Early Mobility in the ICU
Andrew Sims SPTA
Some Statistics
-More than 5.7 million patients are admitted annually to
intensive care units (ICUs) in the United States (U.S.) for
intensive or invasive monitoring
-Approximately 20% of acute care admissions are to an ICU
-Up to 58% of emergency department admissions result in an
ICU admission.
Society of Critical Care Medicine Critical Care Statistics in the US 2014
Learning Objectives
1. Discuss benefits of early mobility
2. Identify barriers to early mobility and harms of
bedrest
3. Recognize that early mobility is safe and feasible in
the ICU
4. Discuss the clinical problem of delirium
5. Apply specific assessment tools to evaluate altered
mental function and/or delirium
BED REST vs. IMMOBILITY
Bed rest:
- Medical treatment involving a
period of consistent day and night
recumbence in bed
- It is a procedure that can be
potentially harmful to patients
- It contributes to deconditioning,
NOT recovery
Immobility:
“Immovable, fixed, not moving,
motionless”
- In a young healthy adult, 45% of
body weight is muscle
- Skeletal muscle strength may
decline 1% to 1.5% per day of strict
bed rest
- When limbs are immobilized by
cast, the decline in strength may be
even more significant, ~5% to 6%
per day
Crit Care Clin 2007 (23) 97-110
Harms of Bed Rest
- ICU acquired weakness
- Skeletal muscle atrophy
- Delirium
- Increased anxiety
- Pressure Sores
- Increased risk of secondary infections
ICUAW
- Generalized muscle weakness which develops during the
course of an ICU admission and for which no other cause can
be identified besides the acute illness or its treatment.
Occurs in:
- 33% of patients on ventilators
- 50% of patients with serious infection/sepsis
- 50% of patients who stay in the ICU at least one week
Society of Critical Care Medicine
ICUAW
• Predictor of:
- Prolonged weaning from ventilator (up to 20 days!)
- Mortality
• Effects are long lasting
- 60% with continued muscle dysfunction after 1 year
- Only 49% able to return to work
• Key contributor to post intensive care syndrome (PICS)
• ICU delirium and ICUAW are both predictors of poor outcomes
Herrige et al NEJM 2011
De Jonge et al CCM2007 (35)
- Two center randomized, controlled trial
- Study design paired SAT/SBT protocol with PT/OT from earliest
days of mechanical ventilation
N=104
Early PT/OT Short-term outcomes
EARLY PT+OT
(n=49)
USUAL CARE
(n=55)
ICU- acquired weakness
31%
49%
Ventilator-free days (out of 28)
23.5
21.1
ICU LOS (days)
5.9
7.9
Hospital Mortality
18%
25%
Early PT/OT and Delirium
Time in ICU with Delirium
EARLY PT+OT
(n=49)
USUAL CARE
(n=55)
33%
57%
Evidenced-Based Mobility Benefits
- Greater functional independence at discharge
- Decreased duration of delirium
- Decreased time on ventilator
- Decreased length of hospital stay
- Decreased medical costs
- Improved neurocognitive outcomes
Needham et al 2010; 91:536
So… What Exactly is Early Mobility?
Early Mobility Includes:
• Positioning
• ROM
• Strengthening exercises
• Chest PT
• Breathing Exercises
• Education
• Mobilization
Team Members Include:
• RNs/PCTs
• Physical and Occupational
Therapists
• MDs
• Respiratory Therapists
• Pharmacists
• Family
ICU Delirium Key Features
1.
Disturbance of consciousness with reduced ability to
focus, sustain, or shift attention
2. A change in cognition or the development of a perceptual
disturbance that is not accounted for by pre-existing,
established, or evolving dementia
3. Develops over a short period of time and tends to
fluctuate over the course of the day
4. There is evidence from the H&P and/or labs that the
disturbance is caused by a medical condition, substance
intoxication, or medication side effect
- Can be hypo or hyperactive
2013 Boston Globe Article on ICU Delirium
“…drowning, poisoned by nursing, crawling on the floor of a walk-in freezer full of
amputated limbs” – Female Nurse Age 45
“The ICU was a horror show of people trying to kill me, ants crawling on faces, finding
myself on a raft, in a space-pod . . . in the Arctic, in the desert . . . each with its own
terrible narrative.” - Filmmaker and college professor from Maine
““Too often we give people so much sedation that they can’t remember anything and
we are doing that in order to protect them. But now we know that the total absence of
memory is a driver of PTSD”
- Dr. Ely, Vanderbilt University Medical Center
Confusion Assessment Method- ICU
Confusion Assessment Method- ICU
• Assesses 4 aspects of a patient’s cognition and arousal
while in the intensive care unit.
– Acute change or fluctuating mental status
– Inattention
– Level of Arousal
– Disorganized Thinking
Advantages
• Developed specifically for use in the acute care setting.
• Valid and Reliable (Gusmao-Flores, 2012)
• Prognostic indicators (Brummel, 2014; Balas, 2009; Abelha, 2013)
- CAM ICU positive is consistent with increased risk for ADL
dependency up to 1 year.
- CAM ICU positive is consistent with increased risk for discharge
to location other than home.
Limitation
- Not as valid or reliable for use outside of the ICU
setting.