Rehabilitation Rehabilitation within critical within critical carecare

By David McWilliamsBy David McWilliamsSenior Specialist Physiotherapist – Critical CareSenior Specialist Physiotherapist – Critical CareManchester Royal InfirmaryManchester Royal Infirmary

ContentsContents

• Negative effects of Critical illness/ Negative effects of Critical illness/ prolonged ventilationprolonged ventilation

• Evidence for early rehabEvidence for early rehab

• Rehab on ITURehab on ITU

• AuditsAudits

• ConclusionConclusion

Negative Effects of prolonged ITU Negative Effects of prolonged ITU StayStay

• PhysicalPhysical

- Muscle atrophy and Muscle atrophy and weaknessweakness

- Lacking energyLacking energy

- Joint sorenessJoint soreness

- Decreased Decreased proprioceptionproprioception

- Poor balancePoor balance

• PsychologicalPsychological

- DepressionDepression

- AnxietyAnxiety

- PTSDPTSD

- CognitionCognition

= Decreased QOL= Decreased QOL

Physiological Adaptations to Bed Physiological Adaptations to Bed RestRest- Muscle atrophy (1-1.5% loss per day)Muscle atrophy (1-1.5% loss per day)- VO2 Max (VO2 Max (↓ 0.9% per day)↓ 0.9% per day)- Bone demineralisation (6mg/day calcium) = Bone demineralisation (6mg/day calcium) =

Approx 2% bone mass/month (Up to 2 years to Approx 2% bone mass/month (Up to 2 years to recover)recover)

- ↑ ↑ HR (required to maintain resting VO2)HR (required to maintain resting VO2)- ↓ ↓ SV (Approx 28% after 10 days bed rest)SV (Approx 28% after 10 days bed rest)

(Compensated by (Compensated by ↑ Ejection Fraction)↑ Ejection Fraction)

* Note all these results involve healthy individuals, * Note all these results involve healthy individuals, disease, malnutrition, sedatives, paralytics and disease, malnutrition, sedatives, paralytics and sepsis all have the potential to increase these sepsis all have the potential to increase these responsesresponses

• Persistent functional disability demonstrated Persistent functional disability demonstrated over 1 year following discharge in ARDS over 1 year following discharge in ARDS patients patients – Herridge Herridge et alet al 2003 2003

• Prolonged ventilation in critical care is Prolonged ventilation in critical care is associated with impaired health related associated with impaired health related quality of life up to 3 years after discharge, quality of life up to 3 years after discharge, even when patients are living independently even when patients are living independently at home at home – Combes Combes et alet al 2003 2003

Long Term EffectsLong Term Effects

Quality Critical Care (DoH, Quality Critical Care (DoH, 2005)2005)

“ “ hospitals should develop patient-centred hospitals should develop patient-centred rehabilitation services to optimise the rehabilitation services to optimise the recovery of patients discharged from recovery of patients discharged from critical care units, integrating with primary critical care units, integrating with primary care services after discharge from care services after discharge from hospital”hospital”

This was followed with the commissioning of the This was followed with the commissioning of the NICE guideline for critical illness rehabilitation – NICE guideline for critical illness rehabilitation – due for publication spring ‘09due for publication spring ‘09

Why Rehab EarlyWhy Rehab Early- Very little evidence to prove effectiveness Very little evidence to prove effectiveness

of early rehab.of early rehab.

