(EARLY) MOBILITY: INTENSIVE CARE UNIT & Acute Care

Question 1

Adverse Effects of Bed Rest

Answer 1

Muscle atrophy
Malnutrition
Reduced bone density (6 months)
Pressure injury/vascular compromise
Delirium
Reduction in heart and lung function
High risk of pulmonary complications

Question 2

Duration of bed rest during critical illness➔

Answer 2

associated with weakness throughout a 24-month follow-up

Question 3

Muscle breakdown begins within___ of AC/ICU admission and declines rapidly during ___

Answer 3

24 hours

the first week

Question 4

AC/ICU Acquired Weakness

Answer 4

Rapid onset of symptoms: 24 hours

Resolve slowly

Pervasive weakness

Polyneuropathy

Difficulty liberating from mechanical ventilator (ICU)

Question 5

Diaphragm muscle atrophy begins within ____ after intubation

Answer 5

18 hours

Question 6

___ seems to be the only treatment yet shown to improve long-term physical function of survivors of critical illness

Answer 6

Early activity

Question 7

Early Physical and Occupational Therapy

Answer 7

starting at day 1-2 versus usual care starting at day 6-10

Question 8

Mobility therapy delivered early in the course of acute respiratory failure was shown to be:

Answer 8

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

Question 9

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

Answer 9

Geared towards reducing symptoms of pain, agitation, and delirium (PAD) that are common with ICU stays

Question 10

ABCDEF Bundle

Answer 10

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

Question 11

Benefits of ICU Liberation

Answer 11

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)

Question 12


Post Intensive Care Syndrome (PICS)


Answer 12

ICU acquired weakness

Long-term cognitive impairment

Depression

Post-traumatic stress disorder

Additionally:
Personal and societal costs
Family/caregiver burden

Question 13

“Early” defined as

Answer 13

initial physiologic stabilization, continuing throughout ICU stay

Question 14

Initiating patient mobilization within 48 hours of patient admission to the ICU through:

Answer 14

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

Question 15

Depth of Sedation for Patients in the ICU

Answer 15

Light levels of sedation associated with improved clinical outcomes ➔ shorter duration of mechanical ventilation and a shorter ICU length of stay

Question 16

OUTCOME TOOLS

Answer 16

Spontaneous Awakening Trial (SAT)


Richmond Agitation Sedation Scale (RASS)


Question 17

Spontaneous Awakening Trial (SAT)

A patient is considered “awake” if able to perform 3 of the following 4 tasks:

Answer 17

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

Question 18


Richmond Agitation Sedation Scale (RASS)


Answer 18

+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

Question 19

25 to 40% of patients with new onset cognitive changes:

Answer 19

Impaired learning and short-term memory
Executive function
Attention

Question 20

Delirium Contributing factors

Answer 20

Hypoxemia
Variable glucose control
Delirium/sedation
Sepsis

Question 21

Confusion Assessment Method for the ICU (CAM-ICU)

Answer 21

1) acute change or fluctuating course of mental status

2) inattention

3) altered level of consciousness

4) disorganized thinking

Question 22

Delirium Prevention

Answer 22

Performing early mobilization of adult patients in the ICU & AC whenever feasible to reduce the incidence and duration of delirium is recommended

Question 23

Early Mobility

Answer 23

Requires investment by the team

Involves actively getting patients off sedation, out of bed as soon as possible, and ambulatory while still intubated

Question 24

EARLY Mobility 
Exclusion “Guidelines”

Answer 24

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

Question 25

Vassopressors ➔

Answer 25

vasoconstriction

Question 26

Ionotropes ➔

Answer 26

Increase heart contractility

Question 27

Open visiting hours and caregiver presence may help ___

Answer 27

reduce over-sedation

Question 28

Family/caregivers are fully invested as:

Answer 28

Advocates
Motivators
Mood elevators

Question 29

Family/caregivers can help with:

Answer 29

Hygiene care
Activities of daily living
Range of motion/exercise
A diary of daily events

Question 30

Family/caregiver presence helps prevent:

Answer 30

Complications
Medication errors
Unnecessary procedures

Question 31

Barriers to Early Mobility in the ICU

Answer 31

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