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Dr. B.L.Kapur Memorial Hospital Department of Physiotherapy and Rehabilitation Critical Care Medicine PHYSIOTHERAPY

Dr. B.L.Kapur Memorial Hospital

Department of Physiotherapy and Rehabilitation Critical Care Medicine

PHYSIOTHERAPY GUIDELINE FOR PHYSIOTHERAPIST

Approved By:

Dr. Mridul Kaushik Head Medical Services

Reviewed & Edited By:

Head of Department Department of Internal Medicine/Critical care medicine

Prepared By:

Dr. Dharam Pani Pandey PT (HOD Dept. Of PT and Rehabilitation)

Dr. Sonia Talreja PT Senior Physiotherapist

Dr. Vashali Bhardwaj PT Senior Physiotherapist

Dr. Ashima Naval PT Attending Physiotherapist

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Goal and Aim of Physiotherapy in Critical Care

Prophylactic

Maintain/improve bronchial hygiene

Prevent Atelectasis

Minimize/Prevent deconditioning Effect of Immobilization

Prevent Pressure Sore

Optimize V/Q Matching

Prevent Proteolysis

o Degradation of Protein from muscle fibre mediated by enzyme Protease

Optimize Neuromuscular Physiology

o Sensory Motor Stimulation

Therapeutic

Remove / Mobilize Retained Secretions

Decrease Work of Breathing

Correct Abnormal Breathing Pattern

Enhance Mucociliary Mechanism

Improve Physical/Functional Activity Tolerance

Improve Muscular Strength/Endurance

Assist In Weaning of Patient from Ventilator

Improve Heamodynamic

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Planning PT Intervention & Goal Setting

Planning PT Intervention & Goal Setting Specific Measurable Achievable Realistic Timed Common Physiotherapy

Specific

Measurable

Achievable

Realistic

Timed

Common Physiotherapy Intervention

Positioning

Postural Drainage

Chest Wall Manipulations

Airway Clearance Techniques

Endo Tracheal Suctioning

Neurophysiological Facilitation

Lung Volume Expansion Techniques

Early Mobilizations

Positioning Physiological Effects

Upright Positioning

o Improves Lung Volumes

o Decreases WOB

Lateral

o Improves V/ Q match

o Airway Clearance

Prone

o

Improves V / Q matching

o

Redistribute Edema

o

Increase FRC

Head Down Tilt

o

Airway Clearance

o

Reduces CO2 Concentration

Postural Drainage

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

11 Positions / 14 Segments

o

Enhances peripheral Airway Clearance

o

Increases Functional Residual Capacity

o

Improves V / Q matching

o

Increases Lung Thoracic Compliance

Chest Wall Manipulations (Improve Mucociliary Motion)

o

Percussion

Frequency 100 480 cycles /minute

o

Vibration

10 to 20 Hz

o

Rib shaking and Springing

Manual Hyper Inflation Effect

o

Slow deep inspiration:

Recruits collateral ventilation thus promoting mobilization of secretions

Enhances interdependence to aid reexpansion of atelectatic segments

Improves gaseous exchange

Assesses and potentially improves compliance.

o

Inspiratory hold(atfullinspiration):

Further utilizes collateral ventilation and interdependence as at higher volume therefore maximizes pressure distribution.

o

Fast expiratory release:

Mimics a forced expiration(huff or cough)

Stimulates a cough.

Active Cycle of Breathing Technique

Relaxed breathing >>>>>>>Deep breaths (2-5)>>>>>>>> Relaxed breathing >>>>>>>> Huffs

Neurophysiological Facilitation(NPF)

Promoting response of neuromuscular mechanism through proprioceptors, Mechanoreceptors.

o Cutaneous and proprioceptive stimulation reflexly increases the depth of breathing .

INDICATIONS:

Non alert patients such as those who are drowsy postoperatively.

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Those with neurological conditions.

Partially breathing patient on ventilator, especially if they are unable to turn.

Lung Volume Expansion Therapy

o

Breathing Exercises

o

Deep Breathing Exercises

o

Segmental Breathing

o

Diaphragmatic Breathing Exercises

o

Costal Breathing

o

Pursed Lip Breathing

o

SMI (Sustained Maximum Inspiration)

o

PNF Techniques Bilateral D2 Symmetrical Flexion Pattern

Endo Tracheal Suctioning Suctioningisdescribedasthemechanicalaspirationofpulmonarysecretionsfromapatientwithanartificial airwayinposition.(AARC)

