1
|
Mariano-Gomes PM, Ouverney-Braz A, Oroski-Paes G. Adverse events with arterial catheters in intensive care units: a scoping review. ENFERMERIA INTENSIVA 2024:S2529-9840(24)00028-4. [PMID: 39004562 DOI: 10.1016/j.enfie.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 02/25/2024] [Accepted: 04/03/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION The installation of an arterial line is one of the invasive procedures performed for hemodynamic monitoring and, even with its clear importance in intensive care, it is still an invasive procedure and liable to cause harms to the patients. OBJECTIVE To identify the adverse events associated with the use of arterial catheters in critically-ill patients in the world scientific production. METHODOLOGY The present scoping review was conducted according to the JBI methodology for scoping reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used for reporting. The research question was "Which adverse events related to the use of arterial catheters in patients admitted to intensive care are more evident in the literature?". Data collection took place in the following databases: LILACS; MEDLINE; EMBASE; CINAHL, EBSCOhost; and WEB OF SCIENCE. RESULTS Through the search strategies, 491 articles were found in the databases. After exclusion of duplicates, peer analysis of titles and abstracts, full reading and screening of lists of references, the final sample of studies included was 38 articles. The main harms cited by the publications were as follows: limb ischemia, thrombosis, hemorrhage, accidental removal, inadvertent connection of inadequate infusion solution, pseudoaneurysm and bloodstream infection. CONCLUSIONS It was evidenced that patients are subjected to risks of adverse events from the insertion moment to removal of the arterial catheter, focusing on the infusion solution used to fill the circuit, the type of securement and dressings chosen, as well as the Nursing care measures for the prevention of bloodstream infection.
Collapse
Affiliation(s)
- P M Mariano-Gomes
- Anna Nery School of Nursing, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - A Ouverney-Braz
- Anna Nery School of Nursing, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - G Oroski-Paes
- Anna Nery School of Nursing, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
2
|
Ostroff M, Elzomor H, Weite TA, Garcia D, Ahn J, Stanko O, Anderson K, Winborne A, Alexandrou E. Femoral to abdomen tunneling at the bedside for medium/long term venous access. J Vasc Access 2024:11297298241251510. [PMID: 38708830 DOI: 10.1177/11297298241251510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Femoral to abdomen tunneling of small-bore central venous catheters is a bedside technique for patients with contraindications to a thoracic approach, or as an alternative to a lower extremity catheter exit site. METHOD A femoral to abdomen tunneling technique was implemented for patients receiving medium and long-term intravenous treatments with contraindications to the thoracic venous approach or as an alternative to a lower extremity catheter exit site. All venous access devices were inserted with ultrasound guidance under local anesthesia, and catheter tip placement assessed by post procedural radiography. RESULTS In this case series, from January 2020 to January 2023, a total of eight FTA-tunneled venous access devices were inserted. There were seven ambulatory patients and one bedbound patient. The median length of the subcutaneous tunnel was 20 cm, ranging from 15 to 27 cm. The median length of the intravenous catheter to the terminal tip was 31 cm, ranging from 23 to 40 cm. Tip location was confirmed by post-procedural abdominal radiograph. The catheter tip locations were interpreted to be at the level of T8-T9 (2), T12 (1), L4 (2), L2 (2), L1(1).No insertion or post insertion related complication was reported. Six patients completed the scheduled intravenous treatment. One patient was unable to be tracked due to transfer to an outside facility. One catheter initially demonstrated to be coiled over the left common iliac vessel was repositioned using a high flow flush technique. There was one reported catheter dislodgment by the nurse providing care and maintenance. The overall implant days were 961, with a median dwell time of 125 days ranging from 20 to 399 days. CONCLUSION Femoral to abdomen tunneling provides an alternative exit site useful in select patients with complex intravenous access. The data of this small retrospective review suggests this a safe and minimally invasive bedside procedure.
Collapse
Affiliation(s)
- Matt Ostroff
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | | | | | - Daniel Garcia
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | - Jane Ahn
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | - Olena Stanko
- Saint Josephs Regional Medical Center, Paterson, NJ, USA
| | | | | | | |
Collapse
|
3
|
Jourdan C, Pradalier F, Chalard K, Ascher M, Miron Duran F, Pavillard F, Greco F, Mellouk M, Fournier S, Djanikian F, Laffont I, Gelis A, Perrigault PF. Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension. J Neuroeng Rehabil 2023; 20:167. [PMID: 38093374 PMCID: PMC10720049 DOI: 10.1186/s12984-023-01291-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS. METHODS This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria. RESULTS Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended. CONCLUSIONS Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated. TRIAL REGISTRATION ClinicalTrials database (ID: NCT04300491).
Collapse
Affiliation(s)
- Claire Jourdan
- Département de Médecine Physique et de Réadaptation, CHU de Montpellier, Hôpital Lapeyronie, Site Lapeyronie, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier cedex 5, France.
| | - Fanny Pradalier
- Département de Médecine Physique et de Réadaptation, CHU de Montpellier, Hôpital Lapeyronie, Site Lapeyronie, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier cedex 5, France
| | - Kevin Chalard
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Margrit Ascher
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Francisco Miron Duran
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Frédérique Pavillard
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Frédéric Greco
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Myriam Mellouk
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Stéphane Fournier
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Flora Djanikian
- Département d'anesthésie-Réanimation Gui de Chauliac, CHU de Montpellier, Montpellier, France
| | - Isabelle Laffont
- Département de Médecine Physique et de Réadaptation, CHU de Montpellier, Hôpital Lapeyronie, Site Lapeyronie, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier cedex 5, France
- Euromov Digital Health in Motion, Université de Montpellier, Montpellier, France
| | - Anthony Gelis
- Département de Médecine Physique et de Réadaptation, CHU de Montpellier, Hôpital Lapeyronie, Site Lapeyronie, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier cedex 5, France
| | | |
Collapse
|
4
|
Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
5
|
Dammeyer J, Freeman R. Early Mobility in Patients With Femoral Catheters. Crit Care Nurse 2023; 43:74-76. [PMID: 37001872 DOI: 10.4037/ccn2023660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Affiliation(s)
- Jennifer Dammeyer
- Jennifer Dammeyer is a clinical nurse specialist, critical care medicine unit, University of Michigan Health, and a clinical adjunct faculty member, University of Michigan School of Nursing, Ann Arbor
| | - Regi Freeman
- Regi Freeman is a clinical nurse specialist, cardiovascular intensive care unit, University of Michigan Health, and a clinical adjunct faculty member, University of Michigan School of Nursing, Ann Arbor, and Michigan State University, East Lansing
| |
Collapse
|
6
|
Teixeira JP, Mayer KP, Griffin BR, George N, Jenkins N, Pal CA, González-Seguel F, Neyra JA. Intensive Care Unit-Acquired Weakness in Patients With Acute Kidney Injury: A Contemporary Review. Am J Kidney Dis 2023; 81:336-351. [PMID: 36332719 PMCID: PMC9974577 DOI: 10.1053/j.ajkd.2022.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
Acute kidney injury (AKI) and intensive care unit-acquired weakness (ICU-AW) are 2 frequent complications of critical illness that, until recently, have been considered unrelated processes. The adverse impact of AKI on ICU mortality is clear, but its relationship with muscle weakness-a major source of ICU morbidity-has not been fully elucidated. Furthermore, improving ICU survival rates have refocused the field of intensive care toward improving long-term functional outcomes of ICU survivors. We begin our review with the epidemiology of AKI in the ICU and of ICU-AW, highlighting emerging data suggesting that AKI and AKI treated with kidney replacement therapy (AKI-KRT) may independently contribute to the development of ICU-AW. We then delve into human and animal data exploring the pathophysiologic mechanisms linking AKI and acute KRT to muscle wasting, including altered amino acid and protein metabolism, inflammatory signaling, and deleterious removal of micronutrients by KRT. We next discuss the currently available interventions that may mitigate the risk of ICU-AW in patients with AKI and AKI-KRT. We conclude that additional studies are needed to better characterize the epidemiologic and pathophysiologic relationship between AKI, AKI-KRT, and ICU-AW and to prospectively test interventions to improve the long-term functional status and quality of life of AKI survivors.
