Early Mobilization Flashcards by Jessica Deak

Chronic critical illness patients are distinguished by a syndrome of significant, characteristic derangement of: (4)

Metabolism
Neuroendocrine
Neuropsychiatric
Immunologic function

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Profound debilitation and continued multiple organ system dysfunction contributes to _____

PMV: prolonged mechanical ventilation

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PMV is generally defined as….

The need for mechanical ventilation for LONGER THAN 21 DAYS

OR when the tracheostomy occurs (7-14 days)

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Multiple risk factors for post ICU mortality include: (5)

Age
Comorbidity
Severity of illness
Duration of ICU delirium
Sepsis

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PICS is?

Post intensive care syndrome

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PICS is the term used to describe the ________

Constellation of complications that endure past ICU stay

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List 6 long term complications of ICU stay

Pulmonary 
Neuromuscular
Physical Function
Psychiatric symptoms
Cognitive
QOL

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Pulmonary long term complications include:

Diffusion capacity: generally mild but can persist for >5 years

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Long term complications: Neuromuscular include:

CINM, disuse atrophy: can extend to over 5 years, CIP may recover more slowly than CIM

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Long term complications: physical function:

ADL dysfunction: may be seen for 1-2 years

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Long term complications: Psychiatric symptoms

Depression, PTSD, anxiety

Can persist for over 1 year

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Long term complications: Cognitive

Impairments in memory, attention, executive function: residual effects for up to 6 years

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Long term complications: QOL

Physical deficits

Improves over 1 year but can persist for over 5 years

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ICU-AW stands for

Intensive care unit acquired weakness

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_______ is clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness

ICU AW

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ICU AW is further classified into _____, _____, or ______

Critical illness myopathy (CIM)
Critical illness polyneuropathy (CIP)
Critical illness neuromyopathy (CINM) Combo of CIP and CIM

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Which one of these affects the nervous system? CIP, CIM?

CIP

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CIM can be further sub-classified into what 3 categories?

Cachectic myopathy
Thick filament myopathy
Necrotizing myopathy

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How do you distinguish between CIP and CIM?

Electrophysiological testing in involved tissues

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What develops first? Myopathy or polyneuropathy?

Myopathy- earlier and more frequent

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ICU AW is the presence of 1, 2, 5 ; and sometimes either 3 or 4. What are 1, 2 and 5?

Weakness after onset of critical illness
Weakness involves prox and distal muscles, symmetrical, flaccid and sparing the CNs. Limbs and resp. Muscles
Cause of weakness NOT related to underlying critical illness

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What can be used in place of MRC when looking at clinical features of ICU AW?

What are the values?

Hand dynamometry

<11 kg force for men
<7 kg force for women

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Pathophysiologically important mechanisms for weakness include

Immobility
Local inflammation
Systemic inflammation

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What causes pro-inflammatory during critical illness?

Cytokines shift
Increased production of reactive O2 species
Decrease in anti-oxidative defenses

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True or false: disuse atrophy and ICU AW are the same?

False

Patients with ICU AW will demonstrate weakness ________ to detectable muscle wasting

PRIOR

Disuse atrophy can demonstrate muscle atrophy and loss of muscle strength by how much percent in the first week?

What is associated with SPECIFIC structural and metabolic changes in muscle?

Disuse atrophy

There is a general shift from _____ fibers to ______ fibers with disuse atrophy

Slow twitch to fast twitch

What is the term that describes the adverse effects on multiple aspects of diaphragmatic structure and function after CMV?