Early mobilisation

o

Improves Respiratory Function

o

Optimizes V / Q Match

o

Increases Lung Volumes

o

Improves Airway Clearance

o

Reduces Adverse Effects of Immobilisation

o

Increases Level of Conscious

o

Somatosensory Stimulation

o

Increases Functional Independence

o

Preventing ICU Syndrome

o

Prevent antigravity muscle Proteolysis

o

Prevent ICU Induced Polyneuropathy Myopathy Pyschosis

Evidence in Practice (Physiotherapy in ICU)

Strong Evidence

PT for Atelectasis

Prone position ARDS

Side lying Unilateral Lung Disease

Continuous Rotational Therapy

Multi Modality PT

Early Mobilization

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Moderate Evidence

MHShort term Effect

Conventional PTShort Term Effect

Postural Drainage

PT In Pneumonia

Remember : A hammer in a carpenter’s hand is not always used to pull out a nail…

Therapist working in the ICU should be aware about the entire setup and should consider the advantages and disadvantages of the various techniques in order to optimize the outcome.

Therapeutic Consideration as per various vital parameters, Lab values and monitoring

A) Vital Signs

a. Obtain parameters from order entry

i. Heart rate (HR): 50-120, avoid 20 bpm increase in HR

ii. Systolic blood pressure: 90-150, avoid 20mmHg increase in blood pressure (BP)

iii. Oxygen saturation: >90%

iv. Respiratory rate (RR): <30 resting do if special recommendation or it may be the congestion it self

May need to clarify specific parameters with doctor consultant.

B) Lab Values:

May need specific clarification for activity orders per consultant

a. Complete Blood Count (CBC)

i. Hematocrit (Hct): normal= 40-54 for males, 36-48 females

ii. White Blood Cells (WBC): normal 4,000-10,000 for males and females

iii. Red Blood Cells (RBC): normal 4.5-6.4 for men, 3.9-6.0 for women

iv. Hemoglobin (Hgb): normal 13.5-18 for men, 11.5-16.4 for women

v. May need to hold treatment, or consult ICU Incharge consultant. If there is a significant decreased in levels from previous day, or:

1. Hct <20

2. Hgb <8

b. Platelet count: normal= 150,000-450,000 i. <10,000= functional activity only

ii. 10-20,000= ambulation, functional mobility, therapeutic active exercise (including no resistive exercises, AROM and isometric exercises allowed), stationary bike (without resistance)

iii. 20-50,000 all of the above, may increase resistance of exercise to 2 kg

iv. 50-150,000 continue progression of program. Resistance must remain <2 kg

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

c. Normal Values for Blood Gases

i. pH: measures blood acidity, 7.35-7.45

ii. PaCo2: partial pressure of carbon dioxide dissolved in arterial blood (related to

pulmonary function), 35-45 mmHg

iii. HCO2: amount of bicarbonate or alkaline substance dissolved in blood (related to metabolic function), 22-26 mHg/L

iv. PaO2: partial pressure of oxygen dissolved in arterial blood, 80-100 mmHg

v. O2 sat: percentage of oxygen carried by hemoglobin, 95-98%

d. International normalized ratio (INR): normal value 1.0-2.0, therapeutic range 2.0-3.0. Obtain

activity orders from consultant. if INR >3.0, or <1.0. Hold PT with INR >4.0

C) Monitoring

a. Electrocardiographic recording- ECG

i.

Noninvasive, continuous monitoring of heart rate

 

ii.

Telemetry unit will be located next to the patient’s bed

 

iii.

Position telemetry unit in view for both therapist and nursing during treatment

iv.

Hold

treatment

with

new

cardiac

arrhythmia,

HR

>150,

ventricular

dysrhythmias, or heart blocks (2 nd and 3 rd degree)

b. Pulse Oximetry

i. Noninvasive, continuous monitoring of oxygen saturation

ii. Detects alternating intensity of oxygenation

iii. Will find probe on finger or ear. Probe must be maintained on patient during

treatment

c. Hemodynamic Monitoring

i. Invasive monitoring of cardiovascular status

ii. May use arterial lines, central venous pressure (CVP) lines, pulmonary artery lines or intra-aortic balloon pump (IABP)

iii. Please see below listed precautions for each line

d. Temperature

i.

Monitoring of patient’s core temperature with rectal line or manual assessment with temperature probe

ii.

Be cautious of rectal line with mobility as this is easily dislodged

D) Lines, Tubes, Drains:

Prior to initiating treatment, take note of each line and tube to avoid dislodging during mobility. Ask for the appropriate assistance when necessary, and check with nurse about lines/tubes that may be disconnected prior to treatment.

Specific precautions and contrainidications.