Collapse
Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico.
| | - Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Kentucky
| | - Benjamin R Griffin
- Division of Nephrology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Naomi George
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico; Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Nathaniel Jenkins
- Department of Health and Human Physiology, University of Iowa, Iowa City, Iowa
| | - C Anil Pal
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Felipe González-Seguel
- Servicio de Medicina Física y Rehabilitación, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
| |
Collapse
|
7
|
Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
8
|
O'Neil AM, Rush C, Griffard L, Roggy D, Boyd A, Hartman B. 5 -Year Retrospective Analysis of a Vented Mobility Algorithm in the Burn ICU. J Burn Care Res 2022; 43:1129-1134. [PMID: 34978322 DOI: 10.1093/jbcr/irab248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Early mobilization with mechanically ventilated patients has received significant attention within recent literature, however limited research has focused specifically on the burn population. The purpose of this single center, retrospective analysis was to review the use of a burn critical care mobility algorithm, to determine safety and feasibility of a burn vented mobility program, share limitations preventing mobility progression at our facility, and discuss unique challenges to vented mobility with intubated burn patients. A retrospective review was completed for all intubated burn center admissions between January 2015 to December 2019. Burn Therapy notes were then reviewed for data collection, during the intubation period, using stages of the mobility algorithm. In 5 years following initial implementation, the vented mobility algorithm was utilized on 127 patients with an average total body surface area of 22.8%. No adverse events occurred. Stage 1 (Range of motion) was completed with 100% of patients (n=127). Chair mode of bed, stage 2a, was utilized in 39.4%(n=50) of patients, while 15.8% (n=20) of patients were dependently transferred to the cardiac chair in stage 2b. Stage 3 (sitting on the edge-of-bed) was completed with 25% (n=32) of patients, with 11% (n=14) progressing to stage 5 (standing), and 3.9% (n=5) actively transferring to a chair. In 5 years, only 4.7% (n=6) reached stage 6 (ambulation). The most common treatment limitations were medical complications (33%) and line placement (21%). Early mobilization during mechanical ventilation is safe and feasible within the burn population, despite challenges including airway stability, sedation, and line limitations.
Collapse
Affiliation(s)
| | | | | | - David Roggy
- Richard M Fairbanks Burn Center, Indianapolis, IN
| | - Allison Boyd
- Richard M Fairbanks Burn Center, Indianapolis, IN
| | - Brett Hartman
- Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
9
|
Newman AN, Kho ME, Harris JE, Fox-Robichaud A, Solomon P. Survey of Physiotherapy Practice in Ontario Cardiac Surgery Intensive Care Units. Physiother Can 2022; 74:25-32. [PMID: 35185244 PMCID: PMC8816362 DOI: 10.3138/ptc-2020-0069] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/28/2020] [Accepted: 10/16/2020] [Indexed: 01/03/2023]
Abstract
Purpose: This article describes current physiotherapy practice for critically ill adult patients requiring prolonged stays in critical care (> 3 d) after complicated cardiac surgery in Ontario. Method: We distributed an electronic, self-administered 52-item survey to 35 critical care physiotherapists who treat adult cardiac surgery patients at 11 cardiac surgical sites. Pilot testing and clinical sensibility testing were conducted beforehand. Participants were sent four email reminders. Results: The response rate was 80% (28/35). The median reported number of cardiac surgeries performed per week was 30 (interquartile range [IQR] 10), with a median number of 14.5 (IQR 4) cardiac surgery beds per site. Typical reported caseloads ranged from 6 to 10 patients per day per therapist, and 93% reported that they had initiated physiotherapy with patients once they were clinically stable in the intensive care unit. Of 28 treatments, range of motion exercises (27; 96.4%), airway clearance techniques (26; 92.9%), and sitting at the edge of the bed (25; 89.3%) were the most common. Intra-aortic balloon pump and extracorporeal membrane oxygenation appeared to limit physiotherapy practice. Use of outcome measures was limited. Conclusions: Physiotherapists provide a variety of interventions to critically ill cardiac surgery patients. Further evaluation of the limited use of outcome measures in the cardiac surgical intensive care unit is warranted.
Collapse
Affiliation(s)
- Anastasia N.L. Newman
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Michelle E. Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada, Physiotherapy Department, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Jocelyn E. Harris
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Patricia Solomon
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
10
|
Wisniewski AM, Mehaffey JH. Commentary: Femoral arterial catheters for cardiac surgery: To do it or not to do it? That is the question. JTCVS OPEN 2021; 8:463-464. [PMID: 36004160 PMCID: PMC9390710 DOI: 10.1016/j.xjon.2021.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 11/07/2022]
|
11
|
Katsukawa H, Ota K, Liu K, Morita Y, Watanabe S, Sato K, Ishii K, Yasumura D, Takahashi Y, Tani T, Oosaki H, Nanba T, Kozu R, Kotani T. Risk Factors of Patient-Related Safety Events during Active Mobilization for Intubated Patients in Intensive Care Units-A Multi-Center Retrospective Observational Study. J Clin Med 2021; 10:jcm10122607. [PMID: 34199207 PMCID: PMC8231849 DOI: 10.3390/jcm10122607] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/31/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
The aim of this study is to clarify the incidence and risk factors of patient-related safety events (PSE) in situations limited to intubated patients in which active mobilization, such as sitting on the edge of the bed/standing/walking, was carried out. A multi-center retrospective observational study was conducted at nine hospitals between January 2017 and March 2018. The safety profiles and PSE of 87 patients were analyzed. PSE occurred in 10 out of 87 patients (11.5%) and 13 out of 198 sessions (6.6%). The types of PSE that occurred were hypotension (8, 62%), heart rate instability (3, 23%), and desaturation (2, 15%). Circulation-related events occurred in 85% of overall cases. No accidents, such as line/tube removal or falls, were observed. The highest incidence of PSE was observed during the mobilization level of standing (8 out of 39 sessions, 20.5%). The occurrence of PSE correlated with the highest activity level under logistic regression analysis. Close vigilance is required for intubated patients during active mobilization in the standing position with regard to circulatory dynamics.
Collapse
Affiliation(s)
- Hajime Katsukawa
- Department of Scientific Research, Japanese Society for Early Mobilization, 1-2-12-2F Kudan-kita, Chiyoda-ku, Tokyo 102-0073, Japan
- Correspondence: ; Tel.: +81-3-3356-5585
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan;
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD 4032, Australia;
| | - Yasunari Morita
- Department of Emergency and Intensive Care Medicine, National Hospital Organization Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001, Japan;
| | - Shinichi Watanabe
- National Hospital Organization Nagoya Medical Center, Department of Rehabilitation Medicine, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001, Japan;
| | - Kazuhiro Sato
- Department of Pulmonology, Japanese Red Cross Nagaoka Hospital, Senshu-2 297-1, Nagaoka, Niigata 940-2085, Japan;
| | - Kenzo Ishii
- Intensive Care Unit, Department of Anesthesiology, Fukuyama City Hospital, 3-8-5 Zao-cho, Fukuyama, Hiroshima 721-8511, Japan;
| | - Daisetsu Yasumura
- Department of Rehabilitation, Naha City Hospital, 2-31-1 Furujima, Naha, Okinawa 902-8511, Japan;
- Department of Healthcare Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yo Takahashi
- Yuuai Medical Center, Department of Rehabilitation, 50-5 Yone, Tomigusuku, Okinawa 901-0224, Japan;
| | - Takafumi Tani
- Department of Rehabilitation, Japanese Red Cross Ishinomaki Hospital, 71 Nishimichishita, Hebita, Ishinomaki, Miyagi 986-8522, Japan;
| | - Hitoshi Oosaki
- Department of Rehabilitation, Japanese Red Cross Maebashi Hospital, 389-1 Asakura-cho, Maebashi Gunma 371-0811, Japan;
| | - Tomoya Nanba
- Department of Rehabilitation, Yao Tokushukai General Hospital, 1-17 Wakakusa-cho, Yao, Osaka 581-0011, Japan;
| | - Ryo Kozu
- Department of Rehabilitation Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan;
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Toru Kotani
- Department of Intensive Care Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan;
| |
Collapse
|
12
|
Gwak DW, Hwang JM. Step-by-step inpatient rehabilitation for critical illness after coronavirus disease 2019: A CARE-compliant case report. Medicine (Baltimore) 2021; 100:e26317. [PMID: 34115043 PMCID: PMC8202574 DOI: 10.1097/md.0000000000026317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Since the coronavirus disease (COVID-19) outbreak in Wuhan, China, in December 2019, COVID-19 has become a worldwide pandemic. Muscle weakness and deconditioning caused by COVID-19-induced critical illness requires rehabilitation. PATIENT CONCERNS A 74-year-old male patient complained of general weakness after COVID-19, requiring ventilator treatment. DIAGNOSIS He was confirmed as having COVID-19 using a polymerase chain reaction test. INTERVENTIONS During admission in the intensive care unit, medical staff wearing level D protective equipment performed the bedside manual range of motion exercise. After a negative COVID-19 test, the patient was transferred to a general ward, where sitting balance training and pulmonary rehabilitation were additionally performed by rehabilitation therapists wearing protective gear. When the patient was able to stand up with support, standing balance training and sit-to-stand training were performed. OUTCOMES After a month of rehabilitation, the patient could sit alone, but he needed help with standing balance. The Berg Balance Scale score improved from 0 to 4, and the Modified Barthel Index score improved from 8 to 18. He was able to breathe in room air without an oxygen supply. LESSONS This case report shows an example of how safe and effective rehabilitation can be provided to COVID-19 patients.
