Avoiding Complications in Acute Care


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Avoiding Complications in Acute Care

  1. 1. Avoiding Complications in Acute Care: Preparing Patients for Rehabilitation Marilyn Pacheco, MD Assistant Professor Department of Physical Medicine and Rehabilitation University of Arkansas for Medical Sciences April 10, 2006
  2. 2. Objective <ul><li>In preparing for life as an intern: </li></ul><ul><li>A PGY1 needs to  </li></ul><ul><li>Learn how to decrease complications in these patients </li></ul><ul><li>Learn who are the patients that will need rehabilitation </li></ul>
  3. 3. WHY THIS TALK? <ul><li>The initial acute hospital care is important and this includes initial assessment and rehabilitation, which begins with the prevention of complications and early treatment. </li></ul>
  4. 4. CMS Magic 13 diagnosis: <ul><li>1. Stroke </li></ul><ul><li>2. Spinal cord injury </li></ul><ul><li>3. Congenital deformity </li></ul><ul><li>4. Amputation </li></ul><ul><li>5. Major multiple trauma </li></ul><ul><li>6. Fracture of femur (hip fracture) </li></ul>
  5. 5. CMS Magic 13 diagnosis: <ul><li>7. Brain injury </li></ul><ul><li>8. Neurological disorders (including, but not limited to, MS, MD, polyneuropathy, and Parkinson’s disease) </li></ul><ul><li>9. Burns </li></ul><ul><li>10. Active, polyarthricular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies </li></ul><ul><li>11. Systemic vasculidities with joint inflammation </li></ul>
  6. 6. CMS Magic 13 diagnosis: <ul><li>12. Severe/advanced osteoarthritis involving two or more major weight-bearing joints (not counting joints with a prosthesis) with joint deformity, substantial loss of range of motion, and atrophy of muscles surrounding the joint </li></ul><ul><li>13. Knee or hip joint replacement, with one or more of the following circumstances applying: </li></ul><ul><ul><li>The patient underwent bilateral knee or bilateral hip joint replacement surgery during acute hospitalization. </li></ul></ul><ul><ul><li>The patient is extremely obese with a Body Mass Index of at least 50 at time of admission to inpatient rehabilitation hospital. </li></ul></ul><ul><ul><li>The patient is age 85 or older at the time of admission. </li></ul></ul>
  7. 7. OTHERS: <ul><li>Cardiac patients </li></ul><ul><li>Pulmonary patients </li></ul><ul><li>Oncology patients </li></ul><ul><li>These patients are prone to DECONDITIONING </li></ul>
  8. 8. DECONDITIONING <ul><li>Deconditioning can be defined as the multiple, potentially reversible changes in body systems brought about by physical inactivity and disuse. Such changes often have significant functional and clinical consequences in older people. </li></ul><ul><li>Deconditioning commonly occurs in two situations: </li></ul><ul><ul><li>(1) a sedentary lifestyle, which is common in older people even in the absence of significant disease or disability and may result in a slow, chronic decline in physical fitness; and </li></ul></ul><ul><ul><li>(2) bed or chair rest during an acute illness, which can lead to disastrously rapid physical decline. </li></ul></ul>
  9. 9. What are the objectives of the PHYSIATRIC PHYSICAL EXAMINATION? <ul><li>Screen for new illnesses that could affect functional performance or rehabilitation participation </li></ul><ul><li>Identify “regions of risk” for deterioration </li></ul><ul><li>Identify and quantify impairments </li></ul><ul><li>Identify limitation in task performance (disability) specifically pertinent to short-term goals (like gait and transfers) </li></ul><ul><li>Demonstrate the patient’s capabilities to self and family. </li></ul>
  10. 10. REGIONS OF RISKS <ul><li>SYSTEM BASED </li></ul>
