Rehabilitation for patients with critical illness: Current and future directions

Transcription

1 KPTA Eastern District Meeting Rehabilitation for patients with critical illness: Current and future directions Kirby Mayer, DPT Graduate Research Assistant

2 Acknowledgements THANK YOU Angie Henning, DPT

3 Acknowledgements No financial disclosures Part of this presentation was presented at ACRM National Conference in 2017

4 Agenda Background Landmark Manuscripts ICU Rehab Early Mobility Interventions Future Directions

5 Learning Objectives To understand the risks associated with critical illness and burden of survivorship To describe a framework for selection of interventions for patients with critical illness To synthesize ICU rehabilitation interventions and importance of continued rehab during recovery

6 Background 6-9 million survivors of critical illness annually Individual and family consequences Societal and healthcare burden

7 Survivorship ICU-acquired weakness: Clinically detectable global and symmetrical muscle wasting and weakness with no plausible etiology other than critical illness Medication (sedation, steroids) Inflammation Multiple organ failure > 2 Immobility Severe infection (SIRS) Prolonged ICU stay > 1 week Prolonged Ventilation Blood Glucose levels

8 Survivorship Puthucheary et al JAMA 2013 Parry et al J Crit Care 2015

9 Survivorship

10 Survivorship Post Intensive Care syndrome (PICS) Survivor Family (PICS) (PICS) Mental Health Cognitive Impairments Physical Impairments Mental Health Needham et al 2011 CCM

11 Survivorship

12 Survivorship 3 mos. 6 mos. 1 year 3 years 5 years N= 80 N=78 N=81 N=71 N=54 6 MWT (m) 281 m 396 m 422 m 418 m 436 m % Predicted 49% 64% 66% 67% 76% Return to work 3 mos 6 mos 1 yr 3 yrs 5 yrs No./ total 13/83 26/82 40/82 50/71 55/71 (%) (16%) (32%) (49%) (70%) (77%)

13 Survivorship

14 Survivorship

15 Survivorship Survivorship will be the defining challenge of critical care in the 21st century Iwashyna 2010

16 Survivorship What is the role of the Physical Therapist during critical illness???

17 ICU Rehabilitation 1899 Dr. Reis published in JAMA period for which it was advisable to confine such cases to bed could be counted by hours instead of days, so that of late I have allowed my patients to get up within 24 to 48 hours. I could not fail to notice these same patients did not present with the same picture of listlessness and muscular weakness Reis E. Some Radical Changes in the After-Treatment of Celiotomy Cases. JAMA. 1899; 33:

18 ICU Rehabilitation 1947 Dr. AJ Asher published in British Medical Journal Dangers of Going to Bed complication of rest may cause considerable crippling weakness and wasting of the general skeletal musculature calcium drains from the bones, disuse osteoporosis can be a serious matter the demoralizing effects of staying in bed may produce fussiness, pettiness, and irritability.

19 ICU Rehabilitation 1972 in PTJ by Foss A method for augmenting ventilation during ambulation early ambulation has been well documented in our ICU by improved sense of well-being and the increased strength the patient develops

20 ICU Rehabilitation 1975 in CHEST by Dr. Burn and Dr. Jones Early ambulation of patients requiring ventilatory assistance

21 ICU Rehabilitation 1998 in CHEST by Dr. Petty Suspended Life or Extending Death what I see these days are sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise. in 1964, patients who required mechanical ventilation were awake and alert by being awake and alert, these individuals could interact with their family, friends, and the environment.

22 ICU Rehabilitation Early Mobility is NOT a new idea!

23 ICU Rehabilitation Early Mobility

24 ICU Rehabilitation ICU Rehabilitation is NOT early mobility Early mobility IS one component of ICU rehabilitation

25 ICU Rehabilitation Interventions when early mobility is contraindicated or patient is physical not ready to mobilize Passive ROM Massage Supine Cycle NMES and FES Tilting Standing frame Ther-Ex Unable to actively participate Active engagement

26 ICU Rehabilitation Determining point of awakening and presence of delirium Riker SAS/RASS CAM ICU (Delirium) De Jonghe (5 commands) Open (close) eyes Nod head Look at me Open mouth and poke out tongue Raise eyebrows when count to five

