Mobilization in the ICU

what are reasons that someone would be in the ICU?

airway, breathing, circulation, + neurologic

what is the apache II score?

measures how sick someone is

what is a huge risk factor for mortality?

age

what is the sofa score used to measure?

septic pts level of sickness

what are adv effects of the ICU?

severe weakness, 40% require mechanical ventilation, cognitive impairments, psych issues, cost

what are short term psych issues?

delirium

what are long term psych issues?

depression, anxiety, PTSD

what puts someone at a higher risk of ICU adv effects?

longer stays, longer time on ventilation, incr age

what are 2 types of severe weaknesses that can result from ICU stays?

critical illness myopathy (CIM), critical illness polyneuropathy (CIP)

what are SXS of ICU morbidity?

CIM, CIP, persistent critical illness acquired weakness (CAW), reduced fxn 6-12 mo post discharge, reduced mm strength seen in many survivors for 5y or more, cost

what is the biggest risk factor that can lead to critical illness myopathy (CIM)?

sedatives/sedation; avoid as much as possible

people in the ICU are unable to deliver O2 well, so what process is used more?

glycolysis

what does stress incr?

cortisol levels

what are some factors that can lead to critical illness myopathy?

septic shock, poor glycemic control, multi-organ failure, pre-existing alcoholic myopathy, NM blocking agents, sedatives/analgesics, steroids

what is a trigger factor that can lead to sepsis?

steroid toxicity

what are predisposing factors that can lead to sepsis?

TNF alpha, IL-6, cortisol

what are priming factors that can lead to sepsis?

denervation CIP, NMBAs membrane hypoexcitability

what is considered the highest risk factor (out of the list) leading to CIM?

sedatives/sedation → avoid as much as possible

what specific sedatives should you factor? what should you stay away from?

favor short acting sedatives like propofol and precedex → stay away from benzodiazepines

what mm wasting is found c ICU stays? what causes it?

dec in type 1 fibers occurs → d/t decr calorie intake

what is used sometimes to make sure pts are receiving proper calorie counts?

feeding tubes

what is the medical research council (MRC)?

measures weakness for critical illness acquired weakness (CAW) → scale out of 60, measures 3 MMTs for the LE/UE B and adds up the score

what are common LE mm involved c MRC?

hip flex, knee ext, ankle DF

what are common UE mm involved c MRC?

shoulder aBD, elbow flex, wrist ext

what LE gait deviation is seen a lot post ICU?

foot drop

what is a motomed device?

used in bed for movement/exer; can be used c e-stim

what are risk factors for developing CAW?

myopathies/neuropathies (or both)

what are barriers to exer within the ICU?

deficit of practitioner knowledge, poor culture of institutional/med team, not enough time or staff, pt factors

what are factors to practitioner knowledge deficits?

training, equip, inconsistent PT practice in ICU

what are factors that affect pt barriers to mobility in ICU?

sedation, neurocognitive status and stability, bleeding, fx stability

t/f: many people are acidotic within the ICU, which could cause a barrier for exer

true

describe the bohr effect

- when pH decr → more acidic → CO2 incr → less saturation of O2 occurs and more is available for mm

- when pH incr → less acidic → CO2 decr→ more saturation of O2 occurs and less is available for mm

does the bohr affect shift to the right or left c exer?

right

what can acidity of ICU pt lead to?

anemia → there is not enough O2 traveling through the blood

what do PTs need to monitor before starting exer c ICU pt?

BP, HR, SpO2

what should pts SpO2 be at for exer in the ICU?

high 80s and low 90s

what is involved c involuntary breathing control?

the NS (basal rate), chemical factors

what are neural structures that are involved c involuntary breathing control?

brainstem, phrenic nerve

what does the phrenic nerve innervate?

diaphragm (CN 3, 4, 5)

what are the chemical receptors that are involved c involuntary breathing control?

H+, PaCO2, PaO2

what chemical receptor is the strongest driver of involuntary breathing control?

PaCO2 elevation

mechanical receptors are ___ receptors

stretch

what is the minimal MAP for exer in ICU pt? normal MAP?

minimal = 65; normal = 70-100

what helps prevent acidosis?

hydrogen ion buffering

what is normal pH?

