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Critical Care and Early
     Mobilization
       Todd Brungardt
    University of Cincinnati
The Effects of Immobility

O Immobility prolongs duration of
  mechanical ventilation

O Increases hospital length of stay


O Increases mortality


O Immobility can persist for years after
  hospital discharge
The effects of Immobility
O Immobility due to prolonged bed rest in
  the ICU leads to ICU acquired-weakness
  O Skeletal muscle strength can decline
     O 1% to 1.5% per day from strict bed rest


     O 4% to 5% for each week of strict bed rest


     O Which leads to 10% reduction in postural
       muscle strength after 1 week of bed-rest
Effects of Immobility

O Neuromuscular weakness is a common
 disease process of critical illness occurring
 in 20% to 25% of ICU patients

  O Extends the duration of mechanical
    ventilation
  O Prolongs the length of the hospital stay
  O Increases mortality
The effects of immobility

O Prolonged immobilization depresses
 insulin-induced glucose transport in
 skeletal muscle and leads to a catabolic
 state in the affected areas:
 MUSCLE WASTING
Interesting Facts
O Prolonged bed rest has been shown to
 hasten a switch in the muscle fibers from
 slow-contracting fatigue-resistance
 myosin isoforms (type I) to fast-twitching
 isoforms (type II)
  O Leads to micro vascular dysfunction
  O Decreased venous compliance
  O Cause third spacing
Skin Breakdown from Immobility
 O In older adults skin becomes weaker and
  prone to breakdown
   O Pressure ulcers are formed
Depression and Anxiety
O Patients who are critically ill often develop
  depression and anxiety symptoms during
  their stay in ICU.
  O Delirium is the most prevalent mental
     disorder among older patients in the ICU
     associated with…
     O Poor prognosis
     O Increased length of hospital stay
Benefits of Early Mobility
O Safe
O Feasible
O Improves patients ICU outcomes
O Discharge patients home earlier
O Decreases neuromuscular weakness
O Decreases bed sores
O Decreases anxiety and depression
Benefits of Early Mobility
O Provides psychological support for
 the…
  O Patient
  O Family members
  O Improves the patient holistic
    pathway
Definition of Early Mobilization
O A pattern of increasing activity beginning
  with active/passive range of motion
  through ambulation:

  O Begins upon stabilization of hemodynamic
    and respiratory physiology

  O Should begin within 24 to 48 hours after
    ICU admission
Safety and Benefits of Early Mobilization

O Physical exercise can activate pathways
  and increase protection against oxidative
  stress

O Moderate exercise triggers the production
  of anti-inflammatory cytokines

O Decreases the pro-inflammatory ones
What will it Take to
Implement this Type of Care
O Critical care nurses
O Motivated patients
O Physicians
O Physical Therapy
O Occupational Therapy
O Respiratory Therapy
What will it Take to Implement this
            Type of Care
O Include mobilization in the plan of care
O Implement mobilization through a broad
  range of activities
  O Passive and active range of motion
  O Moving out of bed to a chair
  O Ambulation
  O Use of active resistive exercise
  O Electrical muscle simulation
What will it Take to Implement this
            Type of Care
O Use mobilization as a goal-directed
  therapy
  O Promotion of comfort
  O Improved responsiveness
  O Increased cardiovascular fitness
  O Expedite recovery
  O Enhance functional abilities
  O Improve psychological well-being
What will it take to Implement
      this Type of care
 O Mobilization will require energy
    O Low energy exercises
    O High energy exercises
 O Mobilization will require an
   interdisciplinary process
   O Nurses
   O Physical Therapist
   O Assistants
Risks with Early Mobilization
O Accidental removal of tubes and
  lines
O Hemodynamically instability
O Oxygen desaturation
O Accidental extubation
O Patient discomfort
O Limited staff and time
O Lack of motivation from the patient
Barriers to Early Mobilization
O Changing the culture of the critical
  care unit
O Changing the philosophy of the unit
  and patient
O Changing the strategies in practice
Ideas How to Overcome the
         Barriers
O Develop a model of care where
  mobilization is a priority
O Teamwork in promoting mobilization
  is valued
O Mobilization outcomes are
  consistently measured
The Synergy Model (System Thinking)

  O The Clinical Nurse Specialist will be able
    to develop strategies based on the needs
    and strengths of the patient
     O Global outlook
     O Holistic outlook
  O The Clinical Nurse Specialist will be able
  to see the whole picture instead of the
  pieces.
In the Right Direction
Any Questions?
Reference
Amidei, C. (2012). Mobilization in critical care: a concept analysis.
   Intensive and Critical Care Nursing, 28(2), 73-81.
Engel, H., Gropper, M., Lipshutz, A. & Thornton, K. (2012). Early
   mobilization in the Intensive Care unit: evidence and
   implementation. ICU Director, 3(1), 10-16.
Ganzini, L. & Misra, S. (2003). Delirium, depression, and anxiety.
   Critical Care Clinics, 19(4), 48-49.
Grap, M. J. & McFetridge, B. (2012), Critical care rehabilitation and
   early mobilization. Intensive and Critical Care Nursing, 22(2),
    55-57.
Hardin, S. R. & Kaplow, R. (2005). Synergy for clinical excellence: The
     Synergy Model for Patient Care. Sudbury, MA: Jones and
Bartlett.
Lowson, S. (2012). Early mobilization in critically Ill patients. ICU
     Director, 3(1), 17-20.

