The Role of Rehabilitation in the Intensive Care Unit

Kimberly Hartman, MDAssistant Professor of Pediatrics, UMKC SOM

Faculty, Division of Rehabilitation Medicine, Children’s Mercy Hospital

January 15, 2015

Objectives

• Define and recognize ICU-acquired weakness• Understand implications of critical illness on

function• Review current interventions and state of the

evidence• Understand barriers to implementing rehab

strategies in the ICU

Critical Illness: Who

• > 5 million patients per year• 55,000 patients per day• Nearly 80% of all Americans will experience

critical illness or injury (as patient or loved one)

Ref 30

Critical Illness: Costs

• ICU length of stay: 6.1-9.3 days• Hospital costs:– 2000: $56.6 billion– 2005: $81.7 billion

Ref 30

Critical Illness: What

Adults• Respiratory

insufficiency/failure• Post-operative management• Ischemic heart disorder• Sepsis• Heart failure

Children and Neonates• Respiratory dysfunction• Hematologic instability• Central nervous system

disorders• Mixed respiratory and

hemodynamic dysfunction• Postcardiac arrest• Hepatic dysfunction• Renal dysfunction

Ref 30

Critical Illness: Common Ground

• Mechanical ventilation• Cardiovascular support• Invasive monitoring• Intensive observation• Frequent interventions (ave. 178 actions per

day)

Critical Illness: Common Ground

Critical Illness: Common Ground

Immobility

Circulation:• VTE• Increased edema• Increased workload on heart• Orthostasis

Endocrine:• Glucose intolerance• Increased fat stores• Disturbed Na-waterbalance

GI:• Aspiration• GER• Poor appetite• Malnutrition• Constipation• Vomiting

GU:• Difficulty voiding• Incontinence• UTI

Skin:• Pressure wound• Friction/shearing

Neuro:• Functional deficits• Delirium• Behavior changes• Sleep dysfunction

Respiratory:• Poor lung expansion• Weak cough• Secretions• Pneumonia

Musculoskeletal:• Loss of muscle mass• Weakness• Osteoporosis• Contractures

Nomenclature

Ref 27

Consensus

Intensive Care Unit-Acquired Weakness(ICU-AW)

Ref 9,27

ICU-AW

• Definition:“Syndrome of generalized limb weakness that

develops while the patient is critically ill and for which there is no alternative explanation other than the critical illness itself”

Ref 9, 19

ICU-AW: “Dx of Exclusion”

Ref 19

Ref 19

ICU-AW: Diagnosis

• Screen for awakening• Respond to at least 3

orders on 2 consecutive occasions separated by 6 hours

• Open/close your eyes• Look at me• Open your mouth and

put out your tongue• Nod your head• Raise your eyebrows

when I have counted up to 5

Ref 8

ICU-AW: Diagnosis

• Medical Research Council (MRC) score < 48– MMT grades 0-5– Six muscle groups bilaterally

– Total possible: 60

Shoulder abduction Hip flexion

Elbow flexion Knee extension

Wrist extension Ankle dorsiflexion

Ref 8 , 9

ICU-AW: Diagnosis

• Challenges– Awake and able to follow commands– Limitations of lines, catheters, trauma– Difficult to assess smaller changes

• Multiple studies ongoing for different assessment tool

Ref 15

ICU-AW: Subcategories

Ref 9 ,19

Pathophysiology

• Dysfunctional microcirculation

• Endothelial cell activation (microvascular leak)

• Neuronal injury and axonal degeneration

• Mitochondrial dysfunction

• Inactivation of Na channels

• Catabolic state• Oxidative stress• Muscle wasting

Ref 19

ICU-AW: Associations

• Elderly• Premorbid DM• Longer ICU stay

before awakening• Extrarenal

replacement• Longer time with

dysfunction of ≥ 2 organs

• Aminoglycosides

Ref 19,29

Functional Implications

• Physical– Weakness– Joint contractures– Long-term deficits

• Cognitive– Delirium– Long-term deficits

• Psychological

Up to 65% of patients with prolonged ventilation have functional limitations

after discharge

Mortality

Ref 13

Activities of Daily Living

• Jackson et al (2014)– N = 821 448 (3m) 382 (12m)– Respiratory failure or shock (ICU survivors)