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a. Arterial Lines

i. Direct arterial puncture for monitoring of blood pressure and central access to arterial blood gases

ii. Generally uses radial artery or femoral artery

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

iii. Do not flex involved limb at site of insertion. May see flat board attached to wrist if radial line is used

iv. If femoral artery is used, patient generally is on bed rest, and no hip flexion allowed on involved side

b. Central Venous Pressure (CVP)

i. Invasive, measures the blood pressure in the large veins of the body

ii. Monitors venous pressures by an indwelling catheter and a pressure manometer

iii. No range of motion (ROM) restrictions

iv. Allows venous blood sampling, medication administration, nutrition or transfusions

v. Could be part of a triple lumen catheter

vi. Normal values in the right atrium are 0-8mmHg

c. Intraaortic Balloon Pump (IABP)

i. No PT intervention except for positioning and splinting

ii. Involved hip must remain in extension, and immobile

iii. Patients with IABP are usually unstable, and not appropriate for therapeutic

exercise programs. Specific orders may be placed by doctor for exercise of the uninvolved extremity.

d. Pulmonary Artery (PA, or Swan-Ganz) line

i. Invasive monitoring, usually for patients that may be hemodynamically unstable

ii. Usually, patients are on bed rest and are not appropriate for PT, except for splinting and positioning

iii. If there are questions, staff members should discuss with their supervisor

Physiotherapist and ICU Doctor in charge prior to initiating treatment

iv. If the patient is stable with the PA line, specific orders need to be provided by the consultant., and occasionally include bed to chair and therapeutic exercise

v. Avoid ROM and therapeutic exercise to ipsilateral shoulder secondary to risk for dislodging or causing arrhythmias with line movement

vi. Patients may have a locked PA line, which prevents movement of the line. Clarify with

nurse prior to treatment. Ipsilateral shoulder may be flexed 90 degrees and functional

use of bilateral UE is allowed

e. Ventriculoperitoneal Shunt (VPS):

i. Patients are generally on bed rest for 24 hours with head of bed flat

ii. Gradual elevation of HOB and out of bed activity orders will be generally be

ordered by consultant. on post op day 1

f. External Ventricular Drainage System (EVD):

i Consultant.order is required for all out of bed mobility. Nurse must clamp the EVD prior to initiating mobility, and generally do not clamp >30min

ii. Head of bed usually kept elevated 30 degrees

iii. Do not adjust the height of the bed since it will change the relationship between

the level of the patient’s ventricular system and the external drain. The external auditory meatus or tragus is the anatomical reference for the correct drain

alignment.

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

iv. Normal intracranial pressure (ICP) range is 4-15mmHg. A monitor may alarm at 20 mmHg

v. Avoid activities that may increase ICP including:

1.

flat supine and trendelenberg positioning

2.

pain

3.

agitation

4.

extreme hip flexion

5.

extreme lateral neck flexion

6.

valsalva maneuver

7.

coughing

8.

isometric exercises

g. Lumbar Drain

i. Consultant. order required for all out of bed mobility. Nurse must clamp drain prior to mobility, and generally do not clamp >30min

ii. Alignment is the same for EVD, nurse must realign device level once returned to static

position

h. Epidural Catheter

i. Must check in chart/flow sheet, or with nurse to determine level of epidural catheter

ii. Patients with a lumbar epidural will have impaired circulation/sensory/motor function at all levels for B/L LE, therefore, out of bed mobility is contraindicated

until 4-6 hours following a capped, or stopped epidural.

iii. Patients with a thoracic epidural, usually s/p abdominal or thoracic surgery should have intact circulation/sensory/motor above and below level of epidural

1. Always assess circulation/sensory/motor function prior to initiating out of bed activity. If circulation/sensory/motor function is impaired, do not progress to weight bearing activities.

2. May progress to ambulation if circulation/sensory/motor function is intact

i. Feeding Tubes

i. Types include: nasogastric tube (NG tube), gastrostromy tube (G-tube or PEG) and jejunostomy tube (J-tube, PEJ)

ii. Provides short to long term nutrition

iii. Caution with line placement during mobility

iv. Place feeding tube on hold when patient is lying flat

j. Hemofiltration (CVVH, plasmophoresis, HD)

i. Continuous venovenous hemofiltration (CVVH) vs. Hemodialysis (HD, non-continuous)

ii. Filter system used to remove fluid and solutes to clean the blood

iii. Plasmophoresis used to separate plasma from blood solute to remove unwarranted antibodies within the blood

iv. Usually through femoral line- see precautions listed above for femoral line in lines, tubes, drains section

Hold PT or may done on specific order or if it is deemed required

k. Vacuum Assisted Sponge Dressing (VAC)

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

i. Do not disconnect VAC sponge without specific order from consultant. Occasionally, the VAC sponge may be clamped prior to ambulation, and nurse will assist with this.

