Transcript Slide 1

Impact of Rehabilitation Early in ICU
Margaret Herridge MD MPH
Associate Professor of Medicine
Interdepartmental Division of Critical Care
University of Toronto
The Canadian Critical Care Trials Group
Overview
The Continuum of ICU Weakness
 Muscle and Nerve Injury after Critical
Illness
 Early Mobility
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Heterotopic Ossification
Tracheal stenosis
Alopecia
frozen joints
contractures
Cosmesis- Scars from CVC, Art line, CT, drain sites
Nerve and Muscle
Brain
striae
Bronchiectasis
Pulmonary
fibrosis
Weakness
Mental Health & Cognition
Ischemic digits
Taste changes
Renal Impairment
The Disease
Griffiths and Jones BMJ 1999:319(7207):427-9
Hearing Loss
Evidence of diaphragmatic atrophy and increased proteolysis
at 18 hours of mechanical ventilation
De Jonghe, B. et al. JAMA 2002;288:2859-2867
Ali N et al. AJRCCM 2008; 178:261-268
Herridge et al. N Engl J Med 2003; 348:683-93.
Five-Year Outcomes in ARDS
Herridge et al. NEJM 2011; 364: 1293304
Persistent exercise limitation
and reduction in Physical QOL
at 5-years after ICU discharge
outpatient
rehabilitation
homecare
pharmacy
imaging and labs
physicians
Other
Subsequent hospitalization
Inpatient rehabilitation
Post-discharge Costs
$28,350
Cheung et al AJRCCM 2006; 174: 538-544
Herridge et al. NEJM 2011; 364: 1293-304
ICU-Acquired Weakness
 CIPN
 CIPNM
 ICUAP
 CRIMYNE
 CINMA
Incidence
25% - 60%
surveillance, definition,
diagnostic testing, bias,
confounding, case-mix
De Letter et al. Crit Care Med 2001; 29: 2281-6
DeJonghe et al. JAMA 2002; 288: 2859-67.
Stevens et al. Int Care Med 2007; 33:1876-91
Hough et al. Int Care Med 2008
Critical Illness Polyneuropathy (CIP)
• Acute axonal sensory-motor polyneuropathy
• Injury related to microcirculatory damage
• Mediated by E-selectin and induced by
proinflammatory cytokines
• Pure functional impairment in the absence of
structural change
Bolton et al. J Neurol Neurosurg Psychiatry 1986; 49: 563-573
Hotchkiss et al. CCM 1999;27:1230-1251.
Fenzi et al. Acta Neuropathol 2003; 106:75-82
Hermans et al. Critical Care 2008; 12: 238
Critical Illness Polyneuropathy (CIP)
Increase in E-selectin on epineurium and endoneurium
TNF-, IL-1
Endothelial cell leukocyte adhesion and extravasation
of activated leukocytes within the endoneurium
Tissue Injury
Critical Illness Myopathy (CIM)
• Acute primary myopathy causing muscle
weakness or paralysis in critically ill patientsbut can also coexist with CIP
• 3 Forms: 1) Diffuse non-necrotizing cachetic
myopathy
2) thick- filament myopathy
3) acute necrotizing myopathy
CIP/ CIM -Pathogenesis
• Inactivation of fast Na channels resulting in
reduced excitability - so-called acquired Na
Channelopathy
• NO mediated mitochondrial dysfunction
• Cytokine-mediated activation of the
ubiquitin-proteasome, calpain, lysosomal
systems- intracellular proteolytic systemseffect catabolism possibly to liberate more
amino acids etc.with stress
Brealey et al. Lancet 2002; 360:219-223
DiGiovanni et al. Ann Neurol 2004;55:195-206
Novak et al. J Clin Invest 2009; 119: 1150-1158
•All biopsies were abnormal (6-24 months after ICU discharge)
•No patients were exposed to steroids or paralytics
•Most common abnormality was type II fiber atrophy
•Manifested as narrow angulated fibers; myofibers were reduced to
clumps of myonuclei
•Myofibrillary disarray on EM
•Changes not exclusively attributable to disuse atrophy
Angel et al. 2007 Can J Neurol Sci 34: 427-432
Prevalence and Risk Factors
• True prevalence difficult to ascertain and
varies widely based on case-mix, timing of
examination and diagnostic criteria
• Linked to sepsis, MODS, female sex, use of
corticosteroids, asthma, ionic (Na)
abnormalities, immobility and malnutrition
Hermans et al. Crit Care 2008; 12 : 238
Crit Care Med 2007; 35: 139-145
Crit Care Med 2008;36: 2238-2243
JAMA 2008; 300(14): 1685-1690
Bailey et al. Crit Care Med 2007; 35: 139-145
Crit Care Med 2009; 37:2499-2505
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Each AM, unresponsive patients had passive range of motion for all limbs
Daily interruption of sedation and PT/OT coordinated with this
Once patient able to interact, active assisted/ independent ROM supine
If tolerated, then bed mobility, sitting, ADLs and exercises
Followed by transfer, pre-gait exercises and walking
Treatment program individualized to patient tolerance and stability
Schweickert et al. Lancet 2009; 373: 1874-82
Schweickert et al. Lancet 2009; 373: 1874-82
Phase-specific Approach to Rehabilitation in Critical
Illness:Targeting Muscle, Nerve and Brain during and after
the ICU Stay
Rehabilitation in ICU
Resuscitation
Steroids, NMB
Ventilation
Glycemic
Control
Sedation
Delirium
Treatment
Wakefulness
Early Mobility
Physical Therapy
Serial Measures of Muscle Weakness: MRC, Strength, Function
Serial Measures of Wakefulness, Sedation, Delirium
Kress et al. NEJM 2000; 342: 1471-1477; Morris et al. CCM 2008; 36: 2238-2243;
Bailey CCM 2007; 35: 139-145; Needham JAMA 2008; 300; 1685-90 ; Gosselink et al. Int Care Med 2008; 34: 1188-1199;
Finfer et al. NEJM 2009; Van den Berghe et al. NEJM 2001; 345: 1359-1367; Hopkins and Jackson Chest 2006; 130: 869-78;
Schweikert and Hall Chest 2007; 131: 1541-1549; Schelling et al. Ann N Y Acad Sci 2006; 1071: 46-53.
Physiotherapy for adult patients with critical illness:
Recommendations of the ERS / ESICM Task Force on Physiotherapy
for Critically Ill Patients
Gosselink et al.Int Care Med 2008; 34:1188-1199
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Active or passive mobilization and muscle training should be
instituted early (Level C)
Positioning, splinting, passive stretching should be used to
preserve joint mobility and skeletal muscle length in patients unable
to move spontaneously (Level C)
Physiotherapist should be responsible for implementing
mobilization plans and exercise prescription ( Level D)
Physiotherapists should ensure treatment sessions address
discomfort and anxiety and patient education as needed ( Level D)
Nava S. Rehabilitation of patients admitted to a respiratory intensive care
unit. Arch Phys Med Rehabil 1998; 79: 849-854.
Challenges and Opportunities
 Heterogeneity of ICUAW - ? Pathophysiology
 Importance of early ICU-based mobility and
rehabilitation- ? Role of EMS/ other Tx
 Unclear impact on those with significant impairment
before ICU admission
 Long-term benefit of early mobility/rehab uncertaindoes it just move the ultimate outcome to an earlier
time point?