201
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Australian critical care nursing professionals' attitudes towards the use of traditional "chest physiotherapy" techniques. Hong Kong Physiother J 2017; 36:33-48. [PMID: 30931037 PMCID: PMC6385091 DOI: 10.1016/j.hkpj.2016.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Chest physiotherapy techniques, such as percussion, postural drainage, and expiratory vibrations, may be employed in a critical care setting. Physiotherapists are primarily responsible for their provision; however, nurses have also traditionally implemented these treatments. It is unclear whether nurses consider chest physiotherapy to be a part of their role, or how they perceive their knowledge and confidence pertaining to these techniques. Objective: To investigate the attitudes of nurses towards traditional chest physiotherapy techniques. Method: A total of 1222 members of the Australian College of Critical Care Nurses were invited to participate in an anonymous online survey. Results: There were 142 respondents (12%) with the majority (n = 132, 93%) having performed chest physiotherapy techniques in clinical practice. Most of them considered that the provision of chest physiotherapy was a part of nurse's role. Commonly cited factors influencing nurses' use of chest physiotherapy techniques were the availability of physiotherapy services, adequacy of nursing staff training and skill, and perceptions of professional roles. Conclusions: Nurses working in critical care commonly utilised traditional chest physiotherapy techniques. Further research is required to investigate the reasons why nursing professionals might assume responsibility for the provision of chest physiotherapy techniques, and if their application of these techniques is consistent with evidence-based recommendations.
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202
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Phillips SM, Dickerson RN, Moore FA, Paddon-Jones D, Weijs PJM. Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient. Nutr Clin Pract 2017; 32:112S-120S. [PMID: 28388378 DOI: 10.1177/0884533616686719] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Many intensive care unit (ICU) patients do not achieve target protein intakes particularly in the early days following admittance. This period of iatrogenic protein undernutrition contributes to a rapid loss of lean, in particular muscle, mass in the ICU. The loss of muscle in older (aged >60 years) patients in the ICU may be particularly rapid due to a perfect storm of increased catabolic factors, including systemic inflammation, disuse, protein malnutrition, and reduced anabolic stimuli. This loss of muscle mass has marked consequences. It is likely that the older patient is already experiencing muscle loss due to sarcopenia; however, the period of stay in the ICU represents a greatly accelerated period of muscle loss. Thus, on discharge, the older ICU patient is now on a steeper downward trajectory of muscle loss, more likely to have ICU-acquired muscle weakness, and at risk of becoming sarcopenic and/or frail. One practice that has been shown to have benefit during ICU stays is early ambulation and physical therapy (PT), and it is likely that both are potent stimuli to induce a sensitivity of protein anabolism. Thus, recommendations for the older ICU patient would be provision of at least 1.2-1.5 g protein/kg usual body weight/d, regular and early utilization of ambulation (if possible) and/or PT, and follow-up rehabilitation for the older discharged ICU patient that includes rehabilitation, physical activity, and higher habitual dietary protein to change the trajectory of ICU-mediated muscle mass loss and weakness.
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Affiliation(s)
- Stuart M Phillips
- 1 McMaster University, Department of Kinesiology, Hamilton, Ontario, Canada
| | - Roland N Dickerson
- 2 Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Frederick A Moore
- 3 Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Douglas Paddon-Jones
- 4 Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter J M Weijs
- 5 Nutrition and Dietetics, Department of Internal Medicine, Department of Intensive Care Medicine, and Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.,6 Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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203
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Medrinal C, Combret Y, Prieur G, Robledo Quesada A, Bonnevie T, Gravier FE, Frenoy É, Contal O, Lamia B. Effects of different early rehabilitation techniques on haemodynamic and metabolic parameters in sedated patients: protocol for a randomised, single-bind, cross-over trial. BMJ Open Respir Res 2017; 4:e000173. [PMID: 28255448 PMCID: PMC5293978 DOI: 10.1136/bmjresp-2016-000173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/04/2017] [Indexed: 11/04/2022] Open
Abstract
Introduction Early rehabilitation has become widespread practice for patients in intensive care; however, the prevalence of intensive care unit-acquired weakness remains high and the majority of physiotherapy is carried out in bed. Several inbed rehabilitation methods exist, but we hypothesise that techniques that provoke muscle contractions are more effective than passive techniques. Methods A randomised, controlled cross-over study will be carried out to evaluate and compare the effectiveness of early rehabilitation techniques on cardiac output (CO) in sedated patients in intensive care. 20 intubated and sedated patients will undergo 4 10 min rehabilitation sessions. 2 sessions will involve ‘passive’ techniques based on mobilisations and inbed cycle ergometry and 2 involving electrostimulation of the quadriceps muscle and Functional Electrical Stimulation-cycling (FES-cycling). The primary outcome is CO measured by Doppler ultrasound. The secondary outcomes are right ventricular function, pulmonary systolic arterial pressure, muscle oxygenation and minute ventilation during exercise. Results and conclusion Approval has been granted by our Institutional Review Board (Comité de Protection des Personnes Nord-Ouest 3). The results of the trial will be presented at national and international meetings and published in peer-reviewed journals. Trial registration number NCT02920684.
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Affiliation(s)
- Clément Medrinal
- Normandie Univ, UNIROUEN, EA3830-GRHV, Rouen, France; Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Intensive Care Unit Department, Groupe Hospitalier du Havre, Montivilliers, France
| | - Yann Combret
- Physiotherapy Department , Groupe Hospitalier du Havre , Montivilliers , France
| | - Guillaume Prieur
- Pulmonology Department , Groupe Hospitalier du Havre , Montivilliers , France
| | | | | | | | - Éric Frenoy
- Intensive Care Unit Department , Groupe Hospitalier du Havre , Le Havre , France
| | - Olivier Contal
- University of Applied Sciences and Arts Western Switzerland (HES-SO) , Lausanne , Switzerland
| | - Bouchra Lamia
- Normandie Univ, UNIROUEN, EA3830-GRHV, Rouen, France; Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Pulmonology Department, Groupe Hospitalier du Havre, Montivilliers, France; Intensive Care Unit, Respiratory Department, Rouen University Hospital, Rouen, France
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204
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Grammatopoulou E, Charmpas TN, Strati EG, Nikolaos T, Evagelodimou A, Vlassia Belimpasaki, Skordilis EK. The scope of physiotherapy services provided in public ICUs in Greece: A pilot study. Physiother Theory Pract 2017; 33:138-146. [PMID: 28075178 DOI: 10.1080/09593985.2016.1266718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The aim of the present study was to determine the scope of physiotherapy services provided in Greek ICUs in Athens. A cross-sectional study was conducted with two postal questionnaires administered separately, one for ICU directors and one for ICU physiotherapists. Responses were received from 19 ICU directors and 103 physiotherapists employed in all the adult public mixed medical and surgical ICUs across Athens. The response rate for the survey completion was 100% for ICU directors and 68.7% for physiotherapists. The results showed a 1:50 to 1:12 range in the ratio of physiotherapists to ICU beds. Among the 19 ICUs, 15 (78.9%) employed physiotherapists on a rotational basis, while four (21.0%) retained them exclusively. On weekdays, all surveyed ICUs were covered by physiotherapists in the morning and 10/19 (52.6%) during the afternoon. On weekends, 12/19 (63.2%) of the surveyed ICUs reported physiotherapy care during the morning and 4/19 (21.0%) during both morning and afternoon. All 103 physiotherapists conducted airway clearance techniques and progressive mobilization, 92/103 (89.3%) were involved in extubating patients, 102/103 (99.0%) in passive and active range of motion exercises, and 61/103 (59.2%) in walking. In conclusion, all Greek ICUs in Athens surveyed had physiotherapy cover. The physiotherapists working in these ICUs in Athens were involved in respiratory care and mobilization.
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Affiliation(s)
- Eirini Grammatopoulou
- a Department of Physiotherapy , Technological and Educational Institution-TEI of Athens , Athens , Greece
| | - Theodoros N Charmpas
- a Department of Physiotherapy , Technological and Educational Institution-TEI of Athens , Athens , Greece
| | - Eftychia G Strati
- a Department of Physiotherapy , Technological and Educational Institution-TEI of Athens , Athens , Greece
| | - Tsamis Nikolaos
- a Department of Physiotherapy , Technological and Educational Institution-TEI of Athens , Athens , Greece
| | - Afroditi Evagelodimou
- a Department of Physiotherapy , Technological and Educational Institution-TEI of Athens , Athens , Greece
| | | | - Emmanouil K Skordilis
- c School of Physical Education and Sport Sciences , National and Kapodistrian University of Athens , Athens , Greece
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205
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Evidence based expert consensus for early rehabilitation in the intensive care unit. ACTA ACUST UNITED AC 2017. [DOI: 10.3918/jsicm.24_255] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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206
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Hodgson CL, Tipping CJ. Physiotherapy management of intensive care unit-acquired weakness. J Physiother 2017; 63:4-10. [PMID: 27989729 DOI: 10.1016/j.jphys.2016.10.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 12/11/2022] Open
Abstract
[Hodgson CL, Tipping CJ (2016) Physiotherapy management of intensive care unit-acquired weakness.Journal of Physiotherapy63: 4-10].
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Affiliation(s)
- Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University; The Alfred Hospital, Melbourne, Australia
| | - Claire J Tipping
- Australian and New Zealand Intensive Care Research Centre, Monash University; The Alfred Hospital, Melbourne, Australia
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207
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Cross-Sectional Examination of Patient and Therapist Factors Affecting Participation in Physical Therapy in Acute Care Hospital Settings. Phys Ther 2017; 97:3-12. [PMID: 27340196 DOI: 10.2522/ptj.20150591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 06/12/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND Research has demonstrated benefits of early and continued physical therapy for patients in acute care hospitals. Despite known benefits, scheduled sessions do not always result in treatment. Reported percentages for nontreatment are 15% to 25%. Understanding when and why nontreatment occurs is fundamental to future interventions to reduce it and provide patients with needed services. OBJECTIVE The study objective was to describe nontreatment and the extent to which attributes of the patient, physical therapist, and environment affect its occurrence at a suburban community hospital. DESIGN This was a cross-sectional study. METHODS Medical records for 1,252 patients who were scheduled for 6,246 physical therapy sessions were reviewed. Therapist demographics were collected via a questionnaire. RESULTS Therapist sexes were equally represented, and most therapists were nonwhite and worked full time at the hospital. The nontreatment percentage for individual therapists ranged from 5.4% to 23.2%. This percentage was 1.3% for the first scheduled session but nearly 20% for the remaining sessions. In more than 30% of nontreatment events, the specific therapist attempting treatment was not identified. Patients were much less likely to experience nontreatment if they were scheduled for therapy on a Tuesday or if they were in the hospital for a musculoskeletal condition. Sunday had a particularly high percentage of nontreatment. LIMITATIONS The participants were recruited from a single hospital. The specific therapist associated with nontreatment events was not always known. CONCLUSIONS Hospital and rehabilitation department policies and culture for weekend therapy staffing should be evaluated in light of the high percentage of nontreatment on Sunday. The impact of patient diagnosis on nontreatment must be evaluated further and may reflect hospital culture. Future research efforts should be designed to obtain data on the assigned therapist for all instances of nontreatment.