  11. 11. POSSIBLE COMPLICATIONS: <ul><li>CARDIAC </li></ul><ul><li>RESPIRATORY </li></ul><ul><li>GASTROINTESTINAL </li></ul><ul><li>GENITOURINARY </li></ul><ul><li>MUSCULOSKELETAL </li></ul><ul><li>INTEGUMENTARY </li></ul><ul><li>ENDOCRINE </li></ul><ul><li>NEUROLOGICAL </li></ul>
  12. 12. Cardiovascular Complications <ul><li>DVT/ PE – </li></ul><ul><ul><li>Virchows Triad: </li></ul></ul><ul><ul><ul><li>STASIS </li></ul></ul></ul><ul><ul><ul><li>VASCULAR INJURY </li></ul></ul></ul><ul><ul><ul><li>HYEPRCOAGULABLE STATE </li></ul></ul></ul>
  13. 13. Chest. 2004;126:338S-400S.) © 2004 American College of Chest Physicians Prevention of Venous Thromboembolism <ul><li>Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. </li></ul><ul><li>Grade 2 suggests that individual patients’ values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S ). </li></ul><ul><li>Among the key recommendations in the chapter are the following: </li></ul><ul><ul><li>The authors recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). </li></ul></ul>
  14. 14. <ul><li>For moderate-risk general surgery patients, </li></ul><ul><ul><li>recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [ 3,400 U once daily] (both Grade 1A). </li></ul></ul><ul><li>For higher risk general surgery patients, </li></ul><ul><ul><li>recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. </li></ul></ul><ul><li>For high-risk general surgery patients with multiple risk factors, </li></ul><ul><ul><li>recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). </li></ul></ul>
  15. 15. <ul><li>recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures , </li></ul><ul><ul><li>recommend prophylaxis with LDUH two times or three times daily (Grade 1A). </li></ul></ul><ul><li>For patients undergoing elective total hip or knee arthroplasty, </li></ul><ul><ul><li>recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). </li></ul></ul><ul><li>For patients undergoing hip fracture surgery (HFS), </li></ul><ul><ul><li>recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). </li></ul></ul><ul><li>Patients undergoing hip or knee arthroplasty, or HFS, </li></ul><ul><ul><li>recommend receive thromboprophylaxis for at least 10 days (Grade 1A). </li></ul></ul>
  16. 16. <ul><li>It is recommended that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). </li></ul><ul><li>In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, it is recommended prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). </li></ul><ul><li>It is recommended, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A). </li></ul>
  17. 17. Orthostasis <ul><li>Orthostatic Hypotension </li></ul><ul><ul><li>defined as 20 mm Hg or greater decrease in systolic or 10 mm Hg or greater decrease in diastolic blood pressure after 3 minutes of standing </li></ul></ul><ul><ul><li>HR increase by 15 bpm </li></ul></ul><ul><ul><li>dizziness upon standing. </li></ul></ul><ul><ul><li>the prevalence was higher at successive ages </li></ul></ul><ul><ul><li>Associated with difficulty walking, frequent falls, histories of MI </li></ul></ul><ul><ul><li>Prevent: use of TED hose, abdominal binders </li></ul></ul>
  18. 18. In cardiac patients <ul><li>Early mobilization in acute care </li></ul><ul><li>Prevention of deconditioning </li></ul><ul><li>Patients learning energy conserving and pacing techniques </li></ul><ul><li>Monitor HR, BP, RR, telemetry for first few exercise sessions </li></ul><ul><ul><li>Target HR = predicted age adjusted maximum heart rate = (220- age) x 60% to 80% (range) </li></ul></ul><ul><ul><li>HR and BP should not deviate more than 20 points for BP and 20 beats for HR </li></ul></ul>
