Avoiding Complications Avoiding Complications in Acute Care:in Acute Care:Preparing Patients for Preparing Patients for RehabilitationRehabilitation

Marilyn Pacheco, MDMarilyn Pacheco, MDAssistant ProfessorAssistant ProfessorDepartment of Physical Medicine and Department of Physical Medicine and RehabilitationRehabilitationUniversity of Arkansas for Medical University of Arkansas for Medical SciencesSciencesApril 10, 2006April 10, 2006

ObjectiveObjective

In preparing for life as an intern:In preparing for life as an intern:

A PGY1 needs to A PGY1 needs to Learn how to decrease Learn how to decrease

complications in these patients complications in these patients Learn who are the patients that Learn who are the patients that

will need rehabilitationwill need rehabilitation

WHY THIS TALK?WHY THIS TALK?

The initial acute hospital care is The initial acute hospital care is important and this includes initial important and this includes initial assessment and rehabilitation, assessment and rehabilitation, which begins with the prevention which begins with the prevention of of complications and early complications and early treatment. treatment.

CMS Magic 13 CMS Magic 13 diagnosis:diagnosis:

1. Stroke1. Stroke 2. Spinal cord injury2. Spinal cord injury 3. Congenital deformity3. Congenital deformity 4. Amputation 4. Amputation 5. Major multiple trauma 5. Major multiple trauma 6. Fracture of femur (hip fracture) 6. Fracture of femur (hip fracture)

CMS Magic 13 CMS Magic 13 diagnosis:diagnosis: 7. Brain injury 7. Brain injury 8. Neurological disorders (including, 8. Neurological disorders (including,

but not limited to, MS, MD, but not limited to, MS, MD, polyneuropathy, and Parkinson’s polyneuropathy, and Parkinson’s disease) disease)

9. Burns 9. Burns 10. Active, polyarthricular rheumatoid 10. Active, polyarthricular rheumatoid

arthritis, psoriatic arthritis, and arthritis, psoriatic arthritis, and seronegative arthropathiesseronegative arthropathies

11. Systemic vasculidities with joint 11. Systemic vasculidities with joint inflammationinflammation

CMS Magic 13 CMS Magic 13 diagnosis:diagnosis:

12. Severe/advanced osteoarthritis involving 12. Severe/advanced osteoarthritis involving two or more major weight-bearing joints (not two or more major weight-bearing joints (not counting joints with a prosthesis) with joint counting joints with a prosthesis) with joint deformity, substantial loss of range of motion, deformity, substantial loss of range of motion, and atrophy of muscles surrounding the joint and atrophy of muscles surrounding the joint

13. Knee or hip joint replacement, with one or 13. Knee or hip joint replacement, with one or more of the following circumstances applying: more of the following circumstances applying: – The patient underwent bilateral knee or bilateral hip The patient underwent bilateral knee or bilateral hip

joint replacement surgery during acute joint replacement surgery during acute hospitalization. hospitalization.

– The patient is extremely obese with a Body Mass The patient is extremely obese with a Body Mass Index of at least 50 at time of admission to inpatient Index of at least 50 at time of admission to inpatient rehabilitation hospital. rehabilitation hospital.

– The patient is age 85 or older at the time of The patient is age 85 or older at the time of admission. admission.

OTHERS:OTHERS:

Cardiac patientsCardiac patients Pulmonary patientsPulmonary patients Oncology patientsOncology patients

These patients are prone to These patients are prone to DECONDITIONINGDECONDITIONING

DECONDITIONINGDECONDITIONING

Deconditioning can be defined as the Deconditioning can be defined as the multiple, potentially reversible changes in multiple, potentially reversible changes in body systems brought about by physical body systems brought about by physical inactivity and disuse. Such changes often inactivity and disuse. Such changes often have significant functional and clinical have significant functional and clinical consequences in older people. consequences in older people.

Deconditioning commonly occurs in two Deconditioning commonly occurs in two situations:situations:– (1) a sedentary lifestyle, which is common in older (1) a sedentary lifestyle, which is common in older

people even in the absence of significant disease or people even in the absence of significant disease or disability and may result in a slow, chronic decline disability and may result in a slow, chronic decline in physical fitness; and in physical fitness; and

– (2) bed or chair rest during an acute illness, which (2) bed or chair rest during an acute illness, which can lead to disastrously rapid physical decline. can lead to disastrously rapid physical decline.