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208
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van Willigen Z, Collings N, Richardson D, Cusack R. Quality improvement: The delivery of true early mobilisation in an intensive care unit. BMJ QUALITY IMPROVEMENT REPORTS 2016; 5:bmjquality_uu211734.w4726. [PMID: 28090326 PMCID: PMC5223689 DOI: 10.1136/bmjquality.u211734.w4726] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/09/2016] [Indexed: 11/04/2022]
Abstract
Early mobilisation initiatives within the critical care environment have been shown to improve outcomes for patients. Early mobilisation has been defined as occurring within the first two to five days of the intensive care stay, but in practice this can be difficult to deliver. We conducted a quality improvement (QI) project to deliver early mobilisation in a large general intensive care unit. Mechanically ventilated medical patients received an integrated package of care involving two additional daily sessions of mobility therapy, in combination with minimal sedation where possible. Prospective baseline data was collected from January to March 2012; the QI project commenced in April 2012. Improvement cycle 1 completed in March 2015 and improvement cycle 2 in March 2016. Results have suggested a reduction in time to first mobilisation for intensive care survivors from 16.3 days in 2012, to 4.3 days at the end of improvement cycle 2. This was associated with a decrease in mean intensive care length of stay from 20.8 days in 2012, to 11.2 days at the end of improvement cycle 2. This QI project enabled patients to mobilise out of bed within the first five days of their intensive care stay and to be discharged earlier from the ICU, on going analysis is required to verify these findings.
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Affiliation(s)
| | - Nikki Collings
- University Hospital Southampton NHS Foundation Trust, UK
| | | | - Rebecca Cusack
- University Hospital Southampton NHS Foundation Trust, UK
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209
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Heyland DK, Rooyakers O, Mourtzakis M, Stapleton RD. Proceedings of the 2016 Clinical Nutrition Week Research Workshop-The Optimal Dose of Protein Provided to Critically Ill Patients. JPEN J Parenter Enteral Nutr 2016; 41:208-216. [PMID: 28005459 DOI: 10.1177/0148607116682003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Recent literature has created considerable confusion about the optimal amount of protein/amino acids that should be provided to the critically ill patient. In fact, the evidentiary basis that directly tries to answer this question is relatively small. As a clinical nutrition research community, there is an urgent need to develop the optimal methods to assess the impact of exogenous protein/amino acid administration in the intensive care unit setting. That assessment can be conducted at various levels: (1) impact on stress response pathways, (2) impact on muscle synthesis and protein balance, (3) impact on muscle mass and function, and (4) impact on the patient's recovery. The objective of this research workshop was to review current literature relating to protein/amino acid administration for the critically ill patient and clinical outcomes and to discuss the key measurement and methodological features of future studies that should be done to inform the optimal protein/amino acid dose provided to critically ill patients.
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Affiliation(s)
- Daren K Heyland
- 1 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Olav Rooyakers
- 2 Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.,3 Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marina Mourtzakis
- 4 Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Renee D Stapleton
- 5 Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington, Vermont, USA
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210
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211
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Sutton LJ, Jarden RJ. Improving the quality of nurse-influenced patient care in the intensive care unit. Nurs Crit Care 2016; 22:339-347. [PMID: 27976489 DOI: 10.1111/nicc.12266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/10/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Quality of care is a major focus in the intensive care unit (ICU). AIM To describe a nurse-initiated quality improvement (QI) project that improved the care of critically ill patients in a New Zealand tertiary ICU. DESIGN A framework for QI was developed and implemented as part of a practice change initiative. METHODS Audit data were collected, analysed and reported across seven nurse-influenced patient care standards. The seven standards were enteral nutrition delivered within 24 h of admission, timely administration of antibiotics, sedation holds for eligible patients, early mobilization and three pressure ulcer prevention strategies. RESULTS Comparison of audit data collected in 2014 and 2015 demonstrated improvements in five of the seven standards. Those standards with the largest practice improvements were related to the following standards: all eligible patients have enteral nutrition commenced within the first 24 h of ICU admission (3% increase); all eligible patients receive antibiotics within 30 min of prescription time (6% increase); all eligible patients have a daily sedation interruption (DSI; 24% increase); and all eligible patients are mobilized daily in their ICU stay (11% increase in percentage of patients mobilized daily). CONCLUSIONS The nursing-initiated QI project demonstrated improved ICU patient care in relation to early enteral nutrition commencement, DSIs and early and daily mobilizing. RELEVANCE TO CLINICAL PRACTICE The use of a nursing QI framework incorporating audit and feedback is one method of evaluating and enhancing the quality of care and improving patient outcomes. This initiative demonstrated the improved quality of nursing care for ICU patients, particularly in relation to early enteral nutrition commencement, timely antibiotics, DSIs and daily mobilizing. It is thus highly relevant to critical care nursing teams, particularly those working to create a culture where change is safe, achievable and valued.
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Affiliation(s)
- Lynsey J Sutton
- Wellington Regional Hospital, Intensive Care Unit, Intensive Care Services, Wellington Regional Hospital, Wellington, New Zealand.,Graduate School of Nursing Midwifery & Health (GSNMH), Victoria University of Wellington, New Zealand
| | - Rebecca J Jarden
- Department of Nursing, School of Clinical Sciences, Auckland University of Technology (AUT), Auckland, New Zealand
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212
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PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children. Pediatr Crit Care Med 2016; 17:e559-e566. [PMID: 27759596 PMCID: PMC5138131 DOI: 10.1097/pcc.0000000000000983] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the safety and feasibility of an early mobilization program in a PICU. DESIGN Observational, pre-post design. SETTING PICU in a tertiary academic hospital in the United States. PATIENTS Critically ill pediatric patients admitted to the PICU. INTERVENTION This quality improvement project involved a usual-care baseline phase, followed by a quality improvement phase that implemented a multicomponent, interdisciplinary, and tiered activity plan to promote early mobilization of critically ill children. MEASUREMENTS AND MAIN RESULTS Data were collected and analyzed from July to August 2014 (preimplementation phase) and July to August 2015 (postimplementation). The study sample included 200 children 1 day through 17 years old who were admitted to the PICU and had a length of stay of at least 3 days. PICU Up! implementation led to an increase in occupational therapy consultations (44% vs 59%; p = 0.034) and physical therapy consultations (54% vs 66%; p = 0.08) by PICU day 3. The median number of mobilizations per patient by PICU day 3 increased from 3 to 6 (p < 0.001). More children engaged in mobilization activities after the PICU Up! intervention by PICU day 3, including active bed positioning (p < 0.001), and ambulation (p = 0.04). No adverse events occurred as a result of early mobilization activities. The most commonly reported barriers to early mobilization after PICU Up! implementation was availability of appropriate equipment. The program was positively received by PICU staff. CONCLUSIONS Implementation of a structured and stratified early mobilization program in the PICU was feasible and resulted in no adverse events. PICU Up! increased physical therapy and occupational therapy involvement in the children's care and increased early mobilization activities, including ambulation. A bundled intervention to create a healing environment in the PICU with structured activity may have benefits for short- and long-term outcomes of critically ill children.
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213
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Connolly B, Salisbury L, O'Neill B, Geneen L, Douiri A, Grocott MPW, Hart N, Walsh TS, Blackwood B. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review. J Cachexia Sarcopenia Muscle 2016; 7:520-526. [PMID: 27891297 PMCID: PMC5114628 DOI: 10.1002/jcsm.12146] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/02/2016] [Indexed: 01/26/2023] Open
Abstract
Skeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and functional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be beneficial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials comparing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or 'usual care' programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were performed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta-analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of outcome measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Lisa Salisbury
- Edinburgh Critical Care Research Group MRC Centre for Inflammation ResearchUniversity of EdinburghEdinburghUK
| | - Brenda O'Neill
- Institute of Nursing and Health Research, School of Health SciencesUlster UniversityNewtownabbeyUK
| | - Louise Geneen
- School of Medicine, College of Medicine, Dentistry, and NursingUniversity of DundeeDundeeUK
| | - Abdel Douiri
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
- Department of Public Health Sciences, Division of Health and Social Care ResearchKing's College LondonLondonUK
| | - Michael P. W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental SciencesUniversity of SouthamptonSouthamptonUK
- Critical Care Research AreaSouthampton NIHR Respiratory Biomedical Research UnitSouthamptonUK
- Anaesthesia and Critical Care Research UnitUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | | | - Bronagh Blackwood
- Health Sciences, School of Medicine, Dentistry, and Biomedical Sciences, Centre for Infection and ImmunityQueen's University BelfastBelfastUK
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214
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Physical Therapist-Led Ambulatory Rehabilitation for Patients Receiving CentriMag Short-Term Ventricular Assist Device Support: Retrospective Case Series. Phys Ther 2016; 96:1865-1873. [PMID: 27256069 DOI: 10.2522/ptj.20150644] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Short-term ventricular assist device (VAD) support is used in the intensive care unit (ICU) to support individuals in end-stage heart failure prior to heart transplantation or implantation of a long-term left VAD. The literature investigating the feasibility, safety, and content of rehabilitation for this patient group is lacking. This report retrospectively describes the rehabilitation strategy, safety measures used, and nature of any adverse events and, therefore, the feasibility of this practice. CASE SERIES DESCRIPTION Ten individuals (80% male) admitted to the ICU in critical cardiogenic shock required support via a short-term VAD. A prerehabilitation risk assessment was used to reduce the risk of cannula dislodgement. The therapeutic strategy was a stepwise progression of exercises, mobilization, and ambulation. OUTCOMES Retrospective inspection of the case notes showed 330 rehabilitation sessions (X̅=33, SD=18.1, range=16-72) were performed and progressed to ambulation on 71 occasions (X̅=7.1, SD=7.7, range=1-27). Distance ambulated ranged from 7 to 1,200 m (X̅=157.7, SD=367.3). The Chelsea Critical Care Physical Assessment Tool (CPAx) score for 7 patients improved from a median of 0 (interquartile range=0-1) on day 1 to a median peak score of 39 (interquartile range=37-42). There were 8 episodes of minor adverse events (2.4% incidence rate), including 7 of transient low VAD flows. There were no major adverse events. DISCUSSION Early rehabilitation and ambulation of recipients of short-term VAD support was safe and feasible. Recipients demonstrated improvements in physical function (CPAx score) while the VAD was in situ.
