Rubine de BeerPhysiotherapist

Steve Biko Academic HospitalFebruary 2014

Mobilisation Asher 1947

“Teach us to live that we may dread unnecessary timein bed. Get people up and we may save our patients from an early grave.”

(Grosselink et al. 2008)

What is Mobilisation in ICU?Physical activity sufficient to elicit acutephysiological effects that enhance

Ventilation,

Central and Peripheral Perfusion,

Circulation,

Muscle metabolism,

Alertness,

Are counter measures for venous stasis and DVT.(Walsham et al. 2009)

Effects of Immobility in ICU CNS Cardiovascular Respiratory Gastro-Intestinal Urinary Tract Dermatological Psychological Musculoskeletal Functional Independence Cost of Care Length of hospital stay

CNS Decrease Perception

Decrease Proprioception / Co-ordination

Decrease Balance

Decrease / Increase muscle tone

Cardiovascular Decrease Cardiac Output, Stroke Volume, Peripheral

Vascular Resistance

Venous stasis

Orthostatic intolerance

Increase risk of venous thrombosis and Pulmonary Emboli

Decrease total cardiac and left ventricular size

Respiratory Decrease ant / post diameter → Decrease alveolar

size → Decrease gas exchange

Decrease in functional residual capacity

Decrease lung compliance

Retained secretions → Pneumonia (VAP)

Atelectasis

Respiratory muscle weakness

Decrease exercise tolerance

Gastro Intestinal Decrease bowel function

Abnormal fluid distribution

Urinary Tract Kidney stones

Increase excretion of Nitrogen, Calcium, Magnesium and Potassium

Dermatological Pressure sore formation

Psychological Depression

Anxiety

Decrease Cognition

Delirium

Musculoskeletal Decrease muscle protein synthesis Muscle atrophy (30% loss in week) Decrease muscle strength (40% loss in week) Contractures Decreased Range of motion (ROM) Loss of bone density – Osteoporosis Neuromuscular weakness

Critical Illness Polyneuropathy or Myopathy

Decrease Quality of Life (5 years post ICU)

Critical IllnessCritical Illness

↑ Reactive O2 Species Bed Rest Malnutrition↑ Inflammatory Cytokines

Neuromuscular Abnormalities

Muscle Weakness

↑ Mechanical Ventilation Time ↑ ICU / Hospital Stay ↓ Physical Function ↓ QOL

(Truyong et al. 2009)

CIP & CIM CIP

Decrease sensation

Distal weakness > Proximal weakness

Deep tendon reflex absent

CIMNormal sensation

Proximal weakness > Distal weakness

Hypoactive deep tendon reflex

(Khan et al. 2006)

When to Start Mobilisation 24-48 hours after ICU admission

Physiological StabilityNeurologically (Conscious)

Cardiovascular (HR <50% age predicted Max HR,Normal BP, Normal ECG)

Respiratory (SaO2 >90%, Respiratory pattern)

Haematologically (HB >7, Platelet count, Glucoselevels 3.5 – 20mmol/L)

Sufficient perfusion to maintain normal organ function

(Dean & Ross, 1994)

Steps of MobilisationPassive or active limb exercises in

bedSitting over side of bed with or without

support

T/F from bed to chair with partial mechanical assistance

T/F from bed to chair without mechanical assistance

Standing and walking on the spot with mechanical assistance

Walking without mechanical assistance

(Walsham et al. 2009)

Mobilisation Techniques Limb exercises (passive, active assisted,

active and resistant)

Active / passive moving or turning in bed

Hoist

Slide board

Motomed

Walking Aid (Walking frame)

Effects of mobilisation Psychological

Central nervous system - Consciousness

Cardiovascular

Respiratory - Improve airway clearance

- Improve lung volumes

Gastro Intestinal

Musculoskeletal – Functional Independence

(Stiller K. 2007)