- Is evidence to show patients do show a Is evidence to show patients do show a response to exercise and can therefore be response to exercise and can therefore be trained.trained.- Weissman (1984 & 1993) 52% increase from rest Weissman (1984 & 1993) 52% increase from rest

in VO2 with ‘chest physiotherapy’in VO2 with ‘chest physiotherapy’- HoriuchiHoriuchi (1997) Chest PT + O2 consumption (1997) Chest PT + O2 consumption- ZafiropoulesZafiropoules (2004) (2004) ↑ RR + ↑ TV↑ RR + ↑ TV

Horiuchi et al (1997) Insights into the Horiuchi et al (1997) Insights into the increased oxygen demands during chest increased oxygen demands during chest physiotherapyphysiotherapy

1 5 0

2 0 0

2 5 0

3 0 0

3 5 0

4 0 0

R e s t C P T R e s t

P a r a l y s e d

N o nP a r a l y s e d

Oxyg

en

Up

take

(m

L/m

in)

Ventilatory Responses in the Ventilatory Responses in the Intubated PatientIntubated Patient

• Zafiropoules B et al (2004)Zafiropoules B et al (2004)

• 21 Subjects (mean = 71 years) 21 Subjects (mean = 71 years) following abdo surgery requiring PSVfollowing abdo surgery requiring PSV

• Mobilised whilst intubated via ET tubeMobilised whilst intubated via ET tube

• Supine, sitting over edge of bed, Supine, sitting over edge of bed, standing, walking on spot for 1 min, standing, walking on spot for 1 min, SOOB (initially), SOOB after 20 mins.SOOB (initially), SOOB after 20 mins.

Zafiropoules et al (2004) Physiological Zafiropoules et al (2004) Physiological responses to the early mobilisation of the responses to the early mobilisation of the intubated, ventilated absominal surgery intubated, ventilated absominal surgery patient. Aust. Journal of Physiotherapy, 50, patient. Aust. Journal of Physiotherapy, 50, 95-10095-100

SupinSupinee

Sitting Sitting on on edge edge

StandStand WOSWOS

1 min1 minSOOBSOOB11

SOOB SOOB 2020

VTVT

(mls)(mls)712.712.55

826.826.88

883.883.44

904.904.33

873.873.11

710.710.00

RRRR

b/pmb/pm21.421.4 24.324.3 24.924.9 26.826.8 26.126.1 20.320.3

VEVE

l/minl/min15.115.1 19.619.6 21.321.3 22.822.8 22.222.2 13.813.8

Chiang et al (2006)Chiang et al (2006)

39 Patients requiring prolonged mechanical

ventilation

N = 20 Rx Group

N = 19 Control Group

Inclusion/exclusionInclusion/exclusion

• Ventilated >14daysVentilated >14days

• Mentally alert Mentally alert

• Haemodynamically stableHaemodynamically stable

• Not on any sedatives or paralytic Not on any sedatives or paralytic agentsagents

• Pts with pre existing neurological Pts with pre existing neurological conditionsconditions

Chiang et al (2006)Chiang et al (2006)• Treatment groupTreatment group

– Physical training 5 days per week for 6/52 with a Physical training 5 days per week for 6/52 with a senior physiotherapistsenior physiotherapist

– Consisted of UL and LL ex’s using weights and Consisted of UL and LL ex’s using weights and breathing ex’s for resp musclesbreathing ex’s for resp muscles

– Also practiced functional activities (e.g. rolling, Also practiced functional activities (e.g. rolling, sitting, standing and walking as strength sitting, standing and walking as strength progressed)progressed)

• Control group was not seen by the PhysioControl group was not seen by the Physio

• Both received standard medical + nursing care Both received standard medical + nursing care and no rehab prior to commencement of studyand no rehab prior to commencement of study

Outcome MeasuresOutcome Measures

• Ax at beginning, 3 and 6 weeks laterAx at beginning, 3 and 6 weeks later

• Functional statusFunctional status– Barthel Index of ADL’sBarthel Index of ADL’s– Functional Indep measureFunctional Indep measure

• Resp muscle strengthResp muscle strength– Max insp pressureMax insp pressure– Max exp pressureMax exp pressure

0

1 0

2 0

3 0

4 0

5 0

b a s e lin e 3 w e e k s 6 w e e k s

F u n c t i o n a l I n d e p e n d e n c e m e a s u r e s f o r s u b j e c t s v e r s u s c o n t r o l s

