The Role of Rehabilitation in the
Intensive Care Unit
Kimberly Hartman, MD
Assistant Professor of Pediatrics, UMKC SOM
Faculty, Division of Rehabilitation Medicine, Children’s Mercy Hospital
January 15, 2015
Objectives
• Define and recognize ICU-acquired weakness
• Understand implications of critical illness on
function
• Review current interventions and state of the
evidence
• Understand barriers to implementing rehab
strategies in the ICU
Critical Illness: Who
• > 5 million patients per year
• 55,000 patients per day
• Nearly 80% of all Americans will experience
critical illness or injury (as patient or loved
one)
Ref 30
Critical Illness: Costs
• ICU length of stay: 6.1-9.3 days
• Hospital costs:
– 2000: $56.6 billion
– 2005: $81.7 billion
Ref 30
Critical Illness: What
Adults
• Respiratory
insufficiency/failure
• Post-operative management
• Ischemic heart disorder
• Sepsis
• Heart failure
Ref 30
Children and Neonates
• Respiratory dysfunction
• Hematologic instability
• Central nervous system
disorders
• Mixed respiratory and
hemodynamic dysfunction
• Postcardiac arrest
• Hepatic dysfunction
• Renal dysfunction
Critical Illness: Common Ground
•
•
•
•
•
Mechanical ventilation
Cardiovascular support
Invasive monitoring
Intensive observation
Frequent interventions (ave. 178 actions per
day)
Critical Illness: Common Ground
Critical Illness: Common Ground
Respiratory:
• Poor lung expansion
• Weak cough
• Secretions
• Pneumonia
Circulation:
Immobility
Endocrine:
• Glucose intolerance
• Increased fat stores
• Disturbed Na-water
balance
• VTE
• Increased edema
• Increased workload on heart
• Orthostasis
Musculoskeletal:
• Loss of muscle mass
• Weakness
• Osteoporosis
• Contractures
Skin:
• Pressure wound
• Friction/shearing
GI:
• Aspiration
• GER
• Poor appetite
• Malnutrition
• Constipation
• Vomiting
GU:
• Difficulty voiding
• Incontinence
• UTI
Neuro:
• Functional deficits
• Delirium
• Behavior changes
• Sleep dysfunction
Nomenclature
Ref 27
Consensus
Intensive Care Unit-Acquired Weakness
(ICU-AW)
Ref 9,27
ICU-AW
• Definition:
“Syndrome of generalized limb weakness that
develops while the patient is critically ill and for
which there is no alternative explanation other
than the critical illness itself”
Ref 9, 19
ICU-AW: “Dx of Exclusion”
Ref 19
Ref 19
ICU-AW: Diagnosis
• Screen for awakening
• Respond to at least 3
orders on 2 consecutive
occasions separated by
6 hours
Ref 8
• Open/close your eyes
• Look at me
• Open your mouth and
put out your tongue
• Nod your head
• Raise your eyebrows
when I have counted up
to 5
ICU-AW: Diagnosis
• Medical Research Council (MRC) score < 48
– MMT grades 0-5
– Six muscle groups bilaterally
Shoulder abduction
Hip flexion
Elbow flexion
Knee extension
Wrist extension
Ankle dorsiflexion
– Total possible: 60
Ref 8 , 9
ICU-AW: Diagnosis
• Challenges
– Awake and able to follow commands
– Limitations of lines, catheters, trauma
– Difficult to assess smaller changes
• Multiple studies ongoing for different
assessment tool
Ref 15
ICU-AW: Subcategories
Ref 9 ,19
Pathophysiology
• Dysfunctional
microcirculation
• Endothelial cell
activation
(microvascular leak)
• Neuronal injury and
axonal degeneration
• Mitochondrial
dysfunction
• Inactivation of Na
channels
• Catabolic state
• Oxidative stress
• Muscle wasting
Ref 19
ICU-AW: Associations
• Elderly
• Premorbid DM
• Longer ICU stay
before awakening
• Extrarenal
replacement
• Longer time with
dysfunction of ≥ 2
organs
• Aminoglycosides
Ref 19,29
Functional Implications
• Physical
– Weakness
– Joint contractures
– Long-term deficits
• Cognitive
– Delirium
– Long-term deficits
• Psychological
Up to 65% of patients with prolonged
ventilation have functional limitations
after discharge
Mortality
Ref 13
Activities of Daily Living
• Jackson et al (2014)
– N = 821  448 (3m)  382 (12m)
– Respiratory failure or shock (ICU survivors)
Ref 17
ICU-AW and Function
• Fan et al (2014)
– N = 222
– Acute lung injury, ICU survivors
– High severity