27 ICU Rehabilitation Supine Cycle

28 ICU Rehabilitation

29 EMS can be applied early Optimal stimulation parameters yet to be determined Need larger RCTs with follow up to determine efficacy

30 ICU Rehabilitation Tilting Early weight-bearing Reduce the time gap between immobility and early mobility Purported to improve: Pulmonary function Regulate BP Arousal GI motility Stimulate musculoskeletal

31 ICU Rehabilitation Multiple Avenues for early weightbearing/tilting: tilt table, total lift beds, Sara combilizer, Moveo platform, Erigo

32 ICU Rehabilitation Massage Massage (cyclic compressive loading): potential anabolic intervention on atrophied muscle Rat immobilization model (hind-limb unloading) Muscle fiber CSA enhanced by 18% in massage during period of regrowth compared to reloading alone Muscle fiber CSA increased by 17% in contralateral (non-massaged limb

33 ICU Rehabilitation Massage also purported: o To reduce pain o To reduce anxiety o To promote relaxation and help with sleep patterns o To regulate the immunomodulatory response o To mitigate cellular stress Reducing inflammation Promoting mitochondrial biogenesis

34 ICU Rehabilitation

35 ICU Rehabilitation

36 ICU Rehabilitation

37 ICU Rehabilitation

38 ICU Rehabilitation

39 ICU Rehabilitation Results Improved ventilator-free days Improved ICU and hospital LOS Improved QOL, function, peripheral and respiratory muscle strength Leg strength improvements correlated with ambulatory ability No difference in mortality risk

40 ICU Rehabilitation Exercise and early PT = only effective intervention to improve long-term physical function in critically ill

41 ICU Rehabilitation ~ 900 admissions with LOS reductions of 22% for the ICU and 19% for floor = $817,836

42 Post- ICU Rehabilitation Be Creative, Be Engaging, and Advocate!

43 Future Directions Multi-Center RCT: estimcycle

44 Future Directions Addressing RCT with negative results

45 Future Directions Despite benefits of early rehabilitation:

46 Future Directions

47 Future Directions ICU Rehabilitation is NOT new ICU Rehabilitation is NOT early mobility Early mobility IS a component of ICU rehabilitation Something is Better than Nothing Utilize technology, resources, and advocate!

48 References 1. SM, El-Ansary D, Cartwright MS, Sarwal A, Berney S, Koopman R, Annoni R, Puthucheary Z, Gordon IR, Morris PE et al: UltrasonHerridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N, Al-Saidi F, Cooper AB, Guest CB, Mazer CD, Mehta S et al: One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003, 348(8): Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE et al: Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011, 364(14): Hill AD, Fowler RA, Pinto R, Herridge MS, Cuthbertson BH, Scales DC: Long-term outcomes and healthcare utilization following critical illness--a population-based study. Crit Care 2016, 20: Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme JF, Jr.: Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2005, 171(4): Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK et al: Long-term cognitive impairment after critical illness. N Engl J Med 2013, 369(14): Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, Shanholtz C, Dennison-Himmelfarb CR, Pronovost PJ, Needham DM: Cooccurrence of and remission from general anxiety, depression, and posttraumatic stress disorder symptoms after acute lung injury: a 2-year longitudinal study. Crit Care Med 2015, 43(3): Hermans G, Van Mechelen H, Clerckx B, Vanhullebusch T, Mesotten D, Wilmer A, Casaer MP, Meersseman P, Debaveye Y, Van Cromphaut S et al: Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensitymatched analysis. Am J Respir Crit Care Med 2014, 190(4): Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Phadke R, Dew T, Sidhu PS et al: Acute skeletal muscle wasting in critical illness. JAMA 2013, 310(15): Parry ography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function. J Crit Care 2015, 30(5):1151 e Ciesla N, Dinglas V, Fan E, Kho M, Kuramoto J, Needham D: Manual muscle testing: a method of measuring extremity muscle strength applied to critically ill patients. J Vis Exp 2011(50). 11. Adler J, Malone D: Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 2012, 23(1): Li Z, Peng X, Zhu B, Zhang Y, Xi X: Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil 2013, 94(3):

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