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215
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Tipping CJ, Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med 2016; 43:171-183. [PMID: 27864615 DOI: 10.1007/s00134-016-4612-0] [Citation(s) in RCA: 351] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/25/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE Early active mobilisation and rehabilitation in the intensive care unit (ICU) is being used to prevent the long-term functional consequences of critical illness. This review aimed to determine the effect of active mobilisation and rehabilitation in the ICU on mortality, function, mobility, muscle strength, quality of life, days alive and out of hospital to 180 days, ICU and hospital lengths of stay, duration of mechanical ventilation and discharge destination, linking outcomes with the World Health Organization International Classification of Function Framework. METHODS A PRISMA checklist-guided systematic review and meta-analysis of randomised and controlled clinical trials. RESULTS Fourteen studies of varying quality including a total of 1753 patients were reviewed. Active mobilisation and rehabilitation had no impact on short- or long-term mortality (p > 0.05). Meta-analysis showed that active mobilisation and rehabilitation led to greater muscle strength (body function) at ICU discharge as measured using the Medical Research Council Sum Score (mean difference 8.62 points, 95% confidence interval (CI) 1.39-15.86), greater probability of walking without assistance (activity limitation) at hospital discharge (odds ratio 2.13, 95% CI 1.19-3.83), and more days alive and out of hospital to day 180 (participation restriction) (mean difference 9.69, 95% CI 1.7-17.66). There were no consistent effects on function, quality of life, ICU or hospital length of stay, duration of mechanical ventilation or discharge destination. CONCLUSION Active mobilisation and rehabilitation in the ICU has no impact on short- and long-term mortality, but may improve mobility status, muscle strength and days alive and out of hospital to 180 days. REGISTRATION OF PROTOCOL NUMBER CRD42015029836.
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Affiliation(s)
- Claire J Tipping
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Physiotherapy, The Alfred Hospital, Melbourne, VIC, Australia
| | - Meg Harrold
- Curtin University, Perth, WA, Australia.,Royal Perth Hospital, Perth, WA, Australia
| | - Anne Holland
- Department of Physiotherapy, The Alfred Hospital, Melbourne, VIC, Australia.,Latrobe University, Melbourne, VIC, Australia
| | | | - Travis Nisbet
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Department of Physiotherapy, The Alfred Hospital, Melbourne, VIC, Australia.
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Parry SM, Remedios L, Denehy L, Knight LD, Beach L, Rollinson TC, Berney S, Puthucheary ZA, Morris P, Granger CL. What factors affect implementation of early rehabilitation into intensive care unit practice? A qualitative study with clinicians. J Crit Care 2016; 38:137-143. [PMID: 27902947 DOI: 10.1016/j.jcrc.2016.11.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/19/2016] [Accepted: 11/06/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To identify the barriers and enablers that influence clinicians' implementation of early rehabilitation in critical care. MATERIALS AND METHODS Qualitative study involving 26 multidisciplinary participants who were recruited using purposive sampling. Four focus groups were conducted using semistructured questions to explore attitudes, beliefs, and experiences. Data were transcribed verbatim and thematic analysis was performed. RESULTS Six themes emerged, as follows: (1) the clinicians' expectations and knowledge (including rationale for rehabilitation, perceived benefits, and experience), (2) the evidence for and application of rehabilitation (including beliefs regarding when to intervene), (3) patient factors (including prognosis, sedation, delirium, cooperation, motivation, goals, and family), (4) safety considerations (including physiological stability and presence of devices or lines), (5) environmental influences (staffing, resources, equipment, time, and competing priorities), and (6) culture and teamwork. Key strategies identified to facilitate rehabilitation included addressing educational needs for all multidisciplinary team members, supporting junior nursing staff, and potential expansion of physiotherapy staffing hours to closer align with the 24-hour patient care model. CONCLUSIONS Key barriers to implementation of early rehabilitation in critical care are diverse and include both clinician- and health care system-related factors. Research targeted at bridging this evidence-practice gap is required to improve provision of rehabilitation.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia.
| | - Louisa Remedios
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia
| | - Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia; Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, 145 Studley Rd, Heidelberg 3084, Victoria, Australia
| | - Laura D Knight
- Department of Physiotherapy, Royal Melbourne Hospital, 300 Grattan St, Parkville 3050, Victoria, Australia
| | - Lisa Beach
- Department of Physiotherapy, Royal Melbourne Hospital, 300 Grattan St, Parkville 3050, Victoria, Australia
| | - Thomas C Rollinson
- Department of Physiotherapy, Austin Hospital, 145 Studely Rd, Heidelberg 3084, Victoria, Australia
| | - Sue Berney
- Department of Physiotherapy, Austin Hospital, 145 Studely Rd, Heidelberg 3084, Victoria, Australia
| | | | - Peter Morris
- Department of Critical Care, University of Kentucky, Lexington, KY
| | - Catherine L Granger
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia; Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, 145 Studley Rd, Heidelberg 3084, Victoria, Australia; Department of Physiotherapy, Royal Melbourne Hospital, 300 Grattan St, Parkville 3050, Victoria, Australia
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217
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Connolly B, O'Neill B, Salisbury L, Blackwood B. Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews. Thorax 2016; 71:881-90. [PMID: 27220357 PMCID: PMC5036250 DOI: 10.1136/thoraxjnl-2015-208273] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 04/11/2016] [Accepted: 04/29/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Physical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery. METHODS Six electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence. RESULTS Five eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge. CONCLUSIONS Patients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for design of future interventional trials and SR. TRIAL REGISTRATION NUMBER CRD42015001068.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research Unit, Guy's and St. Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Aerospace Physiological Sciences, King's College London, London, UK
- Guy's & St Thomas’ NHS Foundation Trust and King's College London, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Brenda O'Neill
- School of Health Sciences, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Lisa Salisbury
- School of Health in Social Science, University of Edinburgh, UK
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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218
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Wickerson L, Rozenberg D, Janaudis-Ferreira T, Deliva R, Lo V, Beauchamp G, Helm D, Gottesman C, Mendes P, Vieira L, Herridge M, Singer LG, Mathur S. Physical rehabilitation for lung transplant candidates and recipients: An evidence-informed clinical approach. World J Transplant 2016; 6:517-31. [PMID: 27683630 PMCID: PMC5036121 DOI: 10.5500/wjt.v6.i3.517] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/31/2016] [Accepted: 08/17/2016] [Indexed: 02/06/2023] Open
Abstract
Physical rehabilitation of lung transplant candidates and recipients plays an important in optimizing physical function prior to transplant and facilitating recovery of function post-transplant. As medical and surgical interventions in lung transplantation have evolved over time, there has been a demographic shift of individuals undergoing lung transplantation including older individuals, those with multiple co-morbidites, and candidates with respiratory failure requiring bridging to transplantation. These changes have an impact on the rehabilitation needs of lung transplant candidates and recipients. This review provides a practical approach to rehabilitation based on research and clinical practice at our transplant centre. It focuses on functional assessment and exercise prescription during an uncomplicated and complicated clinical course in the pre-transplant, early and late post-transplant periods. The target audience includes clinicians involved in pre- and post-transplant patient care and rehabilitation researchers.
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219
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Tsuboi N, Nozaki H, Ishida Y, Kanazawa I, Inamoto M, Hayashi K, Nishimura N, Nakagawa S, Kasahara M, Kamikubo T. Early Mobilization after Pediatric Liver Transplantation. J Pediatr Intensive Care 2016; 6:199-205. [PMID: 31073448 DOI: 10.1055/s-0036-1593387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022] Open
Abstract
Objective This study aims to evaluate the impact of early mobilization (EM) after pediatric liver transplantation in the pediatric intensive care unit (PICU). Design A 14-month prospective before and after study. Setting Multivalent PICU with 20 beds at a tertiary children's hospital. Patients A total of 57 patients aged younger than 16 years who received liver transplantation and were admitted to the PICU after surgery. Interventions EM project, a multifaceted framework for successful EM practice in the PICU focusing on a multidisciplinary team approach. Measurements and Main Results Compared with the period before the implementation of the EM project, there was a significant increase in the proportion of patients who received physical therapy in the PICU (43 vs. 97%, p < 0.001). Also, there were greater median numbers of physical therapy per eligible patient (0 vs. 3, p < 0.001). Moreover, patients achieved higher functional mobility level within a shorter time. Length of intubation, PICU stay, and hospital stay were not significantly different. There were no adverse events or deaths. Conclusion Using an EM project process, the proportion of patients who received physical therapy after liver transplantation increased. However, there was no difference in the length of PICU or hospital stay. Our findings indicated that EM for pediatric patients who received liver transplantation was well tolerated and safe.
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Affiliation(s)
- Norihiko Tsuboi
- Department of Critical Care Medicine, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Hitomi Nozaki
- Department of Rehabilitation, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Yukihiro Ishida
- Department of Rehabilitation, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Ikue Kanazawa
- Department of Rehabilitation, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Miku Inamoto
- Department of Critical Care Medicine, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Kenichiro Hayashi
- Department of Critical Care Medicine, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Nao Nishimura
- Department of Critical Care Medicine, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Satoshi Nakagawa
- Department of Critical Care Medicine, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
| | - Takeshi Kamikubo
- Department of Rehabilitation, National Center for Child Health and Development, Okura, Setagaya-ku, Tokyo, Japan
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220
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[Algorithms for early mobilization in intensive care units]. Med Klin Intensivmed Notfmed 2016; 112:156-162. [PMID: 27600938 DOI: 10.1007/s00063-016-0210-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/09/2016] [Accepted: 08/12/2016] [Indexed: 10/21/2022]
Abstract
Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one's own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient's awareness, pain, anxiety, stress, delirium and family's presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.
