SAFETY ASPECTS OF MOBILISING INTENSIVE CARE PATIENTS

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Lawrence Chapman
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1 SAFTY ASPCTS OF MOBILISING INTNSIV CAR PATINTS Kathy Stiller Physiotherapy Department Royal Adelaide Hospital Adelaide South Australia

4 My girls: Betsey and Peggotty

5 AIM Provide guidelines regarding safety issues when mobilising acutely ill in-patients Based on physiological rationale, articles, clinical experience Presented as 2 flowcharts Mobilisation heirachy

6 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded or discuss with or medical or medical IS THR SUFFICINT RSPIRATORY RSRV? PaO 2 /FIO 2 > 300, SpO 2 > 90% and < 4% recent decrease in SpO 2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment or discuss with or medical or medical AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm 3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm 3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications with or medical or medical SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD

7 Review medical background Is there sufficient cardiovascular reserve? Is there sufficient respiratory reserve? Are all other factors favourable?

8 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded Review medical background with or medical Past and current medical history IS THR SUFFICINT RSPIRATORY RSRV? PaO 2/FIO 2 > 300, SpO 2 > 90% and < 4% recent decrease in SpO 2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm 3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm 3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications or discuss with or medical or medical s t or medical Recent symptoms of cardiovascular or respiratory dysfunction Medications which may affect response to SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD Previous level of mobility and exercise capacity Body weight

9 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded with or medical Is there sufficient cardiovascular reserve? IS THR SUFFICINT RSPIRATORY RSRV? PaO 2/FIO 2 > 300, SpO 2 > 90% and < 4% recent decrease in SpO 2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with or medical Resting HR < 50% age predicted maximal HR AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm 3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm 3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications or discuss with or medical s t or medical SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD

10 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded with IS THR SUFFICINT RSPIRATORY RSRV? PaO 2/FIO 2 > 300, SpO 2 > 90% and < 4% recent decrease in SpO 2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm 3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm 3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications or medical or medical Is there sufficient cardiovascular reserve? Resting HR < 50% age predicted maximal HR BP < 20% variability or discuss with or medical s t or medical SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD

11 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded with IS THR SUFFICINT RSPIRATORY RSRV? PaO 2/FIO 2 > 300, SpO 2 > 90% and < 4% recent decrease in SpO 2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm 3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm 3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications or discuss with or medical or medical or medical s t or medical Is there sufficient cardiovascular reserve? Resting HR < 50% age predicted maximal HR BP < 20% variability Normal CG No other major cardiac conditions SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD

12 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded with IS THR SUFFICINT RSPIRATORY RSRV? PaO2/FIO2 > 300, SpO2 > 90% and < 4% recent decrease in SpO2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with or medical or medical Is there sufficient respiratory reserve? PaO 2 /FIO 2 > 300, SpO 2 > 90% and < 4% recent in SpO 2 AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm 3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm 3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications or discuss with or medical s t or medical SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD

13 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded with IS THR SUFFICINT RSPIRATORY RSRV? PaO2/FIO2 > 300, SpO2 > 90% and < 4% recent decrease in SpO2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm 3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm 3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications or medical or medical Is there sufficient respiratory reserve? PaO 2 /FIO 2 > 300, SpO 2 > 90% and < 4% recent in SpO 2 Respiratory pattern satisfactory or discuss with or medical s t or medical Able to maintain mechanical ventilation SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD

14 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded with or medical IS THR SUFFICINT RSPIRATORY RSRV? PaO2/FIO2 > 300, SpO2 > 90% and < 4% recent decrease in SpO2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with or medical AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications or discuss with s t or medical or medical SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD Are all other factors favourable? Haemoglobin stable, > 7 grams/dl Platelet count stable, > 20,000 cells/mm 3 WCC 4,300-10,800 cells/mm 3 Body temp < 38 C Blood glucose mmol/l Stable conscious state No neurological contraindications No orthopaedic contraindications continued

15 RVIW MDICAL BACKGROUND Past medical history or recent symptoms of cardiovascular/respiratory dysfunction Medications which may affect response to Previous level of mobility and exercise capacity IS THR SUFFICINT CARDIOVASCULAR RSRV? Resting heart rate < 50% age predicted maximal heart rate Blood pressure < 20% variability recently CG normal (ie no evidence of MI or arrhythmia) Other major cardiac conditions excluded with or medical Are all other factors favourable? IS THR SUFFICINT RSPIRATORY RSRV? PaO2/FIO2 > 300, SpO2 > 90% and < 4% recent decrease in SpO2 Respiratory pattern satisfactory Mechanical ventilation able to be maintained during treatment with or medical AR ALL OTHR FACTORS FAVOURABL? Haemoglobin stable and > 7 grams/dl No orthopaedic contraindications Platelet count stable and > 20,000 cells/mm3 No recent SSG / flap to lower limbs or trunk White cell count 4,300-10,800 cells/mm3 Medically stable if DVT and/or P Body temperature < 38 C xcessive weight able to be safely managed Blood glucose level mmol/l No attachments that contraindicate Patient appearance, pain, fatigue, Safe environment, appropriate ing and shortness of breath, emotional status acceptable expertise Stable conscious state Patient consent No other neurological contraindications Appearance, pain, fatigue, SOB, emotional status acceptable No recent SSG/flaps Stable condition if DVT or P No attachments contraindicating or discuss with s t or medical or medical SLCT APPROPRIAT MOD AND INTNSITY OF MOBILISATION, MONITORING QUIPMNT AND PROCD Safe environment, appropriate ing Patient consent

16 Review medical background Is there sufficient cardiovascular reserve? Is there sufficient respiratory reserve? Are all other factors favourable?

20 IS TH PATINT TOLRATING TH MOBILISATION INTRVNTION? Appropriate incremental increase in HR AND Initial rapid rise in systolic BP, stable or slight increase in diastolic BP AND Sinus rhythm AND PaO 2 /FIO 2 stable, < 4% decrease in SpO2, respiratory pattern acceptable AND Patient appears unstressed xcessive increase in HR AND/OR xcessive increase in BP AND/OR Increasing ectopic beats, arrhythmias AND/OR Decrease in PaO2/FIO2, 4% decrease in SpO2, respiratory pattern unacceptable AND/OR Patient appears distressed xcessive increase in HR or BP plus signs and symptoms of cardiovascular stress AND/OR No change or decrease in HR and/or systolic BP plus signs and symptoms of cardiovascular stress AND/OR Increasing ectopic beats, arrhythmias plus haemodynamic instability or signs and symptoms of myocardial ischaemia AND/OR Decrease in PaO 2 /FIO 2, 4% decrease in SpO 2, respiratory pattern unacceptable plus signs and symptoms of respiratory distress AND/OR Patient appears distressed Continue. Increase intensity, mode, frequency and duration as tolerated (see Figure 3) Decrease intensity of Condition stabilises Condition does not stabilise Return to resting position Discontinue Return to resting position Monitor until stabilised Seek assistance if required medical Monitor condition until parameters have returned to be near pre-treatment levels

21 TROUBLSHOOTING DURING MOBILISATION Is the patient tolerating? Yes Unsure No Condition stabilises Condition does not stabilise Continue Discontinue Return to resting position, monitor until stabilised

22 Yes Is the patient tolerating? Unsure No Yes (the patient is tolerating ) Condition stabilises Condition does not stabilise Continue Discontinue Return to resting position, monitor until stabilised Appropriate incremental in HR and Initial rapid in systolic BP, stable or slight in diastolic BP and Sinus rhythm and PaO 2 /FIO 2 stable, <4% in SpO 2, respiratory pattern acceptable and Patient appears unstressed

23 Yes Is the patient tolerating? Unsure No Unsure (if the patient is tolerating ) Condition stabilises Condition does not stabilise Continue Discontinue xcessive in HR and/or BP and/or Return to resting position, monitor until stabilised ectopic beats, arrhythmias and/or in PaO 2 /FIO 2, 4% in SpO 2, respiratory pattern unacceptable and/or Patient appears distressed

24 Yes Is the patient tolerating? Unsure No No (the patient is not tolerating ) Condition stabilises Condition does not stabilise Continue Discontinue xcessive in HR or BP plus S+S and/or Return to resting position, monitor until stabilised No change or in HR and/or systolic BP plus S+S and/or ectopic beats, arrhythmias plus haemodynamic instability or S+S and/or in PaO 2 /FIO 2, 4% in SpO 2, respiratory pattern unacceptable plus S+S and/or Patient appears distressed

25 TROUBLSHOOTING DURING MOBILISATION Is the patient tolerating? Yes Unsure No Condition stabilises Condition does not stabilise Continue Discontinue Return to resting position, monitor until stabilised

26 IN BD Upright positioning MOBILISATION HIRACHY xercises passive, active assisted, active resisted (weights), cycling Functional exercises rolling, sitting, bridging SITTING dge of bed ± assistance (need trunk control) Out of bed sliding transfer, hoist transfer, standing transfer (need trunk control) Functional exercises lie to sit, balance activities, weight shifting

27 MOBILISATION HIRACHY STANDING quipment (eg standing frame/hoist, tilt table) Manual assistance (need trunk control and antigravity limb strength) Functional activities weight shifting MARCHING ON TH SPOT Manual assistance quipment (eg frame) WALKING Manual assistance quipment

30 DISCUSSION Safety - look at whole picture Use clinical judgement Clinical research Stiller et al (2004) The safety of and its effect on haemodynamic and respiratory status of intensive care patients. Physiotherapy Theory and Practice 20:

REHABILITATION OF PATIENTS MANAGED IN ICU

REHABILITATION OF PATIENTS MANAGED IN ICU RECOMMENDATIONS Safety to mobilize / exercise: on the website Recommendation 1 All critically ill patients nursed in ICU should be screened closely before active