1. General considerations
|
Each new patient should be assessed by a physiotherapist within 24 hours of ICU admission. |
|
Teamwork approach (Mobility team)- Nursing team, Physicians team and Physiotherapists should be involved in the formulation of mobilization plan. |
|
Patient safety should be strongly considered while planning and implementing mobilization in the ICU. |
|
Patients are expected to take part in activities to the same degree as their prescribed medicines and other therapies. |
|
Activity should be progressed according to patient tolerance. |
2. Contraindications for Early Mobilization
|
Unsecured airway. |
|
Open Chest/ Abdomen. |
|
Active cardiac ischemia. |
|
Hemodynamically unstable. |
|
Uncontrolled acute arrythmias. |
|
Unstable fracture. |
|
Acute neurological event, Raised ICP (>20 mmHg). |
|
FiO2> 80%, PEEP >10. |
|
Ongoing Hemorrhage. |
3. Discuss with medical teams prior to initiating mobilization activity for following patients
|
Dialysis. |
|
Agitation (RASS>2). |
|
Difficult airway. |
|
Lumber drain/ ventricular Drain. |
|
Venous thromboembolism (VTE). |
|
Specific postsurgical restrictions as per orders. |
|
Requiring FiO 2 ≥ 85% via non-invasive positive pressure ventilation (NIPPV) or high flow oxygen. |
4. Clinical features of intolerance
|
Clinical symptoms: ● Decreased level of consciousness ● Sweating ● Abnormal face color ● Pain ● Fatigue ● Giddiness |
Clinical signs: ● Heart rate <40 / >150 bpm. ● Blood pressure (MAP) <60 mmHg >110mmHg. ● Respiratory frequency >40 b/ min. ● Frequent oxygen saturation <88%. ● Arrhythmia. ● Development of any contraindication ● Strategies for Mobilization |
5. Strategies for Mobilization
5.1. Basic assessment
|
Stable hemodynamics |
|
No signs of myocardial ischemia |
|
Stable neurology |
|
No recent surgery (<24 hours) |
|
Temperature<39 c |
5.2. S5Q questionnaire
|
Open and close your eyes |
|
Look at me |
|
Open your mouth and put out your tongue |
|
Nod your head |
|
Raise your eye brows when i have counted up to 5 |
5.3. MRC 0-5 SCORE
|
0= No Visible Contraction |
|
1= Flicker or Trace of Contraction |
|
2= Active Movement with Gravity Elimination |
|
3= Active Movement Against Gravity |
|
4=Active Movement Against Gravity and Resistance. |
|
5= Normal Power |
|
Left (0-5) |
Right (0-5) |
|
|
Shoulder abduction |
||
|
Elbow flexion |
||
|
Wrist extension |
||
|
Hip flexion |
||
|
Knee extension |
||
|
Ankle dorsiflexion |
||
|
Total score |
(0-30) |
(0-30) |
5.4. Mobilization protocol
|
Level 0 |
Level 1 |
Level 2 |
Level 3 |
Level 4 |
Level 5 |
|
No cooperation S5Q1 = 0 |
No- low cooperation S5Q1 <3 |
Moderate cooperation S5Q1≥3 |
Close to full cooperation S5Q1≥ 4/5 |
Full cooperation S5Q1 = 5 |
Full cooperation S5Q1 = 5 |
|
Fails basic assessment |
Passes basic assessment |
Passes basic assessment |
Passes basic assessment |
Passes basic assessment |
Passes basic assessment |
|
Basic assessment Cardiorespiratory unstable: MAP<60mmhg or RR > 30 bpm HR> 130 Acute MI Life threatening arrhythmias Neurologically unstable Acute surgery(<24hr) Temp > 40° c |
Neurological or surgical or trauma condition does not allow active as well as passive transfer to chair |
Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum ≥36) |
MRCsum 36 + Able to sit with back unsupported for 10-30 sec |
MRCsum 48 + Able to sit more than 2 minutes unsupported under supervision |
MRCsum> 48 + Able to sit safely and securely and Able to stand for 2 min unsupported with supervision |
|
Body positioning: 2hr turning |
Body positioning: 2hr turning Splinting as required Fowler's position Low 15° -30° Semi 30°-45° Standard 45°-60° High 60°-90° |
Body positioning: 2hr turning Splinting as required Upright sitting position in bed (20 mins 3 X per day) Passive transfer from bed to chair (minimum 40 mins X per day) |
Body positioning: 2hr turning Passive transfer from bed to Chair Sitting out of bed (minimum. 45 mins 1 X per day) Standing with assist as tolerable (1 X per day) (2≥ persons) |
Body positioning: Active transfer from bed to chair Sitting out of bed (minimum 45 mins 1 X per day) Standing with assist as tolerable (1 X Day) (≥1 persons) |
Body positioning: Active transfer from bed to chair Sitting out of bed (minimum 45 mins 1 X day) Standing as tolerable |
|
Physiotherapy Passive range of motion (2 X per day) |
Physiotherapy Passive range of motion (2 X per day) Passive bed cycling +/- NMES |
Physiotherapy
Passive/active range of motion (2 X per day) Resistance training arms and legs (2 X per day) Passive/active leg and/or arm cycling in bed or chair (2 X per day) +/- NMES |
Physiotherapy Passive/active range of Motion Resistance training arms and legs (2 X per day) Passive/active leg and/or arm cycling in bed or chair (2 X per day) ADL |
Physiotherapy Active range of motion Resistance training arms and legs (2 X per day) Active leg and/or arm cycling in bed or chair (2 X Day) Walking (with assistance/ frame as tolerable) ADL |
Physiotherapy
Active range of motion (2 X per day) Resistance training arms and legs (2 X per day) Active leg and arm cycling in chair (2 X per day) Walking (with assistance) as tolerable ADL |
If patient develops signs of intolerance
|
Return patient to safe resting position in bed. |
|
Suspend activity and reevaluate in 4-6 hours. |
|
Discuss increasing hemodynamic and respiratory support with ICU physician. |
Further Readings:
1. Linke, C. A., Chapman, L. B., Berger, L. J., Kelly, T. L., Korpela, C. A., & Petty, M. G. (2020). Early mobilization in the ICU: a collaborative, integrated approach. Critical Care Explorations, 2(4).
2. Gosselink, R., Clerckx, B., Robbeets, C., Vanhullebusch, T., Vanpee, G., & Segers, J. (2011). Physiotherapy in the intensive care unit. Neth J Crit Care, 15(2), 66-75.