Collapse
Affiliation(s)
- Dae-Won Gwak
- Department of Rehabilitation Medicine, Kyungpook National University Hospital
| | - Jong-Moon Hwang
- Department of Rehabilitation Medicine, Kyungpook National University Hospital
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| |
Collapse
|
13
|
Safety and Feasibility of Physical Rehabilitation and Active Mobilization in Patients Requiring Continuous Renal Replacement Therapy: A Systematic Review. Crit Care Med 2021; 48:e1112-e1120. [PMID: 33001619 DOI: 10.1097/ccm.0000000000004526] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To evaluate the safety and feasibility of physical rehabilitation and active mobilization in patients requiring continuous renal replacement therapy in the ICU. DATA SOURCES Medline, CINAHL, PubMed, Pedro, and Cochrane Library were used to extract articles focused on physical activity and mobility in this population. STUDY SELECTION Research articles were included in this review if 1) included adult patients greater than or equal to 18 years old requiring continuous renal replacement therapy located in the ICU; 2) described physical rehabilitation, active mobilization, or physical activity deliverables; 3) reported data on patient safety and/or feasibility. The primary outcome was safety, defined as number of adverse events per total number of sessions. DATA EXTRACTION Five-hundred seven articles were evaluated based on title and abstract with reviewers selecting 46 to assess by full text. Fifteen observational studies were included for final analysis with seven studies focused solely on physical activity in patients requiring continuous renal replacement therapy. DATA SYNTHESIS Four-hundred thirty-seven adult ICU patients requiring continuous renal replacement therapy participated in some form of physical rehabilitation, physical activity, or active mobilization. Two major adverse events (hypotension event requiring vasopressor and continuous renal replacement therapy tube disconnection, pooled occurrence rate 0.24%) and 13 minor adverse events (pooled occurrence rate 1.55%) were reported during a total of 840 individual mobility or activity sessions. Intervention fidelity was limited by a low prevalence of higher mobility with only 15.5% of incidences occurring at or above level 5 of ICU Mobility Scale (transfer to chair, marching in place or ambulation away from bed, 122/715 reports). Feasibility in the provision of these interventions and/or continuous renal replacement therapy-specific deliverables was inconsistently reported. CONCLUSIONS Early rehabilitation and mobilization, specifically activity in and near the hospital bed, appears safe and mostly feasible in ICU patients requiring continuous renal replacement therapy. A cautious interpretation of these data is necessary due to limited aggregate quality of included studies, heterogeneous reporting, and overall low achieved levels of mobility potentially precluding the occurrence or detection of adverse events.
Collapse
|
14
|
Newman ANL, Kho ME, Harris JE, Fox-Robichaud A, Solomon P. The experiences of cardiac surgery critical care clinicians with in-bed cycling in adult patients undergoing complex cardiac surgery. Disabil Rehabil 2021; 44:5038-5045. [PMID: 34027750 DOI: 10.1080/09638288.2021.1922515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE In-bed cycling is a novel modality that permits the early initiation of rehabilitation in the intensive care unit. We explored clinicians' experiences and perceptions of in-bed cycling with critically ill cardiac surgery patients. MATERIALS AND METHODS We used an interpretive description methodology. All critical care clinicians who had been present for at least 2 cycling sessions were eligible. Data were collected using semi-structured, audio-recorded, face-to-face interviews transcribed verbatim. Content analysis was used to identify themes. RESULTS Nine clinicians were interviewed. Our sample was predominantly female (77.8%) with a median [IQR] age of 40 [21.5] years. Critical care experience ranged from <5 years to ≥30 years. Acceptability was influenced by previous cycling experiences, identifying the "ideal" patient, and the timing of cycling within a patient's recovery. Facilitators included striving towards a common goal and feeling confident in the method. Barriers included inadequate staffing, bike size, and the time to deliver cycling. CONCLUSIONS Clinicians supported the use of in-bed cycling. Concerns included appropriate patient selection and timing of the intervention. Teamwork was integral to successful cycling. Strategies to overcome the identified barriers may assist with successful cycling implementation in other critical care environments.IMPLICATIONS FOR REHABILITATIONIn-bed cycling is a relatively novel rehabilitation modality that can help initiate physical rehabilitation earlier in a patient's recovery and reduce the iatrogenic effects of prolonged admissions to an intensive care unit.Clinicians found in-bed cycling to be an acceptable intervention with a population of critically ill cardiac surgery patients.Teamwork and interprofessional communication are important considerations for successful uptake of a relatively new rehabilitation modality.Identified barriers to in-bed cycling can assist with developing strategies to encourage cycling uptake in similar critical care environments.
Collapse
Affiliation(s)
- Anastasia N L Newman
- School of Rehabilitation Science, McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Hamilton, Canada
| | - Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Canada.,Physiotherapy Department, St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Jocelyn E Harris
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Alison Fox-Robichaud
- Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Canada
| | - Patricia Solomon
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| |
Collapse
|
15
|
Physical Rehabilitation in Critically Ill Children: A Multicenter Point Prevalence Study in the United States. Crit Care Med 2021; 48:634-644. [PMID: 32168030 DOI: 10.1097/ccm.0000000000004291] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers. DESIGN National 2-day point prevalence study. SETTING Eighty-two PICUs in 65 hospitals across the United States. PATIENTS All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was prevalence of physical therapy- or occupational therapy-provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility-associated safety events, and barriers to mobility. The point prevalence of physical therapy- or occupational therapy-provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13-17 vs < 3 yr, 2.1; 95% CI, 1.5-3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61-0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs > 2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p < 0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1-0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1-0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1-6.6). CONCLUSIONS Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.
Collapse
|
16
|
Timenetsky KT, Serpa Neto A, Lazarin AC, Pardini A, Moreira CRS, Corrêa TD, Caserta Eid RA, Nawa RK. The Perme Mobility Index: A new concept to assess mobility level in patients with coronavirus (COVID-19) infection. PLoS One 2021; 16:e0250180. [PMID: 33882081 PMCID: PMC8059854 DOI: 10.1371/journal.pone.0250180] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/01/2021] [Indexed: 01/10/2023] Open
Abstract
Introduction The Coronavirus Disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. Data on the mobility level of patients with COVID-19 in the intensive care unit (ICU) are needed. Objective To describe the mobility level of patients with COVID-19 admitted to the ICU and to address factors associated with mobility level at the time of ICU discharge. Methods Single center, retrospective cohort study. Consecutive patients admitted to the ICU with confirmed COVID-19 infection were analyzed. The mobility status was assessed by the Perme Score at admission and discharge from ICU with higher scores indicating higher mobility level. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge–ICU admission)/ICU length of stay]. Based on the PMI, patients were divided into two groups: “Improved” (PMI > 0) and “Not improved” (PMI ≤ 0). Results A total of 136 patients were included in this analysis. The hospital mortality rate was 16.2%. The Perme Score improved significantly when comparing ICU discharge with ICU admission [20.0 (7–28) points versus 7.0 (0–16) points; P < 0.001]. A total of 88 patients (64.7%) improved their mobility level during ICU stay, and the median PMI of these patients was 1.5 (0.6–3.4). Patients in the improved group had a lower duration of mechanical ventilation [10 (5–14) days versus 15 (8–24) days; P = 0.021], lower hospital length of stay [25 (12–37) days versus 30 (11–48) days; P < 0.001], and lower ICU and hospital mortality rate. Independent predictors for mobility level were lower age, lower Charlson Comorbidity Index, and not having received renal replacement therapy. Conclusion Patients’ mobility level was low at ICU admission; however, most patients improved their mobility level during ICU stay. Risk factors associated with the mobility level were age, comorbidities, and use of renal replacement therapy.