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221
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Progressive Mobility Protocol Reduces Venous Thromboembolism Rate in Trauma Intensive Care Patients: A Quality Improvement Project. J Trauma Nurs 2016; 23:284-9. [DOI: 10.1097/jtn.0000000000000234] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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222
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Peetz AB, Brat GA, Rydingsward J, Askari R, Olufajo OA, Elias KM, Mogensen KM, Lesage JL, Horkan CM, Salim A, Christopher KB. Functional status, age, and long-term survival after trauma. Surgery 2016; 160:762-70. [DOI: 10.1016/j.surg.2016.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/29/2016] [Accepted: 04/13/2016] [Indexed: 11/24/2022]
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223
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Abstract
OBJECTIVES Functional status at hospital discharge may be a risk factor for adverse events among survivors of critical illness. We sought to examine the association between functional status at hospital discharge in survivors of critical care and risk of 90-day all-cause mortality after hospital discharge. DESIGN Single-center retrospective cohort study. SETTING Academic Medical Center. PATIENTS Ten thousand three hundred forty-three adults who received critical care from 1997 to 2011 and survived hospitalization. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The exposure of interest was functional status determined at hospital discharge by a licensed physical therapist and rated based on qualitative categories adapted from the Functional Independence Measure. The main outcome was 90-day post hospital discharge all-cause mortality. A categorical risk-prediction score was derived and validated based on a logistic regression model of the function grades for each assessment. In an adjusted logistic regression model, the lowest quartile of functional status at hospital discharge was associated with an increased odds of 90-day postdischarge mortality compared with patients with independent functional status (odds ratio, 7.63 [95% CI, 3.83-15.22; p < 0.001]). In patients who had at least 7 days of physical therapy treatment prior to hospital discharge (n = 2,293), the adjusted odds of 90-day postdischarge mortality in patients with marked improvement in functional status at discharge was 64% less than patients with no change in functional status (odds ratio, 0.36 [95% CI, 0.24-0.53]; p < 0.001). CONCLUSIONS Lower functional status at hospital discharge in survivors of critical illness is associated with increased postdischarge mortality. Furthermore, patients whose functional status improves before discharge have decreased odds of postdischarge mortality.
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224
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Effects of mobility training on severe burn patients in the BICU: A retrospective cohort study. Burns 2016; 42:1404-1412. [PMID: 27595451 DOI: 10.1016/j.burns.2016.07.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 07/28/2016] [Accepted: 07/30/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE To assess the effects of mobility training on severe burn patients in the Burn Intensive Care Unit (BICU). METHODS This was a retrospective cohort study. Severe burn patients with equal to or more than 50% Total Body Surface Area (TBSA) burns who received early rehabilitation in the BICU were included in this study. Based on the different early rehabilitation strategies during the two periods, patients admitted to the BICU from January 2011 to April 2013 were identified as the passive training cohort (n=49) while patients admitted to the BICU from May 2013 to December 2013 were identified as the mobility training cohort (n=24). Data on length of BICU stay, length of hospital stay, length of rehabilitation in the BICU, ventilator dependent days, strict bed rest time, range of motion (ROM), the Barthel Index (BI) and the Functional Independence Measure (FIM) were collected. RESULTS Compared with the passive training cohort, patients in the mobility training cohort had significantly shorter length of BICU stay (p=0.002), length of hospital stay (p=0.010), strict bed rest time (p<0.001) and length of rehabilitation in the BICU (p=0.026) with improved ROM of shoulder, wrist, hip, knee and ankle joints. CONCLUSIONS Mobility training in the BICU was shown to be feasible and effective in achieving better outcomes than passive training for severe burn patients.
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225
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Kamdar BB, Combs MP, Colantuoni E, King LM, Niessen T, Neufeld KJ, Collop NA, Needham DM. The association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU. Crit Care 2016; 19:261. [PMID: 27538536 PMCID: PMC4990875 DOI: 10.1186/s13054-016-1433-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/22/2016] [Indexed: 11/16/2022] Open
Abstract
Background Poor sleep is common in the ICU setting and may represent a modifiable risk factor for patient participation in ICU-based physical therapy (PT) interventions. This study evaluates the association of perceived sleep quality, delirium, sedation, and other clinically important patient and ICU factors with participation in physical therapy (PT) interventions. Method This was a secondary analysis of a prospective observational study of sleep in a single academic medical ICU (MICU). Perceived sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates included demographics, pre-hospitalization ambulation status, ICU admission diagnosis, daily mechanical ventilation status, and daily administration of benzodiazepines and opioids via bolus and continuous infusion. Associations with participation in PT interventions were assessed among patients eligible for PT using a multinomial Markov model with robust variance estimates. Results Overall, 327 consecutive MICU patients completed ≥1 assessment of perceived sleep quality. After adjusting for all covariates, daily assessment of perceived sleep quality was not associated with transitioning to participate in PT the following day (relative risk ratio [RRR] 1.02, 95 % CI 0.96–1.07, p = 0.55). However, the following factors had significant negative associations with participating in subsequent PT interventions: delirium (RRR 0.58, 95 % CI 0.41–0.76, p <0.001), opioid boluses (RRR 0.68, 95 % CI 0.47–0.99, p = 0.04), and continuous sedation infusions (RRR 0.58, 95 % CI 0.40–0.85, p = 0.01). Additionally, in patients with delirium, benzodiazepine boluses further reduced participation in subsequent PT interventions (RRR 0.25, 95 % CI 0.13–0.50, p <0.001). Conclusions Perceived sleep quality was not associated with participation in PT interventions the following day. However, continuous sedation infusions, opioid boluses, and delirium, particularly when occurring with administration of benzodiazepine boluses, were negatively associated with subsequent PT interventions and represent important modifiable factors for increasing participation in ICU-based PT interventions.
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Affiliation(s)
- Biren B Kamdar
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at the University of California, 10833 Le Conte Ave., Room 37-131 CHS, Los Angeles, CA, 90095, USA.
| | - Michael P Combs
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, 90095, USA
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Lauren M King
- Department of Palliative Medicine, Wellspan Health, York Hospital, York, PA, 17403, USA
| | - Timothy Niessen
- Department of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Karin J Neufeld
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Nancy A Collop
- Emory Sleep Disorders Center, Wesley Woods Health Center, Emory University, Atlanta, GA, 30322, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, 21205, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, 21205, USA
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226
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Eggmann S, Verra ML, Luder G, Takala J, Jakob SM. Effects of early, combined endurance and resistance training in mechanically ventilated, critically ill patients: a study protocol for a randomised controlled trial. Trials 2016; 17:403. [PMID: 27527501 PMCID: PMC4986184 DOI: 10.1186/s13063-016-1533-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 07/30/2016] [Indexed: 01/04/2023] Open
Abstract
Background Prolonged need for intensive care is associated with neuromuscular weakness, termed Intensive Care Unit Acquired Weakness. Those affected suffer from severe functional impairment that can persist for years. First studies suggest a positive effect of physiotherapy and early mobilisation. However, the ideal intervention for a preferential functional outcome is not known. So far no randomised controlled trial has been conducted to specifically evaluate an early endurance and resistance training in the mechanically ventilated, critically ill patient. Methods/design A randomised controlled trial with blinded assessors and 6-month follow-up will be conducted in a tertiary, interdisciplinary intensive care unit in Switzerland. Participants (n = 115; expected dropouts: n = 15) will be randomised to a control group receiving standard physiotherapy and to an experimental group that undergoes early mobilisation combined with endurance and resistance training. The inclusion criteria are being aged 18 years or older, expected mechanical ventilation for more than 72 h and qualitative independence before the illness. Primary endpoints are functional capacity (6-Minute Walk Test) and the ability to perform activities of daily living (Functional Independence Measure) measured at hospital discharge. Secondary endpoints include muscle strength (Medical Research Council sum score, handgrip strength and handheld dynamometry for quadriceps muscle), joint contractures (range of motion), exercise capacity (Timed ‘Up & Go’ Test) and health-related quality of life (Short Form 36). Safety will be monitored during interventions by indirect calorimetry and continuous intensive care standard monitoring. All previously defined adverse events will be noted. The statistical analysis will be by intention-to-treat with the level of significance set at p < 0.05. Discussion This prospective, single-centre, allocation-concealed and assessor-blinded randomised controlled trial will evaluate participant’s function after an early endurance and resistance training compared to standard care. Limitations of this study are the heterogeneity of the critically ill and the discontinuity of the protocol after relocation to the ward. The strengths lie in the pragmatic design and the clinical significance of the chosen outcome measures. Trial registration German Clinical Trials Register (DRKS): DRKS00004347, registered on 10 September 2012.
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Affiliation(s)
- Sabrina Eggmann
- Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, 3010, Switzerland.
| | - Martin L Verra
- Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, 3010, Switzerland
| | - Gere Luder
- Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, 3010, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, 3010, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, 3010, Switzerland
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227
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Ramsay P, Huby G, Merriweather J, Salisbury L, Rattray J, Griffith D, Walsh T. Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial. BMJ Open 2016; 6:e012041. [PMID: 27481624 PMCID: PMC4985782 DOI: 10.1136/bmjopen-2016-012041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To explore and compare patient/carer experiences of rehabilitation in the intervention and usual care arms of the RECOVER trial (ISRCTN09412438); a randomised controlled trial of a complex intervention of post-intensive care unit (ICU) acute hospital-based rehabilitation following critical illness. DESIGN Mixed methods process evaluation including comparison of patients' and carers' experience of usual care versus the complex intervention. We integrated and compared quantitative data from a patient experience questionnaire (PEQ) with qualitative data from focus groups with patients and carers. SETTING Two university-affiliated hospitals in Scotland. PARTICIPANTS 240 patients discharged from ICU who required ≥48 hours of mechanical ventilation were randomised into the trial (120 per trial arm). Exclusion criteria comprised: primary neurologic diagnosis, palliative care, current/planned home ventilation and age <18 years. 182 patients completed the PEQ at 3 months postrandomisation. 22 participants (14 patients and 8 carers) took part in focus groups (2 per trial group) at >3 months postrandomisation. INTERVENTIONS A complex intervention of post-ICU acute hospital rehabilitation, comprising enhanced physiotherapy, nutritional care and information provision, case-managed by dedicated rehabilitation assistants (RAs) working within existing ward-based clinical teams, delivered between ICU discharge and hospital discharge. Comparator was usual care. OUTCOME MEASURES A novel PEQ capturing patient-reported aspects of quality care. RESULTS The PEQ revealed statistically significant between-group differences across 4 key intervention components: physiotherapy (p=0.039), nutritional care (p=0.038), case management (p=0.045) and information provision (p<0.001), suggesting greater patient satisfaction in the intervention group. Focus group data strongly supported and helped explain these findings. Specifically, case management by dedicated RAs facilitated greater access to physiotherapy, nutritional care and information that cut across disciplinary boundaries and staffing constraints. Patients highly valued its individualisation according to their needs, abilities and preferences. CONCLUSIONS Case management by dedicated RAs improves patients' experiences of post-ICU hospital-based rehabilitation and increases perceived quality of care. TRIAL REGISTRATION NUMBER ISRCTN09412438.
