Lecture 29: ICU Flashcards
what is ICU liberation
aim = to liberate pts from harmful effects of ICU stay
comprehensive “bundle” for interdisciplinary team
decreases likelihood of hospital death w/ 7 days ICU admission by 68%
reduces delirium by 25-50%
decreases ICU readmissions by half
describe A-F of ICU bundle
A = assess, prevent, manage pain
B = both spontaneous awake trials (SATs) and spontaneous breathing trials (SBTs)
C = choice of anesthesia and sedation
D = delirium assessment, prevention, and management
E = early mobility and exercise
F = family engagement and empowerment
describe early mobility in ICU
safe and feasible for adults and kids
decreases/prevents delirium
improves functional outcomes
cost effective
may look different than typical acute care PT eval
requires interdisciplinary team
*need right pt, right time, right therapist
barriers to ICU rehab
pt “too sick”
pt too sedated
medical equipment limits mobility
limited or under qualified staffing
prioritization of ICU pts for follow up intervention along continuum of care
ICU med staff with limited knowledge regarding what rehab services can offer pts
describe the stoplight system
grades various clinical considerations and what is considered safe in bed and out of bed activities
Green = low risk of adverse event; proceed as usual according to ICU protocols
yellow = potential risk of adverse event; risk may be outweighed by benefit of mobilization; clarify precautions/contraindications prior to mobilization
red = significant potential risk; active mobilization should not occur unless specifically authorized by treating ICU specialist in consult with senior PT and senior nursing staff
indications for mechanical vent
acute respiratory failure (hypoxemia vs hypercapnic respiratory failure)
compromised lung function (PNA, COVID, CF, pleural effusions, aspiration)
breathing difficulties (rib fxs, neurological insults, phrenic nn injury)
inability to maintain airway (trauma, severe AMS, ETOH/substance abuse, airway swelling)
what is a Passy-Muir Valve (PMV)
external speaking valve that creates a closed pressure system for the creation of sounds by vocal cords
RR for MV setting
normal = 10-16
may be adjusted depending on goal
Tidal volume use with MV
volume of air moved in and out of lungs with normal breathing
normal = 4-8 ml/kg body weight
may be adjusted depending on goals
fraction inspired O2 (FiO2) with MV
atmospheric = 21%
can go up to 100% with MV
positive end expiratory pressure (PEEP) for MV
amount of pressure at end of expiration that keeps alveoli open to allow for gas exchange and prevents collapse
atmospheric = 3-5 cmH2O
can go up as high as 20 cmH2O depending on goal of MV
minute volume (MV or ME) on mechanical vent
total amount of air moved in and out of lungs in 1 min
rate x volume (RRxTV = MV)
average 4-6 L/min
what is pressure support on a MV
pressure delivered by vent to overcome airway resistance and open airways
spontaneous weaning mode
pre-set pressure given during inhale only
ranges from 5-30 cmH2O
higher number = more work vent is doing, and pt can generate inhale easier
assisted vs spontaneous MV modes
assisted
- vent starts and stops breath, does most of work
- provides pre set parameters set by MD/RT
- non-wearing modes
spontaneous
- pt starts and stops breath, does all or some of work
- vent will provide volume or pressure only AFTER the pt initiates their own breath
- weaning modes
what is assisted control with a vent
non weaning modes of MV
can provide full vent support bt doesn’t have to depending on situation (used if pt is unconscious’s edited, etc and cant generate own breath)
pt can generate inhalation and triggers the vent to provide a pre set pressure or volume
if pt doesn’t generate a breathe, the vent will provide a breath based on pre set parameters
provides ability to keep pts work of breathing very low
pts can tolerate increased demands if medically stable and working with PT since the vent can provide so much more support
what is a spontaneous breathing trial
“test”period to see if pt will be able to tolerate extubation
pt generates 100% of their own breaths
vent matches atmospheric parameters to stimulate atmospheric breathing
usually lasts 2 hours
coordinated by RT, parameters set to pass or fail
no mobility during SBT 99.99% of time
what is extra corporeal membrane oxygenation (ECMO)