Ref 17

ICU-AW and Function

• Fan et al (2014)– N = 222– Acute lung injury, ICU survivors– High severity– Outcomes:• 36% with ICUAW at discharge• Strength generally improved by 12m• Duration of bedrest associated with worsened

weakness at 24m

Ref 10

ICU-AW and Function

• Function remained decreased (also grip strength, mean inspiratory force)

Ref 10

Joint Contracture

• Clavet (2008)– N = 155– ICU ≥ 2 weeks, survivors

≥ 1 contracture

≥ 1 functionally significant contracture

Transfer out of ICU

61/155 (39%) 52/155 (34%)

Discharge home

50/147 (34%) 34/147 (23%)

Ref 5

Joint Contracture

• Risk: 8+ weeks ICU stay (vs. 2-3 weeks)• Protection: steroids

Joint location Number of joints with contracture (total 212 in 61 patients)

Elbow 76 (36%)

Ankle 51 (24%)

Knee 31 (15%)

Hip 30 (14%)

Shoulder 24 (11%)

Ref 5

Joint Contracture

• Clavet (2008, 2014)– Outcomes:• Significantly fewer patients with contractures were

mobilized (55.3% vs. 79.4%)• Low ambulatory status (64.4% vs. 51.0%)• Associated with higher mortality• Associated with more difficulty with mobility 3.3 years

after discharge

Ref 6,28

Interventions

Passive Mobility

• Griffiths et al. (1995)– N =5– 1 leg CPM for 3x/day for 3h per session for 7 days– 1 leg routine nursing care– CPM leg:• Fiber area preserved or slightly increased (mean 11%)• Less protein loss

– Control leg:• Fiber area decreased (-35%)

Ref 11

Ergometry

• Burtin et al. (2009)– N = 90, RCT– Bedside ergometry (active or passive)– Starting day 5; 20 minutes per day– Control: standard PROM/AROM– At hospital discharge, significant improvement in:• 6MWD• Isometric quadriceps force• Functional well-being on SF36 PFS

Ref 4

Early Mobilization

• Schweikert et al. (2009)– N =104 mechanically ventilated– RCT– Intervention: mobilization 1.5 days after ETT– Control: usual care (mobilization 7.3 days)– Outcomes:• return to independent function (59% vs 35%)• physical function (median Barthel Index 75 vs 55)• ventilator-free days (median 23.5 vs 21.1)

Ref 24

Early Mobilization

• Decreased ICU length of stay• Decreased hospital length of stay• Improved survival without readmission at 1

year

Ref 20

Electrical Muscular Stimulation

• Amplitude (mA/A): amount of energy flowing per unit time

• Frequency (Hz): number of pulses per second• Pulse width (μs): duration of stimulation pulse• Ramp up and ramp down: current intensity

will increase or decrease to set intensity• On:off time: length of time the pulse is

delivered vs. no stimulation

Ref 23

EMS: Who responds

• Segers et al. (2014)– Response = muscle

contraction in >75% of sessions

– 50% responders– 50% nonresponders– Nonresponders:

• Sepsis• Edema• Vasopressors

Ref 25

EMS: Outcomes

• Parry et al. (2013): Review– Timing:• <3d: not shown to attenuate quad or bicep wasting• >14d: improved quad thickness (+4.9% vs. -3.2%)

– Severity of illness:• APACHE II > 20: greater muscle loss in general (16-20%);

did not demonstrate muscle preservation• APACHE II < 20: greater degree of preservation (8-14%

reduction)

Ref 23

EMS: Outcomes

• Strength: Increased in 4 studies• ICU AW diagnosis by MRC: – Control: 39%– EMS: 12.5%

• No difference (small study)

Ref 18,23

EMS: Challenges

Ref 23

Functional Electrical Stimulation

Ref 22

FES

• Parry et al. (2014)– N = 16 (8 intervention, 8 matched controls)– Trend toward statistical significance

