Early Mobility in the ICU

1. Early Mobility in the ICU Peter Hurh, MD Assistant Professor University of Pittsburgh Medical Center Medical Director UPMC Rehabilitation Institute at East

2. I have no conflicts of interest to report. I do not endorse any products that may be pictured in any photos.

3. Objectives Understand the complications secondary to immobility in the ICU. Understand short-term and long-term effects of critical illness and immobility. Understand that therapy in the ICU is safe, feasible, and effective.

6. Metabolic Cardiovascular Psychological Pulmonary Dermatological Renal Gastrointestinal Musculoskeletal Genitourinary

7. Adverse Effects of Immobility Cardiovascular • Decreased cardiopulmonary function • Decreased cardiac output • Reduced venous return • Decreased stroke volume • Postural hypotension Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

8. Adverse Effects of Immobility Cardiovascular • Atelectasis • Hypostatic pneumonia • Intubation • Tracheostomy Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

9. Adverse Effects of Immobility Cardiovascular • Decreased appetite/ poor nutrition • Constipation • PEG tube • Rectal trumpet Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

10. Adverse Effects of Immobility Cardiovascular • Urinary stasis • Stone formation • Infection • Foley catheter Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

11. Adverse Effects of Immobility Cardiovascular • Disuse muscle atrophy • Joint contractures • Heterotopic ossification • Decreased strength and endurance • Impaired balance Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

12. Adverse Effects of Immobility Cardiovascular • Pressure ulcers • Infection • Pain Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

13. Adverse Effects of Immobility Cardiovascular • Sensory deprivation • Disorientation and confusion • Depression and anxiety • Delirium Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

14. Adverse Effects of Immobility Cardiovascular • Insulin resistance • Decreased muscle protein synthesis • Myosin changes from slow to fast twitch fibers • Change from fatty acid to less efficient glucose metabolism Pulmonary Gastrointestinal Genitourinary Musculoskeletal Dermatological Psychological Metabolic Kortebein, Am J Phys Med Rehabil, 2009

15. ICU-Acquired Weakness Korupolu, Contemporary Critical Care, 2009 Hough, Clin Chest Med, 2006 Kress, N Engl J Med, 2014 • Critical Illness Polyneuropathy • Clinical findings • Distal sensory and motor deficits, i.e. foot drop • Normal deep tendon reflexes • Electrodiagnostic findings • Symmetric, sensorimotor, axonal polyneuropathy • Decreased SNAP and CMAP amplitudes • Reduced motor recruitment

16. ICU-Acquired Weakness Korupolu, Contemporary Critical Care, 2009 Hough, Clin Chest Med, 2006 Kress, N Engl J Med, 2014 • Critical Illness Myopathy • Clinical findings • Proximal muscle weakness without sensory deficits • Decreased deep tendon reflexes • Electrodiagnostic findings • Preserved SNAP amplitudes; decreased CMAP amplitudes; increased CMAP duration • Small and short motor unit action potentials

17. ICU-Acquired Weakness • Critical Illness Polyneuropathy and Myopathy • Acquired neuromuscular disorder • Difficult to differentiate in the ICU due to factors such as sedation and patient cooperation • Coexist in critically ill patients

18. ICU-Acquired Cognitive Impairment • Wilcox, Crit Care Med, 2013 • Survivors of ARDS • 11 studies, n = 487 • At discharge: 70-100% of patients with cognitive impairments • Most common deficits: attention, concentration, memory, executive function • 1 year follow up: 46-78% • 2 year follow up: 25-47%

19. ICU-Acquired Cognitive Impairment • Wilcox, Crit Care Med, 2013 (con’t) • Mixed populations of medical and surgical ICU patients • At discharge: 39-51% with cognitive impairments • 3-6 month follow up: 13-79% • 12 month follow up: 10-71%

20. “As the population ages and mortality from critical illness declines, the number of ICU survivors is growing.” Needham, Arch Phys Med Rehabil, 2010

