Early Mobilization of Patients in Critical Care

Poramed Chayaratanasin, PhD, MD

Rehabilitation Medicine Department,

Faculty of Medicine Ramathibodi Hospital,

Mahidol University

Outline

• Immobilization syndrome

• Post ICU syndrome

• Benefit of early mobilization

• Safety

• How

• Barrier

• Assisting aid/ technology

Effects of immobilization on body systems

• Musculoskeletal system

• Cardiovascular system

• Pulmonary system

• Integumentary system

• Genitourinary system

• Gastrointestinal system

• Metabolic and endocrine systems

• Cognitive and behavioral systems

Disuse atrophy

• Size of muscle fibers & muscle mass↓

• Generalized and more prominent in antigravity muscles

• Muscle protein synthesis ↓

Disuse atrophy

• Atrophy of type I and IIa muscle fibers > IIb

• Rate of muscle wasting: slow during the 1st

and 2nd days but becomes rapid thereafter

• Muscle wt. loss 50% at 10thday

Loss of Strength

• Myofibrils per fiber volume↓

• Size and number of mitochondria↓

• Sarcomeres ↓

• Strength loss 50% at 4thwk

Loss of Endurance

• ↓ATP & glycogen storage

• Muscle type I and IIa↓

Joint contracture

Prolonged joint immobilization

• Resting flexing muscle length

• Collagen synthesis ↓

(but proportional less than protein synthesis)

• Capsular or soft tissue tightness

Disuse osteoporosis

• Maintenance of skeletal mass depends on mechanical loading (muscle pull and gravity)

• Loss of Ca and hydroxyproline from cancellous portion of long bone (epiphyses and metaphyses) and cortical bone near bone marrow

Immobilization hypercalciuria(± hypercalcemia)

• Urinary calcium excretion above the normal level on 2nd - 3rd day and max loss in 4th -5th wk

• Hypercalcemia may show in young adults (SCI)

Immobilization hypercalciuria(± hypercalcemia)

• Symptoms: anorexia, abd. pain, N/V, constipation, confusion, coma

• Decrease in total Ca can last for months or years (even after resumption of physical act.)

Effects in cardiovascular & pulmonary systems

Redistribution of body fluid

• Lying down : 500-700 ml. of blood shifts to thorax --> CO ↑ & HR ↓

• ↓ secretion of ADH (compensatory diuresis)

• reduction in blood volume and CO

• blood vol. loss max day 14th (20%)

Postural hypotension

• Blood shift

• Venous compliance and intravascular depletion

• Inadequate sympathetic response

Postural hypotension

• Postural CVS responses may completely lost after 3 wk of bed rest in healthy people

• Restoration take 20-72 days

Cardiac deconditioning at rest

• resting HR ↑ 1 bpm every 2 days

(immobization tachycardia)

When resuming submax. activity

• After 3 days of bed rest: HR↑ 32%

• After 7 days of bed rest: HR↑ 62%

• After 21 days of bed rest: HR↑ 89%

Redistribution of body fluid

• Plasma volume ↓ more than RBC mass

→ blood viscosity↑

→ thromboembolic phenomena

Deep venous thrombosis

• Virchow’s triad : venous stasis

↑blood coagulability

injury to the vessel wall

Deep venous thrombosis

• Immobility: exposes two factor

– venous stasis: decrease pumping of calf m.

– ↑blood coagulability: ↑blood viscosity

• May develop pulmonary embolism

Effect on respiratory system

2% 7%

19%

30%

• Diaphragm movement ↓

• Chest excursion ↓

• ROM of costovertebral and costochondral joints↓

Effect on respiratory system

• In recumbency, secretions pool in the dependent part, whereas the upper part is dry and the ciliary function is impaired so the secretion clearance

• Changes in ventilation-perfusion ratio in the dependent part leads to lowered arterial oxygenation

Effect on respiratory system

• ↑Risk of atelectasis and pneumonia

• Diaphram thickness↓in 72 hr of invasive ventilation

Effects of immobilization on Integumentary systems

• Pressure injury

• Dependent edema

Effect on gastrointestinal system

• Loss of appetite

• ↓rate of absorption

• Distaste protein rich food: hypoproteinemia

Effect on gastrointestinal system

• ↓Bowel motility: GE reflux

• Constipation

- ↑adrenergic activity; inh. peristalsis + ↑sphincter contraction

- Plasma vol. loss and dehydration

- Defecate in nonphysiological position

Effects on Genitourinary systems

• Bladder/renal stones & UTI

• Hypercalciuria, ↑urinary phosphorus excretion

• Void in supine position → incomplete bladder emptying → urinary retention

(abdominal weakness, ↓intraab. pressure)

