Critical care

1. Critical care
rehabilitation
JOHNY WILBERT, M.SC[N]
LECTURER,
APOLLO INSTITUTE OF HOSPITAL
MANAGEMENT AND ALLIED SCIENCE

2. CRITICAL CARE
Critical care saves lives
BUTthe deleterious effects of a critical care stay can include
neurocognitive impairment,
skin breakdown,
muscle wasting,
post traumatic distress disorder,
anxiety and
depression
DECREASED QUALITY OF LIFE

3. “Bed rest was not
beneficial and may be
associated with harm”
–Desai (2011)
Bed rest leads to
negative effects on
almost every system
in the body

4. MUSCLE DECAY
–Begins with in hours of immobility
–Strength decreases by 1-1.5% per day
–Muscle wasting highest in first 2-3 weeks
of ICU stay
–After 7 days of mechanical ventilation,
25-33% of patients experience clinically
visible weakness
–ICU acquired paresis
– Joint Contractures: Bone Degradation

5. CVS VARIATIONS
• Heart Rate
– Elevated heart rate
– Reduced heart rate variability
– Increased sympathetic tone
• Decreased plasma volume
• Decreased stroke volume
• Reduction in cardiac output
• Orthostatic instability

6. RESPIRATORY CHANGES
• Changes in ventilation and perfusion
• Atelectasis
• Aspiration
• Increased risk for ventilator acquired
pneumonia (VAP) and hospital
acquired pneumonia
• Hypoxia

7. Get patients up, tubes and all
Optimization of
recovery as a
therapeutic objective,
rather than mere
survival, has
developed increasing
prominence

8. REHABILITATION
‘a process of active change
by which a person who has
become disabled acquires the
knowledge and skills needed for
optimal physical, psychological
and social function’
Gutenbrunner et al., 2006

9. Early rehabilitation
– Decreased risk of neuromuscular abnormalities
and physical impairments
– Decreased ventilator and hospital acquired
diseases
– Decreased length of stay in the ICU and in the
hospital Decreased duration of mechanical
ventilation
– Decreased hospital costs
– Improved quality of life upon discharge
– Promote the maximal level of functional
independence before discharge

10. • Critical care recovery is a holistic
pathway along which the patient moves.
Critical care rehabilitation is part of this
pathway and includes early mobilisation
and psychological support.
• Use of passive movements are an
important first steps in early mobilization.

11. Rehabilitation may begin with
• range of motion and bed mobility
exercise,
• sitting and posture-based exercise,
• bed to chair transfers,
• strength and endurance exercises, and
• ambulation

12. MULTIDISCIPLINARY TEAM
• nurses,
• respiratory
physiotherapists,
• neuro
physiotherapists,
• speech and language
therapists,
• dieticians and
• occupational
therapists

13. IMPORTANCE OF MDT
• Collaborative Weaning Plans (medics)
• Seating Plans, exercises, positioning
(N/S)
• Adequate Nutrition and calories
(dietician)
• Anxiety Management & IADL’s (OT)
• Pain relief, night sedation (Pharmacist)
• Appropriate equipment

14. Unconscious
• exercises
-- Turn every 2hr
-- Passive ROM
exercises

15. • Conscious
• Turn every 2hr
• Sitting position min 20
minutes 3x daily
• Active resistance range of
motion (ROM) with
physical therapy or RN
daily
• Sitting on edge of bed
(SOEOB)
• Active Transfer to Chair
(OOB) with Physical
Therapist Minimum 20
minutes- morris etal2011

16. Upright posture
– encourages basal lung expansion and increases
FRC
– Psychological ++ (progression)
– Increased muscle strength
– Increased exercise tolerance
– Improvetrunk Stability
– Prevents/addresses postural hypotension
– Improved bowel function
– Full weight bearing

17. STAGES OF ASSESSMENT FOR
CRITICAL CARE REHABILITATION
• During the critical care stay
• Before discharge from critical care
• During ward-based care
• Before discharge to home or community
care
• 2–3 months after discharge from critical
care

18. DAILY EVALUATION
• the need for bed rest and immobility,
• assessment of the potential for early rehabilitation
interventions.
• Early ICU rehabilitation is an interdisciplinary
team responsibility, involving physical therapists,
occupational therapists, nurses and medical staff.

