Early mobilization in the critical care unit: A review of adult and pediatric literature.

Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated into daily clinical practice. Early passive, active, and combined progressive mobilizations can be safely initiated in intensive care units (ICUs). Adult patients receiving early mobilization have fewer ventilator-dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data are limited, but recent studies also suggest that early mobilization is achievable without increasing patient risk. In this review, we provide a current and comprehensive appraisal of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient outcomes will require further studies on mobilization timing and intensity, particularly within specific ICU populations

Effects of early, combined endurance and resistance training in mechanically ventilated, critically ill patients: a study protocol for a randomised controlled trial

BACKGROUND Prolonged need for intensive care is associated with neuromuscular weakness, termed Intensive Care Unit Acquired Weakness. Those affected suffer from severe functional impairment that can persist for years. First studies suggest a positive effect of physiotherapy and early mobilisation. However, the ideal intervention for a preferential functional outcome is not known. So far no randomised controlled trial has been conducted to specifically evaluate an early endurance and resistance training in the mechanically ventilated, critically ill patient. METHODS/DESIGN A randomised controlled trial with blinded assessors and 6-month follow-up will be conducted in a tertiary, interdisciplinary intensive care unit in Switzerland. Participants (n = 115; expected dropouts: n = 15) will be randomised to a control group receiving standard physiotherapy and to an experimental group that undergoes early mobilisation combined with endurance and resistance training. The inclusion criteria are being aged 18 years or older, expected mechanical ventilation for more than 72 h and qualitative independence before the illness. Primary endpoints are functional capacity (6-Minute Walk Test) and the ability to perform activities of daily living (Functional Independence Measure) measured at hospital discharge. Secondary endpoints include muscle strength (Medical Research Council sum score, handgrip strength and handheld dynamometry for quadriceps muscle), joint contractures (range of motion), exercise capacity (Timed 'Up & Go' Test) and health-related quality of life (Short Form 36). Safety will be monitored during interventions by indirect calorimetry and continuous intensive care standard monitoring. All previously defined adverse events will be noted. The statistical analysis will be by intention-to-treat with the level of significance set at p < 0.05. DISCUSSION This prospective, single-centre, allocation-concealed and assessor-blinded randomised controlled trial will evaluate participant's function after an early endurance and resistance training compared to standard care. Limitations of this study are the heterogeneity of the critically ill and the discontinuity of the protocol after relocation to the ward. The strengths lie in the pragmatic design and the clinical significance of the chosen outcome measures. TRIAL REGISTRATION German Clinical Trials Register (DRKS): DRKS00004347 , registered on 10 September 2012

Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies

PURPOSE: To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers. METHODS: Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454. RESULTS: Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment. CONCLUSIONS: The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice

Evaluation of low cost high fidelity USB powered arterial line simulation device for ultrasound guided vascular puncture and cannulation

Background: The use of ultrasound imaging before or during vascular cannulation greatly improves first-pass success and reduces complications. Appropriate training is required for ultrasound-guided vascular cannulation and a portion of this training can be accomplished in a simulated environment that allows a trainee to develop the dexterity needed for simultaneous probe manipulation and needle insertion. In this instance, the use of ultrasound simulators (or phantoms) is an attractive component in such training. However, commercial phantoms are expensive and the homemade phantoms require time, skill and suffer from a short shelf life. Objective: To create a low cost, effective, high fidelity arterial line insertion simulator to help train medical professionals to insert radial arterial lines. We developed a fully functional Universal Serial Bus (USB) powered arterial line simulator with a high shelf life. Material and methods: We used low cost materials for the device, which was made based on sizes of an average radial artery. The device is capable of simulating blood flow that can be identified by using the color Doppler mode of Ultrasound and with cannulation of the simulated artery. 18 trainees (medical students and residents) were trained by a staff anesthesiologist on how to perform the US guided arterial line cannulation using the model. The trainees were able to practice both catheter-over-needle and catheter-over-guidewire techniques. The simulator was then evaluated as a training tool using an established assessment questionnaire. Results: So far a total of 18 residents and medical students participated in the anonymous survey out of which 4 were medical students, 7 were CA1, 4 were CA2 and 3 were CA3. All the participants unanimously agreed that they would have preferred to have used this model to practice before placing one on a patient. The survey is still ongoing. (Table presented) Discussion: The dexterity required to successfully manipulate the ultrasound probe and negotiate a needle into a target vessel needs to be taught and practiced prior to its application on a real patient. For this training, a model or phantom is required. An ideal phantom should replicate the texture and resistance of human soft tissue, it should withstand multiple needle punctures, have a long shelf life, be easily transportable, easily reproducible, be inexpensive, simple to construct and finally be reusable. The simulator created by our team has all the above mentioned attributes. Conclusion: It is possible to construct a high fidelity arterial line access simulator phantom device that functions as an effective teaching tool. We believe that formal training, using this simulator will boost trainee\u27s confidence, reduce the failure rate of ultrasound-guided radial artery cannulation and ultimately improve patient safety