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Affiliation(s)
- Pam Ramsay
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Guro Huby
- Faculty of Health and Social Studies, University College Østfold, Halden, Norway
| | - Judith Merriweather
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lisa Salisbury
- Department of Nursing, University of Edinburgh, Edinburgh, UK
| | - Janice Rattray
- School of Nursing and Midwifery, University of Dundee, Dundee, UK
| | - David Griffith
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Timothy Walsh
- Department of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
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The Functional Status Score for the Intensive Care Unit Scale: Is It Reliable in the Intensive Care Unit? Can It Be Used to Determine Discharge Placement? JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2016. [DOI: 10.1097/jat.0000000000000030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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229
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Describing and measuring recovery and rehabilitation after critical illness. Curr Opin Crit Care 2016; 21:445-52. [PMID: 26348422 DOI: 10.1097/mcc.0000000000000233] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Rehabilitation is the cornerstone of management of postcritical illness morbidity. Selection of appropriate tools to measure response to rehabilitation therapy is vital to accurately document trajectory of change across the recovery continuum. In the context of physical-based strategies to redress critical illness associated muscle wasting and dysfunction, this review will discuss a framework to guide assessment of physical recovery in the critical illness population, clinimetric measurement properties for instruments and evidence for their implementation, and recent interventional trial data. RECENT FINDINGS The International Classification of Functioning, Disability and Health (ICF) model is a useful framework to guide selection of outcome measures representing physical function at the level of impairment, activity limitation and participation restriction. Clinimetric data are emerging to support a number of physical function outcome measures in the ICU, albeit further research is required to corroborate tools used beyond ICU discharge. Factors associated with outcome measure selection have contributed to interpreting findings from recent interventional trials of physical rehabilitation. SUMMARY Determining the future design, conduct and impact of physical therapy interventions for critically ill patients will rely on further development of clinimetrically robust metrics to capture individual patient response spanning the recovery pathway. This approach should be similarly applied to rehabilitation interventions addressing other postintensive care syndrome domains.
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Bhat A, Chakravarthy K, Rao BK. Mobilization of patients in neurological Intensive Care Units of India: A survey. Indian J Crit Care Med 2016; 20:337-41. [PMID: 27390457 PMCID: PMC4922286 DOI: 10.4103/0972-5229.183911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Context: The rehabilitation needs of the patients in neurological Intensive Care Units (ICUs) vary from that of a medical ICU patient. Early mobilization is known to improve the various neurological outcomes in patients admitted to neurological ICUs, although little is known about the practice pattern among physiotherapists. The mobilization practice pattern may vary significantly than that of developed countries due to the reasons of differences in training of professionals, availability of equipment, and financial assistance by health insurance. Aim of the Study: To study the current mobilization practices by the physiotherapists in neurological ICUs of India. Subjects and Methods: A cross-sectional survey was conducted with a content validated questionnaire about the mobilization practices. Online questionnaire was distributed to physiotherapists working in neurological ICUs of India. Descriptive statistics were used. Results: Out of 185 e-mails sent, 82 physiotherapists completed the survey (survey response rate = 44%). Eighty participants (97.6%) mentioned that the patients received some form of mobilization during the day. The majority of the physiotherapists (58.5%), “always” provided bed mobility exercises to their patients when it was found appropriate for the patients. Many physiotherapists (41.5%) used tilt table “sometimes” to introduce orthostatism for their patients. Conclusion: Mobilization in various forms is being practiced in the neurological ICUs of India. However, fewer mobilization sessions are conducted on weekends and night hours in Indian Neurological ICUs.
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Affiliation(s)
- Anup Bhat
- Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, Udupi, Karnataka, India
| | - Kalyana Chakravarthy
- Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, Udupi, Karnataka, India
| | - Bhamini K Rao
- Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, Udupi, Karnataka, India
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231
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Kizilarslanoglu MC, Kuyumcu ME, Yesil Y, Halil M. Sarcopenia in critically ill patients. J Anesth 2016; 30:884-90. [PMID: 27376823 DOI: 10.1007/s00540-016-2211-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 06/26/2016] [Indexed: 12/25/2022]
Abstract
Sarcopenia occurring as a primary consequence of aging and secondary due to certain medical problems including chronic disease, malnutrition and inactivity is a progressive generalized loss of skeletal muscle mass, strength and function. The prevalence of sarcopenia increases with aging (approximately 5-13 % in the sixth and seventh decades). However, data showing the prevalence and clinical outcomes of sarcopenia in intensive care units (ICUs) are limited. A similar condition to sarcopenia in the ICU, called ICU-acquired weakness (ICU-AW), has been reported more frequently. Here, we aim to examine the importance of sarcopenia, especially ICU-AW, in ICU patients via related articles in Medline.
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Affiliation(s)
- Muhammet C Kizilarslanoglu
- Division of Geriatrics, Department of Internal Medicine, Hacettepe University School of Medicine, 06100, Ankara, Turkey.
| | - Mehmet E Kuyumcu
- Division of Geriatrics, Department of Internal Medicine, Hacettepe University School of Medicine, 06100, Ankara, Turkey
| | - Yusuf Yesil
- Division of Geriatrics, Department of Internal Medicine, Hacettepe University School of Medicine, 06100, Ankara, Turkey
| | - Meltem Halil
- Division of Geriatrics, Department of Internal Medicine, Hacettepe University School of Medicine, 06100, Ankara, Turkey
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232
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Corcoran JR, Herbsman JM, Bushnik T, Van Lew S, Stolfi A, Parkin K, McKenzie A, Hall GW, Joseph W, Whiteson J, Flanagan SR. Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Interprofessional Performance Improvement Project. PM R 2016; 9:113-119. [PMID: 27346093 DOI: 10.1016/j.pmrj.2016.06.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 06/06/2016] [Accepted: 06/11/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Most early mobility studies focus on patients on mechanical ventilation and the role of physical and occupational therapy. This Performance Improvement Project (PIP) project examined early mobility and increased intensity of therapy services on patients in the intensive care unit (ICU) with and without mechanical ventilation. In addition, speech-language pathology rehabilitation was added to the early mobilization program. OBJECTIVE We sought to assess the efficacy of early mobilization of patients with and without mechanical ventilation in the ICU on length of stay (LOS) and patient outcomes and to determine the financial viability of the program. DESIGN PIP. Prospective data collection in 2014 (PIP) compared with a historical patient population in 2012 (pre-PIP). SETTING Medical and surgical ICUs of a Level 2 trauma hospital. PATIENTS There were 160 patients in the PIP and 123 in the pre-PIP. INTERVENTIONS Interprofessional training to improve collaboration and increase intensity of rehabilitation therapy services in the medical and surgical intensive care units for medically appropriate patients. MEASUREMENTS Demographics; intensity of service; ICU and hospital LOS; medications; pain; discharge disposition; functional mobility; and average cost per day were examined. MAIN RESULTS Rehabilitation therapy services increased from 2012 to 2014 by approximately 60 minutes per patient. The average ICU LOS decreased by almost 20% from 4.6 days (pre-PIP) to 3.7 days (PIP) (P = .05). A decrease of over 40% was observed in the floor bed average LOS from 6.0 days (pre-PIP) to 3.4 days (PIP) (P < .01). An increased percentage of PIP patients, 40.5%, were discharged home without services compared with 18.2% in the pre-PIP phase (P < .01). Average cost per day in the ICU and floor bed decreased in the PIP group, resulting in an annualized net cost savings of $1.5 million. CONCLUSIONS The results of the PIP indicate that enhanced rehabilitation services in the ICU is clinically feasible, results in improved patient outcomes, and is fiscally sound. Most early mobility studies focus on patients on mechanical ventilation. The results of this PIP project demonstrate that there are significant benefits to early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. Benefits include reduced hospitalization LOS, decreased health care costs, and decreased need for postacute care services. LEVEL OF EVIDENCE III.
