(EARLY) MOBILITY: INTENSIVE CARE UNIT & Acute Care Flashcards
Adverse Effects of Bed Rest
Muscle atrophy
Malnutrition
Reduced bone density (6 months)
Pressure injury/vascular compromise
Delirium
Reduction in heart and lung function
High risk of pulmonary complications
Duration of bed rest during critical illness➔
associated with weakness throughout a 24-month follow-up
Muscle breakdown begins within___ of AC/ICU admission and declines rapidly during ___
24 hours
the first week
AC/ICU Acquired Weakness
Rapid onset of symptoms: 24 hours
Resolve slowly
Pervasive weakness
Polyneuropathy
Difficulty liberating from mechanical ventilator (ICU)
Diaphragm muscle atrophy begins within ____ after intubation
18 hours
___ seems to be the only treatment yet shown to improve long-term physical function of survivors of critical illness
Early activity
Early Physical and Occupational Therapy
starting at day 1-2 versus usual care starting at day 6-10
Mobility therapy delivered early in the course of acute respiratory failure was shown to be:
Feasible
Safe
Cost effective
Associated with:
Decreased ICU and hospital LOS
Decreased duration of mechanical ventilation and days with delirium
Increased return to independent functional status at hospital discharge
The ICU Liberation Collaborative is a real-world quality improvement (QI) initiative being implemented across over 76 ICUs designed to engage the ABCDEF bundle through multidisciplinary teamwork and evidence-based care
Geared towards reducing symptoms of pain, agitation, and delirium (PAD) that are common with ICU stays
ABCDEF Bundle
A: Awakening trials and PAIN Assessment
B: Spontaneous Breathing trials
C: Choice of Analgesic and Sedation
D: Delirium assessment, prevention, and management
E: Early mobilization and Exercise
F: Family participation
Benefits of ICU Liberation
Reduction in duration of mechanical ventilation
Reduced ICU & hospital length of stay (LOS)
Increased ability to ambulate at hospital discharge
Reduction in Post Intensive Care Syndrome (PICS)
Post Intensive Care Syndrome (PICS)
ICU acquired weakness
Long-term cognitive impairment
Depression
Post-traumatic stress disorder
Additionally:
Personal and societal costs
Family/caregiver burden
“Early” defined as
initial physiologic stabilization, continuing throughout ICU stay
Initiating patient mobilization within 48 hours of patient admission to the ICU through:
ICU cultural shift toward mobility as necessity ➔ not optional
Practice patterns of all ICU personnel emphasizing teamwork with mobilization
Optimizing the ICU environment to allow for patient mobility:
Multidisciplinary teamwork
Safe patient handling equipment
Proper wake/sleep cycles
Minimal sedation
Depth of Sedation for Patients in the ICU
Light levels of sedation associated with improved clinical outcomes ➔ shorter duration of mechanical ventilation and a shorter ICU length of stay
OUTCOME TOOLS
Spontaneous Awakening Trial (SAT)
Richmond Agitation Sedation Scale (RASS)
Spontaneous Awakening Trial (SAT)
A patient is considered “awake” if able to perform 3 of the following 4 tasks:
Opens eyes in response to voice
Uses eyes to follow the health care provider on request
Squeezes a hand upon request
Stick out the tongue upon request
Richmond Agitation Sedation Scale (RASS)
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
25 to 40% of patients with new onset cognitive changes:
Impaired learning and short-term memory
Executive function
Attention
Delirium Contributing factors
Hypoxemia
Variable glucose control
Delirium/sedation
Sepsis
Confusion Assessment Method for the ICU (CAM-ICU)
1) acute change or fluctuating course of mental status
2) inattention
3) altered level of consciousness
4) disorganized thinking
Delirium Prevention
Performing early mobilization of adult patients in the ICU & AC whenever feasible to reduce the incidence and duration of delirium is recommended
Early Mobility
Requires investment by the team
Involves actively getting patients off sedation, out of bed as soon as possible, and ambulatory while still intubated
EARLY Mobility Exclusion “Guidelines”
Significant doses of increasing vasopressors for hemodynamic stability (maintain MAP> 60)
FiO2 80% or .8 and/or PEEP >12
Acutely worsening respiratory failure
Neuromuscular paralytics
Acute evolving neurological or cardiac event with re-assessment for mobility every 24 hours
RASS less than -3 or greater than +2
Unstable spine or extremity fractures
Open abdomen, at risk for dehiscence
Grave prognosis ➔ transitioning to comfort care
Vassopressors ➔
vasoconstriction
Ionotropes ➔
Increase heart contractility
Open visiting hours and caregiver presence may help ___
reduce over-sedation
Family/caregivers are fully invested as:
Advocates
Motivators
Mood elevators
Family/caregivers can help with:
Hygiene care
Activities of daily living
Range of motion/exercise
A diary of daily events
Family/caregiver presence helps prevent:
Complications
Medication errors
Unnecessary procedures
Barriers to Early Mobility in the ICU
Skeptical clinicians ➔ culture and beliefs
Rotating, changing, in-experienced personnel
Minimal resources/time
Variation in sedation practices
Timing of PT and OT referrals
Awkward equipment
Unclear progression of activities
Comfort level mobilizing prior to extubation