What are the objectives What are the objectives of the PHYSIATRIC of the PHYSIATRIC PHYSICAL EXAMINATION?PHYSICAL EXAMINATION?

Screen for new illnesses that could affect Screen for new illnesses that could affect functional performance or rehabilitation functional performance or rehabilitation participationparticipation

Identify “regions of risk” for deterioration Identify “regions of risk” for deterioration Identify and quantify impairmentsIdentify and quantify impairments Identify limitation in task performance Identify limitation in task performance

(disability) specifically pertinent to short-(disability) specifically pertinent to short-term goals (like gait and transfers)term goals (like gait and transfers)

Demonstrate the patient’s capabilities to Demonstrate the patient’s capabilities to self and family.self and family.

REGIONS OF RISKS REGIONS OF RISKS

SYSTEM BASEDSYSTEM BASED

POSSIBLE POSSIBLE COMPLICATIONS:COMPLICATIONS:

CARDIACCARDIAC RESPIRATORYRESPIRATORY GASTROINTESTINALGASTROINTESTINAL GENITOURINARYGENITOURINARY MUSCULOSKELETALMUSCULOSKELETAL INTEGUMENTARYINTEGUMENTARY ENDOCRINEENDOCRINE NEUROLOGICALNEUROLOGICAL

Cardiovascular Cardiovascular ComplicationsComplications DVT/ PE –DVT/ PE –

– Virchows Triad: Virchows Triad: STASISSTASIS VASCULAR INJURY VASCULAR INJURY HYEPRCOAGULABLE STATEHYEPRCOAGULABLE STATE

Chest.Chest. 2004;126:338S-400S.) 2004;126:338S-400S.)© 2004 © 2004 American College of Chest PhysiciansAmerican College of Chest Physicians Prevention of Venous Thromboembolism Prevention of Venous Thromboembolism

Grade 1 recommendations are strong Grade 1 recommendations are strong and indicate that the benefits do, or do and indicate that the benefits do, or do not, outweigh risks, burden, and costs. not, outweigh risks, burden, and costs.

Grade 2 suggests that individual Grade 2 suggests that individual patients’ values may lead to different patients’ values may lead to different choices (for a full understanding of the choices (for a full understanding of the grading see Guyatt et al, grading see Guyatt et al, CHEST 2004; CHEST 2004; 126:179S–187S126:179S–187S). ).

Among the key recommendations in the Among the key recommendations in the chapter are the following:chapter are the following:– The authors recommend The authors recommend againstagainst the use of the use of

aspirin alone as thromboprophylaxis for any aspirin alone as thromboprophylaxis for any patient group (Grade 1A). patient group (Grade 1A).

For moderate-risk general surgery For moderate-risk general surgery patients, patients, – recommend prophylaxis with low-dose recommend prophylaxis with low-dose

unfractionated heparin (LDUH) (5,000 U bid) unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) or low-molecular-weight heparin (LMWH) [ 3,400 U once daily] (both Grade 1A). [ 3,400 U once daily] (both Grade 1A).

For higher risk general surgery patients, For higher risk general surgery patients, – recommend thromboprophylaxis with LDUH recommend thromboprophylaxis with LDUH

(5,000 U tid) or LMWH (> 3,400 U daily) (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. [both Grade 1A].

For high-risk general surgery patients For high-risk general surgery patients with multiple risk factors, with multiple risk factors, – recommend combining pharmacologic recommend combining pharmacologic

methods (LDUH three times daily or LMWH, methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated > 3,400 U daily) with the use of graduated compression stockings and/or intermittent compression stockings and/or intermittent pneumatic compression devices (Grade pneumatic compression devices (Grade 1C+).1C+).

recommend that thromboprophylaxis be used in recommend that thromboprophylaxis be used in all patients undergoing all patients undergoing major gynecologic major gynecologic surgery (Grade 1A) or major, open surgery (Grade 1A) or major, open urologic proceduresurologic procedures,,– recommend prophylaxis with LDUH two times or three recommend prophylaxis with LDUH two times or three

times daily (Grade 1A). times daily (Grade 1A). For patients undergoing elective total hip or knee For patients undergoing elective total hip or knee

arthroplasty, arthroplasty, – recommend one of the following three anticoagulant recommend one of the following three anticoagulant

agents: LMWH, fondaparinux, or adjusted-dose vitamin agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). target, 2.5; range, 2.0 to 3.0] (all Grade 1A).