C o n t r o l G r o u p T r e a tm e n t G r o u p

0

2 0

4 0

6 0

b a s e l i n e 3 w e e k s 6 w e e k s

M a x i n s p i r a t o r y p r e s s u r e ( c m H 2 0 )

C o n t r o l G r o u p T r e a tm e n t G r o u p

Chiang et al (2006)Chiang et al (2006)

• ConclusionsConclusions– Participation 6 week programme of physical Participation 6 week programme of physical

training led to significant improvements in training led to significant improvements in UL, LL and respiratory muscle strengthUL, LL and respiratory muscle strength

– These improvements were associated with These improvements were associated with improvements in performing functional improvements in performing functional activities such as self care and mobilisationactivities such as self care and mobilisation

– Small numbers and stable ICU populationSmall numbers and stable ICU population

Morris et al (in press)Morris et al (in press)

• University Medical ICU in USAUniversity Medical ICU in USA

• Does mobility protocol increase Does mobility protocol increase proportion of patients receiving proportion of patients receiving physical therapyphysical therapy

330 subjects recruited330 subjects recruited

165 Protocol 165 Routine Care

ProtocolProtocol

• An ICU Mobility team initiated An ICU Mobility team initiated protocol within 48 hours of protocol within 48 hours of mechanical ventilationmechanical ventilation

• Consisted ofConsisted of– Critical care nurseCritical care nurse– Nursing assistantNursing assistant– Physical TherapistPhysical Therapist

ProtocolProtocol

• An ICU Mobility team initiated An ICU Mobility team initiated protocol within 48 hours of protocol within 48 hours of mechanical ventilationmechanical ventilation

• Consisted ofConsisted of– Critical care nurseCritical care nurse– Nursing assistantNursing assistant– Physical TherapistPhysical Therapist

LEVEL 1 LEVEL 4LEVEL 2 LEVEL 3

Can move arms against

gravity

Can move legs against

gravity

Figure 2. Morris et al - Early Therapeutic Mobility Protocol.

Unconscious Conscious Conscious Conscious

Turn every 2hr Turn every 2hr Turn every 2hr Turn every 2hr

Passive ROM Passive ROM exercisesexercises

Sitting position min 20 minutes 3x daily

Sitting position min 20 minutes 3x day.

Sitting position min 20 minutes 3x day.Sitting on edge of bed with Physical therapist

Active resistance range of motion (ROM) with physical therapy or RN daily

Sitting on edge of bed with Physical therapist

Active Transfer to Chair (OOB) with Physical Therapist Minimum 20 minutes

ResultsResultsOutcomeOutcome ProtocoProtoco

llControControll

P ValueP Value

Proportion of patients Proportion of patients receiving physical receiving physical therapytherapy

80%80% 47%47% p<0.00p<0.0011

11stst Day out of bed Day out of bed 55 1111 p<0.00p<0.0011

Ventilator daysVentilator days 8.88.8 10.210.2 p=0.16p=0.1633

Therapy initiated on ICUTherapy initiated on ICU 91%91% 13%13% p<0.00p<0.0011

ICU LOS (days)ICU LOS (days) 5.55.5 6.96.9 p=0.02p=0.0255

Hospital LOS (days)Hospital LOS (days) 11.211.2 14.5 14.5 p=0.00p=0.0066

Conclusions Conclusions

• Also noted no untoward events during Also noted no untoward events during an ICU mobility session and no cost an ICU mobility session and no cost difference between the 2 armsdifference between the 2 arms

ConclusionConclusion Mobility team using a mobility Mobility team using a mobility

protocol initiated earlier physical protocol initiated earlier physical therapy which was feasible, safe, did therapy which was feasible, safe, did not increase costs and was associated not increase costs and was associated with a decreased ICU and Hospital LOSwith a decreased ICU and Hospital LOS

