Role of physiotherapists in ICU Care with bed ridden patients

1. Role of physiotherapists in ICUCare with bed ridden patients Professor of Anaesthesia MRI Alex. University E mail: saharelkaradawy@yahoo.com

2. Role of physiotherapist in ICU • They are responsible for providing patients with rehabilitation regimens. • Decrease incidence of complications. • Decrease ICU stay. • Decrease cost.

3. Objectives • Risk factor for immobilisation in ICU • Disadvantages of immobility • Pressure sores in critically ill patients • Prevention of bed sores • Treatment of bed sores

4. Immobilisation and muscle weakness • The musculoskeletal system is designed to keep moving; it takes only seven days of bed rest to reduce muscle bulk by up to 30%.

5. Causes of immobilisation in ICU • Any serious problems: • Neurological deficit, and general debilitation and weakness. • Polyneuropathy or myopathy after the acute phase of multiple organ dysfunction. • Patients with severe congestive heart failure. • Respiratory faliure. • Myocardial infarction • Controlled ventilation and administration of sedative and neuromuscular blocking agents.

6. Disadvantages of immobility • Cardiovascular • Venous stasis • Increased risk of venous thrombosis • pulmonary embolism • Respiratory • Decreased functional residual capacity • Decreased lung compliance • Retained secretions • Atelectasis

7. Disadvantages of immobility Metabolic • Increased excretion of nitrogen, calcium, potassium, magnesium, and phosphorus • Osteoporosis • Kidney stones Gastrointestinal tract • Lack of digestion • constipation

8. Disadvantages of immobility • Musculoskeletal • Decrease in muscle bulk • Loss of bone density • Decreased range of joints movement • Pressure sores

9. Role of physiotherapists • Encourage active movement in the bed. • active assisted movement • passive movements (shoulders, hands, hips, and ankles ) to avoid contractures.

10. Bed sores • Patients do not move regularly develop pressure sores on dependent areas. • The most vulnerable areas are the tissues over bony prominences. • The cost to heal a single full-thickness pressure sore may be as high as 70,000 dollars.

11. Pathophysiology • Pressure is exerted on surface beneath ( pressure points). • These pressures are often in excess of capillary filling pressure (approximately 32 mm Hg). • prolonged exposure to pressures just slightly above capillary filling pressure initiates a series leads to tissue necrosis and ulceration.

12. Pathophysiology • Shear forces and friction aggravate the effects of pressure and are important components of the mechanism of injury • Maceration may occur in a patient who has incontinence, predisposing the skin to injury

13. Stages of bed sores Suspected Tissue Injury: • This stage is described as a "purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear."

14. Stages of bed sores Stage I: intact skin with signs of impending ulceration. • Initially there is blanchableerythema indicating reactive hyperemia. • Reactive hyperemia should resolve within 24 hours of the relief of pressure. • Finally, the skin may appear white from ischemia.

15. Stages of bed sores • Stage II: • A partial-thickness loss of skin involving epidermis and dermis that appears as an open shallow ulcer with a pink wound bed.

16. Stages of bed sores • Stage III: • A full-thickness loss of skin with extension into subcutaneous tissue but not through the underlying fascia. This lesion presents as an ulcer that may include undermining and tunneling of adjacent tissue. Bone, tendon, and fascia are not exposed.

17. Stages of bed sores • Stage IV: • full-thickness tissue loss with extension into muscle, bone, tendon, or joint capsule. Slough or eschar may be present in the wound. Osteomyelitis with bone destruction and dislocations or pathologic fractures may be present.

18. Factors increase developing pressure sores in critically ill patients • Inability to move • Muscle wasting • Depressed cardiac function • Malnutrition, hypoproteinemia • Incontinence or presence of a fistula contributes to ulceration in several ways.

19. Prevention of bed sores • Turn or ask patients to turn every 2 hours. • Skin lubricant • Avoid hypoxia • Active or passive exercise to enhance blood supply • good nutrition.

20. Management of bed sores Management of pressure ulcers relies on key principles, including: • pressure reduction, • adequate debridement of necrotic and devitalized tissue, • control of infection, and meticulous wound care.

21. management • Pressure reduction Turning and repositioning the patient remains the cornerstone of prevention and treatment through pressure relief. Repositioning should be performed every 2 hours, even in the presence of a specialty surface or bed. Patients who are bed ridden should be positioned at a 30 degree angle when lying on their side to minimise pressure over the ischialtuberosity and greater trochanter.

22. Give over care for pressure points of the body • Use specialized surfaces for bed and wheelchair; foam mattress, air-filled mattress, water-filled mattress, gel-filled mattress.

23. RELIEVE SKIN PRESSURE FROM THE FOOT • Relieve skin pressure by changing position or being positioned so that pressure is taken off a bony area.

24. Side Position Padding • Head: Small, foam support under head. • Hips: Pad placed above and below the hip joint. When pads are placed correctly, a flat hand can be slid between the body and the bed to be certain that pressure has been relieved. • Ankle: Pad placed above the ankle joint • Between Lower Legs: Pillow placed lengthwise between legs to prevent pressure on the knees and ankle joint.

25. Supine (Back) Position Padding • Head: Small, foam support under the head. • Back: Place pad under lower back to provide elevation of the sacrum • Knees: The bend at the knee is a natural curvature. Use a pad above the area behind the knee. • Ankles: A small pad is necessary at the back of the heel to relieve tension on the calf of the leg. • Heels must be off the bed to prevent skin breakdown. • Between Lower Legs: Foam pad or pillow placed between the knees to present possible breakdown at the knee and ankle joints.

26. Prone Position Padding • Head: Small, foam support under head. • Chest: Use one or more pillows according to comfort. • Thighs: Foam pads placed above the knees to prevent redness of knees • Between Knees: Pads placed between knees to keep knees and ankles apart so pressure sores do not develop.

27. RELIEVE SKIN PRESSURE IN A WHEEL CHAIR • Weight reduction is the most essential technique for preventing pressure on the skin and muscle of the sacrum and each hip • Cushions: Air, foam, gel or fluid • A cushion for wheelchair is essential. Cushions provide pressure relief and weight distribution and thus aid in the prevention of pressure sores

28. Take Routine Care of Your Skin • The third way to prevent skin sores, the most serious problem in SCI, is to keep skin healthy. • Health skin is skin which is intact, well lubricated with natural oils, and nourished by a good blood supply. • Skin stays healthy with good diet, good hygiene, regular skin inspection, and regular pressure relief.

29. Other treatment • Nutritional status should be evaluated and optimized to ensure adequate intake of calories, proteins, and vitamins. • Cessation of smoking, adequate pain control, maintenance of adequate blood volume, and correction of anemia. • The wound must be kept clean and free of urine and feces

30. Other treatment • Bacterial contamination must be assessed and treated appropriately. • Wound dressings: • the goal is to achieve a clean, healing wound with granulation tissue. A stage I lesion may not require dressing. • Wound debridement

31. References • Christian N Kirman, Lars M VistnesPressure Ulcers, Nonsurgical Treatment and Principles Treatment & Management. Medscape 2010 • Sheila Adam, Sally Forrest Clinical Review ABC of intensive care, Other supportive care BMJ 319 : 175 (Published 17 July 1999)

32. Thank you