Effects of immobilization on metabolism and endocrine systems

• ↓ lean body mass but ↑ body fat content

• ↓ metabolic activity of muscle → utilization of O2 and glucose↓ → insulin resistance (Glucose intolerance)

Effects of immobilization on metabolism and endocrine systems

• Electrolyte imbalance (Na, K, phosphorus)

• ↑ parathyroid hormone production & other hormones alterations

Effects of immobilization on Cognitive and behavioral systems

• Sensory deprivation

• Confusion and disorientation

• Anxiety and depression

• ↓ intellectual capacity

• Impaired balance and coordination

Post ICU Care Syndrome (PICS)

• New or worsening impairment in physical, cognitive or mental health status arising after critical illness and persisting beyond discharge form the acute care settings

Post ICU Care Syndrome (PICS)

• Symptoms: generalized weakness, fatigue, mobility ↓, anxious/depressed mood, sexual dysfn, sleep disturbances, cognitive issues

• Symptoms can last for few months to many years post recovery

Post ICU Care Syndrome (PICS)

Cognitive impairment

• Incidence 25-75%

• Memory disturbance/loss, slow mental processing, poor concentration, thinking and judgement impairment

• Risk factors: delirium duration, brain dysfn, hypoxia, hypotension, glucose dysregulation, respiratory failure (mech. ventilation), severe sepsis, renal replacement therapy, ARDS, prior cognitive impairment

Post ICU Care Syndrome (PICS)

Psychiatric illnessess

• Incidence 1-62%

• Depression, anxiety, PTSD

• Risk factors: female, lower educational level, preexisting disability, use of sedation and analgesia, other as cognitive risk

Post ICU Care Syndrome (PICS)

Physical impairment

• Incidence > 25%

• ICU-acquired weakness, fatigue, poor mobility, recurrent falls

• Risk factors: prolonged mech. ventilation (>7 days), sepsis, multisystem organ failure, prolonged duration of deep sedation

PICS-F (family)

• acute and chronic psychological effects of critical illness on family of pt. includes symptoms that are experienced during critical illness and those that occur following death or D/C form ICU

• Symptoms: sleep deprivation, anxiety, depression, PTSD

• Risk factors: poor communication, decision-making role, lower education level, having loved one who died/close to death

ABCDE bundle

“Prevention is better than cure”

• Awakening (light/minimal sedation)

• Breathing (spontaneous breathing trial)

• Coordination of care and communication among various disciplines

• Delirium monitoring, assessment, Mx

• Early ambulation in ICU

Early Mobilization

Early Mobilization

• Proposed in 1975 and growing

• “the application of physical activity within the first 2 to 5 days of critical illness or injury”

Early Mobilization

Benefits (esp. start W/I 72 hr)

• prevent ICUAW

• ↑ventilator free days

• ↓ Delirium duration

• ↓ ICU and hospital LOS

• improve functional outcome at D/C (6MWD, independent ambulation)

• Feeling of well-being (SF-36)

Early Mobilization

Consideration

• But recent systematic review showed minimal effect on fn recovery or QoL

• No assoc. bt EM and short-/long-term mortality

Early Mobilization

Limitation of evidence

• Heterogeneity of ICU patient

• Lack of consensus around terms of early mobilization (intensity, duration, freq.)

• Variation in standard pt. care

• Inconsistency in outcome measurement

Early Mobilization

Core set of outcomes measures

• EQ-5D

• HADS (the hospital anxiety and depression scale)

• IES-R (Impact of Events Scale-Revised)

• Survival

• Others – not consensus (MoCA, 6MWT, MMT/grip strength)

Early Mobilization

Large variety of interventions

• PROM

• NMES

• Cycle ergometers

• Tilt tables

• Active assistive exercise

• Strengthening exercise

• Functional mobilization

Early Mobilization

Mobilizing pt

• Screen pt.

• Vital signs and status

• Environment, Cables, instrument

• Titrate with monitor

• Be prepared for all situations

• Enough staffs

Early Mobilization

Titrate mobility

• Bed rolling

• Upright with support (legs on bed)

• Dangling

• Pivot to chair

• Standing

• Marching

• Ambulation

Safety

Event ? %

Safety

• Potential safety event 2.6% (mostly BP change and O2 desat (self resolved))

• Significant complication 0.6%

Safety

Barrier

• Patient factor

• Structural barrier

• Process barrier

• Cultural barrier

Barrier

Patient factor

Barrier

Patient factor

Barrier

Patient factor

Barrier

Barrier

Barrier

Early Mobilization

Management

• Multidisciplinary team

• Team education

• Mobility champions/teams

• Stepwise approach to mobility

Take home message

• Immobility is terrible

• EM start within the first 72 hr may improve outcomes

• Safe and feasible

• Prevention is better than cure