Medical/Pulmonary ICU

1. Medical/Pulmonary ICU Annamarie Asher, BS, PT, NCS

2. Implementation • Early mobility process formalized • Change agents identified • Literature reviewed • Visits to other early mobility programs • Exclusion criteria • Mobility stages defined for nursing • Dedicated therapist and rehab tech • Quality improvement initiative • Identify and address barriers • Track progress

3. Exclusion criteria • Active GI Bleed • Two pressors • Active Delirium Tremens • High vent settings • FiO2>60% • PEEP>12 • Unstable arrhythmias • Acute coronary syndrome • CRRT if femoral or AV fistula access

4. Possible contraindications for initiating mobility session • Mean arterial pressure (MAP) < 60 • Systolic BP > 180 • HR > 140 • Pulse oximetry < 88% • Severe agitation

5. Consult Process • Standing order in Medical/Pulmonary ICU

6. Triage Process • Triage by therapist • Chart review • Trajectory of medical condition • Lab values • Level of alertness • Vital signs as charted previously • Vent settings • Information from nursing • Response to turning or other movement • Treatment plan for the day

7. Patient Assessment • Vital signs • Level of Alertness • Information from Ventilator • Inventory of Lines, Tubes, Devices, Drains • Arterial lines, intrajugular, femoral lines, peripheral I-Vs, dialysis access, monitoring lines such as pulse oximeter, EKG, BP cuff, nasogastric tubes, PEG tubes, colostomy, wound drains, wound vac, chest tubes, PTC tubes, nephrostomy tubes…..

8. Patient Assessment • General appearance • If not following commands is there spontaneous movement • Speak with family to obtain prior mobility status • Strength, ROM, muscle tone, resp status

9. Arterial Blood Gas • pH • Measurement of acidity/alkalinity of blood • Normal is 7.35-7.45 • PaCO2 • Normal is 35-45 mm Hg • > 45 leads to acidosis • < 35 leads to alkalosis • Regulated by ventilation

10. Arterial Blood Gas • HCO3- (bicarbonate) • Normal is 22-26 mEq/Liter • >26 leads to alkalosis • <22 leads to acidosis • Regulated by kidneys • State of compensation • Pulmonary compensation occurs quickly • Metabolic compensation takes hours to days

11. Arterial Blood Gas • PaO2 • Normal is 80-100 mm Hg • Does not influence pH • Permissive hypercapnia

12. Common diagnoses • Septic shock • Acute Respiratory Distress Syndrome • Acute GI Bleeds • Drug/Alcohol overdose • Acute Liver Failure • Acute Kidney Failure • Pulmonary Fibrosis • Cystic Fibrosis • Post Lung Transplant Rejection

13. Sepsis • Systemic Inflammatory Response Syndrome (SIRS) • Confirmed infectious process • Respiratory failure/ARDS • Severe hypotension • Multiple Organ Failure • Mental status changes • Medical treatment can include massive fluid resuscitation, mechanical ventilation, dialysis

14. Acute Respiratory Distress Syndrome • Reaction to infection or injury to lung • Characterized by: • Inflammation of lung tissue • Pulmonary edema • Severe hypoxemia • Medical Treatment • Non invasive ventilation or intubation, avoiding high pressures and Vt to prevent further lung damage

15. Liver Failure • Signs and Symptoms • Ascites • Peripheral edema • Hepatic encephalopathy • Coagulopathy • Portal hypertension • GI bleeding • Medical Treatment can include paracentesis, lactulose

16. Kidney Failure • Acute vs Chronic • Causes • Diabetes • Hepatorenal sydrome • Rhabdomyolysis • Lupus • Hypertension • Primary Kidney diseases

17. Kidney failure • Dialysis • Peritoneal • Hemodynamic • Continuous renal replacement therapy • CRRT • Used if patient cannot tolerate standard HD due to hypotension • Not portable

18. Pulmonary Fibrosis • Associated with known lung disease or exposure but often is idiopathic • Lung tissue gradually replaced with fibrotic tissue which is irreversible • Progressive and severe hypoxia • Progression may be slowed with corticosteroids or immunosuppression • Lung transplant is option for some patients

19. Barriers to Mobility • Oxygen requirements • Edema • Agitation • Somnolence • Encephalopathy • Hypersensitive airway • CRRT

