1. Clinical algorithm for the active mobilization of a patient that can follow commands Next step in the algorithm

2. ON ADMISSION TO UNIT Develop an individually designed mobility plan with outcomes for each patient in consultation with rest of the team. Develop an individually designed mobility plan with outcomes for each patient in consultation with rest of the team. Monitor daily and provide feedback Monitor daily and provide feedback (Nava 2000; Nava 2002; Thomas 2002; Vollman 2004) RECOMMENDATION 2 Next step in the algorithm Previous step in the algorithm

3. PRELIMINARY SCREENING Factors to consider before initiation of active mobilization –Neurological contra indications? –Orthopedic contra indications? –Recent SSG? Environmental factors to consider Patient size and help available Patient size and help available Length and placement of lines / attachments Length and placement of lines / attachments Patient consent Patient consent Stiller et al 2004; Bailey 2007 Next step in the algorithm Previous step in the algorithm

4. DURING ALL ACTIVITIES MONITOR CLOSELY HR to maximum of 75% of APM HR to maximum of 75% of APM Dispnea rating of 13 on MBS Dispnea rating of 13 on MBS SpO2 >90 SpO2 >90 Arythmias on ECG Arythmias on ECG Patient physical appearance: conscious state, respiratory pattern, pallor, flushing, sweating, clamminess, cyanosis, visible or patient reported signs of pain, discomfort or fatigue. Patient physical appearance: conscious state, respiratory pattern, pallor, flushing, sweating, clamminess, cyanosis, visible or patient reported signs of pain, discomfort or fatigue. Stiller et al 2004; Baily et al 2007 RECOMMENDATION 1 Next step in the algorithm Previous step in the algorithm

5. DECIDE ON ACTIVITY LEVEL BASED ON PERIOD OF INTUBATION GROUP 1 Is not intubated or has been intubated less than 14 days Is not intubated or has been intubated less than 14 days Stiller et al 2004; Bailey 2007 RECOMMENDATION 1 GROUP 2 Has been intubated more than 14 days Has been intubated more than 14 days Nava et al 1998; Zanotti et al 2002; Martin et al 2005; Porta et al 2005; Chiang et al 2006 RECOMMENDATION 3 Previous step in the algorithm

6. GROUP 1: Determine cardiovascular reserve Resting heart rate < 50% APM Resting heart rate < 50% APM BP less than 20%variability BP less than 20%variability ECG normal (arithmias) ECG normal (arithmias) Mayor cardiac pathologies excluded Stiller et al 2004 Mayor cardiac pathologies excluded Stiller et al 2004 Absence of orthostatic hypotension Absence of orthostatic hypotension and catecholamine drips Baily et al 2007 and catecholamine drips Baily et al 2007 Next step in the algorithm Previous step in the algorithm

7. GROUP 1: Determine pulmonary reserve PaO2:FiO2>300 PaO2:FiO2>300 SpO2>90 variations less than 4% SpO2>90 variations less than 4% Satisfactory respiratory pattern Satisfactory respiratory pattern Able to maintain adequate respiratory support Stiller et al 2004 Able to maintain adequate respiratory support Stiller et al 2004 FiO2 <.6 FiO2 <.6 PEEP<10 PEEP<10 Next step in the algorithm Previous step in the algorithm

8. GROUP 1: Other factors favorable HB >7gm/dl HB >7gm/dl Platelet 20,000 cells/m3 Platelet 20,000 cells/m3 White cell 4300 – 10800 cells/m3 White cell 4300 – 10800 cells/m3 Body temp 36 Body temp 36 Blood glucose level 3.5-20mmol/L Blood glucose level 3.5-20mmol/L Stiller et al 2004 Next step in the algorithm Previous step in the algorithm

9. If unsure of any of these criteria discuss with the interdisciplinary team members If reserve is sufficient initiate mobilization program Previous step in the algorithm GROUP 1:

10. GROUP 2: Determine pulmonary stability Airway: Tracheostomy for invasive ventilation. Airway: Tracheostomy for invasive ventilation. Minimal aspiration Minimal aspiration Secretions: manageable with infrequent suctioning Secretions: manageable with infrequent suctioning Oxygen: adequate oxygenation with FIO2 <50%, Oxygen: adequate oxygenation with FIO2 <50%, PEEP 92% PEEP 92% Ventilator settings: stable, no sophisticated modes Ventilator settings: stable, no sophisticated modes Patient assessment: comfortable, no increased WOB or dyspnea Patient assessment: comfortable, no increased WOB or dyspnea Martin et al 2005; Porta et al 2005 Next step in the algorithm Previous step in the algorithm

11. GROUP 2: Determine medical stability Sepsis controlled Sepsis controlled No uncontrolled hemorrhage No uncontrolled hemorrhage No uncontrolled arrhythmias, heart failure, or unstable angina No uncontrolled arrhythmias, heart failure, or unstable angina Secure parenteral line Secure parenteral line Martin et al 2005; Porta et al 2005 Next step in the algorithm Previous step in the algorithm

12. GROUP 1: Initiate Mobilization Program Mobilization activities include moving from Mobilization activities include moving from –Lying to sitting on the edge of the bed; –sitting to standing; –a standing transfer from the edge of the bed to a chair; walking with assistance; –walking independently. (Stiller et al 2004; Baily et al 2007) Progress the activities with goal of walking 100m before discharge (Baily et al 2007) Progress the activities with goal of walking 100m before discharge (Baily et al 2007) Temporarily adjust FiO2 if patient desaturates (Stiller et al 2004; Baily et al 2007) Temporarily adjust FiO2 if patient desaturates (Stiller et al 2004; Baily et al 2007) If patient is unable to mobilize out of bed include arm exercises (both strengthening and endurance) into a mobility regime is safe and could potentially facilitate weaning (Porta et al 2005; Vittaca et al 2006) If patient is unable to mobilize out of bed include arm exercises (both strengthening and endurance) into a mobility regime is safe and could potentially facilitate weaning (Porta et al 2005; Vittaca et al 2006) Back to Group allocation

13. GROUP 2: Initiate Combined Mobilization AND Exercise Program In addition to daily mobilization program initiate specific exercise program (de Jonge et al 2007; Greenleef et al 1997; Nava et al 1998); In addition to daily mobilization program initiate specific exercise program (de Jonge et al 2007; Greenleef et al 1997; Nava et al 1998); Program should include both strengthening and endurance component (Porta et al 2005; Vittaca et al 2006; Zanotti et al 2002) Program should include both strengthening and endurance component (Porta et al 2005; Vittaca et al 2006; Zanotti et al 2002) Incorporate trunk and arms (Pectoralis Mayor) Chiang et al 2006; Martin et al 2005; van de Meet et al 2007 Incorporate trunk and arms (Pectoralis Mayor) Chiang et al 2006; Martin et al 2005; van de Meet et al 2007 Exercise at intensity of at least 11 on Borg scale progressing to 13 by week 6 (Chiang et al 2006; Martin et al 2005) Exercise at intensity of at least 11 on Borg scale progressing to 13 by week 6 (Chiang et al 2006; Martin et al 2005) Duration of session at least 30 minutes progress to 45 minutes daily (Chiang et al 2006; Martin et al 2005) Duration of session at least 30 minutes progress to 45 minutes daily (Chiang et al 2006; Martin et al 2005) Temporarily adjust FiO2 if patient desaturates (Stiller et al 2004; Baily et al 2007) Temporarily adjust FiO2 if patient desaturates (Stiller et al 2004; Baily et al 2007) Back to Group allocation