Collapse
Affiliation(s)
- Karina Tavares Timenetsky
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Australian and New Zealand Intensive Care-Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Data Analytics Research & Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Ana Carolina Lazarin
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Andreia Pardini
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | | | - Thiago Domingos Corrêa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raquel Afonso Caserta Eid
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Ricardo Kenji Nawa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- * E-mail:
| |
Collapse
|
17
|
Zink EK, Kumble S, Beier M, George P, Stevens RD, Bahouth MN. Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage. Neurocrit Care 2021; 35:707-713. [PMID: 33751389 PMCID: PMC7983346 DOI: 10.1007/s12028-021-01204-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/30/2021] [Indexed: 01/02/2023]
Abstract
Purpose Evidence suggests that early physical activity can be accomplished safely in the neurocritical care unit (NCCU); however, many NCCU patients are often maintained in a state of inactivity due to impaired consciousness, sensorimotor deficits, and concerns for intracranial pressure elevation or cerebral hypoperfusion in the setting of autoregulatory failure. Structured in-bed mobility interventions have been proposed to prevent sequelae of complete immobility in such patients, yet the feasibility and safety of these interventions is unknown. We studied neurological and hemodynamic changes before and after cycle ergometry (CE) in a subset of NCCU patients with external ventricular drains (EVDs). Methods Patients admitted to the NCCU who had an EVD placed for cerebrospinal fluid drainage and intracranial pressure (ICP) monitoring underwent supine CE therapy with passive and active cycling settings. Neurologic status, ICP and hemodynamic parameters were monitored before and after each CE session. Results Twenty-seven patients successfully underwent in-bed CE in the NCCU. No clinically significant changes were recorded in neurologic or in physiological parameters before or after CE. There were no device dislodgements or other adverse effects requiring cessation of a CE session. Conclusion These data suggest that supine CE in a heterogeneous cohort of neurocritical care patients with EVDs is safe and tolerable. Larger prospective studies are needed to determine the efficacy and optimal dose and timing of supine CE in neurocritical care patients.
Collapse
Affiliation(s)
- Elizabeth K Zink
- Department of Neurosciences Nursing, The Johns Hopkins Hospital, 1800 Orleans Street, Zayed 3 West, Room 3074, Baltimore, MD, 21287, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Sowmya Kumble
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Meghan Beier
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pravin George
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mona N Bahouth
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
18
|
Feuvrier F, Jourdan C, Barber O, Ascher M, Griffiths K, Pavillard F, Chalard K, Bory P, Perrigault PF, Laffont I. Early mobilization in intensive care for patients with brain injury: e-Survey of current practices in France. Ann Phys Rehabil Med 2021; 64:101418. [PMID: 32763483 DOI: 10.1016/j.rehab.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/15/2020] [Accepted: 07/05/2020] [Indexed: 11/29/2022]
Affiliation(s)
- François Feuvrier
- Physical and Rehabilitation Medicine, Montpellier University Hospital, Montpellier, France.
| | - Claire Jourdan
- Physical and Rehabilitation Medicine, Montpellier University Hospital, Montpellier, France
| | - Olivier Barber
- Physical and Rehabilitation Medicine, Montpellier University Hospital, Montpellier, France
| | - Margrit Ascher
- Physical and Rehabilitation Medicine, Montpellier University Hospital, Montpellier, France
| | | | - Frédérique Pavillard
- Neurological ICU, Anesthesia and Critical Care Medicine Department, Montpellier University Hospital, Montpellier, France
| | - Kevin Chalard
- Neurological ICU, Anesthesia and Critical Care Medicine Department, Montpellier University Hospital, Montpellier, France
| | - Paul Bory
- Neurological ICU, Anesthesia and Critical Care Medicine Department, Montpellier University Hospital, Montpellier, France
| | - Pierre-François Perrigault
- Neurological ICU, Anesthesia and Critical Care Medicine Department, Montpellier University Hospital, Montpellier, France
| | - Isabelle Laffont
- Physical and Rehabilitation Medicine, Montpellier University Hospital, Montpellier, France
| |
Collapse
|
19
|
Taniguchi H, Ikeda T, Takeuchi I, Ichiba S. Iliopsoas Hematoma in Patients Undergoing Venovenous ECMO. Am J Crit Care 2021; 30:55-63. [PMID: 33385201 DOI: 10.4037/ajcc2021351] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Iliopsoas hematoma occasionally occurs in patients receiving anticoagulation therapy. It may be a life-threatening complication and can cause disseminated intravascular coagulation, which could develop into abdominal compartment syndrome. The incidence of and factors associated with iliopsoas hematoma during venovenous extracorporeal membrane oxygenation (ECMO) have not been well studied. OBJECTIVES To describe the incidence of iliopsoas hematoma and associated factors among patients undergoing venovenous ECMO. METHODS A retrospective cohort study was conducted at Nippon Medical School Hospital from April 2015 to October 2018. All patients (>18 years old) with iliopsoas hematoma received a diagnosis based on computed tomography. RESULTS During the study period, 54 patients were supported with venovenous ECMO. Iliopsoas hematoma occurred in 8 of those patients (15%), none of whom had disseminated intravascular coagulopathy or abdominal compartment syndrome develop. Univariate analysis indicated that management of ECMO while the patient was awake and mobilization beyond sitting on the edge of the bed were significantly different (P < .05) in patients with and patients without iliopsoas hematoma. Mortality, however, did not differ significantly between the 2 groups. CONCLUSIONS Our findings emphasize that recognizing factors associated with iliopsoas hematoma and detecting them early are crucial during venovenous ECMO in order to treat patients with iliopsoas hematoma appropriately.
Collapse
Affiliation(s)
- Hayato Taniguchi
- Hayato Taniguchi is an assistant professor, Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan, and Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Tokuji Ikeda
- Tokuji Ikeda is an assistant professor, Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital
| | - Ichiro Takeuchi
- Ichiro Takeuchi is a professor, Advanced Critical Care and Emergency Center, Yokohama City University Medical Center
| | - Shingo Ichiba
- Shingo Ichiba is a professor, Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital
| |
Collapse
|
20
|
Munir H, Fromowitz J, Goldfarb M. Early mobilization post-myocardial infarction: A scoping review. PLoS One 2020; 15:e0237866. [PMID: 32804979 PMCID: PMC7430744 DOI: 10.1371/journal.pone.0237866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/04/2020] [Indexed: 02/02/2023] Open
Abstract
Bedrest and immobilization following a myocardial infarction (MI) can lead to functional impairment that can persist following hospitalization. Early mobilization (EM) is associated with good functional and clinical outcomes in critical care, medical and surgical settings. However, the impact and current role of EM in post-MI care has not been well-defined. Our objective was to assess the evidence for post-MI mobilization, define current post-MI mobilization practice, and understand perspectives of cardiovascular professionals toward mobilization. A scoping review related to "early mobilization" and "myocardial infarction" was performed using the Joanna Briggs Institute Methodology. Pubmed, Embase, Google Scholar, Cochrane Library and CINAHL databases were included. Results were categorized into six topic areas. There were 59 references included in the analysis. There was evidence for the effectiveness and safety of earlier mobilization in experimental studies of the pre-revascularization era, but there was a lack of strong evidence for EM in contemporary post-MI care. Mobilization appears to be safe following arterial catheterization and is associated with minimal hemodynamic and respiratory compromise. Most people are delayed in mobilizing post-MI and spend the majority of the initial hospitalization period lying in bed. Only 1 of 7 current major cardiovascular professional societies guidelines recommend EM post-MI. There were no studies exploring the perspectives of cardiovascular professionals toward mobilization. EM may be beneficial in the post-MI care. However, there is an evidence gap for the impact of EM post-MI in the contemporary literature. More robust evidence from randomized clinical trials is required to inform clinicians and influence practice.
Collapse
Affiliation(s)
- Haroon Munir
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Jake Fromowitz
- Nova Southeastern University, Fort Lauderdale, FL, United States of America
| | - Michael Goldfarb
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| |
Collapse
|
21
|
Sakai T, Hoshino C, Okawa A, Wakabayashi K, Shigemitsu H. The Safety and Effect of Early Mobilization in the Intensive Care Unit According to Cancellation Criteria. Prog Rehabil Med 2020; 5:20200016. [PMID: 32844129 PMCID: PMC7429556 DOI: 10.2490/prm.20200016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 07/08/2020] [Indexed: 11/20/2022] Open
Abstract
Objective: The aim of this study was to investigate the effect and risk management of early
mobilization in the intensive care unit (ICU) with multidisciplinary collaboration and
daily goal planning. Methods: Rehabilitation of ICU patients in our hospital between April 1, 2019, and September 30,
2019, was investigated retrospectively. The following factors were evaluated: age and
sex of the subjects; diseases; the total number of early mobilization therapy sessions
done at a lowered goal level; the clinical course of the step-down sessions; reasons for
lowering goal levels that corresponded to the cancellation criteria from the officially
issued guidelines of the Japanese Association of Rehabilitation Medicine, the expert
consensus on ICU, or other reasons for step down; and the rate of planned goals that
were achieved. Results: Of the 1908 overall rehabilitation sessions carried out during the period of
investigation, 9.6% had the planned level lowered; changes in vital signs accounted for
54.6% of the reasons for lowering the level. Of the step-down sessions, 92.3%
corresponded with the cancellation criteria of rehabilitation. Early mobilization in the
ICU in accordance with daily goal planning via collaboration within the
multidisciplinary team during rounds was accomplished in 90.4% of sessions. No serious
mobilization-related adverse events were noted during the study period. Conclusion: Early mobilization should be performed with daily goal planning by a multidisciplinary
team during rounds and should be governed by the cancellation criteria of
rehabilitation.
