1. Hemodynamic Changes Associated with Manual and Automated Lateral Rotation in Mechanically Ventilated ICU Patients Shannan K. Hamlin, PhD, RN, ACNP-BC, CCRN The Methodist Hospital Sandra K. Hanneman, PhD, RN, FAAN Nikhil S. Padhye, PhD The University of Texas Health Science Center at Houston School of Nursing Robert F. Lodato, MD, PhD The University of Texas Health Science Center at Houston Medical School

2. Background Mechanically ventilated ICU patients – high risk Standard of care - manual lateral rotation Q2H Hemodynamic effects – Left > right (Fessler, et al, 1993; Nakao, et al., 1987) Hemodynamic effects transient (Gawlinski & Dracup, 1998) Clinicians reluctant to turn Poor standard adherence (Krishnagopalan et al., 2002) – 2.7% ICU patients turned Q2H – 23% not turned > 8h

3. Background (cont.) RCT pilot study (Hanneman, Gusick, Hamlin, Wachtel, Cron, Jones, Oldham) for efficacy and safety (NCT00542321) – Manual 2-hourly turning (control group) – Automated turning (experimental group) Hemodynamic study: HR, BP, and PP response to turning interventions

4. Specific Aims 1.Describe hemodynamic responses to turning interventions 2.Compare hemodynamic responses between turning intervention groups 3.Compare within groups hemodynamic responses to left and right lateral rotation

5. Research Design RCT pilot study: 2-group, completely randomized experimental – 2 adult ICUs of 2 tertiary care hospitals – Random selection and assignment (Padhye, Cron, Gusick, Hamlin, & Hanneman, 2009) Hemodynamic study: observational, time-series – HR, MAP and PP every 6 seconds for up to 7 consecutive days – 13 adult mechanically ventilated patients

6. Interventions: Manual Turn Every 2 hours ≥ 45° angle Head-of-bed (HOB) ≥ 30°

7. Interventions: Automated Turn Continuous, slow turning TriaDyne Proventa bed (Kinetic Concepts, Inc., San Antonio) ≥ 40° angle HOB ≥ 30°

8. Data Collection Manual-turn position – turning flow sheet (Every 10 minutes) Automated-turn angle – angle sensor (Every 1 second) HR, MAP, SBP, DBP – physiologic monitor → laptop

9. Data Analysis : Ensemble Averaging Within-subject HR, MAP, PP response Average individual turn data Evaluation – Graphical characteristics – Statistical significance – Clinical significance (≥ 10 bpm/mmHg) – Recovery time (manual turn)

10. Data Analysis: Manual Turn Data segregation – Back → Left – Back → Right 12-second bins – 15 minutes before turn (pre-turn) – 45 minutes after turn (post-turn) – 5-minute intervals forward 1-minute intervals – AR 1 model compare intervals estimate recovery time

11. Data Analysis: Automated Turn Segregated into 10° angle bins – Back = - 10° to 10° – Left = - 60° to < - 10° – Right = > 10° to 60° AR1 model (ensemble averaging) ANOVA – HR, MAP, PP changes – Back → Left – Back → Right

12. Data Analysis (cont.) Between-group comparisons – Two-way repeated measures ANOVA – Bonferroni α = 0.017 (Pallant, 2007)

13. Results: Sample 7 males, 6 females Ages 38 – 77 Manual group – 6 patients (46%) 4 with arterial line (67%) Automated group – 7 patients (54%) 3 with arterial line (43%) Data collection time 27 hr 17 min – 168 hr 25 min No differences in patient characteristics

14. Ensemble Averaging: P001 HR Back to Left 6 (100%) statistically significant; 4 (67%) clinically significant; -1 to +22 bpm; recovery: 9 to ≥45 min

15. Ensemble Averaging: P001 MAP Back to Left 2 (50%) statistically & clinically significant; -4 to +22 mmHg; recovery: 9 – 43 min

16. Results: Ensemble Averaging (cont.) Manual Group – PP 4 (100%) statistically significant 1 (25%) clinically important Range: -2 to +23 mmHg Recovery time: 5 to ≥ 43 minutes

17. Ensemble Averaging: P007 HR 3 (43%) statistically significant; 0 clinically significant; maximum ±2 bpm

18. Ensemble Averaging: P007 MAP 3 (100%) statistically significant; 0 clinically significant; - 4 to – 9 mmHg

19. Results: Ensemble Averaging (cont.) Automated Group – PP 2 (67%) statistically significant None clinically significant Maximum ≤ 5 mmHg

20. Results (cont.) Two-way RMEAS ANOVA HR Position – F (2, 22) = 1.64, P = 0.218 Position by group – F (2, 22) = 3.86, P = 0.037 Differences between groups = N.S.

21. Discussion HR, MAP, and PP changes statistically significant Clinically important changes – Manual-turn group only – 50% patients HR and MAP – 25% PP – Prolonged recovery time No differences between groups Automated-turn group changes negligible – Changes if angle ≥ 45°?

22. Conclusions 1.Continuous automated turning has negligible hemodynamic effects 2. 2-hourly manual lateral rotation ≥ 45° associated with modest INCREASES in HR and MAP with prolonged return to baseline values

23. Implications for Practice Standard-of-care turning Anticipate transient changes Consider automated turning

24. Funding American Association of Critical-Care Nurses Mentorship Grant (Hamlin, PI; Hanneman, Mentor) American Association of Critical-Care Nurses, Houston-Gulf Coast Chapter (Hamlin, PI) Society of Critical Care Medicine Norma J. Shoemaker Nursing Research Grant (Hanneman, PI) Texas Medical Center Howell Nursing Research Grant (Hanneman, PI)