Clinical algorithm for Clinical algorithm for the active mobilization the active mobilization of a patient that can of a patient that can

follow commandsfollow commands

Next step in the algorithm

ON ADMISSION TO ON ADMISSION TO UNITUNIT

Develop an individually designed Develop an individually designed mobility plan with outcomes for mobility plan with outcomes for each patient in consultation with each patient in consultation with rest of the team. rest of the team.

Monitor daily and provide Monitor daily and provide feedback feedback

(Nava 2000; Nava 2002; Thomas 2002; Vollman 2004)(Nava 2000; Nava 2002; Thomas 2002; Vollman 2004)RECOMMENDATION 2RECOMMENDATION 2

Next step in the algorithmPrevious step in the algorithm

PRELIMINARY SCREENINGPRELIMINARY SCREENING

Factors to consider before initiation of Factors to consider before initiation of active mobilization active mobilization – Neurological contra indications?Neurological contra indications?– Orthopedic contra indications?Orthopedic contra indications?– Recent SSG?Recent SSG?

Environmental factors to considerEnvironmental factors to consider Patient size and help availablePatient size and help available Length and placement of lines / attachmentsLength and placement of lines / attachments Patient consent Patient consent

Stiller et al 2004; Bailey 2007Stiller et al 2004; Bailey 2007

Next step in the algorithmPrevious step in the algorithm

DURING ALL ACTIVITIES DURING ALL ACTIVITIES MONITOR CLOSELYMONITOR CLOSELY

HR to maximum of 75% of APMHR to maximum of 75% of APM Dispnea rating of 13 on MBSDispnea rating of 13 on MBS SpO2 >90SpO2 >90 Arythmias on ECGArythmias on ECG Patient physical appearance: Patient physical appearance:

conscious state, respiratory pattern, conscious state, respiratory pattern, pallor, flushing, sweating, clamminess, pallor, flushing, sweating, clamminess, cyanosis, visible or patient reported cyanosis, visible or patient reported signs of pain, discomfort or fatigue.signs of pain, discomfort or fatigue.

Stiller et al 2004; Baily et al 2007Stiller et al 2004; Baily et al 2007RECOMMENDATION 1RECOMMENDATION 1

Next step in the algorithmPrevious step in the algorithm

DECIDE ON ACTIVITY LEVELDECIDE ON ACTIVITY LEVELBASED ON PERIOD OF BASED ON PERIOD OF

INTUBATIONINTUBATION

GROUP 1GROUP 1 Is not intubated or has been Is not intubated or has been

intubated less than 14 daysintubated less than 14 daysStiller et al 2004; Bailey 2007 Stiller et al 2004; Bailey 2007

RECOMMENDATION 1RECOMMENDATION 1

GROUP 2GROUP 2 Has been intubated more than 14 Has been intubated more than 14

daysdaysNava et al 1998; Zanotti et al 2002; Martin et al 2005; Porta et al Nava et al 1998; Zanotti et al 2002; Martin et al 2005; Porta et al

2005; Chiang et al 2006 2005; Chiang et al 2006 RECOMMENDATION 3RECOMMENDATION 3

Previous step in the algorithm

GROUP 1: Determine GROUP 1: Determine cardiovascular reservecardiovascular reserve

Resting heart rate < 50% APMResting heart rate < 50% APM BP less than 20%variabilityBP less than 20%variability ECG normal (arithmias)ECG normal (arithmias)

Mayor cardiac pathologies Mayor cardiac pathologies excludedexcluded Stiller et al 2004Stiller et al 2004

Absence of orthostatic hypotensionAbsence of orthostatic hypotension and catecholamine dripsand catecholamine drips

Baily et al 2007Baily et al 2007

Next step in the algorithmPrevious step in the algorithm

GROUP 1: GROUP 1: Determine pulmonary Determine pulmonary reservereserve

PaO2:FiO2>300PaO2:FiO2>300 SpO2>90 variations less than 4%SpO2>90 variations less than 4% Satisfactory respiratory patternSatisfactory respiratory pattern Able to maintain adequate Able to maintain adequate

respiratory support respiratory support Stiller et al 2004Stiller et al 2004

FiO2 <.6FiO2 <.6 PEEP<10PEEP<10

Next step in the algorithmPrevious step in the algorithm

GROUP 1: Other factors GROUP 1: Other factors favorablefavorable

HB >7gm/dlHB >7gm/dl Platelet 20,000 cells/m3Platelet 20,000 cells/m3 White cell 4300 – 10800 cells/m3White cell 4300 – 10800 cells/m3 Body temp <38 >36Body temp <38 >36 Blood glucose level 3.5-20mmol/L Blood glucose level 3.5-20mmol/L

