The Nobility of Mobility

Sandra Hess RN BSN CCRNUniversity of Iowa Hospitals and Clinics

The Nobility of Mobility

Sandra Hess RN BSN CCRNUniversity of Iowa Hospitals and Clinics

Bed rest is not a physiological state

Negative Effects:

-Decrease in respiratory excursion

-Decrease in mobilization of secretions

-Increase in atelectasis and pneumonia

-Increase in dependent edema

-Fluid shifts from lower extremities to the thorax. Volumes can exceed 500cc.

- Decrease in plasma volume due to fluid

shifts, and onset of diuresis.

-Increased workload on the heart related

to fluid shifts.

-Gradual onset of tachycardia and hypotension due to diuresisfollowing fluid shifts.

-Decrease in cardiac output due to diuresis and venous pooling.

- Cardiac deconditioning with a gradual fall in O2 consumption.

-Neuromuscular polyneuropathies due to deconditioning, loss of muscle mass, and release of cytokines in inflammatory response. (Chobanian et al, 1974)

Critical Illness Polyneuropathy and Myopathy

A recent systematic review of 24 studies found that 46% of critical illness survivors developed neuromuscular dysfunction.This disability resulted in prolonged hospital length of stay and extended rehabilitation. (Needham et al 2007)

In a study of long term outcomes after ARDs, critical care survivors were only able to walk 66% of the predicted distance of a 6 minute walk after one year.

Reasons for the deficit included global wasting, weakness, foot drop, joint immobility and dyspnea.Only 49% of survivors were able to return to work. (Herridge et al 2003)

Our patients survive sepsis, systemic inflammatory response syndrome, ARDs and multi-organ failure and transfer out to the floor unable to hold a spoon, stand up from the bed, Walk or even brush their teeth.

Criteria for Starting Upright MobilityFIO2<.50

PEEP<8

P/F Ratio ALI >300 ARDs>200

S/F Ratio ALI >315 ARDs>250

De-conditioned by > than 3 days of immobility

Ready to begin ventilator weaning

Requiring orthostatic training to tolerate an upright position

The patient on CLRT is ready to begin optional forms of mobility when there is: Improvement in the chest X-ray

Improved ABGs

Sedatives are decreased

Patient is able to move and turn self.

CLRT to Upright Mobility Protocol

Vital signs: Watch continuously for the onset of hypertension or hypotension, bradycardia or tachycardia greater than 10% above resting heart rate.

SPO2 drop below 90%-Adjust FIO2 up to maintain the O2 saturation above 90%

ECG-Watch monitor for any dysrhythmias.

Feelings of faintness dizziness, diaphoresis, shortness of breath or nausea.

Allow a 5 minute equilibration period after each position change to allow for the return of hemodynamic stability.

During all mobility interventions, monitor the patient for hemodynamic tolerance.

For hemodynamic intolerance to head up position changes, begin orthostatic training with the reverse trendelenberg position. This position allows the baroreceptorsto respond to the changes in blood pressure, stimulating the central reflex mechanisms that allow adjustments via heart rate changes, vasodilation and vasoconstriction.

( Stiller et al, 2004)

Level IPassive ROM

CLRT

Manual turning

Boots or splints to prevent contractures

Criteria-FIO2 > .50-PEEP>8-P/F Ratio<250-Lobar collapse, atelectasis, -Excessive secretions-Hemodynamic instability with turning-Increased sedation or paralytics to ventilate-Requirement of 2 or more pressors-Progressing to maximal ventilatory support-Oscillator vent

Level II ( Includes Level I interventions )HOB up 45 degrees 20 -30 minutes. Passive ROM

HOB up 45 degrees, legs dependent for 20-30 minutes. Passive ROM. Assess for active participation.

HOB up 65 degrees, feet and legs dependent for

20-30 minutes( Cardiac chair position)

Assess patient for ability to do active ROM

Level III ( Includes Level I & II interventions)Dangle at side of bed with feet supported on a stool. Assess ability to hold self upright and move extremities against gravity in sitting.

Standing trial: Can lift buttocks partially off bed without assistance. Then move to a full upright stand.

Step in place ( march) at the bedside 3 times without assistance. If able to do this , step forward and backward once with each foot.

Transfer to a recliner at bedside 20-30 minutes.

Level IV ( Includes Levels I, II & III interventions)Ambulation with assistance using assistive devices as needed.

Patient is monitored throughout ambulation to assess tolerance.(Ahrens et al, 2005; Kubo, 2008 )

Review the patient’s medical history and current conditions.

Past history to include:

-Medical history of cardiovascular disease

-Recent symptoms of CV/Respiratory dysfunction

Medications:

Pressors Inotrops Beta blockers

Sedatives Analgesia

Review the current drip rates. When a patient needs pressors to maintain an adequate B/P at rest, this is a sign of possible hemodynamic instability with activity.

