1. Mobilising the Critically Ill, an emerging Concept
Shaju Kareem Hassan
Senior Physiotherapist
Dubai Hospital
International Partner, American Physical Therapy Association

2. New technologies in critical care and mechanical ventilation leads to long term survival of critically ill patients and a dramatic increase in the number of ventilator dependent patients
Recently there is being an increased interest in early rehabilitation of the critically ill patient.
The recent articles published demonstrates the effectiveness of early rehab efforts in the short and long term functional outcome.

3. In ICU, patients are frequently exposed to prolonged immobilization
ICU acquired neuromuscular complication are common, debilitating and long lasting.
Contribution of bed rest to the development of ICU acquired weakness is associated with
prolonged mechanical ventilation,
longer ICU stay and
longer recovery time
Marked decline in functional status
Steven et al, Intensive care med ;33(11):

4. Implementation of early rehabilitation programme is associated with
Minimizing complication of bed rest
Facilitating the weaning from ventillatory support
Reduced ICU length of stay
Reduced hospital length of stay
Promoting improved function
Improving patients quality of life
Cost saving
No adverse outcomes
Morris PE, et al. Crit Care Med, 2008;36:

5. Immobility associated complication
Respiratory
Decreased respiratory motion
Abdomen influence on the diaphragm motion
Increased depended edema
Fluid accumulation in the dependent region / compression atelectasis
Impaired ability to clear the tracheo bronchial secretions
Increased risk of atelectasis and development of ventilator associated pneumonia
Increased risk of pulmonary embolism
Weak respiratory muscles due to prolonged mechanical ventilation

6. Skeletal muscle deconditioning
Skeletal muscle strength reduces 20% every week of bed rest. Weak muscles generate an increased oxygen demand.
Healthy individuals on 5 days of strict bed rest develop insulin resistance and microvascular dysfunction
Rapid muscle atrophy
Primary: bed rest, limb casting
Secondary to critically illness polyneuropathy and critical illness myopathy
Muscle groups that lose strength most quickly are those that maintain posture, and ambulation
One day of bed rest requires two weeks of reconditioning to restore baseline muscle strength
Topp R et al. Am J of Crit Care, 2002;13(2):
Candow DG, Chilibick PD. Differences in size, strength, & power of upper & lower body muscle groups in young & older men. J Gerontol Gerontol, 2005:60A:148 ,
Homburg NM,. Arterioscler Thrombo Vasc Biol Biol, 2007;27(12):2650 ,

7. Critical Illness Neuromyopathy
Critical illness polyneuropathy (CIP)
Critical Illness myopathy (CIM)
Hypotension
Microthrombi
Endoneural edema
Mitochondrial dysfunction
Factors that decrease the availability of nutrients
Sepsis
Administration of corticosteroids
Elevated resting metabolism
Increased protein degradation
Two hit hypothesis

8. Immobility associated complication
Cardiovascular
Reduced stroke volume and Cardiac output, heart muscle atrophy, increased heart rate, Hypovolemia,
Orthostatic hypotension
Deep vein thrombosis
Other musculoskeletal problems
Bone demineralization
Joint contractures
Endocrine
Hyperglycemia
Insuline resistance
Skin
Decubitus ulcers
Psychosocial
Depression
Decreased functional capacity
Gastrointestinal
constipation
Renal
Renal calculi
Urinary stasis
The elderly are more vulnerable

9. Immobility = deconditioning
Multiple changes in the organ system physiology that are induced by inactivity are reversed by activity
( Siebens H, et al, J Am Geriatr Soc 2000;48: )

10. Acute care rehabilitation
Upper extremity muscle strength correlates with early weaning and extubations
Martin et al,Crit Care Med 2005;33:
Elderly patients responded well with physical therapy programmes including strengthening exercises , ambulation and functional training.

11. Can we safely mobilize and ambulate mechanically intubated patients ?

12. Bailey P, et al. Crit care Med, 2007;35:139-145
Early Activity is Safe & Feasible in Acute Respiratory Failure Patients
Methodology
Prospective cohort study
103 pateints/1449 activity events
Mechanically ventilated patients for > 4 days
Airway: Tracheotomy & endotracheal tube
Measured recorded activity events & adverse events
Activity events included:
Sit on bed, Sit in chair, Ambulate
Adverse events defined as:
Fall to knees,
Tube removal,
SBP > 200 mmHg, SBP < 90mmHg,
O2 desaturation < 80% &
Extubation
Bailey P, et al. Crit care Med, 2007;35:

13. Early Activity is safe & feasible in mechanically intubated patient
Results
Activity events included:
Sit on bed (233 or 16%)
Sit in chair (454 or 31%)
Ambulate (762 or 53%)
With an ET in place:
Sit on bed, chair or ambulate (593)
Ambulate (249 or 42%)
Adverse events
< 1% activity related adverse events (no extubations
occurred)
69% all to ambulate at > 100 feet at ICU discharge
Early Activity is safe & feasible in mechanically intubated patient

14. 3 Main criteria for early activity initiation
“Early” -- time period beginning after initial physiological stabilization
Neurologic
(responding to verbal stimulus),
Respiratory
(FiO2 < 60% & PEEP < 10cm of H2O)
Circulatory
(absence of orthostatic hypotension and ionotrops drips)
Thomsen GE, et al. CCM 2008;36;

15. Step by step mobility process
The ultimate goal is to promote maximum level of independence before hospital discharge.
For patient’s not actively participating
Maintain HOB of mechanically ventilated patients > 30 degrees unless contraindicated
Perform PROM exercises while in bed rest and
Phase 1
Restricted to bed rest, can progress to sitting on bed and standing
Phase 2
Progress to transfer training and walking assisted inside the room
Phase 3
Progressive walking
Phase 4
Care of patient transferred out of ICU and planning for discharge

16. Progressive UPRIGHT mobility process
Elevate the head of bed to 45 deg (consider large abdomen)
Elevate the HOB to 45 deg plus legs in dependent position (partial chair)
Elevate HOB to 65 deg plus legs in full dependent ( full chair position )
Sitting in bedside chair using a mechanical hoist
Use a tilt table (optional)

17. Progressive upright mobility process
Once patient is conscious, following commands
Dangle the legs in bed with assistance (sitting at the edge of bed )
Stand patient at bedside with support once able to lift the leg against gravity
Transfer to chair by pivoting or taking 1-2 steps, sit up for 1- 2 hour
Use a bedside stationary cycle

18. Progressive upright mobility process
Walk with assistance
Walk independently

19. Exclusion criteria Cardiovascular instability Respiratory instability
Hypotension SBP <90 mmHg
Tachycardia HR >130 beats/ min
Unstable cardiac rhythm
Two or more vasopressors / ionotrops or frequent upward titration
Respiratory instability
FiO2 > 0.60
PEEP > +10 cm H2O
Resp rate >35 bpm
Requirement of neuromuscular blockade
Pressure control ventilation
Neurological instability
Acute brain injury
ICH / SAH
ICP monitoring
Intraventricular drain
Unstable SCI
Any new neurological deterioration
Femoral sheath / arterial line
Balanced skeletal traction
Intra aortic balloon pump
Active bleeding

20. Screening Algorithm

21. Early mobility process
Prolonged complete bed rest is rare and questioned
Early mobility can be considered for patients
Deconditioned by >3 days of immobility
Require orthostatic training to upright positioning
Ready to begin ventilator weaning
Check readiness for and progression of activity on each day / each shift
Customizing the plan
Incorporating in multi disciplinary rounds
Communicating the mobility plan to the concerned staff at the follow up wards

22. Skiller K, et al Physiother Theroy Pract ,2003,;19(4):239-257
Safety Issues
Review medical background
Is their sufficient CV reserve?
Discuss with team to evaluate
Are all other factors or conditions favorable?
Labs values ,Electrolytes etc
Review with team
Select appropriate mode and intensity of mobilization
Skiller K, et al Physiother Theroy Pract ,2003,;19(4):

23. Safety Issues
Use a protocol that work well with other ICU interventions i.e. sedation, weaning etc.
Dedicated trained team (Morris PE, et al 2008)
Physical therapist, nursing, respiratory therapist, Intensivist etc.
Provide detailed patient information to all team members
Sort out any expected problems and precaution

24. Barriers to Mobility Strategies
Sedation
Use sedation protocols and goal directed sedation
Human & Technological Resources
Personnel
Need for leadership and coordination
Cross training of ICU staff
Time management
Education and training of all staff involved for efficient fearless effort
Saftey,feasibilty,and potential benefits of mobilization
Safe lifting and transfer techniques to prevent injuries
Management of lines and tubes
Use of proper lifting equipments
Managing problems with obese patients
Morris PE Crit Care Clin, 2007;23:1-20

25. Change in ICU culture is important
Transferring patient to the unit with an early mobility protocol, significantly increased the probability of ambulation ( p < .0001)
The increase in the ambulation was not explained by the improvement in patient’s underlying pathophysiology
Thomsen GE, et al. CCM 2008;36;
Supports the importance of an ICU culture

26. All hospitalized patients should have a detailed and specific activity program initiated on admission and followed up
Getting Them Moving
Makes a Difference

27. Thank you