19. FUNCTIONAL ASSESSMENT
Physical problems
• Weakness,
• inability/partial ability to sit, rise to standing,
or to walk,
• fatigue,
• pain,
• breathlessness,
• swallowing difficulties,
• incontinence, inability/partial ability to self-
care

20. During the critical care stay
– short clinical assessment
– Perform a comprehensive assessment to
identify current rehabilitation needs and to agree
short-term and medium-term rehabilitation goals for
patients at risk
–Start rehabilitation as early as clinically
possible for patients at risk
– Medication, nutrition, prevention of complications etc

21. Before discharge from
critical care
– Perform a short clinical assessment for patients
previously identified as being at low risk
– Perform a comprehensive clinical reassessment for
patients at risk to identify rehabilitation needs and to
agree or review and update rehabilitation goals
– Involve the family
– Handover following the NICE guidelines for ‘Acutely
ill patients in hospital’

22. During ward-based care
–Perform a short clinical assessment for
patients previously identified as being at
low risk before discharge from critical care
–Perform a comprehensive clinical
reassessment for patients at risk
(delirium/PTSD etc)
–Provide an individualised, structured
rehabilitation programme for patients at
risk and complete appropriate referrals
–Provide a 6 weeks rehabilitation manual
depending on the patient’s ability

23. Before discharge to home
– Perform a functional assessment of physical
and
non-physical dimensions and agree functional
goals for ongoing recovery
– Ensure that arrangements are in place, if
continuing rehabilitation needs are identified
before the patient is discharged, including
appropriate referrals for ongoing care
– Ensure information is understood by the
patient and family, e.g. ICU STEPS

24. 2–3 months after discharge from critical care
– Review the patient and perform a face to face functional
assessment of their health and social care needs
– Refer the patient to the appropriate rehabilitation or
specialist services if:
- the patient is recovering at a slower rate than anticipated
- the patient has developed unanticipated morbidity that was not
previously identified
– Consider the needs of relatives and carers
– Utilise other NICE guidelines

25. INFORMATION PACKAGE
Patients in critical care should
be given structured
comprehensive manual of
rehabilitation plans on
progressive stages to obtain
active participation of patients

26. RISKS OF EARLY
MOBILIZATION
• accidental removal of tubes and
lines,
• haemodynamic instability,
• oxygen desaturation,
• accidental extubation and
• patient discomfort

27. CONTRAINDICATIONS FOR
EARLY REHABILITATION
• Symptomatic dropt in MAP when not in supine position
• HR < 40 or > 130
• R.R < 5 or > 40
• SpO2 < 88% for more than 5 minutes
• SBP >180 mmHg for > 5 minutes
• Active GI bleeding
• Evidence of increasing ICP
• Evidence of Myocardial ischemia is last 24 hrs
• Inadequately secured airway
• Agitate
• Presence of femoral vascular device

28. The ABCDE bundle
Awakening and Breathing Trials,
Choice of appropriate sedation,
Delirium monitoring and
Early mobility and Exercise
has been recently developed to improve
patient outcomes and recovery with a multiple
and systematic approach

29. Interventions to prevent delirium
• Pain control – use analgesia
• Reduce polypharmacy effects
• Prevent poor nutrition
• Reduce immobility by mobilising early
• Ensure hearing aids and glasses are there
• Sleep

30. Respiratory muscle training
–ACBT
– LTEE’s
–manual techniques
–IPPB
–positioning
– incentive spirometeri
–supported cough

31. Swallowing, speech training
– Diet/fluid modification –
– check ward compliance;
– postural swallow strategies; swallow
techniques/exercises;
– voice exercises/therapy;
– articulation exercises/therapy;
– language exercises/therapy;
– oral hygiene

32. COGNITIVE REHABILITATION
 orientation exercise
 progressively more difficult exercises
of attention and memory.
 Finally, each patient will be provided
with games and puzzles to work on

33. CONCLUSION
• Rehab should commence on day of
admission to critical care
• Should be MDT involvement
• Can decrease negative effects of
mechanical ventilation & Bed rest and
facilitate weaning.
• Needs more research to prove
effectiveness and cost benefits of early
physiotherapy led mobilisation