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Affiliation(s)
- John R Corcoran
- Rusk Rehabilitation Therapy Services and New York University Langone Medical Center, New York, NY(∗)
| | - Jodi M Herbsman
- Rusk Rehabilitation Therapy Services and New York University Langone Medical Center, New York, NY(†)
| | - Tamara Bushnik
- Rusk Rehabilitation Therapy Services and New York University School of Medicine, 240 East 38(th) Street, 17-48, New York, NY 10016(‡).
| | - Steve Van Lew
- Rusk Rehabilitation Therapy Services and New York University Langone Medical Center, New York, NY(§)
| | - Angela Stolfi
- Rusk Rehabilitation Therapy Services and New York University Langone Medical Center, New York, NY(¶)
| | - Kate Parkin
- Rusk Rehabilitation Therapy Services and New York University Langone Medical Center, New York, NY(#)
| | - Alison McKenzie
- Critical Care Services (SICU/CVCU)/Alert Team, New York University Langone Medical Center, New York, NY(‖)
| | - Geoffrey W Hall
- Rusk Rehabilitation and Rehabilitation Medicine, New York University School of Medicine, New York, NY(∗∗)
| | - Waveney Joseph
- New York University Langone Medical Center, New York, NY(††)
| | - Jonathan Whiteson
- Cardiac and Pulmonary Rehabilitation & Rusk Outreach and Growth, Rehabilitation Medicine, New York University School of Medicine, New York, NY(‡‡)
| | - Steven R Flanagan
- Rusk Professor of Rehabilitation Medicine, Rehabilitation Medicine, New York University School of Medicine, New York, NY(§§)
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Zorowitz RD. ICU-Acquired Weakness: A Rehabilitation Perspective of Diagnosis, Treatment, and Functional Management. Chest 2016; 150:966-971. [PMID: 27312737 DOI: 10.1016/j.chest.2016.06.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 12/23/2022] Open
Abstract
ICU-acquired weakness (ICUAW) occurs with reported incidence rates from 25% to 100%. Risk factors include immobility, sepsis, persistent systemic inflammation, multiorgan system failure, hyperglycemia, glucocorticoids, and neuromuscular blocking agents. The pathophysiology remains unknown. Clinical features may be neuropathic, myopathic, or a combination of both. Although manual muscle testing is more practical in diagnosing ICUAW, the "gold standard" for the diagnosis of ICUAW remains electromyography and nerve conduction studies. The only potential interventions known to date to prevent ICUAW include insulin therapy and early rehabilitation, but patients still may develop activity limitations in the acute care hospital. For these patients, rehabilitation may continue in long-term care hospitals, inpatient rehabilitation facilities, or skilled nursing facilities. ICUAW is a catastrophic and debilitating condition that potentially leaves patients with permanent residual activity limitations and participation restrictions. Further research on ICUAW needs to better understand its pathophysiology so that more definitive preventive and therapeutic interventions may be developed.
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234
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Toonstra AL, Nelliot A, Aronson Friedman L, Zanni JM, Hodgson C, Needham DM. An evaluation of learning clinical decision-making for early rehabilitation in the ICU via interactive education with audience response system. Disabil Rehabil 2016; 39:1143-1145. [PMID: 27292947 DOI: 10.1080/09638288.2016.1186751] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Knowledge-related barriers to safely implement early rehabilitation programs in intensive care units (ICUs) may be overcome via targeted education. The purpose of this study was to evaluate the effectiveness of an interactive educational session on short-term knowledge of clinical decision-making for safe rehabilitation of patients in ICUs. METHOD A case-based teaching approach, drawing from published safety recommendations for initiation of rehabilitation in ICUs, was used with a multidisciplinary audience. An audience response system was incorporated to promote interaction and evaluate knowledge before vs. after the educational session. RESULTS Up to 175 audience members, of 271 in attendance (129 (48%) physical therapists, 51 (19%) occupational therapists, 31 (11%) nursing, 14 (5%) physician, 46 (17%) other), completed both the pre- and post-test questions for each of the six unique patient cases. In four of six patient cases, there was a significant (p< 0.001) increase in identifying the correct answer regarding initiation of rehabilitation activities. This learning effect was similar irrespective of participants' years of experience and clinical discipline. CONCLUSIONS An interactive, case-based, educational session may be effective for increasing short-term knowledge, and identifying knowledge gaps, regarding clinical decision-making for safe rehabilitation of patients in ICUs. Implications for Rehabilitation Lack of knowledge regarding the safety considerations for early rehabilitation of ICU patients is a barrier to implementing early rehabilitation. Interactive educational formats, such as the use of audience response systems, offer a new method of teaching and instantly assessing learning of clinically important information. In a small study, we have shown that an interactive, case-based educational format may be used to effectively teach clinical decision-making for the safe rehabilitation of ICU patients to a diverse audience of clinicians.
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Affiliation(s)
- Amy L Toonstra
- a Department of Physical Medicine and Rehabilitation , Johns Hopkins Hospital , Baltimore , MD , USA.,b Outcomes after Critical Illness and Surgery (OACIS) Group , Johns Hopkins University , Baltimore , MD , USA
| | - Archana Nelliot
- b Outcomes after Critical Illness and Surgery (OACIS) Group , Johns Hopkins University , Baltimore , MD , USA.,c Division of Pulmonary and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Lisa Aronson Friedman
- b Outcomes after Critical Illness and Surgery (OACIS) Group , Johns Hopkins University , Baltimore , MD , USA.,c Division of Pulmonary and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Jennifer M Zanni
- a Department of Physical Medicine and Rehabilitation , Johns Hopkins Hospital , Baltimore , MD , USA.,b Outcomes after Critical Illness and Surgery (OACIS) Group , Johns Hopkins University , Baltimore , MD , USA.,d Department of Physical Medicine and Rehabilitation , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Carol Hodgson
- e Australian and New Zealand Intensive Care Research Centre, Monash University , Melbourne , Australia.,f Physiotherapy Department , The Alfred Hospital , Prahran , Australia
| | - Dale M Needham
- b Outcomes after Critical Illness and Surgery (OACIS) Group , Johns Hopkins University , Baltimore , MD , USA.,c Division of Pulmonary and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA.,d Department of Physical Medicine and Rehabilitation , Johns Hopkins University School of Medicine , Baltimore , MD , USA
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235
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Skinner EH, Thomas P, Reeve JC, Patman S. Minimum standards of clinical practice for physiotherapists working in critical care settings in Australia and New Zealand: A modified Delphi technique. Physiother Theory Pract 2016; 32:468-482. [PMID: 27259819 DOI: 10.3109/09593985.2016.1145311] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Achieving competency in critical care in entry-level physiotherapy courses across Australia and New Zealand is not essential, and accredited training for qualified physiotherapists working in critical care units is lacking. As a result, practice standards and training may vary. The objective was to establish consensus-based minimum clinical practice standards for physiotherapists working in critical care settings in Australia and New Zealand. DESIGN A modified Delphi technique, which consisted of three rounds of questionnaires, was used to obtain consensus on items. SETTING Australian and New Zealand critical care settings. PARTICIPANTS A panel (n = 61) was invited from a pool of eligible physiotherapists throughout Australia and New Zealand (n = 93). Eligibility criteria were defined a-priori on the basis of possession of expertise and experience in the practice and teaching of critical care physiotherapy clinical skills. MAIN OUTCOME MEASURE Questionnaires were disseminated electronically (either via email, or SurveyMonkey®). Items were designated by participants as being 'Essential/Unsure/Not Essential'. Consensus for inclusion was achieved when items were ranked 'Essential' by more than 70% of participants. RESULTS Fifty physiotherapists consented and participated in the initial Delphi round, of whom 45 (90%) completed all rounds. Consensus was reached on 199 (89%) items. The panel agreed that 132 (58%) items were 'Essential' items for inclusion in the final framework. CONCLUSIONS This is the first study to develop a consensus framework of minimum standards of practice for physiotherapists working in critical care. The clinical utility of this framework now requires assessment.
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Affiliation(s)
- Elizabeth H Skinner
- a Department of Physiotherapy , Western Health , Melbourne , Victoria , Australia
| | - Peter Thomas
- b Royal Brisbane and Women's Hospital , Physiotherapy , Brisbane , Queensland , Australia
| | - Julie C Reeve
- c AUT University , School of Rehabilitation and Occupation Studies , Auckland , New Zealand
| | - Shane Patman
- d University of Notre Dame Australia , Physiotherapy , Fremantle , Western Australia , Australia
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236
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Green M, Marzano V, Leditschke IA, Mitchell I, Bissett B. Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscip Healthc 2016; 9:247-56. [PMID: 27307746 PMCID: PMC4889100 DOI: 10.2147/jmdh.s99811] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives To describe our experience and the practical tools we have developed to facilitate early mobilization in the intensive care unit (ICU) as a multidisciplinary team. Background Despite the evidence supporting early mobilization for improving outcomes for ICU patients, recent international point-prevalence studies reveal that few patients are mobilized in the ICU. Existing guidelines rarely address the practical issues faced by multidisciplinary ICU teams attempting to translate evidence into practice. We present a comprehensive strategy for safe mobilization utilized in our ICU, incorporating the combined skills of medical, nursing, and physiotherapy staff to achieve safe outcomes and establish a culture which prioritizes this intervention. Methods A raft of tools and strategies are described to facilitate mobilization in ICU by the multidisciplinary team. Patients without safe unsupported sitting balance and without ≥3/5 (Oxford scale) strength in the lower limbs commence phase 1 mobilization, including training of sitting balance and use of the tilt table. Phase 2 mobilization involves supported or active weight-bearing, incorporating gait harnesses if necessary. The Plan B mnemonic guides safe multidisciplinary mobilization of invasively ventilated patients and emphasizes the importance of a clearly articulated plan in delivering this valuable treatment as a team. Discussion These tools have been used over the past 5 years in a tertiary ICU with a very low incidence of adverse outcomes (<2%). The tools and strategies described are useful not only to guide practical implementation of early mobilization, but also in the creation of a unit culture where ICU staff prioritize early mobilization and collaborate daily to provide the best possible care. Conclusion These practical tools allow ICU clinicians to safely and effectively implement early mobilization in critically ill patients. A genuinely multidisciplinary approach to safe mobilization in ICU is key to its success in the long term.
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Affiliation(s)
- Margot Green
- Physiotherapy Department, Canberra Hospital, Canberra, ACT, Australia
| | - Vince Marzano
- Physiotherapy Department, Canberra Hospital, Canberra, ACT, Australia
| | - I Anne Leditschke
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia; School of Medicine, Australian National University, Canberra, ACT, Australia
| | - Imogen Mitchell
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia; School of Medicine, Australian National University, Canberra, ACT, Australia
| | - Bernie Bissett
- Physiotherapy Department, Canberra Hospital, Canberra, ACT, Australia; Discipline of Physiotherapy, University of Canberra, Canberra, ACT, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
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237
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Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. [Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]. Anaesthesist 2016; 64:596-611. [PMID: 26260196 DOI: 10.1007/s00101-015-0060-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
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Affiliation(s)
- T Bein
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, 93042, Regensburg, Deutschland,
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238
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Nickels M, Aitken LM, Walsham J, Watson L, McPhail S. Clinicians' perceptions of rationales for rehabilitative exercise in a critical care setting: A cross-sectional study. Aust Crit Care 2016; 30:79-84. [PMID: 27105830 DOI: 10.1016/j.aucc.2016.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/07/2016] [Accepted: 03/09/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Rehabilitative exercise for critically ill patients may have many benefits; however, it is unknown what intensive care unit (ICU) clinicians perceive to be important rationale for the implementation of rehabilitative exercise in critical care settings. OBJECTIVE To identify which rationales for rehabilitative exercise interventions were perceived by ICU clinicians to be important and determine whether perceptions were consistent across nursing, medical and physiotherapy clinicians. METHODS A cross-sectional study was undertaken among clinicians (nursing, medical, physiotherapy) working in a mixed medical surgical ICU in an Australian metropolitan tertiary hospital. Participants completed a customised web-based questionnaire developed by a clinician working-group. The questionnaire consisted of 11 plausible rationales for commencing rehabilitative exercise in ICUs based on prior literature and their own clinical experiences grouped into 4 over-arching categories (musculoskeletal, respiratory, psychological and facilitation of discharge). Participants rated their perceived importance for each potential rationale on a 5-point Likert scale. RESULTS Participants (n=76) with a median (interquartile range) 4.8 (1.5, 15.5) years of experience working in ICUs completed the questionnaire. Responses were consistent across professional disciplines. Clinicians rated rehabilitative exercise as either 'very much' or 'somewhat' important for facilitating discharge (n=76, 100%), reducing muscle atrophy (n=76, 100%), increasing muscle strength (n=76, 100%), prevention of contractures (n=73, 96%), reducing the incidence of ICU acquired weakness (n=62, 82%), increasing oxygenation (n=71, 93%), facilitating weaning (n=72, 97%), reducing anxiety (n=60, 80%), reducing depression (n=64, 84%), reducing delirium (n=53, 70%), and increasing mental alertness (n=65, 87%). CONCLUSIONS Any shortcoming in implementation of rehabilitation exercise is unlikely attributable to a lack of perceived importance by nursing, medical or physiotherapy clinicians who are the most likely clinicians to influence rehabilitation practices in ICUs. It is noteworthy that this study examined self-reported perceptions, not physiological or scientific legitimacy of rationales, or clinician behaviours in practice.
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Affiliation(s)
- Marc Nickels
- Intensive Care Unit and Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia; School of Public Health & Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.
| | - Leanne M Aitken
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia; NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia; School of Health Sciences, City University London, London, United Kingdom
| | - James Walsham
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
| | - Lisa Watson
- Intensive Care Unit and Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Steven McPhail
- School of Public Health & Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia
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239
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Baidya S, Acharya RS, Coppieters MW. Physiotherapy practice patterns in Intensive Care Units of Nepal: A multicenter survey. Indian J Crit Care Med 2016; 20:84-90. [PMID: 27076708 PMCID: PMC4810938 DOI: 10.4103/0972-5229.175939] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Context: As physiotherapy (PT) is a young profession in Nepal, there is a dearth of insight into the common practices of physiotherapists in critical care. Aims: To identify the availability of PT services in Intensive Care Units (ICUs) and articulate the common practices by physiotherapists in ICUs of Nepal. Settings and Design: All tertiary care hospitals across Nepal with ICU facility via an exploratory cross-sectional survey. Subjects and Methods: An existing questionnaire was distributed to all the physiotherapists currently working in ICUs of Nepal with 2 years of experience. The survey was sent via E-mail or given in person to 86 physiotherapists. Statistical Analysis Used: Descriptive and inferential statistics according to nature of data. Results: The response rate was 60% (n = 52). In the majority of hospitals (68%), PT service was provided only after a physician consultation, and few hospitals (13%) had established hospital criteria for PT in ICUs. Private hospitals (57.1%) were providing PT service in weekends compared to government hospitals (32.1%) (P = 0.17). The likelihood of routine PT involvement varied significantly with the clinical scenarios (highest 71.2% status cerebrovascular accident, lowest 3.8% myocardial infarction, P < 0.001). The most preferred PT treatment was chest PT (53.8%) and positioning (21.2%) while least preferred was therapeutic exercise (3.8%) irrespective of clinical scenarios. Conclusions: There is a lack of regular PT service during weekends in ICUs of Nepal. Most of the cases are treated by physiotherapists only after physician's referral. The preferred intervention seems to be limited only to chest PT and physiotherapists are not practicing therapeutic exercise and functional mobility training to a great extent.
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Affiliation(s)
- Sumana Baidya
- Department of Physiotherapy, Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Ranjeeta S Acharya
- Department of Physiotherapy, Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal
| | - Michel W Coppieters
- Department of Physiotherapy, Dhulikhel Hospital, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal; Department of Movement Sciences, MOVE Research Institute Amsterdam, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Department of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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240
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Jolley SE, Bunnell AE, Hough CL. ICU-Acquired Weakness. Chest 2016; 150:1129-1140. [PMID: 27063347 DOI: 10.1016/j.chest.2016.03.045] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/09/2016] [Accepted: 03/24/2016] [Indexed: 12/17/2022] Open
Abstract
Survivorship after critical illness is an increasingly important health-care concern as ICU use continues to increase while ICU mortality is decreasing. Survivors of critical illness experience marked disability and impairments in physical and cognitive function that persist for years after their initial ICU stay. Newfound impairment is associated with increased health-care costs and use, reductions in health-related quality of life, and prolonged unemployment. Weakness, critical illness neuropathy and/or myopathy, and muscle atrophy are common in patients who are critically ill, with up to 80% of patients admitted to the ICU developing some form of neuromuscular dysfunction. ICU-acquired weakness (ICUAW) is associated with longer durations of mechanical ventilation and hospitalization, along with greater functional impairment for survivors. Although there is increasing recognition of ICUAW as a clinical entity, significant knowledge gaps exist concerning identifying patients at high risk for its development and understanding its role in long-term outcomes after critical illness. This review addresses the epidemiologic and pathophysiologic aspects of ICUAW; highlights the diagnostic challenges associated with its diagnosis in patients who are critically ill; and proposes, to our knowledge, a novel strategy for identifying ICUAW.
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Affiliation(s)
- Sarah E Jolley
- Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Aaron E Bunnell
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA.
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241
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Martí Romeu JD. [Intensive care unit-acquired muscular weakness: A problem with a single solution?]. ENFERMERIA INTENSIVA 2016; 27:41-3. [PMID: 27222474 DOI: 10.1016/j.enfi.2016.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 01/04/2023]
Affiliation(s)
- J D Martí Romeu
- Unidad de Cuidados Intensivos en Cirugía Cardiovascular, Instituto Clínico Cardiovascular, Hospital Clínic de Barcelona, Barcelona, España
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242
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Application of Clinical Practice Guidelines for Pain, Agitation, and Delirium. Crit Care Nurs Clin North Am 2016; 28:241-52. [PMID: 27215361 DOI: 10.1016/j.cnc.2016.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Critically ill patients experience several severe, distressing, and often life-altering symptoms during their intensive care unit stay. A clinical practice guideline released by the American College of Critical Care Medicine provides a template for improving the care and outcomes of the critically ill through evidence-based pain, agitation, and delirium assessment, prevention, and management. Key strategies include the use of valid and reliable assessment tools, setting a desired sedation level target, a focus on light sedation, choosing appropriate sedative medications, the use of nonpharmacologic symptom management strategies, and engaging and empowering patients and their family to play an active role in their intensive care unit care.
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Aniort J, Ait Hssain A, Pereira B, Coupez E, Pioche PA, Leroy C, Heng AE, Souweine B, Lautrette A. Daily urinary urea excretion to guide intermittent hemodialysis weaning in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:43. [PMID: 26895760 PMCID: PMC4761179 DOI: 10.1186/s13054-016-1225-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/10/2016] [Indexed: 12/18/2022]
Abstract
Background There are no easily available markers of renal recovery to guide intermittent hemodialysis (IHD) weaning. The aim of this study was to identify markers for IHD weaning in critically ill patients with acute kidney injury (AKI). Methods We performed a retrospective single-center cohort study of patients treated with IHD for at least 7 days and four dialysis sessions for AKI between 2006 and 2011 in an intensive care unit (ICU) of a French university hospital. Blood and urinary markers were recorded on the day of the last IHD in the ICU for unweaned patients and 2 days after the last IHD for weaned patients. Factors associated with IHD weaning were identified by multiple logistic regression. The areas under the receiver operating characteristic curve (AUROC) and the characteristics of the best diagnostic thresholds were compared. Results Sixty-seven patients were analyzed, including thirty-seven IHD-weaned patients. Urine output [odds ratio (OR) 1.59, 95 % confidence interval (CI) 1.20–2.10 (per ml/kg/24 h increase); P = 0.01] and urinary urea concentration [OR 1.29, 95 % CI 1.01–1.64 (per 10 mmol/L increase); P = 0.04] were both associated with IHD weaning. The optimal diagnostic thresholds for IHD weaning were urine output greater than 8.5 ml/kg/24 h, urinary urea concentration greater than 148 mmol/L, and daily urea excretion greater than 1.35 mmol/kg/24 h, with accuracy of 82.1 %, 76.1 %, and 92.5 % (P = 0.03), respectively. The AUROC of daily urinary urea excretion (0.96) was greater than the AUROC of urine output (0.86) or the AUROC of urinary urea concentration (0.83) (P < 0.001). Conclusions A daily urinary urea excretion greater than 1.35 mmol/kg/24 h was found to be the best marker for weaning ICU patients with AKI from IHD. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1225-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julien Aniort
- Nephrology, Dialysis and Transplantation Department, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
| | - Bruno Pereira
- Biostatistics and Research Department (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
| | - Elisabeth Coupez
- Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
| | - Pierre Antoine Pioche
- Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
| | - Christophe Leroy
- Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
| | - Anne Elisabeth Heng
- Nephrology, Dialysis and Transplantation Department, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France. .,Laboratoire Micro-organismes: Génome et Environnement (LMGE), UMR CNRS 6023, Clermont-University, Clermont-Ferrand, France.
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France. .,Laboratoire Micro-organismes: Génome et Environnement (LMGE), UMR CNRS 6023, Clermont-University, Clermont-Ferrand, France.
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Rasid O, Cavaillon JM. Recent developments in severe sepsis research: from bench to bedside and back. Future Microbiol 2016; 11:293-314. [PMID: 26849633 DOI: 10.2217/fmb.15.133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Severe sepsis remains a worldwide threat, not only in industrialized countries, due to their aging population, but also in developing countries where there still are numerous cases of neonatal and puerperal sepsis. Tools for early diagnosis, a prerequisite for rapid and appropriate antibiotic therapy, are still required. In this review, we highlight some recent developments in our understanding of the associated systemic inflammatory response that help deciphering pathophysiology (e.g., epigenetic, miRNA, regulatory loops, compartmentalization, apoptosis and synergy) and discuss some of the consequences of sepsis (e.g., immune status, neurological and muscular alterations). We also emphasize the challenge to better define animal models and discuss past failures in clinical investigations in order to define new efficient therapies.
