Rehabilitasi icu


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peran tim rehabilitasi medik pada pasien kritis di ruang rawat intensive care.

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  • ROM cegah edema
  • Resistive muscle training can include the use of pulleys, elastic bands and weight belts. The chair cycle and the earlier mentioned bed cycle allow patients to perform an individualized exercise training program
  • Figure 5 increasing airway clearance. Interventions aimed at increasing inspiratory volume (deep breathing exercises, mobilization and body positioning)  lung expansion, increase regional ventilation, reduce airway resistance and optimize pulmonary compliance. Interventions aimed at increasing expiratory flow include forced expirations, such as huffing and coughing. Manually- assisted cough, using thoracic or abdominal compression may be indicated for patients with expiratory muscle weakness or fatigue
  • MHI involves a manual slow deep inspiration with a resuscitator bag, an inspiratory hold of 2-3 seconds [52], followed by a quick release of the bag to enhance expiratory flow and mimic a forced expiration. MHI might have important negative side-effects. First, MHI can precipitate marked hemodynamic changes associated with a decreased cardiac output, which result from large fluctuations in intra-thoracic pressure [53]. Second, MHI can also increase intracranial pressure which might have implications for patients with brain injury. This increase is, however, usually limited, so that cerebral perfusion pressure remains stable [54]. A pressure of 40 cm H2O has been recommended as an upper limit. Airway suctioning may have detrimental side effects (bronchial lesions, hypoxaemia), but reassurance, sedation, and pre- oxygenation of the patient may minimize these effects [57]. Suctioning can be performed via an in-line closed suctioning system or an open system. The in-line system increased the costs, but did not decrease the incidence of ventilator-associated pneumonia (VAP) nor the duration of mechanical ventilation, length of ICU stay or mortality [58]. Closed suctioning may be less effective than open suctioning for secretion clearance during pressure support ventilation [59]. The routine instillation of normal saline during airway suctioning has potential adverse effects on oxygen saturation and cardiovascular stability, and variable results in terms of increasing sputum yield [60]. Chest wall compression prior to endotracheal suctioning did not improve airway secretion removal, oxygenation, or ventilation after endotracheal suctioning in an unselected population of mechanically ventilated patients [61]. VAP is a common complication in mechanically ventilated patients and is associated with higher mortality rates, prolonged hospitalization, and high medical costs [62]. Studies have shown that avoidance of intubation by NIV reduces the incidence of nosocomial pneumonia in a subgroup of patients [63,64]. Physiotherapy including manual hyperinflation, positioning plus suctioning showed no differences in VAP versus suctioning alone [65]. Yet, in contrast, another study reported a lower incidence of VAP (8% vs 39%) in the group receiving physiotherapy [66]. However, the duration of mechanical ventilation, length of ICU stay and mortality did not differ between the groups. The addition of physiotherapy in a population of ventilated patients for various reasons of respiratory insufficiency was associated with prolongation of mechanical ventilation [67].
  • Rehabilitasi icu

    1. 1. Rehabilitasi Medik pada Pasien ICU Dr. RaymondIlmu Kedokteran Fisik dan Rehabilitasi 0
    2. 2. Pendahuluan• Rehabilitasi Medik  peran penanganan pasien kritis• Asesmen: 1. Deconditioning syndrome 2. Kondisi respirasi GANGGUAN MOBILISASI SEKRET & MEMPERCEPAT SUKSES WEANING “Mobilisasi dini PENTING dalam mengatasi deconditioning syndrome”• Mobilisasi dini + chest PT  EVIDENCED BASED – Menyesuaikan : KU, ko-morbiditas & kerjasama pasien 1
    3. 3. Imobilisasi Deconditioning Syndrome MUSKULOSKELETAL* RESPIRASI* • Atrofi otot • Pneumonia • Kontraktur • Disuse osteoporosisKARDIOVASKULAR SARAF KULIT• Hipotensi ortostatik • Neuropati • Ulkus dekubitus• DVT/PE • Emosi • Intelektual ENDOKRIN • Intoleransi GENITOURINARI glukosa GASTROINTESTINAL • BSK • konstipasi • ISK METABOLISME • Hiperkalsemia JC Tan. Practical Manual of PMR. Mosby: New York, 1997 2