Ultrasound guided serratus anterior plane block for thoracic analgesia in a patient with multiple rib fractures

Introduction Multiple rib fractures are associated with multiple complications, with pneumonia occurring in up to 30% of elderly patients [1]. Adequate pain control is fundamental in improving patient tolerance for deep breathing, which in turn decrease the risk of respiratory complications. We report a case of an elderly patient with multiple rib fractures post fall and severe kyphoscoliosis, whose pain was safely and adequately managed with a serratus anterior plane block (SAP). Results/Case report A 94 year old female patient with dementia was admitted with right rib fractures (ribs 7 through 10) post fall. She was alert and oriented x 0 at baseline, making an accurate assessment of her pain challenging. However she was hypertensive, tachycardic and appeared uncomfortable. She was initially started on Acetaminophen 650 mg orally every 6 hrs as needed, Fentanyl 12 mcg/hr patch, Hydrocodone -acetaminophen 5-325 mg 2 tablets every 6 hrs as needed and Morphine 6 mg orally every 2 hrs as needed. She did not seem to tolerate the use of the incentive spirometer despite escalating doses of the above medications. A regional technique was considered as an adjunct to her multimodal pain regime. However her severe kyphoscoliosis made a thoracic epidural technically challenging. Therefore, we decided to perform a right serratus anterior plane continuous block. With the patient in slight left lateral decubitus position, the right hemithorax was prepped in a sterile fashion. A high frequency linear probe was placed in a sagittal plane along the mid axillary line. The skin was then infiltrated with 5 cc of 1 % lidocaine and then a 17 G, 89 mm Tuohy needle was advanced in-plane to the plane below the serratus anterior muscle (Fig 1). 30 cc of 0.2% Ropivacaine was then injected with direct visualization of spread of local anesthetic. A 19G catheter was then placed into this plane through the Tuohy needle and secured at 22 cm at the skin (Fig 2). A continuous infusion of 8 cc/hr of 0.2% Ropivacaine was started thereafter via an elastomeric pump. The patient\u27s tachycardia and hypertension significantly improved a few hours later and the patient appeared subjectively more comfortable. The patient was able to better tolerate breathing exercises and the catheter was removed after 5 days without any complications. Patient consent for submission of the case report for publication/presentation has been obtained. Discussion Adequate pain control improves respiratory mechanics in patients with thoracic pain, reducing the risk of pulmonary complications [2]. The SAP is an ultrasound-guided nerve block used to anesthetize the hemithorax by blocking the lateral branches of the intercostal nerves as they traverse the plane below serratus anterior muscles [3]. The SAP has been used to provide thoracic analgesia is patients with multiple rib fractures and post thoracotomies [4] and is a safe and simple alternative to a thoracic epidural in patients with contraindications to thoracic epidurals such as severe kyphoscoliosis. This technique can be used as part of a multimodal analgesia regime or as the sole technique for pain control in patients in whom narcotics are better avoided