Assess for sensory losses or abnormalities that need correction such as vision, hearing or neuropathies.

(Kubo, 2008)

Ideally, a resting heart rate that is less than 50% of the age predicted maximal heart rate is optimal. Critically ill patients with a high resting heart rate may have limited cardiac reserve to tolerate activities that will further increase the rate. If tachycardic, consider treatable causes e.g. pain, fever, volume status or the presence of inotrops.

( Stiller et al, 2004)

Age Target HR Zone 50–85 % Average Maximum Heart Rate

20 years 100–170 beats per minute 200 beats per minute 25 years 98–166 beats per minute 195 beats per minute 30 years 95–162 beats per minute 190 beats per minute 35 years 93–157 beats per minute 185 beats per minute 40 years 90–153 beats per minute 180 beats per minute45 years 88–149 beats per minute 175 beats per minute 50 years 85–145 beats per minute 170 beats per minute55 years 83–140 beats per minute 165 beats per minute 60 years 80–136 beats per minute 160 beats per minute65 years 78–132 beats per minute 155 beats per minute 70 years 75–128 beats per minute 150 beats per minute

(American Heart Association)

Variability of B/P- Not more than a 20% deviation from recent trends.

ECG shows no ischemic changes or arrythmiasaffecting cardiac output e.g. A-fib with RVR.

Patient is not currently in a R/O MI protocol.

All other cardiac conditions excluded. (Stiller et al, 2004)

P/F ratio> 250

SPO2 > 90 with no recent drops in O2 Saturation

Stable respiratory pattern with no dyspnea

If ventilated, ability to maintain mechanical ventilation throughout the trial.

Stable blood gases when ABGs are available.(Stiller et al, 2004)

Hemoglobin stable and greater than 7.0

Platelet count stable and greater than 20,000

Body temperature < 38.5 C. ( Elevations > 38.5 greatly increase O2 demands)

Patient not overtly fatigued or in pain.

No recent acute change in consciousness level.

Suspicion of DVT or PE ruled out or current order to ambulate from physician.

If obese, able to be safely managed.

Adequate staff and level of expertise to be able to manage equipment and monitor patient response.

( Stiller 2007)

A nurse to manage the IV lines and drips, the cables, and to monitor the patient tolerance and vital signs.

A physical therapist to assist with proper transfer techniques and to assess the ability of the patient to meet physical directions.

A respiratory therapist to manage the ventilator, provide the manual resuscitation bag, and make ventilator changes as necessary to meet the physical demands of the patient.

And if the activity includes ambulation , A nursing assistant to follow along with a wheelchair to

provide assistance if the patient becomes weak or fatigued.(Morris et al, 2008)

Good ToleranceAppropriate rise in heart rate—not greater than 10% of resting heart rate, allowing 2 to 5 minutes to equilibrate.

Appropriate rise in systolic B/P from the recent baseline, with a stable or slight increase in diastolic B/P.

Sinus rhythm maintained including baseline rhythm of sinus tachycardia.

P/F ratio is greater than 250 at start of intervention.

No tachypnea, dyspnea, increase in accessory muscle use, nasal flaring or facial expression of distress.

Color good, skin warm and dry, no chest pain, faintness or diaphoresis.

Uncertain of ToleranceExcessive increase in heart rate greater than 10% of the resting heart rate.

Rising B/P –Systolic and diastolic with a greater than 20% rise in systolic B/P above baseline.

Increasing ectopic beats with arrythmias.

Experiencing dyspnea and/or tachypnea.

Patient looks distressed.

Maneuvers:1. Increase the FIO2

2. Decrease or stop the intervention and wait for the patient to stabilize.

If the reaction doesn’t improve, stop the intervention and seek a medical evaluation if necessary.

Poor ToleranceExcessive rise in heart rate and B/P plus signs of cardiac stress e.g. ST depression on monitor, chest pain, multifocal ectopic beats, new onset arrythmias, and hemodynamic instability

OR

No change or decrease in heart rate but exhibiting signs of cardiac stress as listed above.

Fall in B/P ( Either systolic or diastolic or both) of greater than 20% indicating hemodynamic intolerance.

Decrease in baseline SPO2 greater than 4% and not corrected by an increase in FIO2.

If the patient experiences any of the above physical signs and develops faintness, dizziness or chest pain, diaphoresis, or nausea, Stop the intervention and seek a medical evaluation.

( Stiller, 2007)

The previous slides are guidelines. Patient assessments are highly individualized and should be made by the team members with each new intervention.

A signal is needed if the patient is intubated or has a trach so that the team can be alerted when the patient needs to stop. The approach always needs to be patient focused to bring about positive outcomes.

