ventilation
- Intervention group gained functional independence faster
What is acute skeletal muscle weakness in ICU associated with?
Multi-organ failure (Zudin et al 2013)
What is prolonged weaning associated with?
ICU acquired weakness & diaphragm dysfunction (Dres et al 2016)
