EARLY MOBILISATION IN ICU

Megan Whelan

Physiotherapy Department

Chris Hani Baragwanath Academic Hospital

Early Mobilisation

in ICU

ICU Acquired

Weakness (ICUAW)

Benefits

How do we measure its

effectiveness?

How is it done?

Barriers, Safety and Feasibility

Introduction

• Critically ill patients in the intensive care unit often require prolonged mechanical ventilation and have typically been placed on STRICT bed rest in the past (Bailey et al 2007; Adler & Malone 2012)

• Known complications of bed rest include: – Respiratory tract infections – Pneumonia – Constipation – UTI – DVT – Contractures – Pressure sores – Line sepsis – Weakness

ICU Acquired Weakness

• Results in: – Prolonged duration of mechanical ventilation

– Longer ICU stay

– Longer hospital stay (Truong et al 2009)

• Catabolic muscle wasting is inevitable in bedridden patients (Coakley et al 1998)

– Acute phase = massive accumulation of oedema (Coakley et al 1998)

– Oedema masks muscle wasting

– As oedema subsides, the muscle wasting becomes apparent (Coakley et al 1998)

• Specific pathological processes associated with weakness include:

– Critical illness neuromyopathy

– Critical illness polyneuropathy

– Critical illness myopathy

(Coakley et al 1998)

ICU Acquired Weakness

• Results in:

– Poor long term physical outcomes

– Functional limitations

– Poor quality of life

(Bailey et al 2007, Herridge et al 2003, Schweickert & Hall 2007)

ICU Acquired Weakness

Figure 1: Mechanisms and outcomes of neuromuscular weakness in critical

illness

(Truong et al 2009)

ICU Acquired Weakness

Early Mobilisation

• “Early mobilisation is a pattern of increasing activity beginning with passive/active range of motion exercises progressing to ambulation” (Bailey et al 2009, p429)

• This is normally performed within 24-48 hours of admission into ICU or upon relative haemodynamic or respiratory stabilisation (Bailey et al 2007)

• Reduced hospital length of stay (Morris et al 2008, Needham et al)

• Vast improvement in functional outcomes (Adler and Malone 2012)

• Improved muscle strength (Adler and Malone 2012)

• Reduced airway complications (Dean 1994, Clark et al 2013)

Benefits of Early Mobilisation

• Airway complications include: – Ventilation/perfusion mismatch – Reduced lung compliance – Reduced secretion clearance – Increased work of breathing – Atelectasis

• Early mobilisation results in reduced incidence of pulmonary embolism – Patients are less likely to develop DVT (Dean 1994, Clark et al 2013)

Benefits of Early Mobilisation

Safety and Feasibility

• Multiple studies show that early mobilisation is safe and effective provided that a well trained MULTIDISCIPLINARY TEAM is involved in the process (Hodgson et al 2013)

• Ambulation with patients who have endotracheal tubes is safe (Clarke et al 2013, Bailey et al 2007)

– Haemodynamic instability

– Respiratory instability

– Unstable fractures

– Continuous sedation

– Restraints

– Dialysis

– Lack of “mobile ventilators”

– Poor premorbid mobility

– Pain

– Patient lines

(Leditschke et al 2012, Hodgson et al 2013)

Barriers

• Passive ROM exercises • Active ROM exercises • Roll from side to side • Bridge • Lie to sit • Supported/unsupported sitting • Sit to stand • Supported/unsupported standing • Transfer to chair • Stepping • Ambulation

How is it done?

• Prospective study

• 103 participants mechanically ventilated >4 days in a respiratory ICU

• Early Activity Protocol was initiated as soon as the patients were deemed to be physiologically stable – Able to participate neurologically – Maintain BP when upright – Maintain adequate oxygen saturation during activity

• Aim of the protocol was to ambulate >100 feet on discharge

from the RICU

Early activity is feasible and safe in respiratory failure patients

Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriguez L & Hopkins RO (2007) Critical Care Medicine 35(1):139-145

Multidisciplinary team

Barriers, safety and feasibility

How is it done

• Each activity event required:

– Break in sedation

– Removal of restraint

• Full co-operation of the multidisciplinary team

– Physiotherapist

– (Respiratory therapist)