Collapse
Affiliation(s)
- Tomoko Sakai
- Department of Rehabilitation Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Chisato Hoshino
- Department of Rehabilitation Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenji Wakabayashi
- Department of Intensive Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hidenobu Shigemitsu
- Department of Intensive Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
22
|
Walking While Dialyzing: A Retrospective Observation of Early Mobility and Ambulation for Patients on Continuous Renal Replacement Therapy. Crit Care Explor 2020; 2:e0131. [PMID: 32695996 PMCID: PMC7314322 DOI: 10.1097/cce.0000000000000131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives To describe the practice of physical therapy for patients requiring continuous renal replacement therapy and assess data related to the safety and feasibility of physical therapy interventions. Design A retrospective observational cohort study. Patients Surgical and cardiovascular patients receiving continuous renal replacement therapy during a 2-year period from December 2016 to November 2018. Setting Two ICUs at a single academic medical center. Intervention Physical mobility and ambulation while on continuous renal replacement therapy. Measurements and Main Results Therapy data including ICU Mobility Scale score, number of physical therapy sessions with and without ambulation and gait distance, along with safety data including filter life, safety events, and mortality were analyzed. The cohort of patients receiving continuous renal replacement therapy during the 2-year period was 206. Of these, 172 (83.49%) received simultaneous physical therapy. The median ICU Mobility Scale was 5 (interquartile range, 4-7) over a total of 1,517 physical therapy sessions. Ambulation with concomitant continuous renal replacement therapy connected was achieved in 78 patients (37.86%). There were 377 ambulation sessions (24.85% of all sessions) with a mean of 4.83 (sds 4.94) ambulation sessions per ambulatory patient. Patients walked an average of 888.53 feet (sd 1,365.50) while on continuous renal replacement therapy and a daily average of 150.61 feet (sd 133.50). In-hospital mortality was lowest for patients who ambulated (17.95%) and highest for patients who received no therapy (73.53%). Continuous renal replacement therapy filter life was longest for patients who ambulated (2,047.20 min [sd 1,086.50 min]), and shortest in patients who received no therapy (1,682.20 min [sd 1,343.80 min]). One safety event was reported during this time (0.0007% of all physical therapy sessions). Conclusions Ambulation while on continuous renal replacement therapy was not associated with an increased risk of safety events and was feasible with the use of nonfemoral catheters and dialysis equipment with internal batteries.
Collapse
|
23
|
Semsar-Kazerooni K, Dima D, Valiquette J, Berube-Dufour J, Goldfarb M. Early Mobilization in People With Acute Cardiovascular Disease. Can J Cardiol 2020; 37:232-240. [PMID: 32739452 DOI: 10.1016/j.cjca.2020.03.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Early mobilization (EM) is recommended in critical care units. However, there is little known about EM in people with acute cardiovascular disease. METHODS Consecutive admissions to a tertiary-care cardiovascular intensive care unit (CICU) before and after implementation of an EM program were reviewed. The Level of Function (LOF) Mobility Scale, which ranges from 0 (bed immobile) to 5 (able to walk >20 m), was used to measure and guide mobility. The primary outcome was discharge home. RESULTS There were 1489 patients included in the analysis (preintervention, N = 637; intervention, N = 852). There were no differences in age, sex, or admission for ischemic heart disease (age 68.1 ± 16.1 years; 39.3% female). In the intervention cohort, one-quarter (N = 222; 26.1%) had at least mildly impaired prehospital functional status. The LOF was 4.6 ± 0.7 prehospital, 3.2 ± 1.4 on admission, and 4.2 ± 0.9 on CICU discharge. Half of patients (51.6%) increased their LOF by ≥1 during CICU admission. Nearly all mobility opportunities had a mobility activity (97.0%). The adverse event rate was 0.3% with no life-threatening events, falls, line dislodgements, or health care personnel injuries. The intervention group, compared with the preintervention group, was more likely to be discharged home (83.9% vs 78.3%, P < 0.007) and had a lower rate of in-hospital death (4.2% vs 6.8%; P = 0.04). When adjusted for age, sex, and comorbid illness, admission LOF was a predictor of discharge to health care facility (odds ratio = 0.72; P < 0.001). CONCLUSIONS EM is safe and feasible in the CICU and effective at increasing discharge home.
Collapse
Affiliation(s)
| | - Diana Dima
- Department of Nursing, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - Julie Valiquette
- Division of Physiotherapy, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - Joelle Berube-Dufour
- Department of Occupational Therapy, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Québec, Canada.
| |
Collapse
|
24
|
Bhatia M, Kumar PA. Pro: Venoarterial Extracorporeal Membrane Oxygenation Is Superior to Impella for Cardiogenic Shock. J Cardiothorac Vasc Anesth 2020; 34:278-282. [DOI: 10.1053/j.jvca.2019.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/30/2019] [Indexed: 11/11/2022]
|
25
|
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1758] [Impact Index Per Article: 351.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
Collapse
|
26
|
Jang MH, Shin MJ, Shin YB. Pulmonary and Physical Rehabilitation in Critically Ill Patients. Acute Crit Care 2019; 34:1-13. [PMID: 31723900 PMCID: PMC6849048 DOI: 10.4266/acc.2019.00444] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 02/19/2019] [Accepted: 02/22/2010] [Indexed: 12/28/2022] Open
Abstract
Some patients admitted to the intensive care unit (ICU) because of an acute illness, complicated surgery, or multiple traumas develop muscle weakness affecting the limbs and respiratory muscles during acute care in the ICU. This condition is referred to as ICU-acquired weakness (ICUAW), and can be evoked by critical illness polyneuropathy (CIP), critical illness myopathy (CIM), or critical illness polyneuromyopathy (CIPNM). ICUAW is diagnosed using the Medical Research Council (MRC) sum score based on bedside manual muscle testing in cooperative patients. The MRC sum score is the sum of the strengths of the 12 regions on both sides of the upper and lower limbs. ICUAW is diagnosed when the MRC score is less than 48 points. However, some patients require electrodiagnostic studies, such as a nerve conduction study, electromyography, and direct muscle stimulation, to differentiate between CIP and CIM. Pulmonary rehabilitation in the ICU can be divided into modalities intended to remove retained airway secretions and exercise therapies intended to improve respiratory function. Physical rehabilitation, including early mobilization, positioning, and limb exercises, attenuates the weakness that occurs during critical care. To perform mobilization in mechanically ventilated patients, pretreatment by removing secretions is necessary. It is also important to increase the strength of respiratory muscles and to perform lung recruitment to improve mobilization in patients who are weaned from the ventilator. For these reasons, pulmonary rehabilitation is important in addition to physical therapy. Early recognition of CIP, CIM, and CIPNM and early rehabilitation in the ICU might improve patients’ functional recovery and outcomes.
Collapse
Affiliation(s)
- Myung Hun Jang
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Myung-Jun Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
| |
Collapse
|
27
|
Abrams D, Garan AR, Brodie D. Awake and fully mobile patients on cardiac extracorporeal life support. Ann Cardiothorac Surg 2019; 8:44-53. [PMID: 30854311 DOI: 10.21037/acs.2018.08.03] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Early mobilization of critically ill patients is increasingly being recognized as not only safe and feasible, but also as a potential means of optimizing outcomes in the intensive care unit (ICU). With the rapidly expanding use of extracorporeal life support (ECLS) for severe cardiopulmonary failure, there is a growing interest in the application of early mobilization to this patient population, which has been shown to be safe and feasible in select patient populations. However, some patients receiving ECLS support may benefit more than others. For instance, early mobilization may be particularly beneficial in patients awaiting heart or lung transplantation, as maintenance of physical conditioning may be an important component of a patient's transplant candidacy. The ability to engage critically ill patients in active physical therapy and early mobilization necessarily involves minimization of sedation and is often further facilitated by a strategy that favors endotracheal extubation. Whether an awake, extubated and mobile strategy can be applied in any given patient is often dictated by the severity of the underlying disease and the amount of extracorporeal support required. Additionally, whether this approach is superior to usual care, which patients might benefit or be harmed, and which patient characteristics are most likely to predict success of this strategy, are areas of ongoing investigation.
Collapse
Affiliation(s)
- Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, USA
| | - A Reshad Garan
- Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, USA
| |
Collapse
|
28
|
Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Ann Am Thorac Soc 2018; 14:766-777. [PMID: 28231030 DOI: 10.1513/annalsats.201611-843sr] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation. OBJECTIVES To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation. DATA SOURCES Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events. DATA EXTRACTION Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy). SYNTHESIS Heterogeneity was assessed by I2 statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions. CONCLUSIONS Patient mobilization and physical rehabilitation in the ICU appears safe, with a low incidence of potential safety events, and only rare events having any consequences for patient management. Heterogeneity in the definition of safety events across studies emphasizes the importance of implementing existing consensus-based definitions.