For patients undergoing hip fracture surgery For patients undergoing hip fracture surgery (HFS), (HFS), – recommend the routine use of fondaparinux (Grade 1A), recommend the routine use of fondaparinux (Grade 1A),

LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). 3.0) [Grade 2B], or LDUH (Grade 1B).

Patients undergoing hip or knee arthroplasty, or Patients undergoing hip or knee arthroplasty, or HFS,HFS,– recommend receive thromboprophylaxis for at least 10 recommend receive thromboprophylaxis for at least 10

days (Grade 1A).days (Grade 1A).

It is recommended that all trauma patients It is recommended that all trauma patients with at least one risk factor for VTE receive with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). thromboprophylaxis (Grade 1A).

In acutely ill medical patients who have In acutely ill medical patients who have been admitted to the hospital with been admitted to the hospital with congestive heart failure or severe congestive heart failure or severe respiratory disease, or who are confined to respiratory disease, or who are confined to bed and have one or more additional risk bed and have one or more additional risk factors, it is recommended prophylaxis factors, it is recommended prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). with LDUH (Grade 1A) or LMWH (Grade 1A).

It is recommended, on admission to the It is recommended, on admission to the intensive care unit, all patients be intensive care unit, all patients be assessed for their risk of VTE. Accordingly, assessed for their risk of VTE. Accordingly, most patients should receive most patients should receive thromboprophylaxis (Grade 1A).thromboprophylaxis (Grade 1A).

OrthostasisOrthostasis Orthostatic HypotensionOrthostatic Hypotension

– defined as 20 mm Hg or greater decrease in defined as 20 mm Hg or greater decrease in systolic or 10 mm Hg or greater decrease in systolic or 10 mm Hg or greater decrease in diastolic blood pressure after 3 minutes of diastolic blood pressure after 3 minutes of standing standing

– HR increase by 15 bpmHR increase by 15 bpm– dizziness upon standing. dizziness upon standing. – the prevalence was higher at successive the prevalence was higher at successive

agesages– Associated with difficulty walking, frequent Associated with difficulty walking, frequent

falls, histories of MI falls, histories of MI – Prevent: use of TED hose, abdominal bindersPrevent: use of TED hose, abdominal binders

In cardiac patientsIn cardiac patients Early mobilization in acute careEarly mobilization in acute care Prevention of deconditioningPrevention of deconditioning Patients learning energy conserving and Patients learning energy conserving and

pacing techniquespacing techniques Monitor HR, BP, RR, telemetry for first few Monitor HR, BP, RR, telemetry for first few

exercise sessionsexercise sessions– Target HR = predicted age adjusted maximum Target HR = predicted age adjusted maximum

heart rate = (220- age) x 60% to 80% (range)heart rate = (220- age) x 60% to 80% (range)– HR and BP should not deviate more than 20 HR and BP should not deviate more than 20

points for BP and 20 beats for HRpoints for BP and 20 beats for HR

In cardiac patientsIn cardiac patients Exercise should be immediately stopped for:Exercise should be immediately stopped for:

– chest painchest pain– shortness of breathshortness of breath– dizziness dizziness – or if angina symptoms developor if angina symptoms develop

Absolute and relative contraindications to Absolute and relative contraindications to exercise:exercise:– Unstable anginaUnstable angina– Life threatening cardiac arrhythmiasLife threatening cardiac arrhythmias– Uncompensated CHFUncompensated CHF– Critical aortic stenosisCritical aortic stenosis– Uncontrolled hypertensionUncontrolled hypertension– Acute MIAcute MI– Acute pulmonary embolusAcute pulmonary embolus– Acute myocarditis or pericarditisAcute myocarditis or pericarditis– Active endocarditisActive endocarditis

Respiratory Respiratory Complications: Complications: PneumoniaPneumonia AVOID AtelectasisAVOID Atelectasis Aspiration PneumoniaAspiration Pneumonia

– Assess swallow (not just bedside) by Assess swallow (not just bedside) by speech language pathologistspeech language pathologist

– Risk factors: decrease cognition, Risk factors: decrease cognition, tracheostomy, NG tube (any tube) if tracheostomy, NG tube (any tube) if patient has reflux, injury to face and patient has reflux, injury to face and throatthroat

Respiratory Respiratory Complications: special Complications: special consideration to consideration to respiratory management respiratory management in tetraplegicsin tetraplegics The more complete and higher the level of The more complete and higher the level of

cervical injury, the more ventilatory cervical injury, the more ventilatory insufficiency occurs.insufficiency occurs.