Why Rehab earlyWhy Rehab early

• Facilitate weaning from mechanical Facilitate weaning from mechanical ventilationventilation

• Decrease negative effectsDecrease negative effects

• Impact on costs Impact on costs – Approx £1700 per day on ITUApprox £1700 per day on ITU– 1-2% of UK hospital budget per year1-2% of UK hospital budget per year

• Comprehensive Critical Care Comprehensive Critical Care

Whilst in acute phase/ Sedated +/- Paralysed- Daily Passive Movements - Positioning Programme

Once Patient Wakes/ Stable- Commence active exercise programme- Sit on edge of bed- Chair Position if unable to sit out

Seating Plan DocumentedDaily & weekly rehab goalsOngoing active exercise

On Discharge from Critical Care- Discharge summary completed with established rehab plan & Exercise programme (Within 24 hours)

Ongoing Rehab on ward as per rehab plan until discharge (Review/ Monitor by Follow up team as required)

Post Hospital Discharge< 5 days on ITU discharge info/ booklet> 5 Days on ICU Structured Post ITU Rehab programme (Within 2 weeks)

ICU Follow up ClinicApprox 3 months post d/c

Weekly MDT MeetingsJoint Goal settingWeaning / Rehab Plan? To include:- Medical Staff- Nursing Staff- Physiotherapist- Pharmacist- Dietician- Occup. Therapist- SALT (As approp.)

Long Term Patients > 14 Days

Admitted To Critical Care- Physio Ax within 24 hours- History/ Baseline Mobility

Passive Movements

Active/ Active assisted ex’s

Chair Position in Bed

SOEOB

Sitting out in chair

Pat SlideHoist

Standing HoistBanana Board

TransfersMobilisation

SEATING PLAN- Type

-Frequency-Duration

Exerc

ise P

rog

ram

me

Importance of MDTImportance of MDT

• Collaborative Weaning Plans (medics)Collaborative Weaning Plans (medics)

• Seating Plans, exercises, positioning (N/S)Seating Plans, exercises, positioning (N/S)

• Adequate Nutrition and calories (dietician)Adequate Nutrition and calories (dietician)

• Anxiety Management & PADL’s (OT)Anxiety Management & PADL’s (OT)

• Pain relief, night sedation (Pharmacist)Pain relief, night sedation (Pharmacist)

• Appropriate equipmentAppropriate equipment

The Challenges of The Challenges of MobilisationMobilisation

The importance of being The importance of being uprightupright

– Upright posture encourages basal lung Upright posture encourages basal lung expansion and increases FRCexpansion and increases FRC

– Psychological ++ (progression)Psychological ++ (progression)– Increased muscle strengthIncreased muscle strength– Increased exercise toleranceIncreased exercise tolerance– Improve trunk stabilityImprove trunk stability– Prevents/ addresses postural Prevents/ addresses postural

hypotensionhypotension– Improved bowel functionImproved bowel function– Full weight bearingFull weight bearing

McWilliams & Pantelides (2008)Aim:Aim:• To determine the affect of physiotherapy led early mobilisation of patients To determine the affect of physiotherapy led early mobilisation of patients

on ITU on ITU

Objectives:To identify whether sitting patients on the edge of the bed To identify whether sitting patients on the edge of the bed or out in a chair within the first 5 days of admission or out in a chair within the first 5 days of admission decreases length of stay on ITUdecreases length of stay on ITU

To identify limiting factors to early mobilisation & facilitate To identify limiting factors to early mobilisation & facilitate methods to decrease these methods to decrease these

Method:Method:

• 65 Patients admitted to ICU from 20th Jun - 65 Patients admitted to ICU from 20th Jun - 20th Sept 200520th Sept 2005

(Exclusions: Patients on ITU for < 24 hours)(Exclusions: Patients on ITU for < 24 hours)

• Data collected from: Data collected from: – patient’s rehab status on the rehab monitoring patient’s rehab status on the rehab monitoring

formform – Patient notesPatient notes

ResultsResults

•17 patients sat on edge/ out 17 patients sat on edge/ out by day 5 on ITU (26%)by day 5 on ITU (26%)

•48 did not48 did not

So what?So what?