ii. The VAC sponge power source will switch to battery automatically when unplugged from the outlet source.

l. Chest Tube (CT)

i. Patient must remain on suction at all times, unless specified by consultant. Can also be placed on water seal, H2O seal per consultant order. Speak with an experienced therapist, or ask for assistance from nurse for transferring patient from wall suction to portable suction for mobility as necessary.

ii. Defer PT after CT removal until chest x-ray (CXR) follow-up, unless therapist received specific order from consultant

iii. In those cases, monitor O2 sats throughout intervention, and discontinue therapy if O2

<90%

m. Ventricular Assistive Devices (VAD) i. LVAD (left VAD), RVAD ( right VAD), BiVad ii. Provides circulatory support to one or both ventricles of the heart iii. Most often used in situations in which the IABP fails, intraoperative cardiac emergency warrants, bridge to transplant, or life-prolonging circulatory assistance

n. Temporary pacemaker (external pacemaker)

A. Two types:

i. Epicardial wires placed during cardiac surgery 1. No UE ROM limitation as the wires are transthoracic

ii. Transvenous pacing wires 1. No ROM assessment of thorax to the involved shoulder as the wires are placed through juglar or subclavian line

iii. If a patient is 100% dependent on pacing wires, mobility and PT are

contraindicated secondary to cardiac instability

iv. If the patient is on a “back-up” mode, clarify activity parameters. Use caution to avoid dislodging the wires during mobility

v. After the epicardial wires are discontinued, and there are no signs of cardiac tamponade:

vi. Patient may be out of bed with nurse in room after one hour of bedrest

vii. Patient may participate in PT on post-op day after two hours

viii. Patients may initiate or resume stair training after four hours

j) Semi permanent pacer

i. Generally used as a bridge to permanent pacing for patients who are not medically appropriate for permanent pacemaker

ii. Clarify activity orders with consultant and electrophysiologist prior to initiating treatment

iii. Pacer is sutured subcutaneously, therefore, mobility and ipsilateral shoulder ROM is generally allowed as tolerated

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

E) Ensure patient has had stable ECG for 24 hours prior to initiating treatment. The use of the following medications, usually through intravenous (IV) drips, indicates that the patient is hemodynamically unstable. Assess timing of intervention in regard to the patient’s medication schedule and assess appropriateness for PT when a new medication is added.

a. Nitric Oxide (NO)

i. Need specific activity orders for these patients

ii. Must maintain correct ratio of NO/FiO2, therefore do not adjuct FiO2 during

treatment

iii. Consult doctor as needed

b. Dopamine

i. PT intervention allowed if dose <5 (renal dose)

ii. Must have specific activity orders if dosage is >5 mcg/kg

Consult ICU Incharge For assistance regarding Medicine.

i. Hold all PT intervention except positioning and splinting when the following medications are used:

i. IV nitroglycerin (NTG)

ii. Streptokinase

iii. Nipride of Nitroprusside (SNP)

iv. Epinephrine (epi)

v. Norepinephrine

vi. Neosynephrine (neo) or Phenylephrine

vii. Lidocaine

F) Deep Vein Thrombosis (DVT)

a. Signs/Symptoms of DVT in the extremity include:

i. Pain and swelling distal to the thrombus

ii. Localized redness and warmth

iii. Low grade fever

iv. Dull ache or tightness in the region of the DVT

b. Positive Homan’s Sign: pain in calf with forced dorsiflexion

c. Hold PT until cleared by consultant. Diagnostic testing included UE/LE noninvasive study (LENIS/UENIS)

d. Avoid PT until the patient is therapeutic on anticoagulation medication, usually within 24-72

hours.

e. Patient may need an inferior vena cava (IVC) filter placed if there is a high risk for pulmonary embolism (PE)

i. Placed on bed rest for 6 hours following the procedure

ii. PT may resume once activity orders are advanced.

G) Pulmonary Embolism

a. Signs/Symptoms may include:

i. Tachycardia

ii. Possible chest pain

iii. Rapid onset of tachypnea

iv. Anxiety

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

v. Lightheadedness

vi. Dysrhythmia

vii. Hypotension

viii. Decreased oxygen saturation

b. Complications of a DVT are a medical emergency. Notify nurse immediately.