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Affiliation(s)
- Orhan Rasid
- Unit Cytokines & Inflammation, Institut Pasteur, 28 rue Dr. Roux, Paris, France
| | - Jean-Marc Cavaillon
- Unit Cytokines & Inflammation, Institut Pasteur, 28 rue Dr. Roux, Paris, France
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245
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Lima NP, Silva GMCD, Park M, Pires-Neto RC. Mobility therapy and central or peripheral catheter-related adverse events in an ICU in Brazil. J Bras Pneumol 2016; 41:225-30. [PMID: 26176520 PMCID: PMC4541757 DOI: 10.1590/s1806-37132015000004338] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 02/10/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To determine whether mobility therapy is associated with central or peripheral catheter-related adverse events in critically ill patients in an ICU in Brazil. METHODS: A retrospective analysis of the daily medical records of patients admitted to the Clinical Emergency ICU of the University of São Paulo School of Medicine Hospital das Clínicas Central Institute between December of 2009 and April of 2011. In addition to the demographic and clinical characteristics of the patients, we collected data related to central venous catheters (CVCs), hemodialysis (HD) catheters and indwelling arterial catheters (IACs): insertion site; number of catheter days; and types of adverse events. We also characterized the mobility therapy provided. RESULTS: Among the 275 patients evaluated, CVCs were used in 49%, HD catheters were used in 26%, and IACs were used in 29%. A total of 1,268 mobility therapy sessions were provided to patients while they had a catheter in place. Catheter-related adverse events occurred in 20 patients (a total of 22 adverse events): 32%, infection; 32%, obstruction; and 32%, accidental dislodgement. We found that mobility therapy was not significantly associated with any catheter-related adverse event, regardless of the type of catheter employed: CVC-OR = 0.8; 95% CI: 0.7-1.0; p = 0.14; HD catheter-OR = 1.04; 95% CI: 0.89-1.21; p = 0.56; or IAC-OR = 1.74; 95% CI: 0.94-3.23; p = 0.07. CONCLUSIONS: In critically ill patients, mobility therapy is not associated with the incidence of adverse events involving CVCs, HD catheters, or IACs.
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Affiliation(s)
| | | | - Marcelo Park
- School of Medicine, University of São Paulo, São Paulo, Brazil
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Skinner EH, Williams CM, Haines TP. Embedding research culture and productivity in hospital physiotherapy departments: challenges and opportunities. AUST HEALTH REV 2016; 39:312-314. [PMID: 25774754 DOI: 10.1071/ah14212] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/13/2015] [Indexed: 11/23/2022]
Abstract
Few studies have investigated research culture in the Australian hospital system. Although physiotherapists working in tertiary hospital departments conduct and publish research, a conflict between service delivery and research productivity remains. Few departments record research achievements, which limits the accuracy of investigating factors associated with research productivity within allied health. The conduct and translation of research within acute physiotherapy and allied health departments is imperative to improve patient health outcomes, optimise health service efficiency and cost-effectiveness and to improve staff and patient satisfaction and staff retention. Allied health departments should institute a research register and consider implementing other strategies to improve research culture and productivity, such as dedicating equivalent full-time staff to research, supporting staff with joint clinical and academic appointments, ensuring a research register is available and used and having events available for the dissemination of research. Future research should focus on improving research productivity within acute allied health departments to provide Level 1 and 2 evidence of service effectiveness and cost-effectiveness to optimise health care delivery and to maximise the benefit of allied health staff to Australia's healthcare system.
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Affiliation(s)
- Elizabeth H Skinner
- Department of Physiotherapy, Western Health, 176 Furlong Road, St Albans, Vic. 3021, Australia
| | - Cylie M Williams
- Department of Community Health, Peninsula Health, Hastings Road, Frankston, Vic. 3199, Australia. Email
| | - Terry P Haines
- Allied Health Research Unit, Faculty of Medicine, Nursing and Health Sciences, Monash University, Cheltenham, Vic. 3192, Australia. Email
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Laurent H, Aubreton S, Richard R, Gorce Y, Caron E, Vallat A, Davin AM, Constantin JM, Coudeyre E. Systematic review of early exercise in intensive care: A qualitative approach. Anaesth Crit Care Pain Med 2015; 35:133-49. [PMID: 26655865 DOI: 10.1016/j.accpm.2015.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/27/2015] [Accepted: 06/29/2015] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Practice guidelines recommend early physical therapy in intensive care units (ICU). Feasibility, safety and efficacy are confirmed by growing evidence-based data. PURPOSE To perform a qualitative systematic literature review on early exercise in ICUs, focused on the subject areas of "how to do", "for which patients" and "for what benefits". METHODS Articles were obtained from the PubMed, Google Scholar, Physiotherapy Evidence Database (PEDro), Embase, CINAHL, CENTRAL, Cochrane and ReeDOC databases. The full texts of references selected according to title and abstract were read. Data extraction and PEDro scoring were performed. Consort recommendations were used for the drafting of the systematic review, which was declared on the Prospero website. RESULTS We confirm the feasibility and safety of early exercise in the ICU. Convergent evidence-based data are in favour of the efficacy of early exercise programs in ICUs. But the potential benefit of earlier program initiation has not been clearly demonstrated. Our analysis reveals tools and practical modalities that could serve to standardize these programs. The scientific literature mainly emphasizes the heterogeneity of targeted populations and lack of precision concerning multiple criteria for early exercise programs. CONCLUSION Changes in the professional culture of multidisciplinary-ICU teams are necessary as concerns early exercise. Physical therapists must be involved and their essential role in the ICU is clearly justified. Although technical difficulties and questions remain, the results of the present qualitative review should encourage the early and progressive implementation of exercise programs in the ICU.
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Affiliation(s)
- Hélène Laurent
- Physical Medicine and Rehabilitation Department, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Sylvie Aubreton
- Physical Medicine and Rehabilitation Department, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Ruddy Richard
- Department of Sport Medicine and Functional Explorations, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France; Inra UMR 1019, CRNH-Auvergne, 63000 Clermont-Ferrand, France
| | - Yannael Gorce
- Physical Medicine and Rehabilitation Department, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Emilie Caron
- Physical Medicine and Rehabilitation Department, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Aurélie Vallat
- Physical Medicine and Rehabilitation Department, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Anne-Marie Davin
- Physical Medicine and Rehabilitation Department, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Jean-Michel Constantin
- Perioperative Medicine Department, University Hospital of Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, Clermont-Ferrand cedex 1, France.
| | - Emmanuel Coudeyre
- Physical Medicine and Rehabilitation Department, Clermont-Ferrand University Hospital, 58, rue Montalembert BP 69, 63003 Clermont-Ferrand cedex 1, France
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Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). Anaesthesist 2015; 64 Suppl 1:1-26. [PMID: 26335630 PMCID: PMC4712230 DOI: 10.1007/s00101-015-0071-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
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Affiliation(s)
- Th Bein
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany.
| | - M Bischoff
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - U Brückner
- Physiotherapy Department, Clinic Donaustauf, Centre for Pneumology, 93093, Donaustauf, Germany
| | - K Gebhardt
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - D Henzler
- Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine, Pain Management, Klinikum Herford, 32049, Herford, Germany
| | - C Hermes
- HELIOS Clinic Siegburg, 53721, Siegburg, Germany
| | - K Lewandowski
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Elisabeth Hospital Essen, 45138, Essen, Germany
| | - M Max
- Centre Hospitalier, Soins Intensifs Polyvalents, 1210, Luxembourg, Luxemburg
| | - M Nothacker
- Association of Scientific Medical Societies (AWMF), 35043, Marburg, Germany
| | - Th Staudinger
- University Hospital for Internal Medicine I, Medical University of Wien, General Hospital of Vienna, 1090, Vienna, Austria
| | - M Tryba
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Klinikum Kassel, 34125, Kassel, Germany
| | - S Weber-Carstens
- Clinic for Anaesthesiology and Surgical Intensive Care Medicine, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, 13353, Berlin, Germany
| | - H Wrigge
- Clinic and Policlinic for Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103, Leipzig, Germany
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249
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Hopkins RO, Choong K, Zebuhr CA, Kudchadkar SR. Transforming PICU Culture to Facilitate Early Rehabilitation. J Pediatr Intensive Care 2015; 4:204-211. [PMID: 27134761 PMCID: PMC4849412 DOI: 10.1055/s-0035-1563547] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 06/24/2015] [Indexed: 12/16/2022] Open
Abstract
Children who survive a critical illness are at risk of developing significant, long-lasting morbidities that may include neuromuscular weakness, cognitive impairments, and new mental health disorders. These morbidities, collectively known as post-intensive care syndrome (PICS), may lead to functional impairments, difficulty in school and social settings, and reduced quality of life. Interventions aimed at rehabilitation such as early mobilization, sedation minimization and prevention of ICU-acquired weakness, delirium, and posttraumatic stress disorder may lead to improved clinical outcomes and functional recovery in critically ill children. Acute rehabilitation is challenging to implement in a pediatric intensive care unit (PICU), and a culture change is needed to effect widespread transformation in this setting. Our objectives in this article are to review the evidence on PICS in children and strategies for affecting culture change to facilitate early rehabilitation in the PICU.
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Affiliation(s)
- Ramona O. Hopkins
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, United States
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, United States
- Center for Humanizing Critical Care, Intermountain Health Care, Murray, Utah, United States
| | - Karen Choong
- Department of Pediatrics and Critical Care Medicine, Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Carleen A. Zebuhr
- Department of Pediatrics, Section of Critical Care, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine and Pediatrics, Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, Maryland, United States
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Ambrosino N, Casaburi R, Chetta A, Clini E, Donner CF, Dreher M, Goldstein R, Jubran A, Nici L, Owen CA, Rochester C, Tobin MJ, Vagheggini G, Vitacca M, ZuWallack R. 8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – part 2. Multidiscip Respir Med 2015. [PMCID: PMC4594967 DOI: 10.1186/s40248-015-0027-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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