Page 260 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

164 PART 2: General Management of the Patient

effort-intensive therapy, made more challenging by the presence of during MV was first captured by a descriptive cohort study published in
multiple barriers that impede broad uptake. These barriers include 2007. Conducted in a respiratory ICU (RICU), the activity levels of 103
44
sedation and ventilation practices, concern regarding patient safety and patients—averaging 10 days following inception of critical illness—were
physiological stability, inadequate staff to deliver physical therapy, and studied. Patients began exercise once they responded to verbal stimula-
lack of equipment. tion and were stable from both a respiratory and cardiovascular stand-
Physical therapy is feasible only if the patient is awake and cooperative. point (defined as Fi O 2 ≤0.6, PEEP ≤10 cm H O, absence of orthostatic
2
For the mechanically ventilated patient, the use of sedation and analge- hypotension and catecholamine drips). The exercise team, including
sia needs to be titrated to the least necessary dose to foster interaction physical therapist, respiratory therapist, nurse, and critical care technician,
while maintaining comfort. Studies of sedation and analgesia assessment focused training on three activities: sitting on the edge of the bed, sitting
tools, agents, and administration protocols have substantially changed in a chair after bed transfer, and ambulating. At RICU discharge, 77% of
clinical care. Patients are targeted for more awake levels and improved patients were able to ambulate, including 69% able to ambulate >100 ft,
outcomes have been demonstrated with nurse-directed titration of drug, 15% of patients were able to sit in a chair, and 5% of patients able to sit
early transition to intermittent drug administration, and daily interrup- at the edge of the bed. Only 14 of the 1449 activity events, including
tion of sedative infusions. As patients have become more interactive, 593 conducted during intubation, resulted in predefined adverse events.
42
the commonality of ICU delirium is exposed. Early physical therapy may Specifically, there were five falls to the knees without injury, four systolic
help minimize such delirium, working through mechanisms of sedative blood pressures <90, one systolic blood pressure >200, three desatura-
minimization and fostering more sleep. The use of physical exertion to tions to <80%, and one nasal feeding tube removal.
calm the agitated patient—in lieu of drug administration—may be an To further the proof of success, the same investigators studied the
underlying mechanism; however, this inquiry remains incomplete. performance levels of mechanically ventilated patients within a 2-day
Sedative minimization and early mobilization share a key perceived window before and after transfer to their ICU. Within 24 hours
45
barrier: the concern for the accidental dislodgement of vascular lines, of arrival, patients underwent more intense physical activities than
nasogastric tubes, urinary catheters, and, much more importantly, the conducted previously, for example, ambulation increased from 11%
artificial airway. This concern has been exaggerated by the general pretransfer to 41% within 48 hours. Multivariable logistic regression
movement away from early tracheostomy and more advanced therapy demonstrated that transfer to their therapy-dominant ICU was inde-
interventions in the patient with an endotracheal tube. Higher rates of pendently associated with the likelihood of ambulation. This study was
unplanned extubation have not been demonstrated in recent studies the first indication that a unit-based culture of early mobilization could
of physical therapy in ICU patients. However, these studies included significantly influence patient functional performance.
4
appropriately trained staff, careful preintervention assessment for safety, The first prospective comparison between early exercise and mobi-
and team delivery of therapy care. Commonly, a mobilization team lization compared to usual care was published in 2008. In the study,
46
consists of three ICU clinicians, including a physical therapist, a nurse, the “mobility team” (PT, nurse, and nurse assistant) followed a detailed
and an occupational therapist or an assistant. protocol for a stepwise increase in therapy based on patient participation
Similarly, a femoral vascular access device may cause clinician and tolerance, spanning passive ROM to active ROM exercise, sitting,
hesitation. Providers fear catheter dislodgement, vessel injury, or transfers, and, finally, ambulation. Eighty percent of patients in the
thrombosis with extended hip flexion times. For patients with femoral intervention group underwent at least one therapy session compared to
dialysis catheters, flows may be diminished with positioning. Despite the only 47% of patients in the usual care group. Intervention patients were
concerns, no studies have yet demonstrated injury from mobilizing quicker to get out of bed (8.5 vs 13.7 days) and had a reduced hospital
patients with such devices. LOS (14.9 vs 17.2 days). Recently, the 1-year outcomes of hospital survi-
Restrictions in early therapy similarly occur based upon concerns vors from the initial 330 patient cohort were reported. In multivariate
47
that active patient participation in movement might compromise an analysis, the lack of early ICU mobility was independently associated
already marginal oxygenation or hemodynamic parameter. This concern with readmission(s) or death during the first year. Although the etiology
for irreversible hypoxemia or dysrhythmia had traditionally kept most for readmission and death were not specified, these findings suggest a
therapists at a distance until convalescence from critical illness was more durable benefit enacted by early ICU mobility.
achieved. The decision on timing to engage therapy remains a focus of In 2009, a prospective, dual center, randomized clinical trial of very
investigation, but research, detailed below, has yielded evidence inform- early mobilization was published. 104 MICU patients were enrolled
48
ing criteria for safe initiation. within 72 hours of the onset of respiratory failure requiring MV. Patients
Expertise, availability, and team coordination may be the most sub- were randomized to an intervention group that received mandated, pro-
stantial of all barriers to mobility in ICU patients. Physical therapists gressive physical and occupational therapy (PT and OT) versus a control
should be an integral part of the multidisciplinary ICU team—not sim- group that received PT and OT as ordered by their primary team. The
ply intermittent consultants—and serve as the primary proponents of dual therapist team treated patients with exercises such as sitting at the
early exercise. Each session should involve the bedside nurse as he/she edge of the bed, engaging in simulated activities of daily living, transfer
can serve as gatekeeper for safety and recognize existing limits and chal- training, and ambulation. Patients in the intervention group underwent
lenges of individual patients. For the mechanically ventilated patient, a therapy on 87% of days in the study, starting therapy at a median of
respiratory therapist is needed to disconnect the ventilator and assist 1.5 days after intubation compared to 7.4 days in the control group.
with portable ventilation strategies. This interdisciplinary coordination Within 4 days, 76% of intervention patients were sitting at the edge of
is exceptionally complex and may be the optimal test of an ICU’s func- the bed, 33% were standing and transferring to a chair, and 15% were
tion. It is only recently that administrative support for these initiatives ambulating. At hospital discharge, intervention patients had a higher rate
has been possible, driven by measured improvements in ICU and hospi- of return to independent functional status (59% vs 35%), greater inde-
tal lengths of stay by early physical therapy programs. 43 pendent walk distance, and were more likely to be discharged to home
(43% vs 24%). Additionally, intervention patients experienced a reduced
EARLY MOBILIZATION duration of delirium (2 vs 4 days) and more ventilator-free days (23.5 vs
21.1 days), but no significant difference in ICU or hospital length of stay.
Early mobilization is the intensification and early application of the Implementing the combined interventions of sedation minimization
physical therapy that is administered to critically ill patients. This and early mobilization may yield the most striking effects for an individ-
exercise is applied with the intention of maintaining or restoring ual ICU’s outcomes. In 2010, a tertiary academic center reported their
musculoskeletal strength and function to improve functional, patient- quality improvement project to improve outcomes in patients undergo-
centered outcomes. The safety and feasibility for early physical therapy ing MV for 4 or more days. In the preintervention phase, patients were
49

section02.indd 164 1/13/2015 2:05:08 PM