Sedation and mobility in ICU

Sedation and mobility in ICU

• 1.
  Sedation and Mobility Changingthe Paradigm John P. Kress, MD Critical Care Clinics 29, Jan -2013
• 2.
  • Intensivists prioritisetheir attention to maintenance of homeostasis compatible with survival in Critically ill patients . • Cardiovascular, pulmonary, renal , hematological system traditionally have received the highest priority. • Most trials in critically ill have focused on short-term end points pertaining with those organ system. • We have got support systems and even option of organ transplant for stabilising them. • But only few intensivists foresee physical deconditioning (critical illness neuromyopathy) or cognitive impairment as a complication while handling a critically ill patient.
• 3.
  “Problem statement ” HerridgeMS et al. One-year and five year outcomes in survivors of the ARDS. N Engl J Med 2003;2008 Of the 109 ARDS survivors (median age 45 years) 1 year after ICU discharge - 100 % patients reported loss of muscle bulk, proximal muscle weakness, and fatigue - 50% were unemployed 5 years after ICU discharge - 100 % had ongoing physical limitations (subnormal scores on 6-minute walk tests) - mental component scores had returned to a low-normal level
• 4.
  • What weroutinely do in ICU ? Liberal use of sedatives, analgesics and at times muscle relaxants with resultant active immobilisation • The changing paradigm !!!! Minimal sedation to intermittent sedation + early aggressive mobilisation
• 5.
  Bailey et al.Early activity is feasible and safe in respiratory failure patients (Crit Care Med 2007) 100 patients sat at the edge of bed, moved out to a chair, stood, marched at a spot and even walked, all while still intubated (mechanically ventilated or on SBT ) Prerequisites- Responsive to verbal stimuli, Fio2 <60 % or PEEP < 10 No vasopressors or ionotropes or orthostatic hypotension Results- Of 1500 exercise events performed, 40 % done while still ventilated, with rare adverse events noted.
• 6.
  Morris et al,Early ICU mobility in ARDS (Crit Care Med 2008) First prospective comparative study of Early mobilization Vs Usual care in ICU patients. A total of 330 patients were studied. Each group had one physical activity session daily, difference being the timing of initiating mobilisation . Results – • The early mobilization group was out of bed 5 days sooner • Had a lesser hospital stay by 2 days (both statistically significant) • Adverse events did not occur during any activity sessions. • Control patients who did not receive early mobilization had a significantly higher likelihood of death or readmission to the hospital at 1 year (odds ratio, 1.77 [95% , CI- 1.04–3.01])
• 7.
  Burtin C etal, Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009 In SICU patients, bicycle ergometer was attached to foot end of patients and pedals strapped to the feet. Active movements when awake, passive if asleep.
• 8.
  • Patients dividedas cases and controls. • 84% of cases were intubated and mechanically ventilated • Strength and functional assessments were substantially better in the intervention group at the time of hospital discharge. • The 6-minute walk distance was greater (196 vs 143 m,P<.05), • SF-36 physical function score was better (21 vs 15, P<.05) • The cycling sessions were well tolerated, with only rare adverse events reported
• 9.
  Schweickert WD etal. Early physical & occupational therapy in mechanically ventilated, critically ill patients:a RCT. Lancet-2009 First prospective randomized trial. Methodology – • n= 104 , MICU patients • 58 % were with ARDS, patients included irrespective of MODS • Should have a short period of mechanical ventilation (< 72 hrs) • Should be functionally independent before their ICU admission • Randomly assigned as to cases and control • Cases - underwent a progressive physical and occupational therapy regimen focused on mobilization and achievement of occupational tasks like Activities of Daily iving [ADL] • Controls - usual care, no physical therapy until after they were extubated and shiftable from the ICU.
• 10.
  Only difference inmgt was “Early mobilisation” Other evidence-based strategies like daily sedative interruption, daily SBT, early enteral nutrition, and tight glucose control were offered in both. Primary end point - Return to functional independence 1) the ability to perform ADLs i.e. bathing,dressing, eating, grooming, transfer from bed to chair, toileting) and 2) the ability to walk independently @ hospital discharge. Intervention group- activities possible In bed mobility - 76%, Sitting in a chair - 33% Standing- 33%, Ambulation - 15%
• 11.
  Outcomes Intervetion group Control group P value Primary endpoint met 59 % 35 % 0.02 Discharge to home rather than rehab centre 43 % 24% 0.06 Duration of mechanical ventilation (in days ) 3.4 6.1 0.02 Ventilator-free days 23.5 21.1 0.05 Maximal walking distances (in metres) 33.4 0 0.004 Numbers of ADLs performed 6 4 0.06 ICU delerium days 2 4 0.03
• 12.
  • No differencein amount of sedatives • No adverse events • Premature discontinuation – in 4 % cases only. Needham DM et al. Early physical medicine & Rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010 Medical ICU patients additionally received interactive video games, such as boxing, bowling, and balance board, as part of physical therapy. • Length of ICU stay decreased by an average of 2.1 days and • Length of hospital stay decreased by 3.1 days • Better return to functional independence
• 13.
  To conclude • Theburden of neuromuscular weakness and cognitive impairment is on the rise with better ICU survival. • Uninterrupted liberal sedation without active mobilisation is the major cause for same in critically ill patients in longer run. • Early mobilization of mechanically ventilated patients is feasible, safe, and carries the potential for tremendous benefit for such set of patients • To allow widespread use of such a care model, continued focus on minimization of sedation must occur.
• 16.
  Thank You