Impact of Rehabilitation Early in ICU

Margaret Herridge MD MPH Associate Professor of Medicine

Interdepartmental Division of Critical Care University of Toronto

The Canadian Critical Care Trials Group

Overview

The Continuum of ICU Weakness Muscle and Nerve Injury after Critical Illness Early Mobility

The Disease

Weakness Mental Health & Cognition

Heterotopic Ossification

frozen jointscontractures

Taste changes

Tracheal stenosis

Renal Impairment

Hearing Loss

Alopecia

Cosmesis- Scars from CVC, Art line, CT, drain sites

striae

Griffiths and Jones BMJ 1999:319(7207):427-9

Bronchiectasis

Pulmonaryfibrosis

Ischemic digits

Nerve and Muscle Brain

Evidence of diaphragmatic atrophy and increased proteolysis at 18 hours of mechanical ventilation

De Jonghe, B. et al. JAMA 2002;288:2859-2867 Ali N et al. AJRCCM 2008; 178:261-268

Herridge et al. N Engl J Med 2003; 348:683-93.

Five-Year Outcomes in ARDS

Herridge et al. NEJM 2011; 364: 1293-304

Persistent exercise limitation and reduction in Physical QOLat 5-years after ICU discharge

Post-discharge Costs$28,350

OtherSubsequent hospitalization

Inpatient rehabilitation

outpatientrehabilitation

homecare

pharmacy

imaging and labs

physicians

Cheung et al AJRCCM 2006; 174: 538-544

Herridge et al. NEJM 2011; 364: 1293-304

CIPN CIPNM ICUAP CRIMYNE CINMA

Incidence25% - 60%

surveillance, definition, diagnostic testing, bias, confounding, case-mix

De Letter et al. Crit Care Med 2001; 29: 2281-6DeJonghe et al. JAMA 2002; 288: 2859-67.Stevens et al. Int Care Med 2007; 33:1876-91Hough et al. Int Care Med 2008

ICU-Acquired Weakness

Critical Illness Polyneuropathy (CIP)

•Acute axonal sensory-motor polyneuropathy

•Injury related to microcirculatory damage

•Mediated by E-selectin and induced by proinflammatory cytokines

•Pure functional impairment in the absence of structural changeBolton et al. J Neurol Neurosurg Psychiatry 1986; 49: 563-573

Hotchkiss et al. CCM 1999;27:1230-1251.Fenzi et al. Acta Neuropathol 2003; 106:75-82Hermans et al. Critical Care 2008; 12: 238

Critical Illness Polyneuropathy (CIP)

Increase in E-selectin on epineurium and endoneurium

TNF-, IL-1

Endothelial cell leukocyte adhesion and extravasationof activated leukocytes within the endoneurium

Tissue Injury

Critical Illness Myopathy (CIM)

•Acute primary myopathy causing muscle weakness or paralysis in critically ill patients- but can also coexist with CIP

•3 Forms: 1) Diffuse non-necrotizing cachetic

myopathy2) thick- filament myopathy3) acute necrotizing

myopathy

CIP/ CIM -Pathogenesis

• Inactivation of fast Na channels resulting in reduced excitability - so-called acquired Na Channelopathy

• NO mediated mitochondrial dysfunction• Cytokine-mediated activation of the

ubiquitin-proteasome, calpain, lysosomal systems- intracellular proteolytic systems- effect catabolism possibly to liberate more amino acids etc.with stressBrealey et al. Lancet 2002; 360:219-223

DiGiovanni et al. Ann Neurol 2004;55:195-206Novak et al. J Clin Invest 2009; 119: 1150-1158

•All biopsies were abnormal (6-24 months after ICU discharge)•No patients were exposed to steroids or paralytics•Most common abnormality was type II fiber atrophy•Manifested as narrow angulated fibers; myofibers were reduced to clumps of myonuclei•Myofibrillary disarray on EM•Changes not exclusively attributable to disuse atrophy

Angel et al. 2007 Can J Neurol Sci 34: 427-432

Prevalence and Risk Factors

•True prevalence difficult to ascertain and varies widely based on case-mix, timing of examination and diagnostic criteria

•Linked to sepsis, MODS, female sex, use of corticosteroids, asthma, ionic (Na) abnormalities, immobility and malnutrition

Hermans et al. Crit Care 2008; 12 : 238

Crit Care Med 2007; 35: 139-145

Crit Care Med 2008;36: 2238-2243

JAMA 2008; 300(14): 1685-1690

Bailey et al. Crit Care Med 2007; 35: 139-145

Crit Care Med 2009; 37:2499-2505

Each AM, unresponsive patients had passive range of motion for all limbs Daily interruption of sedation and PT/OT coordinated with this Once patient able to interact, active assisted/ independent ROM supine If tolerated, then bed mobility, sitting, ADLs and exercises Followed by transfer, pre-gait exercises and walking Treatment program individualized to patient tolerance and stability

Schweickert et al. Lancet 2009; 373: 1874-82

Schweickert et al. Lancet 2009; 373: 1874-82

Phase-specific Approach to Rehabilitation in Critical Illness:Targeting Muscle, Nerve and Brain during and after the ICU Stay

Rehabilitation in ICU

Glycemic ControlSedation

DeliriumTreatment

WakefulnessEarly MobilityPhysical Therapy

Kress et al. NEJM 2000; 342: 1471-1477; Morris et al. CCM 2008; 36: 2238-2243; Bailey CCM 2007; 35: 139-145; Needham JAMA 2008; 300; 1685-90 ; Gosselink et al. Int Care Med 2008; 34: 1188-1199; Finfer et al. NEJM 2009; Van den Berghe et al. NEJM 2001; 345: 1359-1367; Hopkins and Jackson Chest 2006; 130: 869-78;Schweikert and Hall Chest 2007; 131: 1541-1549; Schelling et al. Ann N Y Acad Sci 2006; 1071: 46-53.

Resuscitation Steroids, NMB Ventilation

Serial Measures of Muscle Weakness: MRC, Strength, FunctionSerial Measures of Wakefulness, Sedation, Delirium

Physiotherapy for adult patients with critical illness: Recommendations of the ERS / ESICM Task Force on Physiotherapy for Critically Ill Patients

Gosselink et al.Int Care Med 2008; 34:1188-1199

Active or passive mobilization and muscle training should be instituted early (Level C)

Positioning, splinting, passive stretching should be used to preserve joint mobility and skeletal muscle length in patients unable to move spontaneously (Level C)

Physiotherapist should be responsible for implementing mobilization plans and exercise prescription ( Level D)

Physiotherapists should ensure treatment sessions address discomfort and anxiety and patient education as needed ( Level D)

Nava S. Rehabilitation of patients admitted to a respiratory intensive careunit. Arch Phys Med Rehabil 1998; 79: 849-854.

Challenges and Opportunities

Heterogeneity of ICUAW - ? Pathophysiology Importance of early ICU-based mobility and rehabilitation- ? Role

of EMS/ other Tx Unclear impact on those with significant impairment before ICU

admission Long-term benefit of early mobility/rehab uncertain- does it just

move the ultimate outcome to an earlier

time point?