When to Stop Mobilisation SaO2 <88%

Hypotension associated with dizziness

Heart rate >max heart rate

Change in heart rhythm

Increased respiratory rate

Chest pain

Excessive pallor of flushing skin

Mobilisation Team Medical staff

Nursing staff

Physiotherapist

Current Treatment Passive exercises

Active Assisted

Active exercises

Resistant exercises

Sitting over side of bed

Sit in chair with hoist

Standing / walking with hoist

Walk with assistive device

Motomed

Motomed Exercise Machine in ICU

Passive exercises

Active exercises

Resistant exercises

Upper limb and Lower limb

Feedback to the patient

Motomed

Motomed General weakness

COPD

Brain Injury / CVI

Paraplegia

Cancer

Awake and orientated

Contra Indications for mobilisation

Different Studies Australian Journal of Physiotherapy – 2004

Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient.

Study was done in Sydney Australia, took ABG before and after mobilisation. Mobilise patient into supine, sit, stand, walk on the spot for 1 minute and sit in chair for 20 minutes. Study showed physiological changes due to change in position from supine to sit / stand. No changes from sit / stand – 20 min sit.

Studies Cont.

Studies Cont.

Studies Cont. Physical Therapy – September 2006

Effects of physical training on functional status in patients with prolonged mechanical ventilation – 6 week training program (active and resistant UL and LL exercises)

Function, QOL and Psychological improvement

Critical Care Medicine – 2007Treatment group received OT and PT during daily wake

up. Control group received standard care. Treatment group had shorter ventilation days, decrease delirium and quicker recovery.

Studies Cont. American Journal of Critical Science - 2011

Questionnaire send 12 months after DC from hospital for patients with respiratory failure – patients not mobilised early - readmission / passed away

Critical Care Research and Practise – July 2012

Randomised control study of 90 patients. Treatment group ride bicycle for 5 days, 20 min per day – Mobiliseindependantly with D/C. Control group need rehab

Case Study: SBAH Surgery ICU19 Year old female patient. Diagnosed with achalasia,

leiomyopathy, diabetes and asthma. She presented with

an unknown syndrome. The patient presented during

May 2013 with abdominal pain. She had several

laparotomies for bowl obstruction. Fistula was formed.

3 months on TPN, with no oral intake.

