Stiller Article Flashcards
What are the general aims of mobilization?
- Improving respiratory function by optimizing ventilation/perfusion
matching, increasing lung volumes, and improving airway clearance - Reducing the adverse effects of immobility
- Increasing levels of consciousness
- Increasing functional independence
- Improving cardiovascular fitness
- Increasing psychological well being
How can mobilization specifically benefit the critically ill patient?
Mobilization may…
Reduce the incidence of pulmonary complications
Hasten recovery
Decrease the duration of mechanical ventilation
Decrease the length of ICU or hospital stay
What were the major findings by Stiller & Phillips After mobilizing 31 ICU patients?
Mobilization resulted in significant increases in
HR and BP, and a nonsignificant fall in SpO2
Deterioration in status required intervention in 4.3% of occasions -> mobilization was a safe intervention
for most subjects.
What intrinsic factors should be assessed in determining if mobilization is appropriate for a patient in the ICU?
Medical background and current condition Cardiovascular reserve Respiratory reserve Hematology and metabolism Other
What is considerd in the medical background and current condition when determining if mobilization is appropriate for a patient in the ICU?
Medical hx
Medications
Previous activity and exercise capacity
Current condition
True of false, formal exercise testing to establish exercise tolerance is contraindicated in the ICU setting
True, use other, indirect measures (look for the other card on this subject)
What should PTs rely on when determining exercise tolerance in the ICU setting?
How well the patient has tolerated other recent interventions and ascertain which systems, if any, limited these interventions. Thus, the patient’s response to these interventions provides an indirect exercise test
True or false, a resting HR of more than 50% of age-predicted max contraindicates mobilization in the ICU
False, mobilization is still well tolerated by most of these patients
While these patients may have a limited cardiac reserve, resting HR should not (usually) be the sole factor considered when considering mobilization
Name some CV signs that a patient is not tolerating mobilization well
Abnormally high increase in HR, particularly if it does not stabilize Marked fall in HR Shortness of breath Clamminess, faintness, or chest pain Excessive increase in BP Fall in BP
What is the normal response of SBP and DBP to exercise? (typical, healthy patient)
SBP: Initial rise followed by increase that correlates linearly with intensity
DBP: Remain stable or increase slightly (at higher intensity levels)
What is the normal response of an ICU patient’s SBP and DBP to exercise?
Data suggests that both SBP and DBP rise significantly
While the evidence is not strong, what are some guidelines for using a patient’s BP to judge the appropriateness and effectiveness of mobilization in the ICU patient?
Stability of BP may be more useful than an absolute value - change > 20% may indicate hemodynamic instability and may contraindicate mobilization
If inotropes (epi, NE, DA) are required to maintain BP, mobilization may be contraindicated
The ACSM lists cardiac conditions that contraindicate exercise testing. The authors suggest that these same conditions may be used as relative or absolute contraindications to mobilization in critically ill patients. What are these conditions?
Recent significant change in the resting ECG, suggesting significant ischemia, recent MI, or other cardiac event Unstable angina Uncontrolled cardiac arrhythmia causing symptoms or hemodynamic compromise Severe symptomatic aortic stenosis Uncontrolled symptomatic heart failure Acute (PE) or pulm infarct Acute myocarditis or pericarditis Suspected or known dissecting aneurysm Acute infections
True or false, ECG is a useful, though not a mandatory, tool for monitoring ICU patients during mobilization
False, it is mandatory - provides an instantaneous measurement of HR and allows the detection of arrhythmias
True or false, the authors recommend using partial pressure of oxygen in the arterial blood (PaO2) to monitor oxygenation and respiratory reserve
False the authors recommend PaO2/FIO2
FIO2 is the inspired fraction of oxygen
How do the authors group PaO2/FIO2 values into categories and what does each mean?
Above 300: pt likely has sufficient respiratory reserve to tolerate mobilization well
200-300: Pt has marginal respiratory reserve
Below 200: Pt has minimal respiratory reserve
True or false, lower PaO2/FIO2 values contraindicate mobilization
False, they indicate the need for extreme care, careful monitoring, and modification of intensity
While the evidence is not strong, what are some guidelines for using a patient’s SpO2 to judge the appropriateness and effectiveness of mobilization in the ICU patient?
A SpO2 of 90% or more, accompanied by a recent
fluctuation of less than 4%, is likely to indicate sufficient respiratory reserve to tolerate mobilization
What is hypercapnia?
elevated partial pressure of arterial CO2
What might hyperapnia indciate
Acute respiratory failure
Chronically, hypercapnia should not affect ability to mobilize
What is considered when determining if the patient has sufficient CV reserve for mobilization?
Heart rate
Blood Pressure
ECG
Cardiac status
What is considered when determining if the patient has sufficient pulm reserve for mobilization?
PAO2/FIO2 and SpO2
Respiratory Pattern
Mechanical ventilation
What ECG findings indicate that a patient may have sufficient cardiac reserve?
Absence of MI or arrhythmia
What is observed when evaluating a patient’s respiratory pattern?
Respiratory rate
Asynchronous or paradoxical movement of the chest wall and abdomen
Overactivity of the accessory respiratory muscles Unduly prolonged expiration or wheezing
If a patient has sufficient oxygenation (PaO2/FIO2, SpO2), does this indicate that their respiratory pattern will be satisfactory?
Not necessarily, the pt may only be able to do this at the expense of an increased work of breathing, reflected by a high respiratory rate and labored breathing.
In such a setting, the numbers may say ‘go’, but subjective observation suggests deferment, or at least caution, if attempting any mobilization.
True or false, mechanical ventilation contraindicates mobilization
False, though these pts should be approached with extra care and caution during mobilization
What is considered when determining if the patient has sufficient pulm reserve for mobilization?
Oxygenation
Hypercapnia
Respiratory Pattern
Mechanical ventilation
What is considered when determining if the pts hematologic and metabolic status is appropriate for mobilization?
Hemoglobin Platelet count White cell count Body temperature Blood glucose level
True or false, Hg values outside of the normal range contraindicate mobilization
False
Side note: an acute fall in hemoglobin may be more clinically appropriate as an indication of active or recent bleeding, especially if it is associated with hemodynamic instability
Why is platelet count considered in determining a pts appropriateness for mobilization?
Pts with a very low platelet count are at higher risk of microvascular trauma and bleeding, which in turn have the potential to result from any activity (such as mobilization) that significantly increases BP.
What might an abnormal WBC count indicate
Both high and low WBC counts can indicate infection
True or false, infection contraindicates mobilization
False
Why does infection indicate that mobilization should be approached with caution?
Infection can increase the patient’s oxygen utilization, thus caution is required if undertaking activities that further increase oxygen demand
What are other things should be considered besides Medical background and current condition
CV and pulm reserve, hematology, and metabolism
when determining appropriateness for mobilization?
Appearance of the patient
Neurological status
Presence of certain orthopedic conditions
Nutritional status
