Innovative mobility strategies for the patient with intensive care unit-acquired weakness: a case report

Patients' experiences of well-being when being cared for in the intensive care unit-An integrative review

OBJECTIVE

The aim of this integrative review was to identify facilitators and barriers to patients' well-being when being cared for in an ICU setting, from the perspective of the patients.

BACKGROUND

To become critically ill and hospitalised in an ICU is a stressful, chaotic event due to the life-threatening condition itself, as well as therapeutic treatments and the environment. A growing body of evidence has revealed that patients often suffer from physical, psychological and cognitive problems after an ICU stay. Several strategies, such as sedation and pain management, are used to reduce stress and increase well-being during ICU hospitalisation, but the ICU experience nevertheless affects the body and mind. DESIGN; METHODS: Since research exploring patients' sense of well-being in an ICU setting is limited, an integrative review approach was selected. Searches were performed in CINAHL, Medline, Psych Info, Eric and EMBASE. After reviewing 66 studies, 12 studies were included in the integrative review. Thematic analysis was used to analyse the studies. The PRISMA checklist for systematic reviews was used.

RESULTS

The results are presented under one main theme, 'Well-being as a multidimensional experience-interwoven in barriers and facilitators' and six sub-themes representing barriers to and facilitators of well-being in an ICU. Barriers identified were physical stressors, emotional stressors, environmental disturbances and insecurity relating to time and space. Facilitators were meeting physical needs and activities that included dimensions of a caring and relational environment.

CONCLUSION

Our main findings were that experiences of well-being were multidimensional and included physical, emotional, relational and environmental aspects, and they were more often described through barriers than facilitators of well-being.

RELEVANCE FOR CLINICAL PRACTICE

This integrative review has shown that it is necessary to adopt an individual focus on patient well-being in an ICU setting since physical, emotional, relational and environmental stressors might impact each patient differently.

Ambulatory Status Is Associated With Successful Discharge Home in Survivors of Critical Illness

BACKGROUND

Survivors of prolonged ICU admissions are bedridden and immobilized for an extended period of time. These patients often are discharged to long-term acute care hospitals (LTACHs) for continued medical care and rehabilitation. Early ambulation has been associated with improved functional outcomes and lower readmission rates in hospitalized patients. The aim of this study was to determine the association between ambulatory status and discharge disposition in survivors of prolonged ICU stays who were admitted to an LTACH.

METHODS

We performed a retrospective cohort study of 285 survivors of prolonged ICU stays who were admitted to a university-affiliated LTACH facility from 2010 to 2013. Outcomes of interest included comparing the relationship between ambulatory status and disposition status (ie, home vs acute rehabilitation facility, nursing home, readmission to an ICU, or death).

RESULTS

The mean age of our cohort was 59.0 ± 15.3 y, with 129 (45%) males, 148 (52%) African-American, 123 (43%) white, and 14 (5%) of subjects other races. Most of these subjects were transferred from a medical ICU (68%). The median ICU and LTACH lengths of stay were 25.5 (13-38.8) d and 34.0 (14-64) d, respectively. Thirty-eight (13.3%) subjects were discharged home, 25 (8.7%) to an acute rehabilitation facility, 70 (24.6%) to a nursing home, 139 (48.8%) were readmitted to an ICU, and 13 (4.6%) died. Of 285 total subjects, 74 (26%) ambulated during physical therapy, while 211 (74%) subjects never ambulated. Of those who ambulated, 24 (32.4%) went home, whereas 14 of 211 (6.6%) subjects who did not ambulate went home (P < .001).

CONCLUSIONS

The ability to ambulate was associated with a greater likelihood of being discharged home in survivors of prolonged ICU stays who were admitted to an LTACH. These results suggest that mobility training for survivors of prolonged ICU stays in LTACH facilities should be strongly emphasized to improve their likelihood of being discharged home.

Physical Therapist-Led Ambulatory Rehabilitation for Patients Receiving CentriMag Short-Term Ventricular Assist Device Support: Retrospective Case Series

BACKGROUND AND PURPOSE

Short-term ventricular assist device (VAD) support is used in the intensive care unit (ICU) to support individuals in end-stage heart failure prior to heart transplantation or implantation of a long-term left VAD. The literature investigating the feasibility, safety, and content of rehabilitation for this patient group is lacking. This report retrospectively describes the rehabilitation strategy, safety measures used, and nature of any adverse events and, therefore, the feasibility of this practice.

CASE SERIES DESCRIPTION

Ten individuals (80% male) admitted to the ICU in critical cardiogenic shock required support via a short-term VAD. A prerehabilitation risk assessment was used to reduce the risk of cannula dislodgement. The therapeutic strategy was a stepwise progression of exercises, mobilization, and ambulation.

OUTCOMES

Retrospective inspection of the case notes showed 330 rehabilitation sessions (X̅=33, SD=18.1, range=16-72) were performed and progressed to ambulation on 71 occasions (X̅=7.1, SD=7.7, range=1-27). Distance ambulated ranged from 7 to 1,200 m (X̅=157.7, SD=367.3). The Chelsea Critical Care Physical Assessment Tool (CPAx) score for 7 patients improved from a median of 0 (interquartile range=0-1) on day 1 to a median peak score of 39 (interquartile range=37-42). There were 8 episodes of minor adverse events (2.4% incidence rate), including 7 of transient low VAD flows. There were no major adverse events.

DISCUSSION

Early rehabilitation and ambulation of recipients of short-term VAD support was safe and feasible. Recipients demonstrated improvements in physical function (CPAx score) while the VAD was in situ.

Steroids for acute respiratory distress syndrome?

The development and severity of acute respiratory distress syndrome (ARDS) are closely related to dysregulated inflammation, and the duration of ARDS and eventual outcomes are related to persistent inflammation and abnormal fibroproliferation. Corticosteroids are potent modulators of inflammation and inhibitors of fibrosis that have been used since the first description of ARDS in attempts to improve outcomes. There is no evidence that corticosteroids prevent the development of ARDS among patients at risk. High-dose and short-course treatment with steroids does not improve the outcomes of patients with ARDS. Additional studies are needed to recommend treatment with steroids for ARDS.

Advances in rehabilitation medicine

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.