1 Mobilising the Critically Ill, an emerging Mobilising the Critically Ill, an emerging Concept Concept Shaju Kareem Hassan Shaju Kareem Hassan Senior PhysiotherapistSenior PhysiotherapistDubai HospitalDubai HospitalInternational Partner, American Physical Therapy Association International Partner, American Physical Therapy Association
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Mobilising the Critically Ill, an emergingMobilising the Critically Ill, an emerging
International Partner, American Physical Therapy AssociationInternational Partner, American Physical Therapy Association
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New technologies in critical careNew technologies in critical care
and mechanical ventilation leadsand mechanical ventilation leadsto long term survival of critically illto long term survival of critically illpatients and a dramatic increasepatients and a dramatic increasein the number of ventilator in the number of ventilator dependent patientsdependent patients
Recently there is being anRecently there is being anincreased interest in earlyincreased interest in earlyrehabilitation of the critically illrehabilitation of the critically illpatient.patient.
The recent articles publishedThe recent articles publisheddemonstrates the effectiveness of demonstrates the effectiveness of early rehab efforts in the short andearly rehab efforts in the short andlong term functional outcome.long term functional outcome.
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In ICU, patients are frequently exposed toprolonged immobilization
ICU acquired neuromuscular complicationare common, debilitating and long lasting.
Contribution of bed rest to the developmentof ICU acquired weakness is associatedwith
± prolonged mechanical ventilation,
± longer ICU stay and
± longer recovery time± Marked decline in functional status
Steven et al, Intensive care med 2007;33(11):1876-1891
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Implementation of early rehabilitation programme isImplementation of early rehabilitation programme isassociated withassociated with
Minimizing complication of bed restMinimizing complication of bed rest
Facilitating the weaning from ventillatory supportFacilitating the weaning from ventillatory support
Reduced ICU length of stayReduced ICU length of stay
Reduced hospital length of stayReduced hospital length of stay
Promoting improved functionPromoting improved function
Improving patients quality of lifeImproving patients quality of life
Cost savingCost saving
No adverse outcomesNo adverse outcomes
Morris PE, et al.Morris PE, et al. C rit C are Med C rit C are Med , 2008;36:2238, 2008;36:2238--22432243
±± Decreased respiratory motionDecreased respiratory motionAbdomen influence on the diaphragm motionAbdomen influence on the diaphragm motion
±± Increased depended edemaIncreased depended edemaFluid accumulation in the dependent region / compressionFluid accumulation in the dependent region / compressionatelectasisatelectasis
±± Impaired ability to clear the tracheo bronchialImpaired ability to clear the tracheo bronchialsecretionssecretions
±± Increased risk of atelectasis and development of Increased risk of atelectasis and development of
ventilator associated pneumoniaventilator associated pneumonia±± Increased risk of pulmonary embolismIncreased risk of pulmonary embolism
±± Weak respiratory muscles due to prolongedWeak respiratory muscles due to prolongedmechanical ventilationmechanical ventilation
Skeletal muscle strength reduces 20% every week of bed rest. WeakSkeletal muscle strength reduces 20% every week of bed rest. Weakmuscles generate an increased oxygen demand.muscles generate an increased oxygen demand.
Healthy individuals on 5 days of strict bed rest develop insulin resistance andHealthy individuals on 5 days of strict bed rest develop insulin resistance andmicrovascular dysfunctionmicrovascular dysfunction
Rapid muscle atrophyRapid muscle atrophy±± Primary: bed rest, limb castingPrimary: bed rest, limb casting
±± Secondary to critically illness polyneuropathy and critical illnessSecondary to critically illness polyneuropathy and critical illnessmyopathymyopathy
Muscle groups that lose strength most quickly are those that maintainMuscle groups that lose strength most quickly are those that maintainposture, and ambulationposture, and ambulation
One day of bed rest requires two weeks of reconditioning to restore baselineOne day of bed rest requires two weeks of reconditioning to restore baselinemuscle strengthmuscle strength
Topp R et al. Am J of Crit Care, 2002;13(2):263 263Topp R et al. Am J of Crit Care, 2002;13(2):263 263--7676
Candow DG, Chilibick PD. Differences in size, strength, & power of upper & lower body muscle groups in young & older men.Candow DG, Chilibick PD. Differences in size, strength, & power of upper & lower body muscle groups in young & older men. J Gerontol Gerontol,J Gerontol Gerontol,2005:60A:148 , 148 2005:60A:148 , 148--155 155
Use a protocol that work well with other ICU interventions i.e. sedation,Use a protocol that work well with other ICU interventions i.e. sedation,
weaning etc.weaning etc.
Dedicated trained teamDedicated trained team (Morris PE, et al 2008(Morris PE, et al 2008))
Physical therapist, nursing, respiratory therapist, Intensivist etc.Physical therapist, nursing, respiratory therapist, Intensivist etc.Provide detailed patient information to all team membersProvide detailed patient information to all team members
Sort out any expected problems and precautionSort out any expected problems and precaution
Transferring patient to the unit with an early mobility protocol, significantlyTransferring patient to the unit with an early mobility protocol, significantly
increased the probability of ambulation ( p < .0001)increased the probability of ambulation ( p < .0001)
The increase in the ambulation was not explained by the improvement inThe increase in the ambulation was not explained by the improvement in