Stiller et al 2004Stiller et al 2004

Next step in the algorithmPrevious step in the algorithm

If unsure of any of these criteria If unsure of any of these criteria discuss with the discuss with the interdisciplinary team interdisciplinary team membersmembers

If reserve is sufficient initiate If reserve is sufficient initiate mobilization programmobilization program

Previous step in the algorithm

GROUP 1:GROUP 1:

GROUP 2: Determine pulmonary GROUP 2: Determine pulmonary stabilitystability

Airway: Tracheostomy for invasive ventilation.Airway: Tracheostomy for invasive ventilation. Minimal aspirationMinimal aspiration Secretions: manageable with infrequent Secretions: manageable with infrequent

suctioningsuctioning Oxygen: adequate oxygenation with FIO2 Oxygen: adequate oxygenation with FIO2

<50%,<50%, PEEP <5 cm H2O, SpO2 >92%PEEP <5 cm H2O, SpO2 >92% Ventilator settings: stable, no sophisticated Ventilator settings: stable, no sophisticated

modes modes Patient assessment: comfortable, no increased Patient assessment: comfortable, no increased

WOB or dyspneaWOB or dyspneaMartin et al 2005; Porta et al 2005Martin et al 2005; Porta et al 2005

Next step in the algorithmPrevious step in the algorithm

GROUP 2:GROUP 2: Determine medical Determine medical stabilitystability

Sepsis controlledSepsis controlled No uncontrolled hemorrhageNo uncontrolled hemorrhage No uncontrolled arrhythmias, No uncontrolled arrhythmias,

heart failure, or unstable anginaheart failure, or unstable angina Secure parenteral line Secure parenteral line

Martin et al 2005; Porta et al 2005Martin et al 2005; Porta et al 2005

Next step in the algorithmPrevious step in the algorithm

GROUP 1:GROUP 1: Initiate Mobilization Initiate Mobilization ProgramProgram

Mobilization activities include moving from Mobilization activities include moving from – Lying to sitting on the edge of the bed;Lying to sitting on the edge of the bed;– sitting to standing;sitting to standing;– a standing transfer from the edge of the bed to a a standing transfer from the edge of the bed to a

chair; walking with assistance;chair; walking with assistance;– walking independently.walking independently. (Stiller et al 2004; Baily et al 2007)(Stiller et al 2004; Baily et al 2007)

Progress the activities with goal of walking Progress the activities with goal of walking 100m before discharge100m before discharge (Baily et al 2007)(Baily et al 2007)

Temporarily adjust FiO2 if patient Temporarily adjust FiO2 if patient desaturatesdesaturates (Stiller et al 2004; Baily et al 2007)(Stiller et al 2004; Baily et al 2007)

If patient is unable to mobilize out of bed If patient is unable to mobilize out of bed include arm exercises (both strengthening include arm exercises (both strengthening and endurance) into a mobility regime is safe and endurance) into a mobility regime is safe and could potentially facilitate weaningand could potentially facilitate weaning (Porta (Porta et al 2005; Vittaca et al 2006)et al 2005; Vittaca et al 2006)Back to Group allocation

GROUP 2: Initiate Combined GROUP 2: Initiate Combined Mobilization AND Exercise Mobilization AND Exercise ProgramProgram In addition to daily mobilization program initiate In addition to daily mobilization program initiate

specific exercise program specific exercise program (de Jonge et al 2007; (de Jonge et al 2007; Greenleef et al 1997; Nava et al 1998);Greenleef et al 1997; Nava et al 1998);

Program should include both strengthening and Program should include both strengthening and endurance component endurance component (Porta et al 2005; Vittaca et al (Porta et al 2005; Vittaca et al 2006; Zanotti et al 2002)2006; Zanotti et al 2002)

Incorporate trunk and arms (Pectoralis Mayor) Incorporate trunk and arms (Pectoralis Mayor) Chiang et al 2006; Martin et al 2005; van de Meet et al Chiang et al 2006; Martin et al 2005; van de Meet et al 20072007

Exercise at intensity of at least 11 on Borg scale Exercise at intensity of at least 11 on Borg scale progressing to 13 by week 6 progressing to 13 by week 6 (Chiang et al 2006; (Chiang et al 2006; Martin et al 2005)Martin et al 2005)

Duration of session at least 30 minutes progress Duration of session at least 30 minutes progress to 45 minutes daily to 45 minutes daily (Chiang et al 2006; Martin et al (Chiang et al 2006; Martin et al 2005)2005)

Temporarily adjust FiO2 if patient desaturates Temporarily adjust FiO2 if patient desaturates (Stiller et al 2004; Baily et al 2007)(Stiller et al 2004; Baily et al 2007)Back to Group allocation