Goals can be reviewed daily with the patient and family and listed on the white board for communication.

Schweickert et al Lancet ( 2009)Randomized controlled trial of 104 functionally independent ICU patients in respiratory failure. Participants were randomized < 72 hours after intubation. The intervention group underwent early physical and occupational therapy. The control group received usual ICU care.

The primary endpoint was a return to functional independence at hospital discharge, including the ability to bathe, dress, eat independently, groom, transfer from the bed to chair, toilet and walk independently.

Days until start of physical therapy: Study group-1.5; Control-7.3

Independent functioning at discharge: Study group-59%; Control- 35%.

Unassisted ambulation: Study group 110 feet; Control- 0 feet.

Ventilator free days: Study group-21.1; Control-23.5

Duration of ICU delirium: Study group- 2 days; Control group-4 days.

Adverse events were 4% for all reasons.

Bailey et al Critical Care Medicine ( 2007) 103 participants; 1449 recorded mobility activities

Purpose of the study was to determine if early physical therapy was safe for ICU patients with respiratory failure.

Activity events were defined as sitting on the edge of the bed without back support, sit in a chair after transfer from a bed, and ambulate without assistance with a walker or with support from the staff.

Goal: Would they improve to the point that most would ambulate by ICU discharge.

Results:

By activity level, on the last day of ICU admission, looking at survivor data only, 2.4% had no activity, 4.7% sat on the bed, 15.3% sat in the chair, 8.2% ambulated < 100 feet and 69% ambulated > 100 feet. Age above 65 did not preclude participation in the activities. Exclusions were patients who would be extubatesd < 4 days, coma patients and palliative care patients. All others were assessed and started on activities as soon as physiologically stable.

At discharge from the ICU, 69% ( majority ) were able to walk> 100 feet . ( mean 212+/- 18 feet.)

Adverse events were < 1% including one fall to knees without injury, one feeding tube removal, one S B/P > 200 , one S B/P < 90 and one desaturation < 80. No extubations.

Morris, et al Critical Care Medicine (2008)

370 patients with 165 enrolled in an early mobility protocol and 165 in usual care in ICU.

Formation of a mobility team consisting of a nurse, physical therapist and a nursing assistant. Mobility protocol was initiated within 48 hours of intubation, 72 hours in the ICU.

Time until PT initiated in the ICU: Protocol-91%; Usual care-13%

Results:

Time until out of bed: Protocol - 5 days; Usual care- 11 days

ICU LOS : Protocol 5.5 days ; Usual care 6.9 days.

Hospital LOS: Protocol 11.2 days; Usual care 14.5 days.

Use of a team did not increase hospital costs, and there were no adverse events. The most frequent reason for ending a mobility session was patient fatigue.

Thomsen et al Critical Care Medicine( 2008 )Prospective study of 104 Ventilated respiratory failure ICU patients who received an early mobility protocol after transfer to a unit where mobility was a priority.

Within 2 days in there was a three fold increase in the number of patients ambulating compared to pre-transfer rates.

Burtin et al Critical Care Medicine ( 2009 )RCT In a medical and surgical ICU in a university hospital.90 patients were randomized to the study or control group.Both groups received respiratory physiotherapy and standard passive ROM. In

addition, the study group received passive and active 20 minute sessions each day pedaling on a bedside ergometer.

Results: Functional exercise capacity quadriceps force and self-perceived functional status was higher at hospital discharge than with the control group. 73% of the study group vs 55% of the control group could walk independently.

!7% of the control group was referred to a rehab center after discharge VS 10 % of the study group.

74% of the treatment group v.s. 66% of the control group were discharged to home.

FINIS

Aherns, T. et al ( 2005) Progressive mobility guidelines for critically ill patients( electronic version) Website: Kathleen Vollman, Advancing Nursing. Retrieved, November 2009

Chobanian, A.V. et al (1974) Metabolic and hemodynamic effects of prolonged bedrest on normal subjects. Circulation (49) 551-559

Herridge MS et al (2003) One year outcome of survivors of the acute respiratory distress syndrome. New England Journal of Medicine 348:683-693

Bailey, P. et al (2007) Early activity is feasible and sfe in respiratory failure patients Critical Care Medicine, 35(1) 139-145

Morris, P. et al (2008) Early intensive care mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine 36(8) 2238-2243

Needham, D. et al (2007) Neuromuscular dysfunction acquired in critical care: a systematic review. Intensive Care Medicine 1876-189133:

Stiller, K. ( 2007) Safety issues that should be considered when mobilizing critically ill patients. Critical Care Clinics, 23(1) 35-53

Stiller, K., Phillips, A., Lambert, P. (2004) The safety of mobilization and its effect on hemodynamic and respiratory status of intensive care patients. Physiotherapy Theory and Practice, 20, 175-185