21. Herridge Trials

22. Herridge, N Engl J Med, 2003 • Evaluated 109 survivors of ARDS • 3, 6, and 12 months post-discharge from ICU • Median age: 45 years • Median duration of ICU admission: 25 days • Physical exam, pulmonary function testing, six-minute walk test, quality-of-life evaluation • QOL measures: physical functioning, social functioning, physical role, emotional role, mental health, pain, vitality, general health

23. Herridge, N Engl J Med, 2003 • Global assessment • At discharge, patients lost average of 18% of body weight • All patients reported poor function due to loss of muscle bulk, proximal muscle weakness, and fatigue • 12% had persistent pain at chest tube insertion sites at 1 year • 7% had entrapment neuropathies • 5% had large joint immobility due to heterotopic ossification • 4% had contractured fingers or frozen shoulders

24. Herridge, N Engl J Med, 2003

25. Herridge, N Engl J Med, 2003

26. Herridge, N Engl J Med, 2003 • Discussion • Persistent functional limitation at one year mainly due to muscle wasting and weakness • Multifactorial including corticosteroid-induced and critical-illness-associated myopathy • Six-minute walk test and quality-of-life assessments are correlated • Impaired muscle function -> compromised functional ability -> compromised quality of life • Findings consistent with previous published reports

27. Herridge, N Engl J Med, 2003 • Conclusion “…survivors of the acute respiratory distress syndrome continue to have functional limitations one year after their discharge from the ICU.” “…still do not know how long it takes for these patients to recover fully from their critical illness or whether complete recovery is possible in every case.”

28. Herridge, N Engl J Med, 2011 Continued follow up of same patients at 2, 3, 4, and 5 years after discharge from ICU

29. Herridge, N Engl J Med, 2011

30. Herridge, N Engl J Med, 2011

31. Herridge, N Engl J Med, 2011

32. Herridge, N Engl J Med, 2011

33. Herridge, N Engl J Med, 2011 • Conclusions • Persistent exercise limitations and reduced physical quality of life 5 years after critical illness • Quality of life and exercise capacity may have resulted from combination of persistent weakness, and other physical and neuropsychological impairments • Depression, anxiety, PTSD, agitation, family/caregiver mental health problems, social isolation, sexual dysfunction, job loss, dispute with insurance claims

34. “When we started our ICU in 1964, patients who required mechanical ventilation were awake and alert and often sitting in a chair…” “…what I see these days are paralyzed, sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise.” Petty T. Chest. 1998; 114(2): 361-363

35. Safety and Feasibility

36. Bailey, Crit Care Med, 2007 • 103 mechanically ventilated patients >4 days • 1,449 activity events • Sit on edge of bed, sit in chair, ambulation • Adverse events • Fall to knees, tube removal, systolic blood pressure >200mmHg or <90 mmHg, O2 sat <80%, extubation

37. Bailey, Crit Care Med, 2007 • Total of 14 adverse events in 1449 activity events (0.96%) • Fall to knees, orthostatic hypotension, O2 desaturation, nasal feeding tube removal, hypertension • No adverse event resulted in extubation, complications requiring additional intervention, additional cost, longer hospital stay

38. Morris, Crit Care Med, 2008 • 280 mechanically ventilated patients • 135 patients in control group, 145 patients in protocol • Protocol initiated within 48 hours of mechanical ventilation • Activity ranged from PROM, AAROM, AROM, sit edge of bed, transfers, standing, ambulation

39. Morris, Crit Care Med, 2008 • No adverse events • Deaths, near-deaths, cardiopulmonary resuscitation, removal of device • No difference in numbers of arterial catheters, venous devices, need for re-intubation between control and protocol groups

40. Pohlman, Crit Care Med, 2010 • 49 mechanically ventilated patients • 498 activity sessions • Time from intubation to initial therapy = 1.5 days • Adverse events in 16% of all sessions (80/498) • Desaturation (6%), tachycardia (4.2%), tachypnea (4%), agitation/ discomfort (2%), device removal (0.8%) • No serious consequences noted for any adverse event

41. Conclusion Immobility and critical illness can affect every organ system, leading to significant functional impairments. These impairments, both physical and psychological, can be long lasting. Early intervention in the ICU is safe and feasible, and may prove to prevent the risk of ICU-acquired impairments and disabilities.

42. Thank You