  19. 19. In cardiac patients <ul><li>Exercise should be immediately stopped for: </li></ul><ul><ul><li>chest pain </li></ul></ul><ul><ul><li>shortness of breath </li></ul></ul><ul><ul><li>dizziness </li></ul></ul><ul><ul><li>or if angina symptoms develop </li></ul></ul><ul><li>Absolute and relative contraindications to exercise: </li></ul><ul><ul><li>Unstable angina </li></ul></ul><ul><ul><li>Life threatening cardiac arrhythmias </li></ul></ul><ul><ul><li>Uncompensated CHF </li></ul></ul><ul><ul><li>Critical aortic stenosis </li></ul></ul><ul><ul><li>Uncontrolled hypertension </li></ul></ul><ul><ul><li>Acute MI </li></ul></ul><ul><ul><li>Acute pulmonary embolus </li></ul></ul><ul><ul><li>Acute myocarditis or pericarditis </li></ul></ul><ul><ul><li>Active endocarditis </li></ul></ul>
  20. 20. Respiratory Complications: Pneumonia <ul><li>AVOID Atelectasis </li></ul><ul><li>Aspiration Pneumonia </li></ul><ul><ul><li>Assess swallow (not just bedside) by speech language pathologist </li></ul></ul><ul><ul><li>Risk factors: decrease cognition, tracheostomy, NG tube (any tube) if patient has reflux, injury to face and throat </li></ul></ul>
  21. 21. Respiratory Complications: special consideration to respiratory management in tetraplegics <ul><li>The more complete and higher the level of cervical injury, the more ventilatory insufficiency occurs. </li></ul><ul><li>Need a good respiratory therapist in ICU </li></ul><ul><li>IPPB (intermittent positive pressure breathing) QID with bronchodilators and mucolytics </li></ul><ul><li>Humidified O2 </li></ul><ul><li>Chest PT and breathing exercises </li></ul>
  22. 22. <ul><li>Suctioning and drainage </li></ul><ul><li>Incentive spirometry </li></ul><ul><li>Neck isometrics </li></ul><ul><li>Assisted cough </li></ul><ul><li>Abdominal binding when upright </li></ul><ul><li>Avoid weaning with IMV/SIMV in SCI patients (because it increases work of breathing); go slow with weaning </li></ul><ul><li>Avoid infections </li></ul><ul><li>Always assess lung exam, ABGs and CXR </li></ul>
  23. 23. Gastrointestinal Complications <ul><li>GI Bleed Risk </li></ul><ul><ul><li>Stress related ulcers and bleed </li></ul></ul><ul><ul><li>Prophylaxis with H2 blockers (most none sedating is Axid, misoprostol) </li></ul></ul><ul><ul><li>Withdraw medication once acute risk has passed </li></ul></ul><ul><li>Nutrition </li></ul><ul><ul><li>High caloric needs in polytrauma patients </li></ul></ul><ul><ul><li>Needs for hyper alimentation </li></ul></ul><ul><ul><li>Isotonic enteral feedings </li></ul></ul><ul><ul><li>Positive nitrogen balance </li></ul></ul><ul><ul><li>Check Hb, Hct, total protein, albumin and prealbumin </li></ul></ul><ul><ul><li>Weekly weights needed </li></ul></ul><ul><ul><li>Nutrition consult </li></ul></ul>
  24. 24. Gastrointestinal complications <ul><li>Bowels </li></ul><ul><ul><li>Constipation is common – due to immobility, pain medications and decrease intake </li></ul></ul><ul><ul><li>Diarrhea – check C. Difficile; or could be a sign of constipation </li></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>High fiber diet/ bulk agents </li></ul></ul></ul><ul><ul><ul><li>Glycerin suppositories </li></ul></ul></ul><ul><ul><ul><li>Stool softeners </li></ul></ul></ul><ul><ul><ul><li>In Acute SCI – usually still in spinal shock, disimpaction might be needed </li></ul></ul></ul>
  25. 25. Genitourinary complication <ul><li>Urinary tract infection </li></ul><ul><ul><li>Early removal of Foley catheters if possible </li></ul></ul><ul><ul><li>Beware of VRE </li></ul></ul><ul><ul><li>In TBI, stroke patients, once Foley removed, do timed voiding </li></ul></ul><ul><ul><li>In SCI patients, clean intermittent catherization needed every 4 to 6 hours </li></ul></ul>
  26. 26. MUSCULOSKELETAL complication <ul><li>In orthopedic patients </li></ul><ul><ul><li>Make sure weight bearing precautions are written and followed </li></ul></ul><ul><ul><li>Hip precautions </li></ul></ul><ul><li>In immobile/paralyzed patients </li></ul><ul><ul><li>Avoid contractures via ROM, splinting, stretching </li></ul></ul><ul><li>Vertebral Compression fractures </li></ul><ul><ul><li>Esp. in elderly, osteoporosis pts, MM </li></ul></ul>