– Outcomes:
• 36% with ICUAW at discharge
• Strength generally improved by 12m
• Duration of bedrest associated with worsened
weakness at 24m
Ref 10
ICU-AW and Function
• Function remained decreased (also grip
strength, mean inspiratory force)
Ref 10
Joint Contracture
• Clavet (2008)
– N = 155
– ICU ≥ 2 weeks, survivors
≥1
contracture
≥1
functionally
significant
contracture
Transfer out of
ICU
61/155 (39%)
52/155 (34%)
Discharge
home
50/147 (34%)
34/147 (23%)
Ref 5
Joint Contracture
Joint location
Number of joints with
contracture
(total 212 in 61 patients)
Elbow
76 (36%)
Ankle
51 (24%)
Knee
31 (15%)
Hip
30 (14%)
Shoulder
24 (11%)
• Risk: 8+ weeks ICU stay (vs. 2-3 weeks)
• Protection: steroids
Ref 5
Joint Contracture
• Clavet (2008, 2014)
– Outcomes:
• Significantly fewer patients with contractures were
mobilized (55.3% vs. 79.4%)
• Low ambulatory status (64.4% vs. 51.0%)
• Associated with higher mortality
• Associated with more difficulty with mobility 3.3 years
after discharge
Ref 6,28
Interventions
Passive Mobility
• Griffiths et al. (1995)
– N =5
– 1 leg CPM for 3x/day for 3h per session for 7 days
– 1 leg routine nursing care
– CPM leg:
• Fiber area preserved or slightly increased (mean 11%)
• Less protein loss
– Control leg:
• Fiber area decreased (-35%)
Ref 11
Ergometry
• Burtin et al. (2009)
– N = 90, RCT
– Bedside ergometry (active or passive)
– Starting day 5; 20 minutes per day
– Control: standard PROM/AROM
– At hospital discharge, significant improvement in:
• 6MWD
• Isometric quadriceps force
• Functional well-being on SF36 PFS
Ref 4
Early Mobilization
• Schweikert et al. (2009)
– N =104 mechanically ventilated
– RCT
– Intervention: mobilization 1.5 days after ETT
– Control: usual care (mobilization 7.3 days)
– Outcomes:
• return to independent function (59% vs 35%)
• physical function (median Barthel Index 75 vs 55)
• ventilator-free days (median 23.5 vs 21.1)
Ref 24
Early Mobilization
• Decreased ICU length of stay
• Decreased hospital length of stay
• Improved survival without readmission at 1
year
Ref 20
Electrical Muscular Stimulation
• Amplitude (mA/A): amount of energy flowing
per unit time
• Frequency (Hz): number of pulses per second
• Pulse width (μs): duration of stimulation pulse
• Ramp up and ramp down: current intensity
will increase or decrease to set intensity
• On:off time: length of time the pulse is
delivered vs. no stimulation
Ref 23
EMS: Who responds
• Segers et al. (2014)
– Response = muscle
contraction in >75% of
sessions
– 50% responders
– 50% nonresponders
– Nonresponders:
• Sepsis
• Edema
• Vasopressors
Ref 25
EMS: Outcomes
• Parry et al. (2013): Review
– Timing:
• <3d: not shown to attenuate quad or bicep wasting
• >14d: improved quad thickness (+4.9% vs. -3.2%)
– Severity of illness:
• APACHE II > 20: greater muscle loss in general (16-20%);
did not demonstrate muscle preservation
• APACHE II < 20: greater degree of preservation (8-14%
reduction)
Ref 23
EMS: Outcomes
• Strength: Increased in 4 studies
• ICU AW diagnosis by MRC:
– Control: 39%
– EMS: 12.5%
• No difference (small study)
Ref 18,23
EMS: Challenges
Ref 23
Functional Electrical Stimulation
Ref 22
FES
• Parry et al. (2014)
– N = 16 (8 intervention, 8 matched controls)
– Trend toward statistical significance
Ref 22
Cognitive Rehab
Ref 3
Barriers
Ref 2
Safety: Mobilization
• Sricharoenchai 2014
– N = 1110 patients; 5267 PT sessions
– Median PT start: 2 days (IQR: 1-3)
– Physiological abnormalities: 34 events in 25
patients
• 0.6% of sessions
• 2% of admissions
– Median time of event: 6 days (IQR 2-11)
Ref 26
Safety: Mobilization
Ref 26
Safety: Mobilization
Ref 26
Safety: Mobilization
Ref 26
Safety: Mobilization
• Consensus guidelines (94 clinicians): Dec 2014
• Active mobility:
– “any activity where the patient assists with the activity
using their own muscle strength and control: the patient
may need assistance from staff or equipment, but they are
actively participating in the exercise.”