Collapse
|
29
|
Safety and Feasibility of Early Physical Therapy for Patients on Extracorporeal Membrane Oxygenator: University of Maryland Medical Center Experience. Crit Care Med 2017; 46:53-59. [PMID: 29053491 DOI: 10.1097/ccm.0000000000002770] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the feasibility and safety of mobilizing patients while on extracorporeal membranous oxygenation support. DESIGN Retrospective cohort study. SETTING Medical and Surgical ICUs in a large tertiary care hospital in the United States. PATIENTS Adults supported on extracorporeal membranous oxygenation from January 2014 to December 2015. MEASUREMENTS AND MAIN RESULTS We reviewed the medical records from physical therapy, perfusion, and intensivists to obtain the number and type of physical therapy interventions and discharge status; extracorporeal membranous oxygenation type and description of support, cannulation sites; and risk management details of adverse effects, if any. Of 254 patients supported on extracorporeal membranous oxygenation, 167 patients (66.7%) received a total of 607 physical therapy sessions while on extracorporeal membranous oxygenation support. In this cohort, 134 patients (80.2%) had at least one femoral cannula during physical therapy intervention. Sixty-six of the 167 patients (39.5%) were supported on extracorporeal membranous oxygenation with bifemoral cannulas, and 44 (26.3%) were on veno-arterial extracorporeal membranous oxygenation. A dual lumen catheter was only used in five cases. Twenty-five patients (15%) (13 bifemoral cases) participated in standing or ambulation activities. Seventy-five patients (68.8%) who were successfully weaned from extracorporeal membranous oxygenation were discharged to a rehabilitation facility; 26 patients (23.8%) went home. Three minor events (< 0.5%) involving two episodes of arrhythmias and a hypotension event interrupted the therapy sessions, but mobility activities and exercises resumed that day. No major events were reported. CONCLUSIONS With a highly trained multidisciplinary team and a focus on restoring function, it is feasible and safe to deliver early rehabilitation including standing and ambulation to patients on extracorporeal membranous oxygenation support even those with femoral cannulation sites with veno-arterial extracorporeal membranous oxygenation and veno-venous extracorporeal membranous oxygenation.
Collapse
|
30
|
Feasibility and Safety of Physical Therapy during Continuous Renal Replacement Therapy in the Intensive Care Unit. Ann Am Thorac Soc 2017; 13:699-704. [PMID: 26788890 DOI: 10.1513/annalsats.201506-359oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Early rehabilitation in an intensive care unit is associated with improved physical functioning and patient outcomes. However, relatively few data have been reported on physical therapy interventions during continuous renal replacement therapy (CRRT) for patients in intensive care units. OBJECTIVES To evaluate the feasibility and safety of physical therapy interventions, delivered as part of routine clinical care, for patients undergoing CRRT in an intensive care unit. METHODS Consecutive patients in the adult medical intensive care unit of one large tertiary care hospital who received physical therapy sessions while on CRRT were prospectively evaluated over 13 months. Physical therapy sessions were individualized on the basis of patients' physical impairments and activity tolerance, with patients' highest level of mobility recorded. Data on 15 different physiological abnormalities and potential safety events, including bleeding, dislodgement, or dysfunction of the CRRT catheter or circuit, were prospectively collected. MEASUREMENTS AND MAIN RESULTS Eleven physical therapists delivered 268 rehabilitation sessions to 57 patients while they were receiving CRRT, with the following highest levels of mobility achieved during individual sessions: 78 (29%) bed exercises, 72 (27%) supine cycle ergometry, 80 (30%) sitting at edge of bed, 13 (5%) transfer to chair, and 25 (9%) standing or marching in place. No CRRT-specific safety events occurred (0%; 95% upper confidence interval, 6.3%). There were six non-CRRT-related potential safety events (2.2% of all physical therapy sessions; 95% confidence interval, 0.6-8.2%), all of which were transient changes in blood pressure. CONCLUSIONS In this prospective observational study at one adult medical intensive care unit, we found that provision of bedside physical therapy while patients underwent CRRT is feasible, and appears safe.
Collapse
|
31
|
Abstract
Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial. However, implementation of early mobility as part of routine clinical care can be challenging. The objective of this review is to identify barriers to early mobilization and discuss strategies to overcome such barriers. Based on a literature search, we synthesize data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were patient-related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%) process-related barriers. These barriers varied across ICUs and within disciplines, depending on the ICU patient population, setting, attitude, and ICU culture. To overcome the identified barriers, over 70 strategies were reported and are synthesized in this review, including: implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and involvement of physician champions. Systematic efforts to change ICU culture to prioritize early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.
Collapse
|
32
|
Abstract
OBJECTIVES Prolonged hospitalization due to burn injury results in physical inactivity and muscle weakness. However, how these changes are distributed among body parts is unknown. The aim of this study was to evaluate the degree of body composition changes in different anatomical regions during ICU hospitalization. DESIGN Retrospective chart review. SETTING Children's burn hospital. PATIENTS Twenty-four severely burned children admitted to our institution between 2000 and 2015. INTERVENTIONS All patients underwent a dual-energy x-ray absorptiometry within 2 weeks after injury and 2 weeks before discharge to determine body composition changes. No subject underwent anabolic intervention. We analyzed changes of bone mineral content, bone mineral density, total fat mass, total mass, and total lean mass of the entire body and specifically analyzed the changes between the upper and lower limbs. MEASUREMENTS AND MAIN RESULTS In the 24 patients, age was 10 ± 5 years, total body surface area burned was 59% ± 17%, time between dual-energy x-ray absorptiometries was 34 ± 21 days, and length of stay was 39 ± 24 days. We found a significant (p < 0.001) average loss of 3% of lean mass in the whole body; this loss was significantly greater (p < 0.001) in the upper extremities (17%) than in the lower extremities (7%). We also observed a remodeling of the fat compartments, with a significant whole-body increase in fat mass (p < 0.001) that was greater in the truncal region (p < 0.0001) and in the lower limbs (p < 0.05). CONCLUSIONS ICU hospitalization is associated with greater lean mass loss in the upper limbs of burned children. Mobilization programs should include early mobilization of upper limbs to restore upper extremity function.
Collapse
|
33
|
Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies. Intensive Care Med 2017; 43:531-542. [PMID: 28210771 DOI: 10.1007/s00134-017-4685-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers. METHODS Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454. RESULTS Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment. CONCLUSIONS The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.
Collapse
|
34
|
Zeiser E. [Physiotherapy interventions in the ICU : Outcome-relevant measurement parameters]. Med Klin Intensivmed Notfmed 2017; 112:356-370. [PMID: 28116462 DOI: 10.1007/s00063-016-0259-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 08/28/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guidelines cannot provide differentiated recommendations for physiotherapy (PT) in intensive care medicine. Scientific publications for PT in the intensive care unit (ICU) usually only have low levels of evidence and often express safety and feasibility of PT in the ICU. OBJECTIVE Which measurement parameters are relevant for defining outcome and what interventions should one take into consideration? MATERIALS AND METHODS A literature review was conducted. This was based on a PubMed search with full text access, as well as specific definitions for physical therapy, intensive care and four out of seven conditions from the manual "Physiotherapy in intensive care". RESULTS The availability of 172 studies clearly shows that there is certainly PT research concerning the critical environment of the ICU. However, parameters for quantitative and qualitative detection of vigilance and state of consciousness as well as assessments to evaluate the mobility and the ability to help themselves are important for everyday use. CONCLUSIONS The difficulties of using PT in the ICU are not useful in ensuring the safety of the patient or performing a PT treatment. The conditions of the intensive care environment are not an obstacle. It is of immanent importance to use the limited resources of PT in an optimal and targeted manner in the ICU environment. The determination of ICU-adapted goals plays a crucial role.