Ref 22

Cognitive Rehab

Ref 3

Barriers

Ref 2

Safety: Mobilization

• Sricharoenchai 2014– N = 1110 patients; 5267 PT sessions– Median PT start: 2 days (IQR: 1-3)– Physiological abnormalities: 34 events in 25

patients• 0.6% of sessions• 2% of admissions

– Median time of event: 6 days (IQR 2-11)

Ref 26

Safety: Mobilization

Ref 26

Safety: Mobilization

Ref 26

Safety: Mobilization

Ref 26

Safety: Mobilization

• Consensus guidelines (94 clinicians): Dec 2014• Active mobility:

– “any activity where the patient assists with the activity using their own muscle strength and control: the patient may need assistance from staff or equipment, but they are actively participating in the exercise.”

– Activities included:• Out-of-bed mobilization (i.e. any activity where the patient sits over

the edge of the bed [dangling], stands, walks, marches on the spot or sits out of bed)

• In-bed mobilization (i.e. any activity undertaken whilst the patient is sitting or lying in bed such as rolling, bridging, upper limb weight training).

Ref 14

Safety: Mobilization

Ref 14

Safety: Mobilization

Ref 14

Safety: Mobilization

Ref 14

Safety: Mobilization

Ref 14

Safety: Mobilization

Ref 14

Safety: Mobilization

Ref 14

Safety: Mobilization

• Respiratory– Airway secure– Supplemental O2 if

anticipated need– FiO2 < 0.6

• Cardiovascular– Vasoactive drugs?

• Absolute dose• Changing dose• Clinically well perfused

Ref 14

Safety: EMSVariable EMS Pre EMS Post Control Pre Control Post

HR (bpm) 94 ± 16 99 ± 16* 74 ± 16 76 ± 15

SBP (mmHg) 127 ± 21 133 ± 23* 154 ± 30 156 ± 32

DBP (mmHg) 66 ± 15 67 ± 17 81 ± 12 83 ± 14

MAP (mmHg) 86 ± 15 88 ± 17 106 ± 17 110 ± 20

RR (bpm) 18 ±6 19 ± 7 21 ± 6 21 ± 3

SpO2 (%) 98 ± 23 99 ± 1 99 ± 1 99 ± 1

Lactate (mEq/ml) 1.4 ± 0.8 1.3 ± 0.7 1.5 ± 1.1 1.5 ± 1.4

Ref 25

Safety: FES

• Iwatsu et al. (2014)– N = 61– Post-operative cardiovascular patients on inotropic

and/or vasopressor support– No vent, no renal failure/insufficiency, no control– Outcomes:

• No significant changes in BP or HR• No pacemaker malfunction• No increase in ventricular arrhythmia• Atrial fibrillation noted but reported as no different than

anticipated

Ref 16

Facilitators

Ref 2

Consult Algorithm

Ref 20

ICU Protocols• Awakening and Breathing Coordination, Delirium

monitoring/management and Early exercise/mobility (ABCDE Bundle)1. spontaneous awakening trials (SATs)2. spontaneous breathing trials (SBTs)3. coordination of components 1 and 2 (so that sedation is held before

the breathing trial begins)4. routine delirium and sedation/agitation screening and management5. early progressive mobilization.

– Each component (except delirium monitoring/ management) is guided by predefined safety screen questions and success/failure criteria derived from RCTs

Ref 1,20

ICU Protocols: ABCDE

Ref 7,20

ICU Protocols: PAD

Ref 7, 31

Future Directions

• Improved method of diagnosis for ICU-AW• Determination of who benefits and resource

utilization• Standardized intervention trials• Prior disability and outcomes• Cognitive and psychological rehab• Pediatrics!

Ref 9

Summary

• ICU-AW is generalized, symmetric weakness defined by MRC < 48 with no attributable cause other than critical illness

• Many challenges to assessing for ICU-AW based on current measures

• ICU-AW leads to functional deficits• Inconsistent protocols lead to difficulty

interpreting results of interventions• Safe mobilization can be achieved

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