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P. Nydahl Neurological ICU & Stroke Unit, Department of Neurology, University of Schleswig-Holstein, Campus Kiel, Germany Walking with ventilated ICU patients Systematic literature research and case description Background: Immobility of patients on intensive care units (ICU) leads to several, long lasting complications. In the last years a paradigma shift took place and the light sedated, mobile and ventilated ICU patient becomes possible. Aim: What impact has got walking on ventilated ICU patients? Method: A pubmed search was conducted in spring 2010 with search terms mobilisation, 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 under ventilation. 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: [email protected] German network early mobilization: www.fruehmobilisierung.de Results: 10 studies were found. The first studies which have all been performed with mixed populations of patients point out that early mobilisation and even walking with ventilated patients is feasible and safe and can have a positive influence on the duration of ICU- stay and delirium. An oral endotracheal tube is no contra-indication for mobilisation, even walking is possible and safe. Walking with ventilation can contribute significantly to the quality of life, motivation and well-being of patients. Conclusions: There is an evidence for early mobilisation up to walking with ventilated patients. A team approach including good communication and coordination is highly recommended. Algorithms and adaptable beds 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 be intubated and ventilated. Day 1: Ventilated, RASS -2, Kalymin ® , Propofol, Noradrenalin Day 2: RASS -1 - 0, Kalymin ® , ø Propofol or Noradrenalin Day 3: sitting on the edge of the bed, ASB (incl ATC) 16 mbar Day 4: stands beside the bed, ASB 16 mbar (reduction failed) Day 5: stands and walks on spot, then ASB 14 mbar Day 6: free walking denied (felt 2 times at home), ASB 12 mbar Day 7: same, ASB 10 mbar Day 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 her pressure support, especially (evidence based) spontaneous breathing trials. But that has been possible a few hours after the mobilisation. Day by day her pressure support could be reduced without anxiety or hyperventilation. Comparable patients would have a high risk for tracheostomy and multimorbidity. This case description illuminates a new and different approach for difficult or prolonged to wean patients: if weaning trials fail, mobili- sation is the first goal and weaning becomes secondary - but successful! 24-26.3.2011 Copenhagen 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 immedeate weakness. 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, Practice Guideline, Randomized Controlled Trial, Review, Case Reports, published in the last 5 years Result 51 Fulltexts (studies with purpose being out of bed): 9 Excluded 3 articles (without purpose being out of bed or no study) Added from reference list: 3 Personal contact 1 Summary: 10 Excluded 42 articles (without purpose being out 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 FiO 2 (+ 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, unstable cardiovascular 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 FiO 2 ≤ 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 mobilisation 1. 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 spot 6. Active transfer into a chair 7. Walk Passive transfers into a chair are possible from 3rd Achieved level, duration and characteristics will be documentated yes Daily evaluation and documentation no Tolerance ? Tolerance criteria Heart rate <150 <90 syst. BP <200 O 2 saturation> 90 In dyspnea: FiO 2 +0.2 & PEEP +2 Back to Start Reflection: Circulation? Sedation? Pain? Interaction? yes no
