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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:

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mobilization in the critical care unit how it works

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
The Physical Therapist’s Role in the ICU
  • 3 main goals:
  • Optimize oxygen transport and the function of its supporting systems
  • Reduce multi-system complications
  • Maximize functional recovery and minimize diffuse atrophy
what we as therapists need to know
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
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
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
~The Mobility Team~

Physician

Nursing Staff

Pharmacist

Occupational Therapist

Speech Therapist

Physical Therapist

Respiratory Therapist

Rehabilitation Aides

the action what can we do
The Action! What Can We Do?

Positioning

Postural Drainage

Cough Assist

Splinting

Exercise

Transfer, ADL, and Balance Training

Ambulation

Education (invaluable)

therapy icu intervention
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…
    • 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 intervention1
Therapy ICU Intervention

Exercise:

  • Get Family Involved
  • Educate Nursing
  • Strengthen Respiratory Musculature
    • Primary: Diaphragm, Intercostals
    • Accessory: Sternocleidomastoid, Scalene
therapy icu intervention2
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 intervention3
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 intervention4
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!!
who does what
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 intervention5
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 intervention6
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
When Does the Therapist Modify Activity???

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
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~~~