  27. 27. Neurologically impaired skin <ul><li>SCI above T6 level, the skin functional properties is altered. </li></ul><ul><li>When temperature reaches 32-34 degrees C, visible sweating normally takes place and is called reflex sweating. This is lost in SCI individuals with above T6 level. </li></ul>
  28. 28. Neurologically impaired skin <ul><li>Biochemical factors: increase collagen catabolism, decrease amino acid concentration in insensate skin; decrease of lysyl hydrosylase activity; decrease type I to type II collagen in skin below level of injury; decrease adrenergic receptors; increase excretion of GAGs in urine </li></ul><ul><li>Mechanical Factors: slower blood reflow rate after pressure in SCI group; smaller increase in temperature during occlusion; muscle atrophy provides less cushioning around bony prominences </li></ul>
  29. 29. SKIN complication <ul><li>Pressure ulcers </li></ul><ul><ul><li>Norton Scale </li></ul></ul><ul><ul><ul><li>physical condition, mental condition, activity, mobility and incontinence </li></ul></ul></ul><ul><ul><li>Braden Risk Assessment Scale </li></ul></ul><ul><ul><ul><li>sensory perception, moisture, activity, mobility, nutrition and friction/shear </li></ul></ul></ul><ul><ul><ul><li>grade 1 to4 and score 6 to 23; lower score is higher risk </li></ul></ul></ul><ul><ul><li>Areas at risk: </li></ul></ul><ul><ul><ul><li>when in bed – sacrum, occiput, heels </li></ul></ul></ul><ul><ul><ul><li>When in chair – ischium, sacrum, greater trochanters </li></ul></ul></ul><ul><ul><li>Turn patients every 2 hours </li></ul></ul><ul><ul><li>Protect skin with paste </li></ul></ul><ul><ul><li>Prevention is key </li></ul></ul>
  30. 30. Skin <ul><li>Maceration </li></ul><ul><ul><li>Avoid patient being wet – urine or feces </li></ul></ul><ul><ul><li>Good nursing care </li></ul></ul><ul><li>Fungal infection </li></ul><ul><ul><li>Esp. in obese patients; use of creams and powders </li></ul></ul>
  31. 31. Endocrine complications <ul><li>SIADH </li></ul><ul><li>DI </li></ul><ul><li>Thyroid dysfunction </li></ul>
  32. 32. NEUROLOGICAL COMPLICATIONS <ul><li>Most common encountered situations in possible rehab patients: Stroke, Traumatic Brain Injury, Spinal Cord Injury, MS, etc. </li></ul><ul><li>HYPERTENSION </li></ul><ul><li>BRAIN EDEMA </li></ul><ul><li>Central fever </li></ul>
  33. 33. NEUROLOGICAL COMPLICATIONS <ul><li>Peripheral Neuropathies </li></ul><ul><li>Spasticity  contractures  limited function </li></ul><ul><li>PAIN CONTROL </li></ul>
  34. 34. Neurological complications <ul><li>Confusion and agitation </li></ul><ul><ul><li>Place patients in quiet room, 1:1 sitter, decrease all stimuli </li></ul></ul><ul><ul><li>AVOID HALDOL – it has been proven to cause delay in cognitive recovery (more harm than good) </li></ul></ul><ul><li>For EMERGENCIES: </li></ul><ul><ul><li>Ativan 0.5 to 2 mgs PO or IM q8 to q12h </li></ul></ul><ul><ul><li>Desyrel (Trazodone) 50 mgs PO/NGT q8h or qHS </li></ul></ul><ul><ul><li>Klonipin 0.5 mg q8h </li></ul></ul><ul><ul><li>Chloral hydrate 500-1000 mg qHS </li></ul></ul>
  35. 35. GOALS <ul><li>Prevention of harmful events </li></ul><ul><li>Getting patients ready for rehabilitation or their next phase of recovery </li></ul><ul><li>Consult Physical Medicine and Rehabilitation early to help watch out for complications. </li></ul>
  36. 36. References <ul><li>DeLisa and Gans, Rehabilitation Medicine, 3 rd edition </li></ul><ul><li>PM&R Secrets </li></ul><ul><li>Chest </li></ul><ul><li>Kirshblum, Spinal Cord Medicine </li></ul><ul><li>Medical Management of Head Injury </li></ul><ul><li>Clinical Practice Guidelines: Pressure Ulcer Prevention and Management </li></ul>
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