Results 3:Results 3:Reason for not

sitting outNumber of cases

(n=48):Percentage:

Poorly/ Sedated/ paralysed

22 46%

Decreased staffing* 8 17%

Fractures 4 8.5%

Weekend* 4 8.5%

Reason not stated 2 4%

Decreased GCS 2 4%

On Noradrenaline 2 4%

CVS unstable 2 4%

Agitated ++ 1 2%

Deranged Clotting 1 2%

Results 3:Results 3:Reason for not

sitting outNumber of cases

(n=48):Percentage:

Poorly/ Sedated/ paralysed

22 46%

Decreased staffing* 8 17%

Fractures 4 8.5%

Weekend* 4 8.5%

Reason not stated 2 4%

Decreased GCS 2 4%

On Noradrenaline 2 4%

CVS unstable 2 4%

Agitated ++ 1 2%

Deranged Clotting 1 2%

*Approx 30% reversible

Results 2:Results 2:

Met standard

Met Standard

Did not meet

standard

Mobilisation took place

By the 5th day

Not by 5th day

Not by the 5th day

No. of cases

17/65 (26%)

14/65 (22%)

34/65 (52%)

Mean LOS 5.7 days 12.9 days 21.1 days

Range (LOS)

2-18 days 3-29 days 5-86 days

Conclusion to AuditConclusion to Audit

• Small numbersSmall numbers• Numerous variablesNumerous variablesBUTBUT• Significant difference for those patients Significant difference for those patients

mobilised (approx 7 days)mobilised (approx 7 days)• 7 days = £10,0007 days = £10,000• 14 pts = £140,000 over 3 months14 pts = £140,000 over 3 months= £560,000 p/a potentially avoidable with = £560,000 p/a potentially avoidable with ↑↑

staff/ resourcesstaff/ resources

Mobility On Leaving ICU Mobility On Leaving ICU (Hospital LOS in days)(Hospital LOS in days)

19.225.35

45.75

0

10

20

30

40

50

A = Mobile 10m or more

B = SOEOB/ out in chair

C = Not sat up/out yet

A B C

Results 3:Results 3:Reason for not

sitting outNumber of cases

(n=48):Percentage:

Poorly/ Sedated/ paralysed

22 46%

Decreased staffing* 8 17%

Fractures 4 8.5%

Weekend* 4 8.5%

Reason not stated 2 4%

Decreased GCS 2 4%

On Noradrenaline 2 4%

CVS unstable 2 4%

Agitated ++ 1 2%

Deranged Clotting 1 2%

*Approx 30% reversible

More questionsMore questions

• When CVS is compromisedWhen CVS is compromised– Aggressive positioningAggressive positioning– Challenge the systemChallenge the system– Leg Dangling?Leg Dangling?

Annual FiguresAnnual Figures

Mean ICU LOS

Mean Post ICU LOS

ICU Deaths

HospitalDeaths

Total Mortality

2003 9.8 34 25% 20% 45%

2004 8.9 40.6 25% 15% 40%

2005 8 34.7 22% 14% 36%

2006 7.7 27.8 19% 16% 35%

ConclusionConclusion• Rehab should commence on day of Rehab should commence on day of

admission to critical careadmission to critical care

• Should be MDT involvementShould be MDT involvement

• Can decrease negative effects of Can decrease negative effects of mechanical ventilation & Bed rest and mechanical ventilation & Bed rest and facilitate weaning.facilitate weaning.

• Needs more research to prove Needs more research to prove effectiveness and cost benefits of early effectiveness and cost benefits of early physiotherapy led mobilisationphysiotherapy led mobilisation

Any QuestionsAny Questions

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