heart and lung bypass for acute pulmonary and/or cardiac failure when no other form of treatment is successful
blood is removed from the venous system and oxygenated outside the body, then returned
requires very large cannulas and continuous attachment to ECMO machine
most advanced form of life support available
indications
- MSOF
- bridge to transplant
what is veno-venous (VV) ECMO
blood removed from vein
blood returned to vein
normal cardiac function
ECMO only supporting the lungs
what is veno-arterial (VA) ECMO
blood removed from vein
blood returned to artery
ECMO supporting heart and lungs
what is continuous renal replacement therapy
continuous dialysis, requires large central venous Cath
frequently in jugular or subclavian vein, more safety concerns if in femoral
indications:
- severe AKI
- hyprtkalemia
- fluid overload
- acidosis
- hemodynamic instability
compared to iHD
- increased hemodynamic stability
- greater solute and electrolyte control
- superior fluid balance management
- can dialyze at a slower rate over longer periods of time
where to start with PT ICU eval
chart review/team communication
- admission/progress notes
- procedures
- medications
- RT documentation
get baseline vitals and vent settings
locate wires, IVs, Caths, ad determine which can be disconnected
plan/set up; clear communication of timing, goals, plans, expectations and roles to pt, family, and nursing staff
components of ICU Eval
PLOF/hx
cognitive screen
orthostatic tolerance using bed controls
bed level ROM, strength, sensation
slow progression of mobility: supine to sit; sitting balance/EOB; STS; standing balance; pre-gait tasks; transfers or gait
goal = not to return to supine if pt remains medically stable
if leaving pt out of bed, ensure ability for other staff to return to supine later
*constant monitoring of vitals and pt response
keys to successful mobility in ICU
room set up, equipment, planning
move IV poles, lines, vent, etc to side of bed pt is mobilizing to
try to keep all accessories in front of pt to avoid dislodging
create clear roles for everyone
explain what is going to happen to pt
precautions to keep in mind with ICU PT
mechanical vent, ECMO, or CRRT are not absolute contraindications to mobility
- must consider WHY device is being used
- remember that they are life support devices, so appropriate caution must be taken
vital signs and meds
- must look at trends not just snapshot
- expected vs normal
titration of activity ay be indicated
- PT intervention may not look the same as other acute care or even critical care pts
- have multiple options if initial goal is not safe or feasible to complete
- be prepared to change tactics rapidly if needed
contraindications in ICU
hemodynamic instability requiring medical interventions
recent respiratory instability or increased vent settings
O2 sat <88%
RR >40
FiO2 >60%, PEEP >10cmH2O
active bleeding
increasing trend of pressors, cardiac drugs, sedation, etc
extreme agitation
increased ICP
what is the Richmond agitation sedation scale (RASS)
10 point scale used to measure agitation and sedation
most PT guidelines set parameters between +2 and -2
what is confusion assessment method for the ICU (CAM-ICU)
score for assessing severity of delirium in ICU pts
combines mentation, attention, level of alertness, and disorganized thinking
what is activity measure for post acute care (AMPAC “6 clicks”)
very widely used in acute care settings to predict discharge destinations and functional impairment level
6 functional tasks scored
can be what pt reports being able to complete, not what they actually perform in that moment
Medicare uses for approval/denial
<17/24 = might need post acute rehab
what is functional status score for the ICU (FSS-ICU)
physical function measure specifically designed and validated to be used in the ICU
scores functional ability on 5 tasks: rolling, supine to sit, EOB sitting, STS, and ambulation
out of 35 points, the lower the score the higher the functional impairment
what is perme ICU mobility score
reflects pt mobility status, scored in 7 categories
- mentation
- potential mobility barriers
- functional strength
- bed mobility
- transfers
- gait
- endurance
only score that incorporates barriers to mobility unique to ICU
out of 32, the lower the score, the higher the functional impairment and higher barriers to functional mobility