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Immobility

  • 1. Critical Care and Early Mobilization Todd Brungardt University of Cincinnati
  • 2. The Effects of Immobility O Immobility prolongs duration of mechanical ventilation O Increases hospital length of stay O Increases mortality O Immobility can persist for years after hospital discharge
  • 3. The effects of Immobility O Immobility due to prolonged bed rest in the ICU leads to ICU acquired-weakness O Skeletal muscle strength can decline O 1% to 1.5% per day from strict bed rest O 4% to 5% for each week of strict bed rest O Which leads to 10% reduction in postural muscle strength after 1 week of bed-rest
  • 4. Effects of Immobility O Neuromuscular weakness is a common disease process of critical illness occurring in 20% to 25% of ICU patients O Extends the duration of mechanical ventilation O Prolongs the length of the hospital stay O Increases mortality
  • 5. The effects of immobility O Prolonged immobilization depresses insulin-induced glucose transport in skeletal muscle and leads to a catabolic state in the affected areas: MUSCLE WASTING
  • 6. Interesting Facts O Prolonged bed rest has been shown to hasten a switch in the muscle fibers from slow-contracting fatigue-resistance myosin isoforms (type I) to fast-twitching isoforms (type II) O Leads to micro vascular dysfunction O Decreased venous compliance O Cause third spacing
  • 7. Skin Breakdown from Immobility O In older adults skin becomes weaker and prone to breakdown O Pressure ulcers are formed
  • 8. Depression and Anxiety O Patients who are critically ill often develop depression and anxiety symptoms during their stay in ICU. O Delirium is the most prevalent mental disorder among older patients in the ICU associated with… O Poor prognosis O Increased length of hospital stay
  • 9. Benefits of Early Mobility O Safe O Feasible O Improves patients ICU outcomes O Discharge patients home earlier O Decreases neuromuscular weakness O Decreases bed sores O Decreases anxiety and depression
  • 10. Benefits of Early Mobility O Provides psychological support for the… O Patient O Family members O Improves the patient holistic pathway
  • 11. Definition of Early Mobilization O A pattern of increasing activity beginning with active/passive range of motion through ambulation: O Begins upon stabilization of hemodynamic and respiratory physiology O Should begin within 24 to 48 hours after ICU admission
  • 12. Safety and Benefits of Early Mobilization O Physical exercise can activate pathways and increase protection against oxidative stress O Moderate exercise triggers the production of anti-inflammatory cytokines O Decreases the pro-inflammatory ones
  • 13. What will it Take to Implement this Type of Care O Critical care nurses O Motivated patients O Physicians O Physical Therapy O Occupational Therapy O Respiratory Therapy
  • 14. What will it Take to Implement this Type of Care O Include mobilization in the plan of care O Implement mobilization through a broad range of activities O Passive and active range of motion O Moving out of bed to a chair O Ambulation O Use of active resistive exercise O Electrical muscle simulation
  • 15. What will it Take to Implement this Type of Care O Use mobilization as a goal-directed therapy O Promotion of comfort O Improved responsiveness O Increased cardiovascular fitness O Expedite recovery O Enhance functional abilities O Improve psychological well-being
  • 16. What will it take to Implement this Type of care O Mobilization will require energy O Low energy exercises O High energy exercises O Mobilization will require an interdisciplinary process O Nurses O Physical Therapist O Assistants
  • 17. Risks with Early Mobilization O Accidental removal of tubes and lines O Hemodynamically instability O Oxygen desaturation O Accidental extubation O Patient discomfort O Limited staff and time O Lack of motivation from the patient
  • 18. Barriers to Early Mobilization O Changing the culture of the critical care unit O Changing the philosophy of the unit and patient O Changing the strategies in practice
  • 19. Ideas How to Overcome the Barriers O Develop a model of care where mobilization is a priority O Teamwork in promoting mobilization is valued O Mobilization outcomes are consistently measured
  • 20. The Synergy Model (System Thinking) O The Clinical Nurse Specialist will be able to develop strategies based on the needs and strengths of the patient O Global outlook O Holistic outlook O The Clinical Nurse Specialist will be able to see the whole picture instead of the pieces.
  • 21. In the Right Direction
  • 23. Reference Amidei, C. (2012). Mobilization in critical care: a concept analysis. Intensive and Critical Care Nursing, 28(2), 73-81. Engel, H., Gropper, M., Lipshutz, A. & Thornton, K. (2012). Early mobilization in the Intensive Care unit: evidence and implementation. ICU Director, 3(1), 10-16. Ganzini, L. & Misra, S. (2003). Delirium, depression, and anxiety. Critical Care Clinics, 19(4), 48-49. Grap, M. J. & McFetridge, B. (2012), Critical care rehabilitation and early mobilization. Intensive and Critical Care Nursing, 22(2), 55-57. Hardin, S. R. & Kaplow, R. (2005). Synergy for clinical excellence: The Synergy Model for Patient Care. Sudbury, MA: Jones and Bartlett. Lowson, S. (2012). Early mobilization in critically Ill patients. ICU Director, 3(1), 17-20.