H) Blood Transfusion

a. Usually hold PT until blood transfusion is completed. Exceptions may include positioning interventions, or specific orders from consultant. Speak with an experienced therapist and consultant prior to initiating treatment.

b. One unit of blood takes approximately 3-4 hours to transfuse

c. Most adverse reactions to blood transfusions occur within first 15 minutes of the transfusion. Vitals signs are taken every 15-30 min by nursing staff

d. Observe for the following signs/symptoms of possible allergic or adverse reaction to the transfusion:

I) Specific Testing

i. Low grade fever

ii. Chills

iii. Myalgias

iv. Hypotension

v. Tachypnea

vi. Emesis

vii. Headache

viii. Flushed skin

ix. Anxiety

x. Tachycardia

xi. Severe cough

xii. Diarrhea

a. Rule Out (R/O) myocardial infarction (MI) Protocol

i. Consultant determines R/O. Usually three sets (one every eight hours) of cardiac enzymes (CK-MB and Tn-I) and ECGs

ii. Strict bed rest and defer PT until R/O is complete

iii. If the patient rules in for a new MI, new activity orders must be obtained from

consultant prior to proceeding with PT intervention.

b. Cardiac Catheterization

i. Generally activity orders are as followed:

1. Left heart cath: bed rest x 6-8 hours with involved LE straight. Patients may have knee immobilizer donned to prevent hip flexion 2. Right heart cath: no restrictions, consider patient’s tolerance to anesthesia 3. Can be used for diagnostic and/or interventional purposes when a stent is deemed appropriate for a non-patent vessel.

c. Cerebral Angiography

i. Patients are on bed rest for 6-8 hours, with involved hip and knee immobilized

ii. Defer therapy until activity orders are advanced

iii. Used for diagnosis and possible treatment of carotid artherosclerotic lesions

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

d. Lumbar Puncture

i. Patients are on bed rest for 4-6 hours following procedure

ii. Short term complications, and indications to hold PT until pt is stable or cleared by

consultant for out of bed activity include: headache, backache, bleeding at needle site, CSF leak, voiding difficulty and fever

iii. Used for diagnostic purposes and for short term relief of hydrocephalus

e. Myelography

i. Depending on type of dye used, patients may be on bed rest with specific out of bed

instructions

ii. Short term complications, and/or indications to hold PT for additional time, include:

headache, back spasm, fever, nausea or vomiting

iii. Used for diagnostic purposes for imaging of spinal column

Considerations for Appropriateness of Treatment:

A) Mechanical Ventilation

a. Types of intubation include: endotracheal (ETT, short term), nasotracheal (NTT, short term) or tracheostomy tube (long term, chronic)

b. A cuff is inflated around the tube to ensure that the air is being delivered directly to the lungs

i. If a cuff leak is suspected, the pt may be able to phonate or make audible sounds from mouth. Nursing should be notified immediately

c. Modes vary depending on the needs of the patient and will be determined by the consultant and ICU incharge. Control mode is the most dependent level, and progresses to intermittent mandatory ventilation (SIMV), pressure support volume (PSV) and continuous positive airway pressure (CPAP), until extubation.

d. Be cautious with progressing activity during weaning period as patient may be less tolerant to exercise as the demand on respiratory system increases. Signs of distress may include: autonomic changes, paradoxical breathing, tachypnea, agitation, panic, diaphoresis, cyanosis, angina and arrhythmias.

e. Patients who require prolonged ventilatory support are at risk for developing respiratory muscle atrophy, skin breakdown, contractures and deconditioning.

B) Pharmacology

a. Common agents used in the ICU settings include paralytic, sedatives and analgesics. Cardiovascular medications previously mentioned in the Lines, Tubes and Drains section above.

i. Narcotics are used for the analgesic effect. Side effects may include: hypotension, gastric hypomobility, and respiratory depression.

• Examples: morphine, fentanyl

ii. Benzodiazepines are used to promote amnesia to pain. Known for anticonvulsant and muscle relaxant properties. Side effects include delayed recovery secondary to accumulation of the drug in fat, and high potential for physiological and psychological dependence.

• Examples: diazepam, midazolam, lorazepam

iii. Barbituates are used for sedation, and tend to heighten pain intensity/awareness.

Side effects may include cardiovascular depression, cerebrovascular

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

vasoconstrictors and high potential for physiological and psychological dependence.

• Example: phenobartbital

iv. Neuromuscular paralytic agents are used to decrease or stop muscular contractions.

Indicated in surgical interventions, endotracheal intubation, intractable convulsive

activity, and/or prevention of increased intracranial pressures for patients with head injuries. Side effects may include: unrecognizable signs of distress, skin breakdown, and abnormal histamine responses causing hypotension and bronchospasm.