Collapse
Affiliation(s)
- E Zeiser
- Berufsförderungswerk Mainz, DIPLOMA Hochschule - Private Fachhochschule Nordhessen, z.H. Dorit Engelmann Lortzingstraße 4, 55127, Mainz, Deutschland.
| |
Collapse
|
35
|
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]
|
36
|
Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, Murphy C, Camposilvan L, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Zanni JM, Mourtzakis M, Piraino T, Cook DJ. TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients. PLoS One 2016; 11:e0167561. [PMID: 28030555 PMCID: PMC5193383 DOI: 10.1371/journal.pone.0167561] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022] Open
Abstract
Introduction The objective of this study was to assess the safety and feasibility of in-bed cycling started within the first 4 days of mechanical ventilation (MV) to inform a future randomized clinical trial. Methods We conducted a 33-patient prospective cohort study in a 21-bed adult academic medical-surgical intensive care unit (ICU) in Hamilton, ON, Canada. We included adult patients (≥ 18 years) receiving MV who walked independently pre-ICU. Our intervention was 30 minutes of in-bed supine cycling 6 days/week in the ICU. Our primary outcome was Safety (termination), measured as events prompting cycling termination; secondary Safety (disconnection or dislodgement) outcomes included catheter/tube dislodgements. Feasibility was measured as consent rate and fidelity to intervention. For our primary outcome, we calculated the binary proportion and 95% confidence interval (CI). Results From 10/2013-8/2014, we obtained consent from 34 of 37 patients approached (91.9%), 33 of whom received in-bed cycling. Of those who cycled, 16(48.4%) were female, the mean (SD) age was 65.8(12.2) years, and APACHE II score was 24.3(6.7); 29(87.9%) had medical admitting diagnoses. Cycling termination was infrequent (2.0%, 95% CI: 0.8%-4.9%) and no device dislodgements occurred. Cycling began a median [IQR] of 3 [2, 4] days after ICU admission; patients received 5 [3, 8] cycling sessions with a median duration of 30.7 [21.6, 30.8] minutes per session. During 205 total cycling sessions, patients were receiving invasive MV (150 [73.1%]), vasopressors (6 [2.9%]), sedative or analgesic infusions (77 [37.6%]) and dialysis (4 [2.0%]). Conclusions Early cycling within the first 4 days of MV among hemodynamically stable patients is safe and feasible. Research to evaluate the effect of early cycling on patient function is warranted. Trial Registration Clinicaltrials.gov: NCT01885442
Collapse
Affiliation(s)
- Michelle E. Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- * E-mail:
| | - Alexander J. Molloy
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - France J. Clarke
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daana Ajami
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Magda McCaughan
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Kristy Obrovac
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Christina Murphy
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Laura Camposilvan
- Department of Physiotherapy, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Margaret S. Herridge
- Department of Medicine, University of Toronto, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen K. Y. Koo
- Swedish Early Mobility Program in Critical Care, First Hill Campus, Swedish Medical Group, Seattle, Washington
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jill Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J. E. Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer M. Zanni
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Thomas Piraino
- Respiratory Therapy Service, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Deborah J. Cook
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
37
|
Hashem MD, Parker AM, Needham DM. Early Mobilization and Rehabilitation of Patients Who Are Critically Ill. Chest 2016; 150:722-31. [PMID: 26997241 PMCID: PMC6026260 DOI: 10.1016/j.chest.2016.03.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/28/2016] [Accepted: 03/01/2016] [Indexed: 11/17/2022] Open
Abstract
Neuromuscular disorders are increasingly recognized as a cause of both short- and long-term physical morbidity in survivors of critical illness. This recognition has given rise to research aimed at better understanding the risk factors and mechanisms associated with neuromuscular dysfunction and physical impairment associated with critical illness, as well as possible interventions to prevent or treat these issues. Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of patients who are critically ill may help prevent or mitigate the sequelae of bed rest and improve patient outcomes. Research studies and quality improvement projects have demonstrated that early mobilization and rehabilitation are safe and feasible in patients who are critically ill, with potential benefits including improved physical functioning and decreased duration of mechanical ventilation, intensive care, and hospital stay. Despite these findings, early mobilization and rehabilitation are still uncommon in routine clinical practice, with many perceived barriers. This review summarizes potential risk factors for neuromuscular dysfunction and physical impairment associated with critical illness, highlights the potential role of early mobilization and rehabilitation in improving patient outcomes, and discusses some of the commonly perceived barriers to early mobilization and strategies for overcoming them.
Collapse
Affiliation(s)
- Mohamed D Hashem
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Ann M Parker
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
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.
Collapse
Affiliation(s)
| | | | - Marcelo Park
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | | |
Collapse
|
40
|
Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior. J Crit Care 2015; 30:1243-50. [PMID: 26365000 DOI: 10.1016/j.jcrc.2015.08.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 07/27/2015] [Accepted: 08/11/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions. MATERIALS AND METHODS A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator. RESULTS Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture. CONCLUSIONS Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions.
Collapse
|
41
|
A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury. Ann Am Thorac Soc 2015; 11:1230-8. [PMID: 25167767 DOI: 10.1513/annalsats.201406-231oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice. OBJECTIVES To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI). METHODS This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU. MEASUREMENTS AND MAIN RESULTS The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]). CONCLUSIONS In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.
Collapse
|
42
|
Pires-Neto RC, Lima NP, Cardim GM, Park M, Denehy L. Early mobilization practice in a single Brazilian intensive care unit. J Crit Care 2015; 30:896-900. [PMID: 26093803 DOI: 10.1016/j.jcrc.2015.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 05/04/2015] [Accepted: 05/09/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To characterize the provision of early mobilization therapy in critically ill patients in a Brazilian medical intensive care unit (ICU) and to investigate the relationship between physical activity level and clinical outcomes. METHODS Intensive care unit and physiotherapy data were collected retrospectively from 275 consecutive patients. Here we report on the subset of patients (n = 120) who were mechanically ventilated during their ICU stay (age, 49 ± 18 years; Simplified Acute Physiology Score 3, 45 [25]). RESULTS Median (interquartile range) time of mechanical ventilation and ICU length of stay were 3 (4) and 8 (10) days, respectively. Intensive care unit and 1-year mortality were 31% and 50%, respectively. During the ICU stay, these patients all received respiratory physiotherapy and 90% (n = 108) received mobilization therapy. When intubated and ventilated, mobilization therapy was performed in 76% (n = 92) of the patients with no adverse events. The most common activity was in-bed exercises (55%), and the number of out-of-bed activities (sitting out of bed, standing, or walking) was small (29%) and more prevalent in patients with tracheostomy than with an endotracheal tube (27% × 2%, respectively). CONCLUSION In our Brazilian ICU, mobilization therapy in critically ill patients was safe and feasible; however, similar to other countries, in-bed exercises were the most prevalent activity. During mechanical ventilation, only a small percentage of activities involved standing or mobilizing away from the bed.
Collapse
Affiliation(s)
- Ruy Camargo Pires-Neto
- Department of Pathology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
| | - Natalia Pontes Lima
- Physiotherapy Service, Instituto Central do Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, SP, Brazil
| | - Gregorio Marques Cardim
- Physiotherapy Service, Instituto Central do Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Park
- Intensive Care Unit, Clinical Emergency Department, Instituto Central do Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, SP, Brazil
| | - Linda Denehy
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Parkville, Melbourne, Australia
| |
Collapse
|
43
|
Lee H, Ko YJ, Suh GY, Yang JH, Park CM, Jeon K, Park YH, Chung CR. Safety profile and feasibility of early physical therapy and mobility for critically ill patients in the medical intensive care unit: Beginning experiences in Korea. J Crit Care 2015; 30:673-7. [PMID: 25957499 DOI: 10.1016/j.jcrc.2015.04.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 04/16/2015] [Accepted: 04/18/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate risk factors for potential safety events during mobility physical therapy sessions in the medical intensive care unit. METHODS The safety profiles and potential risk factors of 99 patients who were admitted to the medical intensive care unit of a single teaching hospital in Korea between May 1 and December 31, 2013, were retrospectively evaluated. RESULTS A total of 26 potential safety events (5.0%; 95% confidence interval [CI], 3.4%-7.3%) during 520 mobilization sessions were observed in 17 (17.2%; 95% CI, 10.6%-26.4%) of 99 patients. The common potential safety events were as follows in order of frequency: 11 events of tachypnea or bradypnea (2.1%; 95% CI, 1.1%-3.9%), 6 events of desaturation (1.2 %; 95% CI, 0.5%-2.6%), 4 events of tachypnea or bradycardia (0.8%; 95% CI, 0.3%-2.1%), 4 events of patients' intolerance (0.8%; 95% CI, 0.3%-2.1%), and 1 event of tracheostomy tube removal (0.2%; 95% CI, 0%-1.2%). In multivariate analysis, the use of extracorporeal membrane oxygenation was associated with potential adverse events with an adjusted odds ratio of 5.8 (95% CI, 2.2-15.6), respectively. CONCLUSION Early mobility physical therapy performed by a newly established group was feasible for critically ill patients in Korea. However, potential safety events need to be monitored carefully for patients with extracorporeal membrane oxygenation support.
Collapse
Affiliation(s)
- Hyun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Jun Ko
- Department of Rehabilitation and Physical Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yun Hee Park
- Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Chi Ryang Chung
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
44
|
Cameron S, Ball I, Cepinskas G, Choong K, Doherty TJ, Ellis CG, Martin CM, Mele TS, Sharpe M, Shoemaker JK, Fraser DD. Early mobilization in the critical care unit: A review of adult and pediatric literature. J Crit Care 2015; 30:664-72. [PMID: 25987293 DOI: 10.1016/j.jcrc.2015.03.032] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/19/2015] [Accepted: 03/28/2015] [Indexed: 11/19/2022]
Abstract
Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated into daily clinical practice. Early passive, active, and combined progressive mobilizations can be safely initiated in intensive care units (ICUs). Adult patients receiving early mobilization have fewer ventilator-dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data are limited, but recent studies also suggest that early mobilization is achievable without increasing patient risk. In this review, we provide a current and comprehensive appraisal of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient outcomes will require further studies on mobilization timing and intensity, particularly within specific ICU populations.