    4. 4. PendahuluanDeconditioning syndrome – Kelemahan otot >>> angka mortalitas – Neuropati / Miopati  kegagalan weaningDisfungsi Nafas – Ggg ventilasi + compliance +  resisten jalan nafas   kerja otot pernafasan  disfungsi pernafasan  kebutuhan ventilator (durasi?) 3
    5. 5. Mobilisasi dini dan aktivitas fisikMobilisasi dini: mengatasi deconditioningsyndromeAsesmen :• Kerjasama pasien• Kardiorespirasi• Kekuatan otot• Mobilitas sendi• Status fungsional (sebelumnya) 4
    6. 6. Mobilisasi dini dan aktivitas fisik• Prinsip – Segera (pasif  bila belum stabil) – Bertahap – Aktif + agresif u/ Px stabil (hemodinamik, neurologis, metabolik, respirasi)• Pemberian modalitas (peresepan) disesuaikan dengan kondisi pasien 1. Kondisi kritis – akut, non kooperatif 2. Kondisi stabil dan ko-operatif, ETT [+] 5
    7. 7. Mobilisasi dini dan aktivitas fisik1. Kondisi kritis – akut, non kooperatif – Proper positioning – Upright position & roll over q2h (mika-miki) – PROM exercise – Muscle stretching – Passive cycling – Stimulasi elektrik (NMES) • (kontraksi otot involunter  beban kardiorespirasi minimal)2. Kondisi stabil dan kooperatif, ETT [+] – Mobilisasi di samping tempat tidur – kursi – AROM exercise (AA, A, R) – Active cycling (bed/chair cycle) – Walk w/wo assistance 6
    8. 8. Pasien Kritis non Kooperatif PROPER POSITIONING mencegah • Pemendekan otot – kontrakturPOSISI TEGAKmemperbaiki rasio ventilasi- perfusi (max 20 menit)(Vasomotor training); mencegah:• Pneumonia hipostatik• Hipotensi ortostatik POSISI TENGKURAP / MIRING 45O (5 – 10 menit) • Membantu PD • Mengurangi resiko atelektasis • Ulkus dekubitus 7
    9. 9. 8
    10. 10. PROM exc + Stretching Menjaga ROM Mencegah atrofi (Str.) + DVT Mencegah drop foot Passive cyclingEarly application of daily bedside (initially passive) leg cycling in critically illpatients showed improved functional status, muscle function and exerciseperformance at hospital discharge compared to patients receiving standardtherapeutic exercise without leg cycling. RCT. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009;37:2499-505. 9
    11. 11. MOBILISASI TAHAP MOBILISASIMemperbaiki 1. Transfer di tempat tidur (MiKa-MiKi,• ventilasi/perfusi geser ↑↓, duduk sentral – perifer, bertahap)• sirkulasi, 2. duduk ongkang-ongkang• metabolisme 3. berpindah dari tempat tidur ke kursi• Alertness 4. Dst …. (bangsal) Alat bantu Standing - Tilting tables Mobilisasi dini mengurangi lama perawatan di ICU dan LOS di RS 1. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36:2238-43. 2. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373:1874-82. 10
    12. 12. 11
    13. 13. 12
    14. 14. Kondisi PernafasanChest–PT gol:1. membersihkan sekresi jalan nafas – mengurangi kerja otot pernafasan2. meningkatkan kekuatan otot inspirasi – peningkatan kapasitas paru – mempercepat pernafasan spontan• Terapi latihan otot inspirasi pre op  <i angka komplikasi pasca operasi pasca bedah thorak• Mobilisasi dini + posisi tegak  >>> volume paru & mencegah komplikasi pasca bedah abdomen 13
    15. 15. N =60 (36 control :24 interv.)Durasi pemasangan ventilator minimal 48 jam 14
    16. 16. Chest therapy : WEANING fokus 1. kontrol pernapasan 2. penguatan otot inspirasi 3. latihan batuk efektif Latihan diberikan small-frequent (beban ringan, waktu pendek, jangan sampai lelah) → umumnya 5-10 menit; 2-4 sesi latihan/hari
    17. 17. WeaningInspiratory muscle training (IMT) + Thresholdloading   kekuatan otot inspirasi mempercepat weaning“IMT 2x5’ 30% PImax  PImax & durasi weaning”Cader SA, Vale RG, Castro JC, Bacelar SC, Biehl C, Gomes MC, et al.Inspiratory muscle training improves maximal inspiratory pressure andmay assist weaning in older intubated patients: a randomised trial. JPhysiother 2010;56:171-7. 16
    18. 18. Bila sudah lepas ETT, dapat diberikan peresepan latihan mandiri dengan :  incentive spirometry  flutter / acapella (oscillating) “MENCEGAH RE-INTUBASI”
    19. 19. PATHWAYS AND TREATMENT MODALITIES FOR INCREASING AIRWAYCLEARANCE.PEP=positive expiratory pressureCPAP=continuous positive airway pressureHFO=high frequency oscillationIPV=intrapulmonary percussive ventilationNIV=non- invasive ventilation 18
    20. 20. 19
    21. 21. Take Home Message• Penanganan tim rehabilitasi medik ditujukan pada deconditioning syndrome & kondisi pernafasan• Mobilisasi dini & chest Th. merupakan EBM dan harus diberikan pada pasien penyakit kritis menyesuaikan pada “kondisi umum, komorbiditas & kerjasama pasien”• Pasien tidak stabil dapat diberikan latihan secara pasif dan chest therapy dengan monitor ketat sebelum, selama, dan sesudah latihan• Chest therapy merupakan latihan utama pada pasien dengan ventilator mekanik 20
