Early Mobility in ICU Flashcards
Ventilator Settings
PEEP (Positive End Expiratory Pressure)
* Assists with opening closed alveoli at end of expiration
* Normal = 5cmH2O
FiO2 (Fraction of Inspired Oxygen)
* FiO2 on normal room air is 20%
* Normally set <60% to prevent oxygen toxicity
Ventilator Modes
AC (Assist Control) or CMV (Continuous Mechanical Ventilation)
* Most common
* Full ventilator support
– Inspiration is triggered by ventilator
– Additional breaths by patient are at a fixed Tidal Volume
SIMV (Synchronized Intermittent Mandatory Ventilation)
* Not full ventilator support
* Set Rate and Volume
– Spontaneous breaths synchronized with ventilator breaths
– Patient inspiratory efforts above set Rate are unassisted
PS (Pressure Support) - popular weaning mode as patient does some of the work
* All breaths spontaneous by patient (no Rate setting)
* Ventilator delivers a set Pressure (high pressure = bigger breaths)
* As the Pressure is modified, the spontaneous respiratory rate and tidal volume adapt (alarms set to indicate volumes that are too high or low)
– PEEP (Positive End-Expiratory Pressure)
— Patient starts / stops breath
—- PEEP set to assist with opening closed alveoli at end of expiration
– Can also be provided in non-invasive manner (though mask) for BiPAP / CPAP
Traffic Light System
Yellow indicates addiitonal consultation necessary before mobility
Ventilator Weaning Process
- Takes hours
- exhausting process for the patient; coordinte care around this
Respiratory Considerations
Traffic Lights
Cardiovascular Considerations
ECMO: Extracorporeal Membrane Oxygenation
- Blood is pumped outside the body to a heart-lung machine that removes CO2 and sends O2 back to tissues in the body
- Administered during acute respiratory distress or shock following a massive heart attack; utilized for patients awaiting lung transplantation
- Used when lungs cannot provide enough oxygen to the body even when extra oxygen is provided, lungs cannot remove CO2 even with assist from a mechanical ventilator, and/or the heart cannot pump enough blood to the body
- Physical therapy during ECMO is feasible and safe when performed by a multidisciplinary team
VAD: Ventricular Assist Device
Goal is to relieve the stress on the heart before complications of heart failure leads to irreversible end organ dysfunction
* Bridge to transplantation
* Bridge to candidacy (allow time for patient to become eligible for transplantation)
* Destination therapy (final intervention for heart failure)
* Bridge to recovery
Physical Therapy Implications
* Acute rehabilitation focus on restoring functional mobility and improving activity tolerance to prepare for discharge home (challenging to discharge these patients to another facility for rehabilitation)
* Consider biomechanical changes during functional mobility with patient carrying / managing the VAD, batteries, and controller
* Important to monitor MAP as hypertension will make it difficult for pump to circulate blood forward while hypotension may lead to suck down (ventricle collapse)
WCD: Wearable Cardioverter Defibrillator
- Prevents sudden cardiac death for those with cardiomyopathy, heart failure, a recent cardiac surgical procedure, and previous myocardial infarction
– Including life-threatening arrythmias (ventricular tachycardia / fibrillation) and decreased ventricular ejection fraction (≤ 35%) - Worn externally and designed to automatically detect and defibrillate ventricular tachycardia and fibrillation
- Physical Therapy Implications
– Initial interventions include improving hemodynamic tolerance to upright, progressive lower extremity strengthening, dynamic sitting and standing activities, and progressive ambulation / stair training
– Important to monitor vitals and hemodynamics (HR, BP, RPE) during therapy sessions
Neurological Considerations
Confusion Assessment Method for the ICU
Other Considerations
Post-Intensive Care Syndrome (PICS)
- Syndrome manifests itself in 3 domains:
- Physical complications
- Occurs in 25-80% of patients with PICS
- Includes generalized weakness, pain, decreased exercise capacity, falls, poor mobility
Cognitive symptoms
* Occurs in 30-80% of patients with PICS
* Includes problems with attention,impaired memory, reduced mental processing, and difficulty organizing / completing tasks
* Appear similar to moderate TBI or mild dementia
Mental health disorders
* Occurs in 8-57% of patients with PICS
* Includes depression, anxiety,PTSD, sleep impairments
* Home health and outpatient physical therapists are ideally positioned to address the reduced functioning and participation associated with PICS
Diagnostic Testing for PICS
Cognition
Montral Cognitive Assessment (MoCA)
Modified Mini-Mental State Exam (MMSE)
Mini-Cog
Psychiatric
Hospital Anxiety and Depression Scale
Beck Depression or Anxiety Inventory
Posttraumatic Stress Syndrome 10-Questions Inventory (PTSS-10)
Physical
Formal PT / OT Assessment
Outcomes with PICS
Generally, see improvement over 6-12 months; however, impairments may persist for several years
Physical function is the most likely deficit to improve in initial 12 months
PICS survivors:
Report a lower health-related quality of life
May be unable to return to work(>30%)
Reduced hours and/or different type of job acceptance likely
Demonstrate increased risk of re-hospitalization
Have an increased mortality risk (especially in the first 3-6 months post-ICU stay)