– Nurse

– Critical care technician

Early activity is feasible and safe in respiratory failure patients

Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriguez L & Hopkins RO (2007) Critical Care Medicine 35(1):139-145

• Activity events identified: – Sit on the edge of the bed unsupported – Transfer from bed to chair – Ambulate

• Activities were progressed accordingly

• Patients received bidaily treatment sessions

• Fi02 was increased by 0.2 at the start of activity initiation for intubated patients

Early activity is feasible and safe in respiratory failure patients

Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriguez L & Hopkins RO (2007) Critical Care Medicine 35(1):139-145

• 1449 activity events in total were performed

– 16% included sitting on the edge of the bed

– 31% had patients out of bed

– 53% of the activities involved ambulation

• 41% of activity events were performed in intubated patients of which 42% included ambulation

• Number of adverse events was low and none of these events were serious

Early activity is feasible and safe in respiratory failure patients

Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriguez L & Hopkins RO (2007) Critical Care Medicine 35(1):139-145

• None of the adverse events resulted in: – Extubation

– Complications that required additional medical treatment

– Complications that required additional costs to the unit

– Longer hospital stay

• Majority of the patients were able to ambulate>100 feet on discharge from RICU

Early activity is feasible and safe in respiratory failure patients

Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriguez L & Hopkins RO (2007) Critical Care Medicine 35(1):139-145

• According to the algorithm created, patients can be divided in to 3 categories

• On admission into the ICU, the patient is screened and evaluated for treatment “stability” using preset criteria

• A patient specific mobilisation programme with objectives and measurable outcomes is then developed with input from all members of the MDT depending on which category the patient is placed into

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion

and its translation

Hanekom S, Gosselink R, Dean E, van Aswegan H, Roos R, Ambrosino N & Louw Quinette (2011) Clinical Rehabilitation 25(9):771-787

• Category A: Unconscious patient

– Nursing the patient in a head up position

– 2 hourly position changes

– Passive ROM of upper and lower limbs

– Once patient is awake refer to Category B

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion

and its translation

Hanekom S, Gosselink R, Dean E, van Aswegan H, Roos R, Ambrosino N & Louw Quinette (2011) Clinical Rehabilitation 25(9):771-787

• Category B:

Patient is awake (within first 5 days of admission) – Criteria for consideration of active mobilisation

include: • Pulmonary reserve

• Cardiovascular reserve

• Other factors

– If patient does not meet the criteria, refer back to category A

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion

and its translation

Hanekom S, Gosselink R, Dean E, van Aswegan H, Roos R, Ambrosino N & Louw Quinette (2011) Clinical Rehabilitation 25(9):771-787

– Progressive mobilisation occurs depending on how well the patient copes

– This will includes upper and lower limb strengthening exercises especially if the patient is unable to mobilise out of bed

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion

and its translation

Hanekom S, Gosselink R, Dean E, van Aswegan H, Roos R, Ambrosino N & Louw Quinette (2011) Clinical Rehabilitation 25(9):771-787

• Category C: Deconditioned patient

– Specific exercises targeting weak muscle groups of upper limbs, lower limbs and trunk

– Low resistance with multiple repetitions (eg. 3 sets of 8-10 reps at 50-70% of repetition maximum)

– Exercises intensity should be considered between 11-13 on the Borg Scale of Perceived Exertion

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion

and its translation

Hanekom S, Gosselink R, Dean E, van Aswegan H, Roos R, Ambrosino N & Louw Quinette (2011) Clinical Rehabilitation 25(9):771-787

HOW AND WHAT DO I MEASURE?

How do I know that my treatment is effective?

• Muscle strength – MRC Scale

– Oxford scale

• Function – Functional independence measure (FIM)

– Physical Function ICU Test (PFIT)

– Chelsea Critical Care Physical Assessment Tool (CPAx)

Outcome Measures in ICU

The Chelsea Critical Care Physical Assessment Tool (CPAx): validation of an innovative new tool to

measure physical morbidity in the general adult critical care population; an observational proof-of-concept

pilot study

Corner EJ, Wood H, Englebretsen C, Thomas A, Grant RL, Nikoletou D & Soni N (2013) Physiotherapy 99:33-41

Intensive care unit acquired weakness: measuring recovery from critical illness

Corner EJ (2012)