Admitted in ICU 26 July 2013 – 46 days in ICU

Daily Physiotherapy Rx Chart

Date Treatment Date Treatment

26/7 Chest Physiotherapy 05/8 Mobilise bedside

27/7 - 06/8 Mobilise chair

28/7 - 07/8 Stand – with assistance

29/7 Mobilise bedside 08/8 Motomed exercise

30/7 Bed exercise 09/8 -

31/7 Stand – with assistance 10/8 -

01/8 Motomed exercise 11/8 -

02/8 Mobilise bedside 12/8 Bed exercise

03/8 - 13/8 Bed exercise

04/8 - 14/8 -

Daily Physiotherapy Rx Chart

Date Treatment Date Treatment

15/8 Stand, walk next to bed 25/8 -

16/8 Motomed 26/8 Motomed exercise

17/8 - 27/8 Sit w/chair outside

18/8 - 28/8 -

19/8 - 29/8 Bed exercise

20/8 Motomed exercise 30/8 Walk with walking frame

21/8 Bed exercise 31/8 -

22/8 Stand with assistance 01/9 -

23/8 Motomed exercise 02/9 Bed exercise

24/8 - 03/9 Mobilise bedside

Daily Physiotherapy Rx Chart

Date Treatment

04/9 Mobilise in chair

05/9 Motomed exercise, Stand, Sit outside

06/9 Mobilise with ventilator

07/9 -

08/9 -

09/9 Mobilise in chair

10/9 Motomed exercise

Motomed ChartPatient Info 08/08 16/08 20/8 05/9 10/9

Mode of ventilation

SIMV SIMV SIMV SIMV CPAP

FiO2 40% 40% 40% 40% 40%

PEEP 10 8 6 5 5

PSV 24 10 12 18 8

Set Rate 10 10 8 1 0

SaO2 97% 91% 96% 98% 98%

Type of feeding TPN = 60 TPN = 60Intestimine

= 8

TPN = 60Survimed

= 10

Survimed= 40

Survimed= 40

Weight 29 kg 25 kg 25 kg 30 kg 30 kg

Type of Exercise Arms Arms Arms Arms Arms

Motomed Chart

Patient Info 08/08 16/8 20/8 05/9 10/9

MotomedProgram

Servo cycle Servo cycle Servo cycle Servo cycle Servo cycle

Active Distance 0.4km 0.15km 0.53km 0.42km 0.67km

Passive Distance 0.06km 0.29km 0.11km 0.20km 0.00km

Total Distance 0.46km 0.44km 0.64km 0.62km 0.67km

Active Time 4:17 2:04 4:22 3:43 5:05

Passive Time 0:45 3:03 1:14 2:03 0:03

Total Time 5:02 5:07 5:36 5:46 5:05

Active Speed 20km/h 16km/h 28km/h 24km/h 29km/h

Motomed Chart

Patient Info 08/8 16/8 20/8 05/9 10/9

Total Energy 3.7kcal 1.8kcal 3.8kcal 3.2kcal 4.5kcal

Energy 15.5KJ 7.5KJ 15.8KJ 13.5KJ 19.0KJ

Symmetry 35/65 42/58 56/44 48/52 52/48

Muscle Tone - 1 - 0 -

Muscle Spasm 0 0 1 0 0

Peak Performance

- - 1 0 1

Conclusion Early mobilisation is beneficial to critically ill patients

Decrease duration of mechanical ventilation

Decrease delirium

Decrease length of stay

Improve Functional independency

Safe money

Inter-professional team work is essential

Conclusion Mobilise…

Mobilise…

Mobilise….

References Adam S. ABC of ICU. BMJ. 1999;319:175-178 Chiang L. Effects of Physical Training on Functional Status

in patients with prolonged mechanical ventilation. Physical Therapy. 2006;86(9):1271-1281

Clini E. Early physiotherapy in the respiratory ICU. Respiratory Medicine. 2005;99:1096-1104

Clark E. Effectiveness of an early mobilization protocol in TBICU: Retrospective cohort study. Journal of the American Physical Therapy Association. 2013; 93:186-196

Dale M. Mobilizing patients in the ICU. JAMA. 2008;300:1685-1690

Grosselink R. Physiotherapy for adult patients with critical illness. Intensive Care Medicine. 2008;34:1188-1199

Khan J. Acquired weakness in the ICU. Minerva Anestesiol. 2006;7:401-405

References Parker A. The importance of early rehabilitation and

mobility in the ICU. 2013 Perme C. Early mobility and walking program for

patients in ICU. AJCC. 2009;18:212-221 Ruth M. How early should we mobilize ICU patients?

Medscape. 2011 Stiller K. Physiotherapy in ICU. Chest. 2000;118:1801-

1813 Stiller K. Safety aspects of mobilising acutely ill

inpatients. Physiotherapy Theory and Practice. 2003;19:239-257

Truyong A. Bench-to-bedside review: Mobilizing patients in ICU – from pathophysiology to clinical trials. Critical Care. 2009;13:216

References Van Aswegen H. Physiotherapy in ICU. 2011 Walsham J. Should we mobilise critically ill patients?

Critical Care And Resusitation. 2009;11:290-300

Zafiropoulos B. Physiological responses to the early mobilisation of intubated, ventilated abdominal surgery patients. Australian Journal of Physiotherapy. 2004;50:95-99

Zomorodi M. Developing a mobility protocol for early mobilisation of patients in a surgical / trauma ICU. Critical Care Research and Practise. 2012

QUESTIONS ????