Collapse
Affiliation(s)
- Saoirse Cameron
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study
| | - Ian Ball
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medicine, Western University, London, ON, Canada
| | - Gediminas Cepinskas
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medical Biophysics, Western University, London, ON, Canada
| | - Karen Choong
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Timothy J Doherty
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Physical Medicine and Rehabilitation, Western University, London, ON, Canada
| | - Christopher G Ellis
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medicine, Western University, London, ON, Canada; Medical Biophysics, Western University, London, ON, Canada
| | - Claudio M Martin
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Medicine, Western University, London, ON, Canada
| | - Tina S Mele
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Surgery, Western University, London, ON, Canada
| | - Michael Sharpe
- Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Anesthesia and Perioperative Medicine, Western University, London, ON, Canada
| | - J Kevin Shoemaker
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Kinesiology, Western University, London, ON, Canada
| | - Douglas D Fraser
- Functional Recovery in Critically Ill Children: The "Wee-Cover" Longitudinal Cohort Study; Targeted Exercise to Reduce Morbidity and Mortality in Severe Sepsis (TERMS) Study; Pediatrics, Western University, London, ON, Canada.
| |
Collapse
|
45
|
Eakin MN, Ugbah L, Arnautovic T, Parker AM, Needham DM. Implementing and sustaining an early rehabilitation program in a medical intensive care unit: A qualitative analysis. J Crit Care 2015; 30:698-704. [PMID: 25837800 DOI: 10.1016/j.jcrc.2015.03.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/10/2015] [Accepted: 03/15/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Early rehabilitation programs in a medical intensive care unit can improve patient outcomes, but clinicians face barriers in implementing and sustaining such programs. We sought to describe a multidisciplinary team perspective regarding how to implement and sustain a successful early rehabilitation program. METHODS Semistructured interviews were conducted with 20 staff and faculty who were involved in the early rehabilitation program at the Johns Hopkins Hospital Medical Intensive Care Unit. Transcripts were evaluated using the Consolidated Framework of Implementation Research Theory. RESULTS Four major constructs emerged as important, as follows: (1) necessary components, (2) implementation strategies, (3) perceived barriers, and (4) positive outcomes. All participants reported that staff buy-in was necessary, whereas having a multidisciplinary team with good communication among team members was reported as helpful by 90% of participants. The most common barrier reported was increased staff workload (80%). All participants (100%) noted improved patient outcomes as an important benefit, and 95% reported improved job satisfaction. CONCLUSIONS This qualitative study of a successful early rehabilitation program highlights the importance of assessing and engaging a multidisciplinary team before implementation and the positive outcomes of early rehabilitation on staff by improving job satisfaction and changing the culture of a hospital unit.
Collapse
Affiliation(s)
- Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Linda Ugbah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Tamara Arnautovic
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ann M Parker
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
46
|
Wang YT, Haines TP, Ritchie P, Walker C, Ansell TA, Ryan DT, Lim PS, Vij S, Acs R, Fealy N, Skinner EH. Early mobilization on continuous renal replacement therapy is safe and may improve filter life. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R161. [PMID: 25069952 PMCID: PMC4262200 DOI: 10.1186/cc14001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/30/2014] [Indexed: 02/07/2023]
Abstract
Introduction Despite studies demonstrating benefit, patients with femoral vascular catheters placed for continuous renal replacement therapy are frequently restricted from mobilization. No researchers have reported filter pressures during mobilization, and it is unknown whether mobilization is safe or affects filter lifespan. Our objective in this study was to test the safety and feasibility of mobilization in this population. Methods A total of 33 patients undergoing continuous renal replacement therapy via femoral, subclavian or internal jugular vascular access catheters at two general medical-surgical intensive care units in Australia were enrolled. Patients underwent one of three levels of mobilization intervention as appropriate: (1) passive bed exercises, (2) sitting on the bed edge or (3) standing and/or marching. Catheter dislodgement, haematoma and bleeding during and following interventions were evaluated. Filter pressure parameters and lifespan (hours), nursing workload and concern were also measured. Results No episodes of filter occlusion or failure occurred during any of the interventions. No adverse events were detected. The intervention filters lasted longer than the nonintervention filters (regression coefficient = 13.8 (robust 95% confidence interval (CI) = 5.0 to 22.6), P = 0.003). In sensitivity analyses, we found that filter life was longer in patients who had more position changes (regression coefficient = 2.0 (robust 95% CI = 0.6 to 3.5), P = 0.007). The nursing workloads between the intervention shift and the following shift were similar. Conclusions Mobilization during renal replacement therapy via a vascular catheter in patients who are critically ill is safe and may increase filter life. These findings have significant implications for the current mobility restrictions imposed on patients with femoral vascular catheters for renal replacement therapy. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12611000733976 (registered 13 July 2011) Electronic supplementary material The online version of this article (doi:10.1186/cc14001) contains supplementary material, which is available to authorized users.
Collapse
|
47
|
Safety of physical therapy interventions in critically ill patients: A single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care 2014; 29:395-400. [DOI: 10.1016/j.jcrc.2013.12.012] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 12/19/2013] [Accepted: 12/22/2013] [Indexed: 01/04/2023]
|
48
|
Abrams D, Javidfar J, Farrand E, Mongero LB, Agerstrand CL, Ryan P, Zemmel D, Galuskin K, Morrone TM, Boerem P, Bacchetta M, Brodie D. Early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R38. [PMID: 24571627 PMCID: PMC4056162 DOI: 10.1186/cc13746] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 02/03/2014] [Indexed: 01/18/2023]
Abstract
Introduction Critical illness is a well-recognized cause of neuromuscular weakness and impaired physical functioning. Physical therapy (PT) has been demonstrated to be safe and effective for critically ill patients. The impact of such an intervention on patients receiving extracorporeal membrane oxygenation (ECMO) has not been well characterized. We describe the feasibility and impact of active PT on ECMO patients. Methods We performed a retrospective cohort study of 100 consecutive patients receiving ECMO in the medical intensive care unit of a university hospital. Results Of the 100 patients receiving ECMO, 35 (35%) participated in active PT; 19 as bridge to transplant and 16 as bridge to recovery. Duration of ECMO was 14.3 ± 10.9 days. Patients received 7.2 ± 6.5 PT sessions while on ECMO. During PT sessions, 18 patients (51%) ambulated (median distance 175 feet, range 4 to 2,800) and 9 patients were on vasopressors. Whilst receiving ECMO, 23 patients were liberated from invasive mechanical ventilation. Of the 16 bridge to recovery patients, 14 (88%) survived to discharge; 10 bridge to transplant patients (53%) survived to transplantation, with 9 (90%) surviving to discharge. Of the 23 survivors, 13 (57%) went directly home, 8 (35%) went to acute rehabilitation, and 2 (9%) went to subacute rehabilitation. There were no PT-related complications. Conclusions Active PT, including ambulation, can be achieved safely and reliably in ECMO patients when an experienced, multidisciplinary team is utilized. More research is needed to define the barriers to PT and the impact on survival and long-term functional, neurocognitive outcomes in this population.
Collapse
|
49
|
Japanese guidelines for the management of Pain, Agitation, and Delirium in intensive care unit (J-PAD). ACTA ACUST UNITED AC 2014. [DOI: 10.3918/jsicm.21.539] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
50
|
Parker A, Sricharoenchai T, Needham DM. Early Rehabilitation in the Intensive Care Unit: Preventing Physical and Mental Health Impairments. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013; 1:307-314. [PMID: 24436844 DOI: 10.1007/s40141-013-0027-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Survivors of critical illness often experience new or worsening impairments in physical, cognitive and/or mental health, referred to as post-intensive care syndrome (PICS). Such impairments can be long-lasting and negatively impact survivors' quality of life. Early rehabilitation in the intensive care unit (ICU), while patients remain on life-support therapies, may reduce the complications associated with PICS. This article addresses evidence-based rehabilitation interventions to reduce the physical and mental health impairments associated with PICS. Implementation of effective early rehabilitation interventions targeting physical impairments requires consideration of 5 factors: barriers, benefits, feasibility, safety, and resources. Mental health impairments may be addressed by the following interventions: ICU diaries, early in-ICU psychological intervention, and post-ICU coping skills training. In both cases, a multidisciplinary team-based approach is paramount to the successful incorporation of early rehabilitation into routine practice in the ICU.
Collapse
|