Early Mobilization of Ventilated Patients in ICU

[HoJoPhysio]

Hello all, our hospital's ICU is about to commence Early Mobilization of Ventilated Patients by placing all patients on a Sedation Vacation. Does anyone have any information/esperience with this new program. Aside from the benefits, are there any pitfalls and detriments for the patients and the Physio. Has any research been done to examine any airway muscosa trauma ?
Has anyone found this program to be effective ? Of course, before Physio intervenes the patients have to meet medical stability criteria visa vie blood pressure, heart rate and oxygen saturation. My question would be, if the patient is medically stable, why would they still be ventillated. I live and work in the USA and PT is not normally involved in respiratory medicine giving way to Respiratory Therapy. So, I have not done any Respiratory Medicine/Chest Physio ever since I have lived in the USA over 21 year period. So, any input to the discussion would be very much welcomed. Thanks in advance. Howard

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[ICU PT]

Hi Howard,

In Canada, we have seen a significant trend toward early mobilization of intubated/ventilated patient's over the past 5-10 years. Multiple studies have investigated that benefits of early mobilization, with the evidence showing a decrease in muscle atrophy, decreased length of required ventilator support, reduced ICU and hospital length of stay and improved functional outcomes post-d/c from hospital. No increased risk of adverse patient outcomes were observed. But that being said, knowing what to look out for is critical to maintaining staff and patient safety.

In many cases, patients are "stable" from the standpoint that they can tolerate therapy and mobilize, but from a respiratory standpoint (ventilator settings, copious secretions, unable to protect airway), patients are not "stable" for extubation. For many of these respiratory patients, decreasing sedation to improve alertness allows for neurological assessment. In addition, mobilizing these patients in turn improves strength of trunk, extremity and respiratory muscles to aid in the weaning of ventilator settings and improve the chances of effective cough post-extubation.

In my practice, the majority of patients are post-op abdominal surgeries, cardiac arrests/arrythmias and general medical ICU admits, with most being >60 yrs of age. Early mobilization of ventilated patients often includes rolling in bed/ bed mobility, lie to sit transfers, dangling (sitting) at EOB and pivot transfers to chair. Depending on the patients balance and mobility, we will sometimes progress to ambulating intubated patients (but this is often after trach has been done, not usually ETT- but it does happen). When possible, nursing can disconnect any appropriate lines to help reduce the risk of pulling out necessary central/arterial lines.

Determining patient stability for mobilization is obviously critical and comes with experience. As a general rule of thumb, looking at nursing tracking sheets is a good place to start. For example, a patient with a BP of 90-100 systolic may indicate that they are not stable, however, if the patient has maintained this BP for several days without effect, then mobilizing slowly and watching for symptoms and monitoring BP could be appropriate. If the BP recently dropped from 140 systolic then mobilizing would be less likely. The same is true for patients in controlled A fib and sinus tachycardia, etc. The most important thing is to look at the trends.

Patients are NOT typically mobilized if they are on high dose pressors (ie levophed), have recent drop in Hgb (indicating acute bleed), acute increase in troponins, or acute cardiac arrythmias. We also rarely mobilize patients with a Swan Ganz catheter due to the risk associated with arrythmias caused by catheter placement.

Hope this helps!