• Examples include: pancuronium, doxacurium, vecuronium

C) Effects of Anesthesia

a. Many patients in the ICU are status post surgical intervention and in the recovery phase, and have a recent history of an anaesthesia.

b. General effects include:

i. Neurological: decrease cortical and autonomic function

ii. Cardiovascular: potential for arrhythmias, decreased BP, decreased

myocardial contractility and peripheral vascular resistance iii. Respiratory: decreased arterial oxygenation, decreased surfactant, decreased airway reflex

c. Most common post-op complications include:

i. Neurological: delayed arousal, agitation, altered consciousness, cerebral

edema, seizure, stroke, peripheral muscle weakness

ii. Cardiovascular: hypotension, hypertension, dysrhythmia, MI, DVT, PE

iii. Respiratory: airway obstruction, hypoxemia, hypercapnia, pulmonary

edema

iv. General: acute renal failure, urine retention, abdominal distention,

hypothermia, sepsis, hyperglycemia, fluid imbalance, acid-base disorders

D) Communication Barriers

a. Patients may have difficulty with communication secondary to tubes obstructing their vocal cords (i.e: ventilation), pharmacologic intervention, neurological or musculoskeletal impairments

b. Factors influencing effective communication include: level of arousal, physical limitations, visual impairments, speech/language impairments, letter/number recognition, and ability to recognize familiar pictures

c. Alternative forms of communication may include: visual cues, such as a communication board (OT can assist with introducing this device), nod yes/no, hand signaling, sign language with appropriately trained professional, and passe- muir valve to allow the trached patient to speak through a one way valve expiring air to pass through the larynx. Speech and Swallowing will need to be consulted for introduction and training to the valve.

d. All alternative forms of communication need to be assessed for accuracy and reliability prior to use.

E) Effects of Prolonged Bed Rest

a. Musculoskeletal:

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

i. Muscle: muscle atrophy, decreased strength and endurance, potential contractures, weakened myotendinous junctions and tendon and ligament insertion on bone

ii. Bone: osteoporosis

iii. Joints: cartilage degeneration, synovial atrophy and ankylosis

b.

Cardiovascular

 
 

iv. At rest: increased heart rate, decreased stroke volume, decreased cardiac size and volume

v. With exercise: increased heart rate with submaximal exercise, decreased

 

VO2 maximum, decreased stroke volume, decreased cardiac output

 

vi.

In general: increased risk for venous thrombosis, decreased blood cell flow or increased blood viscosity

c.

Neuromuscular vii. Orthostatic intolerance

e.

Fluid Balance i. Decreased volume, including total blood volume, decreased red blood cell mass and loss of mineral and plasma protein

f.

Skin

i. Potential for skin breakdown secondary to prolonged pressure over bony prominences and decreased mobility

F) Potential Neuropathy and Myopathy Related to Critical Illness a. Critical illness polyneuropathy may be a common complication which presents 7 or more days following onset of severe sepsis.

I. Pt will most likely require mechanical ventilation.

II. Will have limb muscle weakness/atrophy, reduced or absent deep tendon

reflexes, loss of peripheral sensation to light and sharp touch. Cranial nerves usually intact.

III. Recovery of patients with mild to moderate injury will take weeks to months. Some residual nerve dysfunction noted several years post onset.

b. Critical illness myopathy is also associated with sepsis and multi-organ dysfunction. Muscles may be damaged through direct effects of toxins or via inflammatory mediators.

I. Nerve and muscle injury may occur sequentially.

II. Normal deep tendon reflexes, normal sensation, diaphragmatic weakness and spared facial muscles

G) Acid-Base Metabolic Disorders a. Respiratory Acidosis- CO2 retention

i. May result from hypoventilation, ventilation/perfusion mismatch, CNS injury, or airway obstruction

ii. Signs may include: diaphoresis, headache, tachycardia, agitation, cyanosis, lethargy, ventricular fibrillation

iii. Lab values: pH <7.35, PaCo2 >45 mmHg, HCO2 >26 mmHg/L

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

b. Respiratory Alkalosis- CO2 excretion

i. May result from hyperventilation, or respiratory stimulation

ii. Signs may include: rapid deep respirations, light-headedness, muscle twitching, anxiety and fear, parasthesias, cardiac arrhythmias

iii. Lab values: pH : 7.45, PaCO2 <35 mmHg, HCO2 >26 mmHg/L

c.

Metabolic Acidosis- HCO2 loss or acid retention

i. May result from renal disease, excessive production of organic acid due to endocrine disorder, decreased excretion of acids due to hepatic disease

ii. Signs may include: rapid, deep respirations, headache, lethargy, drowsiness, nauseas, vomiting, coma, cardiac arrhythmias

iii. Lab values: pH <7.35, HCO2 <22mmHg/L

d. Metabolic Alkalosis- HCO2 retention or acid loss

i. May result from loss of HCL (prolonged vomiting or gastric suctioning), loss of K (diuresis), or excessive alkali ingestion

ii. Signs may include: slow shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, convulsions, coma, cardiac arrhythmias

e.

