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166 PART 2: General Management of the Patient

exercise modality. Investigators have proposed detailed approaches to • Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe
the progression of activities based on levels of patient consciousness, G. Interventions for preventing critical illness polyneuropa-
cooperation, and functional status. Acutely ill, comatose patients receive thy and critical illness myopathy. Cochrane Database Syst Rev.
passive ROM, muscle stretching, splinting as needed, and body posi- 2009:CD006832.
tioning. Once interactive, patients can increase their level of activity
progressing from active ROM to sitting at the edge of the bed, transfers • Morris PE, Goad A, Thompson C, et al. Early intensive care unit
to chair, marching in place, and then ambulating. Standing and walk- mobility therapy in the treatment of acute respiratory failure. Crit
ing frames enable the patient to mobilize safely with attachments for Care Med. 2008;36:2238-2243.
bags, lines, and leads that cannot be disconnected. For the patient with • Morris PE, Griffin L, Berry M, et al. Receiving early mobility dur-
advanced weakness, standing aids and tilt tables enhance physiologi- ing an intensive care unit admission is a predictor of improved
cal responses as a modality to promote early mobilization of critically outcomes in acute respiratory failure. Am J Med Sci. 341:373-377.
ill patients. • Needham DM, Korupolu R, Zanni JM, et al. Early physical medi-
All programs beginning an exercise program will want to track stan- cine and rehabilitation for patients with acute respiratory failure: a
dard ICU metrics, such as duration of MV, ICU and hospital lengths of quality improvement project. Arch Phys Med Rehabil. 91:536-542.
stay. To better understand the specific strength and function outcomes
of ICU patients, we advocate adoption of the Functional Status Score • Parry SM, Berney S, Granger CL, Koopman R, El-Ansary D,
for the ICU (FSS-ICU). The scoring system, based on the validated Denehy L. Electrical muscle stimulation in the intensive care
Functional Independence Measurement (FIM), rates activities between setting: a systematic review. Crit Care Med. 41(10):2406-2418.
1 (total assist) and 7 (complete independence). Recognizing that a finite • Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physi-
number of functional activities can be enacted by most ICU patients, cal and occupational therapy in mechanically ventilated, criti-
five are selected for measurement: rolling, transfer from supine to sit, cally ill patients: a randomised controlled trial. Lancet. 2009;373:
sitting at the edge of the bed, transfer from sit to stand, and ambulation. 1874-1882.
These four tasks, plus ambulation, are combined in the cumulative • Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients
FSS-ICU, which is a simple sum of the five individual scores. Additionally, with respiratory failure increase ambulation after transfer to an
investigators advocate measuring the duration of unsupported sitting at intensive care unit where early activity is a priority. Crit Care Med.
the edge of the bed and the maximum distance ambulated. Tracking 2008;36:1119-1124.
these outcomes may help translate the success of an expanding program.

CONCLUSIONS REFERENCES
An aging population combined with increasing numbers of patients Complete references available online at www.mhprofessional.com/hall
needing and seeking ICU services creates an environment in which
critical care delivery must be optimal. Research investigations have
proven that specific supportive strategies (eg, low tidal volume ventila-
tion, goal-directed sepsis resuscitation) as well as ICU structure, such as
daily rounds by a multidisciplinary team, are associated with improved CHAPTER Cardiopulmonary
47
mortality for ICU patients. The implementation of an early exercise and
mobilization program spans both, requiring the intricacy of individual 25 Resuscitation
process delivery combined with the infrastructure for detailed commu-
nication across disciplines. Physicians, nurses, respiratory, physical, and Benjamin S. Abella
occupational therapists must generate team plans to promote wakeful- Marion Leary
ness, assess readiness for ventilator liberation, and negotiate competing
procedures and testing, while seeking to maximize daily physiotherapy. KEY POINTS
Clinical trials have shown these programs to be safe and feasible at
individual centers. Importantly, mobilization protocols have demonstra- • Most cardiac arrests in the community setting occur as a result of
ble benefit for short-term patient outcomes, including improvements in coronary artery disease and cardiac ischemia.
functional performance, brain function, and earlier ICU and hospital • Given the high mortality of cardiac arrest, prevention is crucial.
discharge. Future research needs to address the dose and specific exer-
cise strategies for the general population. Furthermore, the impact of • Cardiopulmonary resuscitation and rapid defibrillation are the
these interventions on long-term outcomes must be better understood keys to successful resuscitation from cardiac arrest.
to meet the needs of our expanding survivor population. • Advanced Cardiopulmonary Life Support (ACLS) guidelines pro-
vide treatment algorithms for the different cardiac rhythms of arrest.
• Automatic external defibrillators provide a means for rapid defi-
brillation by the public.
KEY REFERENCES • High-quality CPR and prompt defibrillation when appropriate are
the only proven therapies to increase survival from cardiac arrest.
• Bailey PR, Thomsen GE, Spuhler VJ, et al. Early activity is feasible
and safe in respiratory failure patients. Crit Care Med. 2007;35: • Rapid response teams have been developed to help decrease the
139-145. incidence of in-hospital cardiac arrest.
• Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill
patients enhances short-term functional recovery. Crit Care Med.
2009;37:2499-2505. Cardiac arrest, defined as the sudden complete loss of cardiac output
• De Jonghe B, Bastuji-Garin S, Sharshar T, Outin H, Brochard L. and therefore blood pressure, is the leading cause of death in the United
Does ICU-acquired paresis lengthen weaning from mechanical States and much of the developed world, claiming at least 300,000 lives
1
ventilation? Intensive Care Med. 2004;30:1117-1121. each year in the United States alone. In the majority of cases, myocar-
dial ischemia in the setting of coronary artery disease represents the

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