JICS 13(3):216-220

Construct validity of the Chelsea Critical Care Physical Assessment Tool: an observational study of recovery

from critical illness

Corner EJ, Soni N, Handy JM & Brett SJ (2014) Critical Care 18 R55

Corner et al. Critical Care 2014 18:R55 doi:10.1186/cc13801

• ‘Easy to use’ outcome measure

• Composed of 10 commonly assessed functional components

• Component scores (0-5) range from complete dependence to independence

• Total overall score of 50 – 0 represents total dependence – 50 represents full independence

CPAx

1. Respiratory function 2. Cough 3. Moving within the bed 4. Supine to sitting on the edge of the bed 5. Dynamic sitting 6. Standing balance 7. Sit to stand 8. Transferring from bed to chair 9. Stepping 10.Grip strength

CPAx

Why CPAx??

• Tool identifies specific areas for improvement

• Treatment is goal orientated

• Patients can actively participate in goal setting

• Progress is easily identified by everyone including the patients

Conclusion

• Early mobilisation

– Improves strength

– Improves functional outcome

– Improves quality of life

– Reduces ICU and hospital length of stay

– Saves money for the unit

WIN – WIN!

References • Adler & Malone (2012). Early Mobilisation in the Intensive Care Unit: A Systematic Review. Cardiopulmonary

Physical Therapy Journal 23(1):5-13

• Bailey PP, Miller RR & Clemmer TP (2009). Culture of early mobility in mechanically ventilated patients. Critical Care Medicine 37:429-435

• Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriguez L & Hopkins RO (2007). Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine 35(1):139-145

• Clini E & Ambrosino N (2005). Early physiotherapy in the respiratory intensive care unit. Respiratory Medicine 99:1096-1104

• Coakley JH, Nagendran K, Honovar M & Hinds CJ (1998). Preliminary observations on the neuromuscular abnormalities in patients with organ failure and sepsis. Int Care Medicine 19:323-328

• Corner EJ (2012). Intensive care acquired weakness: measuring recovery from critical illness. JICS 13(3):216-220

• Corner EJ, Wood H, Englebretson C, Thomas A, Grant RL, Nikoletou D & Soni N (2013). The Chelsea Critical Care Physical Assessment Tool (CPAx): validation of an innovative new tool to measure physical morbidity in the general adult critical care population; an observational proof of concept pilot study. Physiotherapy 99:33-41

• Corner EJ, Soni N, Handy JM & Brett SJ (2014). Construct validity of the Chelsea critical care physical assessment tool: an observational study of recovery from critical illness. Critical Care 18 R55

• Dean E (1994). Oxygen transport: a physiologically-based conceptual frameowrk for the practice of cardiopulmonary physiotherapy. Physiotherapy 80:347-355

• Hanekom S, Gosselink R, Dean E, van Aswegan H, Roos R, Ambrosino N & Louw Q (2011). The development of a clinical management algorithm for early physical activity and mobilization of critically ill patietnts: synthesis of evidence and expert opinion and its translation into practice. Clinical Rehabilitation 25(9):771-787

• Herridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N, Al-Saidi F, Cooper AB, Guest CB, Mazer D, Mehta S, Stewart TE, Barr A, Cook D & Slusky AS (2009). One-year outcomes in survivors of the Acute Respiratory Distress Syndrome. The New England Journal of Medicine 348(8):683-693

• Hodgson CL, Berney S, Harrold M, Saxena M & Bellomo R (2013). Clinical review: Early patient mobilisation in the ICU. Critical Care 17(207):1-7

• Leditschke A, Irvine J, Bissett B & Mitchell I (2012). What are the barriers to mobilising intensive care patients? Cardiopulmonary Physical Therapy Journal 23(1):26-29

• Needham DM (2008). Mobilising patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA 300:1685-1690

• Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB & Kress JP (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised control trial. Lancet 373:1874-1882

• Truong AD, Fan E, Brower RG & Needham DM (2009). Bench-to-bedside review: Mobilizing patients in the intensive care unit – from pathophysiology to clinical trials. Critical Care 13(4)1-8. Figure 1: Mechanisms and outcomes of neuromuscular weakness in critical illness, Accessed 09/02/2015 ncbi.nlm.nih.gov/pmc/articles/PMC2750129