7.35-7.45

what are buffers that help keep pH normal?

weak acids/bases

what are the 2 primary organs that regulate pH?

lungs and kidneys

what is hydrogen ion buffering?

when pH incr, the lungs incr ventilation and blow off CO2 (decr H+); kidneys reabsorb HCO3-, secreting H+

what happens if pH incr too much?

kidneys will remove HCO3- and retain H+; lungs decr ventilation and retain CO2 to incr H+

what is respiratory acidosis?

ventilation failure (hypoventilation)

what is acute respiratory acidosis?

when CO2 builds up very quickly before the kidneys can return the body to a state of balance

what is respiratory alkalosis?

hyperventilation d/t acute CNS injury, high altitude, anxiety, etc

what is metabolic acidosis caused by?

lactic acidosis, ketoacidosis, kidney failure

what causes metabolic alkalosis?

excessive vomiting

what is carbaminohemoglobin?

carried on globin protein, not attached to iron (Hb can carry 4 O2 & 4 CO2)

how do you determine if somebody is ready to be mobilized in the ICU?

awake? able to minimally participate, stable hemodynamics, normal tissue O2, ICP stable, no active bleeding, stable fx, special circumstances

what is the ABCDEF ICU safety bundle for treatment?

assess & address px, both awake + breathing, choice of analgesia/sedation, delirium, early mob/exer, family

what are the two steps of the level of consciousness assessment for evaluating readiness for exer?

perform RASS scale, perform a delirium assessment

t/f: you want to be a zero on the RASS scale

true

what is the RASS scale?

+4 to -5 scale

- positives mean the pt is too agitated

- negatives mean the pt is too sedated

what are "good" scores for rehab ont he RASS scale?

+2 or -2

what does a -2 mean on the RASS scale?

eyes open to voice

what is the CAM-ICU?

assesses delirium that can be associated c worse prognosis, incr morbidity/mortality in ICU pts

- able to answer questions c out needing to speak

what has been shown to be able to reduce delirium?

early mobility and exer

how does delirium effect pt prognosis?

declines

what is the FSS-ICU?

5 categories: rolling, supine to sit, unsupported sitting, sit to stand, amb (score 0-7 for each)

what is the PFIT?

looks at fxn, strength, endurance in ICU pts; measured 3 times: awakening, ICU discharge, and hospital discharge

what does the PFIT look at?

sit to stand, marching on spot, strength (shoulder flex, knee ext)

what are the uses of the PFIT?

look at prognosis, look at progression of interventions

what is the Perme ICU mobility score?

factors both fxn and ICU support level; 0-32 c 32 = best; 7 categories

how can perme ICU mobility score be increased?

c improved fxnal mobility OR decr in ICU support (may impact mobility)

what is the chelsea critical care phys assessment tool?

assess phys and respiratory fxn and morbidity; 0-5 scale, 8 categories

what lines/leads does CPAx take into account?

ventilators and supplemental O2

what lines/leads does the perme ICU mobility score take into account?

ventilators, drips, catheters, supplemental O2

phase 1 of ICU mobility/walking program:

bed exer, stretcher chair, unable to bear wt

phase 2 of ICU mobility/walking program:

transfers & pre gait/walking in room

phase 3 of ICU mobility/walking program:

walking out of the room

phase 4 of ICU mobility/walking program:

out of ICU, preparing for discharge

what is the vanderbilt protocol of treatment for a pt with RASS score of -5/-4?

PROM

what is the vanderbilt protocol of treatment for a pt with RASS score of 3-/2-?

PROM, sitting

what is the vanderbilt protocol of treatment for a pt with RASS score of -1/0/+1?

AROM, exer, sit, stand, walk, ADLs

what are the risk factors for PICS?

incr age, sepsis, corticosteroids, sedatives, delirium

what are the consequences of PICS?

long term deficits in IADLs, difficulty returning to work

what are the benefits of exer in the ICU?

decr PICS effects, incr survival/decr mortality rates

what are barriers to earliy mobility in the ICU?

staff culture, overuse of sedation, false perception that people are "too sick", lack of staff/PT training/lack of confidence

how is readiness for mobility in ICU assessed?

- RASS/CAM

- ability to follow simple commands to ensure safety of leads/lines/procedure

- MAP > 60 mmHg/hemodynamic stability

- SpO2 high 80s low 90s