Need a good respiratory therapist in ICU Need a good respiratory therapist in ICU IPPB (intermittent positive pressure IPPB (intermittent positive pressure

breathing) QID with bronchodilators and breathing) QID with bronchodilators and mucolyticsmucolytics

Humidified O2Humidified O2 Chest PT and breathing exercisesChest PT and breathing exercises

Suctioning and drainageSuctioning and drainage Incentive spirometryIncentive spirometry Neck isometricsNeck isometrics Assisted coughAssisted cough Abdominal binding when uprightAbdominal binding when upright Avoid weaning with IMV/SIMV in SCI Avoid weaning with IMV/SIMV in SCI

patients (because it increases work patients (because it increases work of breathing); go slow with weaningof breathing); go slow with weaning

Avoid infectionsAvoid infections Always assess lung exam, ABGs Always assess lung exam, ABGs

and CXRand CXR

Gastrointestinal Gastrointestinal ComplicationsComplications

GI Bleed RiskGI Bleed Risk– Stress related ulcers and bleedStress related ulcers and bleed– Prophylaxis with H2 blockers (most none sedating is Prophylaxis with H2 blockers (most none sedating is

Axid, misoprostol)Axid, misoprostol)– Withdraw medication once acute risk has passedWithdraw medication once acute risk has passed

NutritionNutrition– High caloric needs in polytrauma patientsHigh caloric needs in polytrauma patients– Needs for hyper alimentationNeeds for hyper alimentation– Isotonic enteral feedingsIsotonic enteral feedings– Positive nitrogen balancePositive nitrogen balance– Check Hb, Hct, total protein, albumin and prealbuminCheck Hb, Hct, total protein, albumin and prealbumin– Weekly weights neededWeekly weights needed– Nutrition consultNutrition consult

Gastrointestinal Gastrointestinal complicationscomplications

BowelsBowels– Constipation is common – due to Constipation is common – due to

immobility, pain medications and immobility, pain medications and decrease intakedecrease intake

– Diarrhea – check C. Difficile; or could be Diarrhea – check C. Difficile; or could be a sign of constipationa sign of constipation

– Treatment:Treatment: High fiber diet/ bulk agentsHigh fiber diet/ bulk agents Glycerin suppositoriesGlycerin suppositories Stool softenersStool softeners In Acute SCI – usually still in spinal shock, In Acute SCI – usually still in spinal shock,

disimpaction might be neededdisimpaction might be needed

Genitourinary Genitourinary complicationcomplication Urinary tract infectionUrinary tract infection

– Early removal of Foley catheters if Early removal of Foley catheters if possiblepossible

– Beware of VREBeware of VRE– In TBI, stroke patients, once Foley In TBI, stroke patients, once Foley

removed, do timed voiding removed, do timed voiding – In SCI patients, clean intermittent In SCI patients, clean intermittent

catherization needed every 4 to 6 catherization needed every 4 to 6 hourshours

MUSCULOSKELETAL MUSCULOSKELETAL complicationcomplication

In orthopedic patientsIn orthopedic patients– Make sure weight bearing precautions Make sure weight bearing precautions

are written and followedare written and followed– Hip precautionsHip precautions

In immobile/paralyzed patientsIn immobile/paralyzed patients– Avoid contractures via ROM, splinting, Avoid contractures via ROM, splinting,

stretchingstretching Vertebral Compression fracturesVertebral Compression fractures

– Esp. in elderly, osteoporosis pts, MMEsp. in elderly, osteoporosis pts, MM

Neurologically Neurologically impaired skinimpaired skin SCI above T6 level, the skin SCI above T6 level, the skin

functional properties is altered.functional properties is altered. When temperature reaches 32-When temperature reaches 32-

34 degrees C, visible sweating 34 degrees C, visible sweating normally takes place and is normally takes place and is called reflex sweating. This is called reflex sweating. This is lost in SCI individuals with above lost in SCI individuals with above T6 level.T6 level.

