ICU monitoring and devices

what is physical therapy in the ICU?

• patients in the ICU are critically ill and require specialized hemodynamic monitoring and medical interventions

• PTs are part of the multidisciplinary team that provides care to these patients

how can level of consciousness be assessed?

using the richmond agitation sedation scale (RASS) or the bispectral index (BIS)

what is the richmond agitation sedation scale (RASS)?

• it measures the level of agitation or sedation of a patient

• it is scored -5 to +4

what level of agitation on the RASS scale would you see patients?

probably at a 1, or 0, the others positive numbers are dangerous and negative levels are SICK

what is the bispectral index (BIS)?

• it is used to measure consciousness/sedation

• it measures muscular and cortical activity

• it is scored 0-100

how is delirium assessed?

• using the confusion assessment method in the ICU (CAM ICU)

what is the confusion assessment method in the ICU (CAM ICU)?

• it is a valid and reliable method to assess for delirium in the ICU

• reported as either CAM+ or CAM -

what is CAM +?

DELIRIUM

what is CAM -?

NO DELIRIUM

what can you see on the ICU monitor?

it provides real time monitoring of the patient’s vital signs

• EKG

• RESP RATE

• SpO2

• CO2

• BP

• pulmonary artery pressure

what is an arterial catheter?

A line!

provides continuous BP monitoring via cannulation of a peripheral artery

what are indications for an A- Line?

• need for continuous BP monitoring

• frequent analysis of ABGs or labs

what are PT implications for A-lines?

• NO excessive flexion or extension of the joint that the A-Line is in

• NWB of joint that A-line is in

• DONT WANT TO COME OUT (provide pressure if it does, could lose lots of blood)

what is a pulmonary artery catheter (AKA swan ganz catheter)?

thin, flexible, balloon-tipped tube inserted through a large central vein into the right side of the heart and out into the pulmonary artery

monitors real time function

what are the things that the pulmonary artery (swan ganz catheter) directly measures?

• central venous pressure

• right atrium pressure

• pulmonary artery pressure

• cardiac output

• mixed venous oxygen saturation (SvO2)

what are normal values for central venous pressure?

2-6 mmHg

what are normal values for right atrium pressure?

0-8 mmHg

what are normal values for pulmonary artery pressure?

15-30/5-15 mmHg

mean 10-20 mmHg

what happens if the pulmonary artery pressure is high?

it is pulmonary artery hypertension

what are normal values for cardiac output?

4-8 L/min

what are normal values for mixed venous oxygen saturation?

65-70%

what should you be cautious of if mixed venous oxygen saturation is low?

the peripheral muscles may not be getting enough oxygen, so be cautious with exercise

what are PT implications for a pulmonary artery (swan ganz catheter)?

• medically stable prior to mobilization

• is movement allowed?

• always have an extra set of hands for movement

  • let the RNs disconnect

• Monitor vitals closel

what does capnography assess?

it assesses ventilation! (air movement in/out of the lungs)

it measures the amount of CO2 in exhaled breaths

• this allows for the identification of potential breathing complications (airway obstruction, hyper or hypoventilation or apnea)

what is end tidal carbon dioxide (ETCO2)?

the amount of CO2 that is release at the end of an exhaled breath

what is normal value end tidal carbon dioxide?

35-45 mmHg

what is hypoventilation values for end tidal CO2?

• > 45 mmHg

what is hyperventilation values for end tidal CO2?

• < 35 mmHg

what are mechanical ventilators?

• provide external ventilatory support

• usually found in the ICU but can be found in home settings

• requires an artificial airway (endotracheal or tracheostomy tube)

what are common moves of mechanical ventilation?

• assist control (AC)

• synchronized intermittent mandatory ventilation (SIMV)

• continuous positive airway pressure (CPAP)

what mechanical ventilation mode is the most support?

assist control (AC)

what mechanical ventilation move is partial support?

• synchronized intermittent mandatory ventilation (SIMV)

what mechanical ventilation is no support?

• continuous positive airway pressure (CPAP)

what are the FiO2 settings normally at?

between 40% and 100%

what is continuous positive airway pressure (CPAP)?

a breathing therapy and medical treatment that delivers a steady, mild stream of pressurized air through a mask to keep the upper airway open

what is bilevel positive airway pressure (BiPAP)?

a noninvasive medical device and therapy that helps people breathe by delivering pressurized air through a mask at two alternating levels:

a HIGHER pressure when you breathe in and a LOWER pressure when you breathe out.

what is an intra aortic balloon pump (IABP)?

• used for patients with cardiogenic shock

• catheter with a balloon at the end is inserted into a large artery into the descending aorta

• inflates/deflates during diastole/systole

does the IABP inflate or deflate during systole?

deflates which decreases afterload

does the IABP inflate or deflate during diastole?

inflates! it increases coronary blood flow

what are possible complications of the IABP?

• vascular complications

• bleeding

• dislodgement

what are PT implications for the IABP?

• depending on the hospital… bed rest!

• if in femoral artery… DONT FLEX HIP MORE THAN 30 DEGREES

• mobilizing is safer if in the axilla

• MONITOR VITALS

what does ECMO stand for?

extra corporeal membrane oxygenation

what is ECMO?

temporarily takes over the function of the heart and/or the lungs

what are the two types of ECMO?

• venovenous (VV) ECMO

• Veno-arterial (VA) ECMO

what are PT implications for ECMO?

• get medical clearance!

• where is the ECMO placed?

what can bed rest lead to?

• muscle atrophy and weakness

  • ICU patients lose around 2% of skeletal muscle per day during the first week of ICU admission

• DECREASE activity tolerance

  • lose .9% a day

• contractures: start to form within 8 hours

• DECREASE bone density - 1% bone density loss/week

• INCREASED risk of developing pressure injuries and DVTs

what is ICU acquired weakness?

it is a clinically detectable weakness that has no other cause: diffuse and Symmetrical

• it often develops after 5-6 days in the ICU

• effects peripheral and respiratory muscles

• can be caused by a critical illness, polyneuropathy and/or myopathy

what is the incidence of ICU AQUIRED WEAKNESS?

incidence is 20-50%

• more common in people on the MV ? 7 days, sever sepsis/multi organ failure OR conditions that require high dose steroids

what are the consequences of ICU acquired weakness?

• INCREASE ICU and hospital LOS

• INCREASED mortality

• prolonged mechanical ventilation

• INCREASE risk of swallowing disorders

• functional impairments

• INCREASES healthcare utilization

• DECREASE QoL

• impaired ability to return to work

what are benefits of early mobility in the ICU?

• DECREASED ICU acquired weakness

• DECREASED delirium

• DECREASED hospital/ICU LOS

• DECREASED DVT

• DECREASED ventilator associated pneumonia

• DECREASED pressure sores

• DECREASED duration on mech ventilator

• INCREASED ability to perform ADLs

• INCREASED ability to stand

• INCREASED unassisted ambulation distance

• INCREASED DC to home rate

• INCREASE vent free days

is early mobility in the ICU safe?

yes!

• early mobilization/rehab in the ICU appears safe, with a low incidence of potential safety events

  • incidence of 2.6%

  • ONLY .6% required medical intervention

what does PT assessment look like in the ICU?

• vital signs

• mental status

• pain

• sensation

• skin/edema

• ROM

• strength

• mobility assessment

• lung/heart auscultation

• medications

• equipment

what are common PT problems in the ICU?

• weakness

• low activity tolerance

• contractures

• impaired mobility

• unstable hemodynamics

• pulmonary impairments

what are goals of PT in the ICU?

• return patient to PLOF or higher

• reduce complications associated with immobility in the ICU

what are potential PT interventions in the ICU?

• respiratory techniques

• positioning

• ROM/Strengthening

• mobility/endurance training

what must you do with patients in the ICU?

VITALS MONITORING and TEAMWORK