    22. 22. 21
    23. 23. ‘Start to move’ – protocol Leuven:step-up approach for progressive mobilization and physical activity program. 22
    24. 24. ‘start to move’ - protocol leuven: step-up approach of progressive mo- bilisation and physical activity program1s5Q: response to 5 standardized questions for cooperation:open and close your eyeslook at meopen your mouth and stick out your tongueshake yes and no (nod your head)I will count to 5, frown your eyebrows afterwards2:FAIls= atleast1riskfactorpresent3 : if basic assessment failed, decrease to level 04 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occurduring the interventionmRC (medical Research Council) muscle strength sum scale(0-60) BBs: Berg Balance scoresIttIng to stAndIng4 able to stand without using hands and stabilize independently 3 able to stand independently using hands2 able to stand using hands after several tries 1 needs minimal aid to stand or stabilize0 needs moderate or maximal assist to standstAndIng unsuPPoRted4 able to stand safely for 2 minutes3 able to stand 2 minutes with supervision2 able to stand 30 seconds unsupported 1needsseveraltriestostand30secondsunsupported 0 unable to stand30 seconds unsupportedsIttIng wItH BACK unsuPPoRted But Feet suPPoRted on FlooR oR on A stool4 able to sit safely and securely for 2 minutes3 able to sit 2 minutes under supervision2 able to able to sit 30 seconds1 able to sit 10 seconds0 unable to sit without support 10 seconds 23
    25. 25. “prevent pulmonary atelectasis, re-expand collapsed alveoli, improve oxygenation, improve lung compliance,and facilitate movement of airway secretions towards the central airways” 24
    26. 26. Tanpa alat: -Positioning/alih baring -Chest therapy pasif, kolaborasi dengan inhalasi dan suction (bila perlu) -Ankle pumping dan ankle stretch -Latihan LGS -Pertahankan posisi tegak di luar latihan (≥30o) Alat Sederhana:Full Support / -Chest vibratorControl Ventilator -NMES pocket -Elastic bandage Canggih: -NMES -CPM untuk gerakan sendi - Rotational bed -Pneumatic compression / compression stocking -Tilting table (pendampingan)
    27. 27. Tanpa Alat: -Positioning / alih baring / rotasi trunk 45o -Chest therapy pasif / aktif asistif kolaborasi dengan inhalasi dan suction -Assistive breathing -Ankle pumping dan ankle stretch Assist Support -Latihan LGS Setting: -Pertahankan posisi tegak di luar latihan -Volume Control (≥30o) -Pressure Control -Dual mode Alat Sederhana: -Chest vibratorCanggih: -NMES pocket- NMES -Elastic bandage-CPM untuk gerakan sendi-Rotational bed-Pneumatic compression / compression stocking-Tilting table (pendampingan)
    28. 28. Tanpa alat: -Fokus pada breathing exercise (penguatan inspirasi) dan kontrol breathing -Positioning/alih baring/rotasi trunk 45o -Chest therapy aktif asistif / aktif kolaborasi dengan inhalasi dan suction, fasilitasi batuk / batuk efektif CPAP atau Spontan -Ankle pumping dan ankle stretch dengan PEEP -Latihan LGS -Mobilisasi aktif  duduk  berdiri -Pertahankan posisi tegak di luar latihan (≥30o) Alat Sederhana: -Chest vibratorCanggih -NMES pocket-NMES -Elastic bandage-Pneumatic compression / -Theraband exercise dan dumble untuk compression stocking Upper Extremity training-Tilting table (pendampingan) -Walker untuk alat bantu berdiri dan jalan
    29. 29. Tanpa alat: -Fokus pada peningkatan kemampuan bernapas dalam dan kontrol breathing -Chest therapy dan fasilitasi batuk efektif / mandiri -Mobilisasi di tingkatkan, ambulasi sekitar bed dengan / tanpa bantuan Alat Sederhana: -Chest vibrator -NMES pocket -Elastic bandageT Piece -Theraband exercise dan dumble untuk Upper Extremity training -Walker untuk alat bantu berdiri dan jalan Canggih: -NMES -Pneumatic compression /compression stocking -Tilting table (pendampingan)
    30. 30. Tanpa alat: -Latihan inspirasi dalam dan PLB, kontrol breathing -Chest therapy dan fasilitasi batuk efektif / mandiri -Tingkatkan mobilisasi aktif dan ambulasi Extubasi Alat Sederhana: -Chest vibrator dan nebuliser -Insentive spirometri (latihan inspirasi) -Elastic bandageCanggih: -Theraband exercise dan dumble-Acapella (bila perlu, untuk untuk Upper Extremity trainingmembantu pengeluaran -Walker untuk alat bantu berdirisputum) dan jalan-Postural drainage bed-Static bike-Pneumatic compression / compression stocking-Tilting table (pendampingan)