P. Nydahl Neurological ICU & Stroke Unit, Department of Neurology, University of Schleswig-Holstein, Campus Kiel,

Germany

Walking with ventilated ICU patientsSystematic literature research and case description

Background:Immobility of patients on intensive care units (ICU) leads toseveral, long lasting complications. In the last years a paradigmashift took place and the light sedated, mobile and ventilated ICUpatient becomes possible.

Aim:What impact has got walking on ventilated ICU patients?

Method:A pubmed search was conducted in spring 2010 with search termsmobilisation, walking, ambulation, ventilation, intensive care unit,critical care in combination. Secondary hand search was added.Included were studies with the aim of being out of bed underventilation. Excluded have been studies without this purpose.

Web:http://video.yahoo.com/watch/2190081/6932798 (Interview)http://www.youtube.com/watch?v=UMSbOiw0icQ (Techniques)Handout on www.nydahl.de Mail: peter@nydahl.deGerman network early mobilization: www.fruehmobilisierung.de

Results:10 studies were found. The first studies which have all beenperformed with mixed populations of patients point out that earlymobilisation and even walking with ventilated patients is feasibleand safe and can have a positive influence on the duration of ICU-stay and delirium. An oral endotracheal tube is no contra-indicationfor mobilisation, even walking is possible and safe.Walking with ventilation can contribute significantly to the quality oflife, motivation and well-being of patients.

Conclusions:There is an evidence for early mobilisation up to walking withventilated patients. A team approach including good communicationand coordination is highly recommended. Algorithms and adaptablebeds can be used to facilitate mobilisation.

Case descripton:Mrs. B., 70 years, lived in a nursinghome, able to walk with rollator.She had a myasthenia crisis with pneumonia, needed to beintubated and ventilated.

Day 1: Ventilated, RASS -2, Kalymin®, Propofol, NoradrenalinDay 2: RASS -1 - 0, Kalymin®, ø Propofol or NoradrenalinDay 3: sitting on the edge of the bed, ASB (incl ATC) 16 mbarDay 4: stands beside the bed, ASB 16 mbar (reduction failed)Day 5: stands and walks on spot, then ASB 14 mbarDay 6: free walking denied (felt 2 times at home), ASB 12 mbarDay 7: same, ASB 10 mbarDay 8: free walking with physiotherapists and nurse. ASB 8 mbar. Successfully extubated in the evening.

Interesting has been that she failed every attempt to reduce herpressure support, especially (evidence based) spontaneousbreathing trials. But that has been possible a few hours after themobilisation. Day by day her pressure support could be reducedwithout anxiety or hyperventilation. Comparable patients would havea high risk for tracheostomy and multimorbidity.This case description illuminates a new and different approach fordifficult or prolonged to wean patients: if weaning trials fail, mobili-sation is the first goal and weaning becomes secondary - butsuccessful!

24-26.3.2011Copenhagen

Mobilisation:Mrs. B. with an oral tube on a mobile respirator, two physiotherapists and the author.A second nurse follows behind with a wheelchair for the case of immedeateweakness.

Database: pubmed#1 Search icu OR intensive care unit OR critical care 157083#2 Search mobili* OR ambulat* OR walk* 338474#3 Search ventilat* OR respirator 116024#1 AND #2 AND #3 310

Literature research

Limits added:Clinical Trial, Meta-Analysis, PracticeGuideline, Randomized Controlled Trial,Review, Case Reports, published in thelast 5 yearsResult 51

Fulltexts (studies with purpose being outof bed): 9

Excluded 3 articles(without purpose beingout of bed or no study)

Added from reference list: 3Personal contact 1

Summary: 10

Excluded 42 articles(without purpose beingout of bed or no study)

Algorithm mobilisation of ventilated patients - a work proposal:

Metarules• Prefere a light sedation, that allows a daily wake-up and breathing trial• Activity and mobilisation will be suspended for 24 hours if the patient has an acutely unstable event• A mobilisation trial can be more effective than other physical challenging activities• Teamplayer are more mobile than single heroes• Mobility can often be initiated if the FiO2 (+ 0.2) and PEEP (+2) are increased for short time• The algorithm can be evaluated twice a day

Contraindications acute intracerebral hemorrhage or stroke, prior immobility, CPR at admission, unstablecardiovascular disease, BMI> 45, increased intracranial pressure, open chest or abdomen, unstable fractures, large-bore femoralistubes (> 24h), high-dose catecholamines.

Checklist before mobilisation• Supports the bed mobility?• Have a portable monitor, ventilator, suction?• What perfusors, infusions needs the patient in walking?• All tubes are securable?

• Can the equipment be transported?• Is a walker, etc. available for the patient?• Is a wheelchair available?• Are there 2-3 people for 20 minutes?

Inclusion criteria• Intubated and ventilated?• Is the FiO2 ≤ 0.6 and PEEP ≤ 10?• Does the patient understand language?• Is he hemodynamically stable?• Can an angina or a heart attack be excluded?• Min 1 hour since last analgesia bolus?• No physical therapy 1h before mobilisation?

Levels of mobilisation1. Passive movement (Unconsciousness)2. Sitting position in bed (Awareness, answers questions)3. Free sitting in bed (bedside) (able to raise arms against gravity)4. Stand (can lift legs against gravity)5. Walk on the spot6. Active transfer into a chair7. Walk

Passive transfers into a chair are possible from 3rdAchieved level, duration and characteristics will bedocumentated

yes

Dailyevaluation anddocumentation

no

Tolerance?

Tolerance criteriaHeart rate <150

<90 syst. BP <200O2 saturation> 90

In dyspnea:FiO2 +0.2 &PEEP +2

Back to StartReflection:Circulation?Sedation?

Pain?Interaction?

yes

no