Transcript Mobilization in the Critical Care Unit

Mobilization in the Critical Care Unit
(How It Works)
Craig Moreland, PT, MS
Director of Physical Therapy, UPMC Presbyterian,
Montefiore, and Western Psychiatric Institute & Clinic
Annual PM&R Assembly
The Physical Therapist’s Role in
the ICU
• 3 main goals:
1. Optimize oxygen transport and the function
of its supporting systems
2. Reduce multi-system complications
3. Maximize functional recovery and
minimize diffuse atrophy
What we, as therapists, need to
know…
• Basic cardiopulmonary pathophysiology
• Complications of bedrest and physiologic change
associated with deconditioning
• Common ICU medications
• Emergency procedures
• Role of the other ICU team members
• All monitoring equipment
• Ventilator and respiratory equipment
The Physical Therapist Evaluation
• Previous Level of Function
• Mental Status
• Time of DIS (Daily Interruption of
Sedation)
• Assessment of Lines, Tubes,
and Drains
What We Need to Coordinate to
Set Us Up to Succeed!
• Timing is Everything!!
Medications (pain, anxiety)
Sedation Interruption
Weaning Trials
Respiratory Therapy
Occupational Therapy
Nursing
~The Mobility Team~
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Physician
Nursing Staff
Pharmacist
Occupational Therapist
Speech Therapist
Physical Therapist
Respiratory Therapist
Rehabilitation Aides
The Action! What Can We Do?
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Positioning
Postural Drainage
Cough Assist
Splinting
Exercise
Transfer, ADL, and Balance Training
Ambulation
Education (invaluable)
Therapy ICU Intervention:
Positioning and Postural Drainage:
 Position the patient for respiratory success (eg. Anterior vs. Posterior
Pelvic Tilt)
 Postural drainage is accomplished by positioning the patient so that the
position of the lung segment to be drained allows gravity to have its
greatest effect
 We to remember to write signs in the patient’s rooms to increase
communication…
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Patient is in semi-left-sidelying to drain the right middle lobe for 30-45
minutes for optimal respiratory mobilization; patient positioned at 10:30am
Therapy ICU Intervention
Exercise:
Get Family Involved
Educate Nursing
Strengthen Respiratory Musculature
Primary: Diaphragm, Intercostals
Accessory: Sternocleidomastoid, Scalene
Therapy ICU Intervention
Cough Assist:
 Asthma Patient:
~teach a “pump cough”
~a forceful prolonged exhalation can lead to distress
 COPD Patient:
~difficulty with expiration
~do not teach “take a deep breath”
~controlled small breaths
 Neuromuscular Paralysis:
~maximize airway clearance
~make sure the patient can swallow safely
~position for success, couple extension & inhalation, couple flexion & exhalation
Therapy ICU Intervention
Prior to initiating our mobility project,
we needed to train all staff in…
• Body Mechanics
• Proper Lifting
• Safety with Functional Transfers
• Proper Guarding Techniques
Therapy ICU Intervention
Transfer and Balance Training:
 Monitor the Ventilator and Vital Signs
 Blood Pressure with Change in Position
 Transfers are the mainstay of our ICU treatment sessions
 Who is doing what to ensure safety???
 ONE PERSON IN CHARGE
 We always try incorporate quality of life into our
treatment sessions!!
Safe Mobilization with Multiple
Lines, Tubes, and Drains
Arterial Line
EVD
Central Line
IABP
Chest Tube
Licox Monitor
Dialysis Catheter
Sheath
ECMO
Swan-Ganz Catheter
Who Does What?
• Setting Up the Room
• Scanning the Lines, Tubes,
Drains
• Scanning the Ventilator
• Inspecting the Patient
• Who Holds What Line?
• What is each healthcare worker’s role?
Therapy ICU Intervention
Ambulation is Our Ultimate Goal!!
• Preparation
• Multi-disciplinary Approach
• Portable Ventilator Available?
Education is Invaluable!!
• Patient, Family Member, Health Care Team
Therapy ICU Intervention
What Equipment will the mobility team
need?
Ventilator, Ambu Bag, or Portable Oxygen
Portable Monitor or Pulse Oximeter
IV pole
Lines, tubes, drains
Assistive Devices
Chairs
When Does the Therapist Modify
Activity???
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FiO2 greater than 60%
PEEP greater than 10 cm H20 pressure
Consistent O2 Saturations less than 92%
Hx of desaturations with positional changes
Unstable Blood Pressure
Severe Acidosis with pH less than 7.30
~~~While many of these may not be absolute contraindications
to mobilization, they should be cause to stop and discuss
with the medical and nursing team prior to continuing~~~
Just Remember…
~~~The most important skill for a
therapist to develop in the Critical
Care Unit is to recognize when to
initiate, delay, progress, and
terminate treatment~~~