Rehab implications

i. Metabolic disorders requiring medical intervention to reverse states

ii. Patient may be less able to participate in therapy, or treatment session must be tapered to the patient’s needs and tolerance. Avoid changing the percentage of FiO2 without notifying nurse or consultant as this will shift the patient’s acid-base balance.

Examination:

1) Chart Review

A. HPI & PMH

• Onset and duration of symptoms and reason for admission to hospital

• Presence of disability and functional limitations prior to admission

• Prior medical/surgical history

• Systems review

B. HC

• Previous and ongoing medical and/or surgical treatment, date of procedures and any post- op complications

• Pertinent laboratory and diagnostic tests

• Cardiac and pulmonary status, including need for medical intervention for stability and use of ventilatory support

C. Medications

Type

of

medications,

side

contraindications/precautions

2) Social History

effects

and

rehab

implications.

Please

see

the

listed

• Home environment and current/potential barriers to returning home

• Family/caregiver support system available

• Family, professional, social and community roles

• Patient’s goals and expectations of returning to previous life roles 3) Physical Examination

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Select the appropriate examination measurements depending on patient’s diagnosis and ability to participate in therapy. Patients may be limited in ability to communicate/participate secondary to medication or ventilation dependence. Please see above section on considerations for additional information.

• Vital Signs (HR, BP, RR, SpO2) and subjective response to intervention

• Skin Integrity: areas for potential skin breakdown, temperature, edema and any surgical

incisions

• Pain

• Respiratory Pattern

Sensation

• ROM

• Strength and Motor Function

• Tone

• Balance

• Endurance

• Postural Alignment

• Mobility

• Positioning

4) Cognitive-Perceptual and Psychological Considerations

• Mental Status

o

Level of alertness, orientation, and ability to follow commands

o

Safety Awareness

• Psychological Considerations

o Assess patient’s coping mechanisms to altered functional status

• Teaching/Learning Considerations

o

Patient’s goals, motivators and learning style

o

Patient’s ability to comprehend and apply information

Evaluation / Assessment:

The primary goal for inpatient physiotherapy for a patient with a critical illness requiring intensive care is to maximize functional independence while minimizing impairments as a result of the illness and hospital admission. Potential impairments may include but are not limited to impaired cognition, ROM, endurance, strength, skin integrity, respiratory capacity, balance, and patient knowledge regarding exercise progression during and after their acute hospital course. The predicted optimal level of improvement for these patients is to return to their previous level of function in their homes, community and work environments and resume their previous life roles. The timeframe for optimal recovery is widely variable impairments and functional impairments that may result from multi-organ dysfunction and disorders of the central and peripheral nervous system. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patient’s ability to achieve functional independence. Collaboration with the critical care team is essential in forming the PT prognosis as the consultant and nurse can provide valuable information on the expectations for the patient’s medical recovery. Age specific considerations in this population include all the normal physiological changes that occur with aging. Look for more details. The physiotherapist will consider all of the patient’s impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient.

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Individual and measurable goals should be formulated for each patient, taking into consideration the patient’s medical, physical and cognitive status and their own goals for recovery. Suggested goals (1-6 weeks) may include:

1) Maximize functional mobility 2) Normalize tone and motor function 3) Minimize abnormal movement patterns 4) AROM UE/LE, as appropriate 5) Strength grossly >3/5 throughout bilateral UE/LE, as appropriate 6) Improve patient’s ability to participate in guided exercise 7) Maintain stable vital signs 8) Prevent loss of ROM and function by proper positioning and splinting 9) Maximize safety awareness with all functional mobility

Treatment Planning / Interventions Established problem list and Plan of treatment Established Protocol This section is intended to capture the most commonly used interventions for this ICU patients. It is not intended to be either inclusive or exclusive of appropriate interventions. Intervention Initiate physiotherapy intervention, as appropriate, given the patient’s medical status, precautions and activity orders as indicated by the physician’s orders. Refer to the above listed precautions/contraindications and additional information. 1. Functional Mobility • Bed mobility, rolling, bridging, and supine sit activities. • Transfer training, ( bed chair, wheelchair, commode) use of adapted equipment as appropriate

2. Balance Training

• Sitting and standing activities as appropriate

3. Gait Training

• Pre-gait activities.

• Assistive device prescription as indicated.