20. Risks of early mobility • Decompensation of patient • Accidental removal of tubes/lines • Dignacare and FCD most commonly disrupted • Discomfort to patient • Fall risk or injury to patient

21. Safeguards • Constant monitoring of vital signs • Careful planning for contigencies • Ability to increase FiO2 • Suction prior to leaving room • Wheelchair follow for ambulation • Stepping at bedside prior to stepping away from bed • Overhead lifts available if needed for transfer • Mobilize with assistance • Nurse aware of treatment plan • Disconnect non essential lines prior to mobility

22. Possible contraindications for initiating mobility session • MAP < 60 • Systolic BP > 180 • HR > 140 • Pulse oximetry < 88% • High vent settings • Agitation

23. Physiologic Measures • What are the options? • Standard vital signs • HR, BP, RR, SpO2 • Composite parameters • Minute ventilation (RR x Vt) • Rapid Shallow Breathing Index (RR/Vt) • PaO2/FiO2

24. Outcome Measures • FSS Functional Independence Measure • FSS-ICU Functional Status Score-ICU • Individual scores of 0-7 for: • Rolling • Supine <-> sit • Sitting EOB • Sit <-> stand • Ambulation • Maximum score is 35

25. Risk vs Benefit • Example: Patient who is very uncomfortable on vent and will be extubated that day. Wait to mobilize after extubation. • Example: Patient who requires FiO2 of 100% and has exhausted all tx options and desires to return home. Mobilize carefully.

26. Risk vs Benefit • Example: Patient with DNI who is on high FiO2 and RR of 40 at rest, just starting medical treatment. Hold mobility to see if medical treatment will improve condition and allow for safer mobilization.

27. Risk vs Benefit • Example: Agitated patient who requires restraints and/or sedation. Attempt mobility carefully to see if patient will be calmer if allowed to get out of bed. • Example: Agitated patient who is pulling and lines and threatening staff. Hold mobility to see if as medical condition improves pt will be calmer.

28. Treatment • Evaluate strength, ROM, resp system • If hemodynamically stable start with sitting. • If patient with minimal signs of self mobility start with bed in chair position. • Proceed to sitting EOB • Provide foot support • Provide trunk support if needed with pillow at back or sheet held from each side • Activities: reaching, UE/LE AROM, breathing exercise, trunk extension

29. Bed in chair position

30. Bed in chair position

31. Sitting on the edge of the bed

32. Sitting Options

33. Treatment • Standing • Walker • Two person assist • Weight shift, marching in place, side stepping • All of these allow plan for early return to sitting • Transfer to chair • Interval walking with wheelchair follow

35. Case studies • Presented at conference

36. Web sites • Web sites for Arterial Blood Gas interpretation http://realnurseed.com/abg.htm This is a self learning module for ABGs, taught with humor http://orlandohealth.com/MediaBank/Docs/SLP/2010%20ABG%20SLP.pdf Self-Learning Packet for Arterial Blood Gas Interpretation • Mobilization-network.org Lists of up to date publications, web sites and news

37. References • Stiller, K., Phillips, A., Safety Aspects of mobilising acutely ill patients. Physiotherapy Theory and Practice. 2003, Vol. 19: 239-257 • Stiller, K., Phillips, A., Lambert, P., The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care unit patients. Physiotherapy Theory and Practice. 2004, Vol. 20: 175-185. • Adler, J., Malone, D., Early Mobilization in the Intensive Care Unit: A Systematic Review. Cardiopulmonary Physical Therapy. 2012, Vol. 23, 1:5-13. • Roschmann, R. and Rothenberg, J., Pulmonary Fibrosis in Rheumatoid Arthritis: A Review of Clinical Features and Therapy. Seminars in Arthritis and Rheumatism, 1987, Vol. 16, No. 3: 174-185 • Luce, J. Acute lung injury and the acute respiratory distress syndrome. Critical Care Medicine, 1998, Vol. 26 (2): 369-376

38. References • Zafiropoulos B, Alison JA, McCarren B., Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient. Aust J Physiother 2004;50(2):95-100 • Zanni JM, Korupolu R, Fan E, et al., Rehabilitation therapy and outcomes in acute respiratory failure: An observational pilot project. J Crit Care 2010 Jun;25(2):254-62.