Neurologically Neurologically impaired skinimpaired skin Biochemical factors: Biochemical factors: increase collagen increase collagen

catabolism, decrease amino acid catabolism, decrease amino acid concentration in insensate skin; decrease of concentration in insensate skin; decrease of lysyl hydrosylase activity; decrease type I to lysyl hydrosylase activity; decrease type I to type II collagen in skin below level of injury; type II collagen in skin below level of injury; decrease adrenergic receptors; increase decrease adrenergic receptors; increase excretion of GAGs in urineexcretion of GAGs in urine

Mechanical Factors: slower blood reflow rate Mechanical Factors: slower blood reflow rate after pressure in SCI group; smaller increase after pressure in SCI group; smaller increase in temperature during occlusion; muscle in temperature during occlusion; muscle atrophy provides less cushioning around atrophy provides less cushioning around bony prominencesbony prominences

SKIN complicationSKIN complication Pressure ulcersPressure ulcers

– Norton ScaleNorton Scale physical condition, mental condition, activity, mobility physical condition, mental condition, activity, mobility

and incontinenceand incontinence

– Braden Risk Assessment ScaleBraden Risk Assessment Scale sensory perception, moisture, activity, mobility, sensory perception, moisture, activity, mobility,

nutrition and friction/shearnutrition and friction/shear grade 1 to4 and score 6 to 23; lower score is higher grade 1 to4 and score 6 to 23; lower score is higher

riskrisk

– Areas at risk: Areas at risk: when in bed – sacrum, occiput, heelswhen in bed – sacrum, occiput, heels When in chair – ischium, sacrum, greater trochantersWhen in chair – ischium, sacrum, greater trochanters

– Turn patients every 2 hoursTurn patients every 2 hours– Protect skin with pasteProtect skin with paste– Prevention is keyPrevention is key

SkinSkin

MacerationMaceration– Avoid patient being wet – urine or Avoid patient being wet – urine or

fecesfeces– Good nursing careGood nursing care

Fungal infectionFungal infection– Esp. in obese patients; use of Esp. in obese patients; use of

creams and powderscreams and powders

Endocrine Endocrine complicationscomplications SIADHSIADH DIDI Thyroid dysfunctionThyroid dysfunction

NEUROLOGICAL NEUROLOGICAL COMPLICATIONSCOMPLICATIONS Most common encountered Most common encountered

situations in possible rehab situations in possible rehab patients: Stroke, Traumatic Brain patients: Stroke, Traumatic Brain Injury, Spinal Cord Injury, MS, etc.Injury, Spinal Cord Injury, MS, etc.

HYPERTENSIONHYPERTENSION BRAIN EDEMABRAIN EDEMA Central feverCentral fever

NEUROLOGICAL NEUROLOGICAL COMPLICATIONSCOMPLICATIONS Peripheral NeuropathiesPeripheral Neuropathies Spasticity Spasticity contractures contractures

limited functionlimited function

PAIN CONTROLPAIN CONTROL

Neurological Neurological complicationscomplications Confusion and agitation Confusion and agitation

– Place patients in quiet room, 1:1 sitter, Place patients in quiet room, 1:1 sitter, decrease all stimulidecrease all stimuli

– AVOID HALDOL – it has been proven to AVOID HALDOL – it has been proven to cause delay in cognitive recovery (more cause delay in cognitive recovery (more harm than good)harm than good)

For EMERGENCIES:For EMERGENCIES:– Ativan 0.5 to 2 mgs PO or IM q8 to q12hAtivan 0.5 to 2 mgs PO or IM q8 to q12h– Desyrel (Trazodone) 50 mgs PO/NGT q8h Desyrel (Trazodone) 50 mgs PO/NGT q8h

or qHSor qHS– Klonipin 0.5 mg q8hKlonipin 0.5 mg q8h– Chloral hydrate 500-1000 mg qHSChloral hydrate 500-1000 mg qHS

GOALSGOALS

Prevention of harmful events Prevention of harmful events Getting patients ready for Getting patients ready for

rehabilitation or their next phase rehabilitation or their next phase of recoveryof recovery

Consult Physical Medicine and Consult Physical Medicine and Rehabilitation early to help watch Rehabilitation early to help watch out for complications. out for complications.

ReferencesReferences

DeLisa and Gans, Rehabilitation DeLisa and Gans, Rehabilitation Medicine, 3Medicine, 3rdrd edition edition

PM&R SecretsPM&R Secrets ChestChest Kirshblum, Spinal Cord MedicineKirshblum, Spinal Cord Medicine Medical Management of Head InjuryMedical Management of Head Injury Clinical Practice Guidelines: Pressure Clinical Practice Guidelines: Pressure

Ulcer Prevention and ManagementUlcer Prevention and Management