Early mobility: intensive care unit and acute care

Question 1

Demonstrate an understanding of the ABCDEF Bundle for Early Mobilization in the Intensive Care Unit (ICU)

Question 2

Examine the typical progression of exercise/activity for early mobility in the ICU

Question 3

Identify safe handling equipment used to mobilize patients in the ICU

Question 4

what is the adverse effects of bed rest

Answer 4

muscle atrophy
malnutrition
reduced bone density (6 months)
pressure injury/vascular compromise
delirium
reduction in the heart and lung function
high risk of pulmonary complications

Question 5

Muscle breakdowns begin how fast in ICU/ac

Answer 5

Muscle breakdown begins within 24 hours of AC/ICU admission and declines rapidly during the first week

associated with weakness throughout a 24-month follow-up

Question 6

AC/ICU acquired weakness

Answer 6

Rapid onset of symptoms: 24 hours
Resolve slowly
Pervasive weakness
Polyneuropathy
Difficulty liberating from mechanical ventilator (ICU)

Question 7

the diaphragm muscle atrophies after how long a ventilator

Answer 7

18 hours

Question 8

what is the one intervention that hemps with long term physical function?

Answer 8

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

Question 9

what does the research show about early mobilization of patients with respiratory failure?

Answer 9

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

Question 10

what does the ABCDEF bundle do for patients in the ICU?

Answer 10

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

Question 11

what is the ABCDEF bundle?

Answer 11

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 12

what are the benefits of ICU liberation

Answer 12

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 13

what is post intensive care syndrome (PICS)?

Answer 13

ICU acquired weakness

Long-term cognitive impairment

Depression

Post-traumatic stress disorder

Additionally:
Personal and societal costs
Family/caregiver burden

Question 14

what is the definition of early mobilization in the ICU

Answer 14

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

Question 15

who might all be apart of early mobilization in the ICU?

Answer 15

Physician advocate
Nursing champions
Respiratory therapy
Physical therapy
Occupational therapy
Mobility aides
Case manager/social worker

Question 16

what depth should ICU patients be sedated at for best outcomes?

Answer 16

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

Recommend routinely using either daily sedation interruption or targeting light level of sedation in patients requiring mechanical ventilation

Question 17

what is the spontaneous awakening trial?

Answer 17

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

Question 18

what are the levels of the Richmond agitation sedation scale (+4 to -5)

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

how do you perform a spontaneous breathing trial (SBT)

Answer 19

Start (0400-0500)
Place head of bed > 40º unless on full spine precautions
PSV 5 and PEEP 5  both measures of positive ventilation pressure

Terminate wean if any of the following threshold values are observed and return to previous ventilator settings:
Pulse < 60 or > 130
Sustained RR > 38
Systolic Blood Pressure > 180 or < 90 mmHg
SpO2 < 88% despite increasing FIO2 to 50% or higher
Significant change in respiratory pattern, diaphoresis, or paradoxical breathing pattern

Question 20

what are the cognitive changes related to the ICU stay

Answer 20

25 to 40% of patients with new onset cognitive changes
Impaired learning and short-term memory
Executive function
Attention

Contributing factors
Hypoxemia
Variable glucose control
Delirium/sedation
Sepsis

Question 21

explain the pathway through the confusion assessment method for the icu?

Answer 21

slide 26

Question 22

what prevents delirium?

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

what does the E stand for in ABCDEF and what does it require?

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

what’s the red reason for exclusion from early mobolization?

Answer 24

Significant doses of increasing vasopressors for hemodynamic stability (maintain MAP> 60)

Question 24

what are the exclusion guidelines for early mobility?

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

what are the pharmacological treatments for these patients

Answer 25

Vassopressors- vasoconstriction

Ionotropes- Increase heart contractility

Question 26

How does family participation help patients in sedation?

Answer 26

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

Question 27

what are barriers to early mobolization?

Answer 27

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

Question 28

what is the main take away for this powerpoint slide dec?

Answer 28

ICU Liberation and early mobility

Takes TEAMWORK

Takes TIME

Takes the Drive to do what is the BEST Practice for your patient