– Activities included:
• Out-of-bed mobilization (i.e. any activity where the patient sits
over the edge of the bed [dangling], stands, walks, marches on the
spot or sits out of bed)
• In-bed mobilization (i.e. any activity undertaken whilst the patient
is sitting or lying in bed such as rolling, bridging, upper limb weight
training).
Ref 14
Safety: Mobilization
Ref 14
Safety:
Mobilization
Ref 14
Safety: Mobilization
Ref 14
Safety: Mobilization
Ref 14
Safety: Mobilization
Ref 14
Safety:
Mobilization
Ref 14
Safety: Mobilization
• Respiratory
– Airway secure
– Supplemental O2 if
anticipated need
– FiO2 < 0.6
Ref 14
• Cardiovascular
– Vasoactive drugs?
• Absolute dose
• Changing dose
• Clinically well perfused
Safety: EMS
Ref 25
Variable
EMS Pre
EMS Post
Control Pre
Control Post
HR (bpm)
94 ± 16
99 ± 16*
74 ± 16
76 ± 15
SBP (mmHg)
127 ± 21
133 ± 23*
154 ± 30
156 ± 32
DBP (mmHg)
66 ± 15
67 ± 17
81 ± 12
83 ± 14
MAP (mmHg)
86 ± 15
88 ± 17
106 ± 17
110 ± 20
RR (bpm)
18 ±6
19 ± 7
21 ± 6
21 ± 3
SpO2 (%)
98 ± 23
99 ± 1
99 ± 1
99 ± 1
Lactate (mEq/ml)
1.4 ± 0.8
1.3 ± 0.7
1.5 ± 1.1
1.5 ± 1.4
Safety: FES
• Iwatsu et al. (2014)
– N = 61
– Post-operative cardiovascular patients on inotropic
and/or vasopressor support
– No vent, no renal failure/insufficiency, no control
– Outcomes:
•
•
•
•
Ref 16
No significant changes in BP or HR
No pacemaker malfunction
No increase in ventricular arrhythmia
Atrial fibrillation noted but reported as no different than
anticipated
Facilitators
Ref 2
Consult Algorithm
Ref 20
ICU Protocols
• Awakening and Breathing Coordination, Delirium
monitoring/management and Early exercise/mobility
(ABCDE Bundle)
1.
2.
3.
4.
5.
spontaneous awakening trials (SATs)
spontaneous breathing trials (SBTs)
coordination of components 1 and 2 (so that sedation is held
before the breathing trial begins)
routine delirium and sedation/agitation screening and
management
early progressive mobilization.
– Each component (except delirium monitoring/ management) is
guided by predefined safety screen questions and
success/failure criteria derived from RCTs
Ref 1,20
ICU Protocols: ABCDE
Ref 7,20
ICU Protocols: PAD
Ref 7, 31
Future Directions
• Improved method of diagnosis for ICU-AW
• Determination of who benefits and resource
utilization
• Standardized intervention trials
• Prior disability and outcomes
• Cognitive and psychological rehab
• Pediatrics!
Ref 9
Summary
• ICU-AW is generalized, symmetric weakness
defined by MRC < 48 with no attributable
cause other than critical illness
• Many challenges to assessing for ICU-AW
based on current measures
• ICU-AW leads to functional deficits
• Inconsistent protocols lead to difficulty
interpreting results of interventions
• Safe mobilization can be achieved
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