• Progress to stair navigation, as appropriate, prior to d/c to home

4. Positioning Techniques

• Initiate program to maintain ROM and skin integrity, and prevent deformities secondary to prolonged bedrest

5. Facilitation of normal movement patterns

6. Therapeutic exercise program

7. Endurance training

8. Lower extremity splinting and bracing

Patient/Family Education

1. Discuss realistic expectations regarding function, appropriate level of assist that the patient requires from family and their anticipated rehab progression

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

2. Provide emotional support to the patient and their family as needed 3. Instruct the patient on safe activity progression, applicable precautions (i.e. craniotomy precautions) 4. Instruct the patient and family members in the following and assess their understanding via return demonstration:

• Therapeutic exercise and endurance program

• Safe mobility techniques to encourage maximal independence

Frequency & Duration Patients will have follow-up physiotherapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his or her impairments and functional limitations.

Recommendations and referrals to other providers Discuss the patient’s needs for additional services with the primary team. A patient may benefit from the following services if appropriate:

1. Occupational Therapy: If a patient presents with impairments that affect his or her ability to perform activities of daily living independently and/or who may have adaptive equipment needs. Occupational therapy should be consulted for any patient with a new onset of cognitive impairments.

2. Speech and Swallowing: If a patient presents with impairments that affect his or her ability to swallow difficulty and/or a new communication impairment.

3. Care Coordination: If a patient has a complicated discharge situation and the care coordination team is not involved.

4. Social Work: If a patient has a complicated social history and pt and/or family require additional support or

counselling. Re-evaluation / assessment Reassessment will occur under the following circumstances: within 10 days from the previous assessment, all physical therapy goals are met, significant change in medical status occurs, prior to discharge from services or facility, and/or failure to respond to physical therapy interventions. Discharge Planning Discharge planning will occur on an individual basis depending on the patient’s medical, physical and social needs. Discharge planning is a coordinated effort that occurs with the physician, care coordinator, nurse, physical and

occupational therapists, the patient and his or her family. status, but the acuity of the patient’s needs is less. Physiotherapy will remain involved on the step-down ward, and further assist with discharge planning. If the patient continues to have significant impairments and functional limitations and/or complicated medical needs at the time of discharge from the acute hospital, he/she may be discharged to an acute or sub-acute rehabilitation facility, skilled nursing facility), or extended care facility. The patient will continue to progress towards their physiotherapy goals at the alternate inpatient facility. If the patient has met all inpatient physiotherapy goals and is medically stable, he/she may be discharged to home with or without services. Consider the following resources for continued therapy:

• Home PT

• Outpatient PT for patients who have a high level of function but continue to have specific impairments

• Outpatient Occupational Therapy Cognitive Clinic

• Adult Day Programs

References

1. APTA Guide to Physical Therapy Practice, Second Edition. Physical Therapy 81: (1); 2001.

2. Ambrosino, N, Clini E, et. al. Supported Arm Training in Patients Recently Weaned from Mechanical Ventilation. Chest. 2005. 128:

2511-2520.

3. Arnall, D. Paralytics. PT Magazine. 1996. 4(1): 13,18.

4. BWH Department of Rehabilitation Services Guidelines for frequency of physical therapy patient care in the acute-care hospital setting.

5. Campbell, A, Dicker, R, et. al. Effects of Tidal Volume on Work of Breathing During Lung-Protective Ventilation in Patients with Acute Lung Injury and Acute Respiratory Distress Syndrome. Crit Care Med. 2006. 34(1):8-14.

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

6. Criner, G, Gaughan, J, et. al. Impact of Whole-Bosy Rehabilitation in Patients Receiving Chronic Mechanical Ventilation. Crit Care Med. 2005. 33(10): 2259-2265.

7. Fenzi, F, Latronico, N. Critical Illness Myopathy and Neuropathy. Lancet. 1996. 347: 1579-1581.

8. Ghasemi, Z, Martin, T. The Role of the Physical Therapist in the Intensive Care Unit. PT

9. Greenleaf, JE. Intensive Exercise Training During Bed Rest Attenuates Deconditioning. American College of Sports Medicine. 207-215.

1997

10. Hansen-Flaschen, J. Neuromuscular Disorders of Critical Illness.

11. Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark, CT: Prentice Hall, 1994.

12. Nava, S. Rehabilitation of Patients Admitted to a Respiratory Intensive Care Unit. Arch Phys Med Rehabil. 1998. 79: 849-854.

13. Paz JC, West MP. Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinmann. 2002.

14. Polich S, Faynor SM. Interpreting Lab test Values. PT Magazine. 1996;76-88.

15. Stiller, K. Physiotherapy in Intensive Care Towards an Evidence-Based Practice. Chest. 2000, 118:1801-1813.

16. Wheeler, AP. Sedation, Analgesia, and Paralytics in the Intensive Care Unit. Chest. 1993; 104:566-77.

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Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist