M. Norrenberg. Service des Soins Intensifs Hôpital Erasme Université Libre de Bruxelles

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1 M. Norrenberg Service des Soins Intensifs Hôpital Erasme Université Libre de Bruxelles

2 Improvement of critical care, more survivors but they often present poor physical, functional and cognitive outcomes often lasting for years Post-Intensive Care Syndrome Impacts on: productivity, return to work rates, health care costs

3 One-year outcomes in ARDS survivors " 6 min walk test: < predicted value at 1 year due to global muscle wasting, weakness, foot drop, immobility of large joints, dyspnea Herridge M et al NEJM 348, 2003

4 109 patients At 5 years, the median 6-minute walk distance was 436 m (76% of predicted distance) SF 36 was 41 (mean norm score matched for age and sex, 50). Pulmonary function was normal to nearnormal. Herridge MS et al NEJM 2011

5 Treatment No specific treatment for ICUAW

6 Prevention Control of sepsis

7 Prevention 5 trials Strict control of glycaemia (intensive insulin therapy): significant reduction of CIP/CIM, duration MV, ICU stay, 180 days mortality Corticosteroids: no effect EMS: no effect Hermans D et al Systematic review Cochrane Database 2014

8 Prevention/Treatment EARLY Mobilization Decrease of length on mechanical ventilation Hermans D et al Systematic review Cochrane Database 2014

9 103 patients MV > 4 days Sit on bed, in chair, ambulate Adverse events: fall to knee feeding tube removal systolic blood pressure < 90 or > 200 mmhg O2 desaturation < 80% extubation Bailey P et al CCM 2007;35

10 Results: 1449 activity events 16% sit on bed, 31% sit on chair, 53% ambulate Activity of mechanically ventilated patients: 19 % site on bed, 39% sit in chair, 42% ambulation ICU survivors 69% ambulate > 100 feet Adverse events: < 1% Bailey P et al CCM 2007;35

11 Level 1 Level 2 Level 3 Level 4 Unconscious Conscious Conscious Conscious PROM 3x/d PROM 3x/d PROM 3x/d PROM 3x/d 2 hr turning 2 hr turning 2 hr turning 2 hr turning Active resistance Active resistance Active resistance Sitting min 20 min 3x/d Sitting min 20 min 3x/d Sitting min 20 min 3x/d Can move arms against gravity Sitting on edge of bed Can move legs against gravity Sitting on edge of bed Sitting in a chair min 20 min

12 330 medical patients Within 48h of mechanical ventilation Protocol group: Out of bed earlier (5 vs 11 days) Shorter ICU and hospital length of stay (5,5 vs 6,9 days and 11,2 vs 14,5 days) Morris P et al CCM 2008;36

13 MOBILIZATION ü Passive ü Active-assisted ü Active ü Standing ü Transferring ü Chair exercises ü Walking

14 MOBILIZATION ü Passive Prevents and treats soft tissue contracture and joint stifness Maintains maximum range of motion Prevents loss of muscle weight and fat free mass Herbert R et al J Ortop Res 1993; 11 Williams P et al Ann Rheum Dis 1990;49 Griffiths RD et al Nutrition 1995 Kayambu G et al MBC anesthesiol 2011

15 Williams PE, Ann Rheum Dis 1990, 45

16 155 patients existing data base 2 weeks in ICU 50 patients responded, 48 patients deceased Clavet H, Disability and Rahabilitation 2014

17 Clavet H, Disability and Rahabilitation 2014

18 Results: - More contractures in deceaded group during ICU stay - Contractures related to mobility Joint contractures begin at 4rd day, are visible at 10st days and serious limitation at 14st days (8 weeks of immobilization (rats) after 4 weeks of remobilization ROM not restaured) Clavet H, Disability and Rahabilitation 2014

20 Early rehabilitation? Neurological patient «The period of maximal reorganization of the brain is in the first few weeks after an insult It would probably be beneficial to begin intensive rehabilitation as soon as possible after injury» Karkin M, Reorganization and rehabilitation Headlines 1993, 4:18-19 Understanding and managing coma stimulation: are we doing everything we can? structured coma stimulation programs as early as 72 hours postinjury in the intensive care unit. Gerber CS, Crit Care Nurs, 2005, 28:94-108

21 AIM: Rehabilitation process begins early after acute phase to minimize the deleterious effects of immobility and to facilitate restoration of function

23 Is passive physical activity able to decrease the loss in muscle proteins (nitrogen balance and 3-MH/creatinine ratio)? to influence muscle mass (anthropometric)? to influence muscle function (electrophysiology)? De Prato C et al Reanimation 2009;18

24 Proportion of baseline 3MH/creat p<.05 Bicycle Control 20 EARLY Time LATE De Prato C et al Reanimation 2009;18

25 Effect of early PT on ICP and CPP 84 patients (298 treatments PROM) G1 ICP<15 mmhg, G2 ICP>=15mmHg Results: mean ICP 9,4 mmhg before PT, decrease 0,7mmHg after PT in G1 mean ICP 18 mmhg decrease 2 mmhg after PT Persistent ICP reduction only in G2 No difference CPP, MAP after PT Roth C et al Neurocrit Care 2013; 18: 33-8

26 Brain injury rehabilitation Prevention of deep venous trombosis, skin care, spasticity, Help to prevent later complications and poorer outcomes for many of these patients.

27 Upright position Challenged sitting in ICU: Must be recommended as quick as possible to decrease risk of nosocomial pneumonia

28 stroke rehabilitation Positioning for stroke patients Effect of SaO2: 125 patients Results: side lying on left side in SaO2 which is significant for patient with right hemiparesis For patient with chest disease and right hemiparesis, in SaO2 to 90% or lower importance of positioning strategies to improve outcome after stroke Rowat AM et al Cerebrovasc Dis 2001;12:66

29 stroke rehabilitation Positioning for stroke patients 1st week following stroke, 674 physios Results: specific position recommended by 98% of physios Aims: to modulate the muscle tone to prevent damage of affected limbs to support and stabilize body segments Chatterton HJ et al Disabil Rehabil 2001;23:413

30 stroke rehabilitation Positioning for stroke patients Results: sitting in an armchair 98% side lying on the non-hemiplegic side (96%) «««side (92%) position is an important part of physiotherapy practice and therefore requires evaluation Chatterton HJ et al Disabil Rehabil 2001;23:413

31 stroke rehabilitation Positioning for stroke patients Nurses and physiotherapists opinions: Best position - for conscious patients : sitting in a chair (74%) - for unconscious patients: lying on the nonparetic side (80%) No consensus for lying on paretic side, supine or sitting at 30 to 70 research to confirm which position to use Rowat AM J Adv Nurs 2001;34:795

32 Brain injury rehabilitation Major problems: - cognitive and behavioral dysfunction - non-compliant patients with rehabilitation programs

33 MOBILIZATION ü Active

34 Wasserman C et al Principles of exercice testing and interpretation 1994

35 Decreased oxidative capacity dependance on glycolysis with lactate formation rapid fatigue of the skeletal muscle Response to mild exercice in an ICU patient = intense exercice in a healthy individual

36 MOBILIZATION v Frequency: Short sessions v Resistive muscle training: Low-resistance multiple repetitions (3 sets of 8-10 repetitions at 50-70% of 1 max test) Kasper CE et al AACN Clin Issues 13;2002 Powers SK et al Sports Med 24; 1997 Hoppeler H et al Med Sci Sports Ex 35; 2003 Braith RW et al Am J Geriatr Cardiol 8; 1999

38 Effects of exercices on ICP PROM ICP stable or even in ICHT Exercice ICP stable PT can be performed without deleterious effect in patients with ICP Supine position should be avoided Brimioulle S et al Phys Ther 1997; 12:1682

39 stroke rehabilitation Simultaneous bilateral movement To involve and to encourage the undamaged hemisphere in reconstruction of neural networks damaged by stroke. 18 studies 549 patients No difference in activities of daily living, functional movement of the hand in comparison to other interventions Coupar F et al Cochrane Database Syst Rev 2010

41 Inactivity type I fibers of the antigravity muscles lose myofilaments cross sectional area Morris P Crit Care Clinics 2007;23

42 ü Transferring

45 stroke rehabilitation Positioning for stroke patients

Goals: Robotic rehabilitation therapy 1. To rise patients out of bed! in a vertical/standing position. 2. To prevent the adverse effects resulting from prolonged bedrest.

46 Goals: Robotic rehabilitation therapy 1. To rise patients out of bed! in a vertical/standing position. 2. To prevent the adverse effects resulting from prolonged bedrest. 3. To increase awakeness in patients with cerebral injury by sensorial stimulation. (progressive verticalisation(0~80 ) by tilt up table and simultaneous movements of legs.)

48 29 patients (66%M, 33%F), 49 recorded sessions Age: Mean 54 years (11-81 years) Monitoring and treatment: 29 patients with central venous catheter (100%) 9 patients on mechanical ventilation (30%) 6 patients with tracheostomy (20%) 4 patients on CVVH (13%) 6 patients with pulmonary artery catheter (20%) 5 patients on vasopressors (16%) 1 patient with left ventricular assist device (3%)

49 All patients completed the procedure Mean duration of procedure: 29±4 min (20 increments every 5 min until 80 ) Mean number of steps: 1382±237

50 Results: HR/min 96 ± 3 99± 3* 101 ± 3* 105 ± 3* 107 ± 3* MAP mmhg CO L/min 6 patients 96 ± 3 90 ± 2 89 ± 2 87 ± 2 88 ± ± ± ± ± ± 0.5 SpO2 % 95 ± 1 96± 1 95 ± 1 95 ± 1 95 ± 1 Vt ml 9 patients 513 ± ± ± ± ± 40 RR/min 27 ± 1 29 ± 1 29 ± 1 31 ± 1 32 ± 1 * statistically significant at p<0.05 vs 0

53 Apport de la robotique Patients hémiparétiques suite à un accident vasculaire cérébral. Interaction mécanique entre le robot et le contrôle moteur humain Facilite l initiation des gestes, la répétition de gestes de qualité, et un meilleur contrôle de la récupération des synergies. Quantification des gestes et évaluation objective.

55 Electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function, and arm muscle strength after stroke. 19 trials (666 patients) Improvement activities of daily living «arm function No «arm muscle strength Mehrholz J Cochrane Database Syst Rev 2012

56 22 patients (52 years) 42 sessions of Wii Indications: balance (52%) endurance (45%) Games: boxing 38%, bowling 24%, balance board 21% 45% of sessions on mechanical ventilation, 69% in standing position. No adverse events Kho ME et al J Crit Care 2012

57 use of major muscle groups performance of fine movements mental effort motivation Kho ME et al J Crit Care 2012 Morone G et al Editorial Advances in Neuromotor Stroke Rehabilitation BioMed Research International 2014

58 Walking

60 Prevalence of patient able to ambulate Comparison of both groups Time between ICU admission and attaintment of procedure Impact of time between ICU admission and 1st standing or capacity to ambulate at hospital discharge 190 patients on MV > 7 days Patman S Journal of Crit Care 2012;27

61 Patman S Journal of Crit Care 2012;27

62 Patman S Journal of Crit Care 2012;27

63 Results: Patients able to walk independently before 30 days after ICU admission: good prognosis Between days 5 fold risk to not be able to ambulate at hospital discharge > 60 days: 28 fold In ICU 8% walking, 22% standing, 65% sitting out of bed weight bearing as soon as possible after admission Patman S Journal of Crit Care 2012;27

64 Early rehabilitation after intracerebral hemorrhage stroke 245 patients standard care + early PT at 48 hours or standard care At 6 months SF 36: 6 points difference Mental component Summary Score: 7 points difference Modified Barthel Index Score: 13 points difference Self Rating Anxiety Score 6 point difference Liu N et Al Stroke 2014; 21

65 Real (oversation) Perceived (drugs, vasopressors, obesity ) Shift from bed rest and heavy sedation to a culture of prioritizing awake, spontaneously breathing patient and to an early rehabitation

66 Coordination between members of the interdisciplinary team Patients on mechanical ventilation require equipment, time, staff for ambulation

67 Early Mobilization in Critically Ill Patients: Patients Mobilization Level Depends on Health Care Provider s Profession Garzon-Serrano J et al Phys Med Rehab 2011;3

68 Early Mobilization in Critically Ill Patients: Patients Mobilization Level Depends on Health Care Provider s Profession Garzon-Serrano J et al Phys Med Rehab 2011,3

69 77 patients with femoral catheter (92 catheters: 50 arterial, 15 venous, 27 dialysis) BMI>25 65% of patients, 44% of patients on MV for the 1st session 210 sessions of PT (630 activities) beginning 5-7 days after admission o 33% sitting on the side of the bed o 33% «in stretcher or regular chair o 25% standing at the bedside o 9% walking Perme Ch Cardiopulmonary Physical Therapy Journal 2013;24

70 No adverse effects: trombosis, bleeding, hematoma, removal, nonfunctioning catheter, pain Experienced PT Perme Ch Cardiopulmonary Physical Therapy Journal 2013;24

71 Deconditioning during ECMO 3 pediatric patients (16,20,24 years) Early tracheostomy for weaning MV Ambulating 700 feets before Tx and within 7 days after ECMO Tx within 2 weeks Turner D et al Crit Care Med 2011

74 Hypoxemia

76 What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. Veerbeek JM et al PLoS One 2014

77 Reduced QOL, autonomy, physical abilities, activities of daily living, anxiety, depression = Post Intensive Care Syndrome PT in ICU team= best practice Bemis-Dougherty AR Physical Therapy 2013;93

78 Family participation in care improve the family experience and benefit the patient. Participation in helping staff change the patient s position in bed or transfer to a chair. With appropriate training and supervision, families may be able to participate in early mobilization and significantly increase the amount of therapy provided each day. Garrouste-Orgeas M et al J Crit Care 2010,

79 Self Actualization Esteem Love and belonging Incorporation spirityual values, self limitation Recognition, optimizing pre illness cognition, rehabilitation Visit, family, interaction, daily awakening, post ICU support Safety Physiological Prevention of errors: monitoring, falls, medication errors, pressure ulcers Support for living organs (drugs..), pain, nutrition

80 Strategies for post ICU rehabilitation (integration of PICS) Research with larger sample sizes Special units dedicated to weaning, to rehabilitation, neuro rehabilitation for faster recovery Special attention for older patients and for nutrition

81 Results: The only effective intervention to improve longterm PF in critically ill patients is exercise/pt. Its benefit may be higher if started earlier. Calvo-Ayala E et alchest 2013

83 Jackson JC Journal of Critical Care 2014

84 Developpment of evidenced based guidelines by SCCM in 2013 Number studies showind deleterious effects of oversedation and immobilization. Lowest compliance and adaptation (safety reason) Slow adoption of evidence because of invisible problem. Need to identify cognitive dysfunction (poor outcome) Multidisciplinary team to provide holistic care Patients are debilitaded, physical activities, pain, cognitive impairement (Alzheimer or TBI) Jackson JC Journal of Critical Care 2014

85 136 patients > 4 days in ICU 61 patients for follow-up (3, 6, 12 months) 30 «for 3 follow-up, 13 for 2, 18 came for 1 follow-up Results: 11 with PT, 40 with recommendations for PT at home with specific instructions or to a PT. Improvement of performances 34 patients with psychological problems (PTSD, anxiety, depression). Improvement of anxiety 3 patients for pain clinic. 4 «for the patient councellor for social problems Schandl AR Intensive and Critical Care Nursing 2011;27

86 Conclusions: Multidisciplinary follow-up is useful Liaisons with other specialists for referral is very important Decrease of interventions at 12 months with follow-up at 3 and 6 months Schandl AR Intensive and Critical Care Nursing 2011;27

87 Actual techniques: holidays sedation,delirium monitoring, early mobilization Cognitive rehabilitation: memory book, daily planner, smart phone (alarms) to compensate impaired memory Jackson JC Journal of Critical Care 2014

88 11 studies on early mobilization and rehabilitation evaluating physical function Results: Short Form 36 MRC Handheld dynamometers have proven interrater reliability and population validity in ICU Tipping CJ Crit Care Resusc 2012

89 3 designed days between Australian and NZ ICU 1 day in 116 ICU in Germany in patients 48% on MV: 28% mobilization in bed, 19% sat over side of the bed, 37% sat out of bed, 18% walked Not walking patients: 23% in ICU>7 days 783 patients: 24% out of the bed (8% with tube, 39% xith tracheodtomy, 53% with NIV) Barriers: instability, sedation Berney SC Crit Care Resusc 2013 Nydahl P Vrit Care Med 2014

90 US National survey: 482 responses 10% of PT routinely in ICU Hodgin K et al CCM 2009;37 27% of patients with ALI have PT Only 6% of ICU days Needham DM et al J Crit Care 2007;22 20 ICU stable patients therapeutic activity represents 1,5% (sitting )of observed activities Winkelman C et al Crit Care Nurs 2008;36 63% of patients with tracheostomy sit out of bed Bahadur BK et al Physiotherapy 2008;94

91 Technological advances in critical care have reduced mortality. Conversion of many lethal diseases to a syndrome of acute illness with long-term consequences

92 MOBILIZATION 26 pat mech vent Results: TEMS preserves muscle mass 52 pat mech vent (24 control vs 28 EMS) Results: 3 CIPNM vs vs 52 MRC score weaning 1 day vs 3 Gerovasili Vet al Crit Care 2009;13 Routsi C et al Crit Care 2010;14

93 Quality of critical care has focused on mortality outcomes Now fonctional status and health-related quality of life after critical illness are also important

94 165 patients (neurological, cardiorespiratory, neuromuscular problems) post acute rehabilitation Time from event to rehabilitation: +/-1 month Length of stay: +/-1 month Common disability of 3 categories: ü muscle power function ü changing basic body position ü lifing and carrying objects ü walking and moving ü some of self-care categories Müller M, J Rehab Med 2011;43

95 Immobilisation of muscle induces a shortened position with a reduction of muscle fiber length due to a loss of serial sarcomeres and an accumulation of collagen Stretching partially prevents these 2 adaptations and the muscle fiber architecture WILLIAMS PE J. Anat. 1988, 158

96 Activity can be explored as a process that influences inflammatory regulation and muscle function

97 Activity may restore balance in proinflammatory and antiinflammatory factors improving outcome

98 One-year outcomes in ARDS survivors 109 survivors of ARDS at 1 year Physical examination: " 18% of body weight at ICU discharge (71% return at baseline) " 12% pain at the site of insertion tube at 1 year " 7% neuropathy " 5% immobility of large joints (< heterotopic ossification) " 4% contractured fingers or frozen shoulders (< immobility) Herridge M et al NEJM 348, 2003

MOVE IT or LOSE IT EARLY REHABILITATION IN THE ICU: Deconditioning Inactivity. Rik Gosselink, PT,PhD Dept Rehabilitation Sciences KU Leuven

MOVE IT or LOSE IT EARLY REHABILITATION IN THE ICU: Deconditioning Inactivity. Rik Gosselink, PT,PhD Dept Rehabilitation Sciences KU Leuven Deconditioning Inactivity Eal functioning Retained secretions Lung collaps Weaning EARLY REHABILITATION IN THE ICU: Deconditioning Inactivity MOVE IT or LOSE IT Rik Gosselink, PT,PhD Dept Rehabilitation