Ventilator induced diaphragmatic dysfunction (VIDD)

As few as ____hours of CMV can result in diaphragmatic atrophy

6-18 hours

_______ will also decrease diaphragm strength by oxidative stress (reactive oxygen species ROS)

Hyperglycemia

Hyperglycemia decreases _____ which is one of the key proteins involved in regulation of cross bridge cycling

Troponin T

Increased ________, decreased ________, and increased ________ causes the muscle atrophy

Increased proteolysis Decreased protein synthesis Increased apoptosis

Hypermetabolic stresses of critical illness with result in significant ______ loss in the form of ______

Protein loss | Amino acids

Muscle exhibits a syndrome of _________ where it is unable to use the supply of AA available

Anabolic resistance

Critically ill patients commonly receive less than ___% of their goal nutritional intake during their ICU stay

60%

Bioenergetic failure is reduced ____________ and ATP formation leads to _________ and increased ________

Reduced glucose uptake Mitochondrial dysfunction Free radial production

Muscle atrophy occurs with approximately a ____% decrease in muscle fiber area per day with the greatest atrophy in the contractile myosin filaments and relative preservation of other structural proteins. The muscle protein loss can approach _____% per day

3-4% 2%

ICU AW will affect the ____ and _____ muscles and space the _____ muscles

Limb Trunk/respiratory Facial

name some risk factors for ICU AW

``` Sepsis Multi organ failure Muscle immob HYPERglycemia Corticosteroids Neuromuscular blockers Increased duration or SIRS (systemic inflammatory response syndrome) Mechanical vent for greater than 1 week ```

Recognized brain dysfunction complicating critical illness and constitutes a major challenge to ICU practioners

Delirium

Characterized by acute disturbances of consciousness accompanied by: Inattention Disorganized thinking Perceptual disturbances that fluctuate over a short period of time

Delirium

Delirium is an important factor in ______time even with light sedation

Ventilation

Three types of delirium:

Hypoactive: lethargy and inattenton Hyperactive: agitated and combative Mixed

What does the ABCDE Bundle of Optimal Management consist of?

Awakening and Breathing trial coordination Choice of sedatives Daily delirium monitoring Early mobility and Exercise

Positions that reduce dyspnea:

Upright Lean forward Fixation of arms

What is the OPTIMAL position to reduce dyspnea:

Sitting and leaning forward with the arms resting on the thighs

Sitting and leaning forward for COPD patients ______ intra abdominal pressure, causing the curvature of the diaphragm to ______

Increases | Increase

Fixing the arms ______ the load on the diaphragm

Decreases

Safe exercise parameters for HR

Between 40-130 bpm

Safe exercise parameters for RR

Between 5-40 b/min

Safe exercise parameters for SPO2

>88%

Safe exercise parameters for MAP

Between 65-110 mmHg

Safe exercise parameters for SBP

<200 mmHg

Safe exercise parameters for RPE

Between 10 and 15

Should you do activity with development of arrythmia, angina, or complaint of distress or fatigue?

NOOOOOOOO

Green circle means:

Low risk of adverse event

Yellow triangle means:

Potential risk and consequences of an adverse event are higher than green, but may be outweighed by the potential benefits of mobilization

What does a red octagon mean?

Significant potential risk or consequences of an adverse effect

If percutaneous oxygen saturation is <90%, then....

NO OUT OF BED EXERCISES

Graded mobilization program: Phase 1 | Description:

CANNOT FOLLOW SIMPLE DAMANDS

Graded mobilization program: Phase 1 | Treatment suggestions

PROM, sitting in chair | 3x/day for 20 min

Graded mobilization program: Phase 1 | Criteria for next phase

Able to follow simple commands

Graded mobilization program: Phase 2 | Description

Follow simple commands, requires max assistance to stand or unable to stand

Graded mobilization program: Phase 2 | Treatment suggestions

AA/AROM UE and LE Bed mobility Assisted sitting balance activities Mobile leg press

Graded mobilization program: Phase 2 | Criteria for next phase

Requires min-mod assistance to stand and can support majority of BW

Graded mobilization program: Phase 3 | Description

Still weak Requires min to mod assistance Can support majority or BW

Graded mobilization program: Phase 3 | Treatment suggestions

Progress standing with hydraulic assist platform walker Transfer training to chair Preaumbulation training with walker Gait training

Graded mobilization program: Phase 3 | Criteria for next phase

Requires min assist to ambulate >10 ft with a walker

Graded mobilization program: Phase 4 | Description

Able to transfer and ambulate >10 ft with a walker and min or no assistance

Graded mobilization program: Phase 4 | Treatment suggestions

Progressive walking and gait training High level balance activities Endurance Start HEP