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Impact of Rehabilitation Early in ICU

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

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Impact of Rehabilitation Early in ICU

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  1. 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

  2. Overview • The Continuum of ICU Weakness • Muscle and Nerve Injury after Critical Illness • Early Mobility

  3. Heterotopic Ossification Tracheal stenosis Alopecia frozen joints contractures Cosmesis- Scars from CVC, Art line, CT, drain sites Nerve and Muscle Brain striae Bronchiectasis Pulmonary fibrosis Weakness Mental Health & Cognition Ischemic digits Taste changes Renal Impairment The Disease Hearing Loss Griffiths and Jones BMJ 1999:319(7207):427-9

  4. 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

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

  6. Five-Year Outcomes in ARDS Herridge et al. NEJM 2011; 364: 1293-304 Persistent exercise limitation and reduction in Physical QOL at 5-years after ICU discharge

  7. outpatient rehabilitation homecare pharmacy imaging and labs physicians Other Subsequent hospitalization Inpatient rehabilitation Post-discharge Costs $28,350 Cheung et al AJRCCM 2006; 174: 538-544

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

  9. ICU-Acquired Weakness • CIPN • CIPNM • ICUAP • CRIMYNE • CINMA Incidence 25% - 60% surveillance, definition, diagnostic testing, bias, confounding, case-mix De Letter et al. Crit Care Med 2001; 29: 2281-6 DeJonghe et al. JAMA 2002; 288: 2859-67. Stevens et al. Int Care Med 2007; 33:1876-91 Hough et al. Int Care Med 2008

  10. 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 change Bolton et al. J Neurol Neurosurg Psychiatry 1986; 49: 563-573 Hotchkiss et al. CCM 1999;27:1230-1251. Fenzi et al. Acta Neuropathol 2003; 106:75-82 Hermans et al. Critical Care 2008; 12: 238

  11. Critical Illness Polyneuropathy (CIP) Increase in E-selectin on epineurium and endoneurium TNF-, IL-1 Endothelial cell leukocyte adhesion and extravasation of activated leukocytes within the endoneurium Tissue Injury

  12. 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 myopathy 2) thick- filament myopathy 3) acute necrotizing myopathy

  13. 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 stress Brealey et al. Lancet 2002; 360:219-223 DiGiovanni et al. Ann Neurol 2004;55:195-206 Novak et al. J Clin Invest 2009; 119: 1150-1158

  14. 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

  15. 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

  16. Crit Care Med 2007; 35: 139-145 Crit Care Med 2008;36: 2238-2243 JAMA 2008; 300(14): 1685-1690

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

  18. Crit Care Med 2009; 37:2499-2505

  19. 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

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

  21. Phase-specific Approach to Rehabilitation in Critical Illness:Targeting Muscle, Nerve and Brain during and after the ICU Stay Rehabilitation in ICU Resuscitation Steroids, NMB Ventilation Glycemic Control Sedation Wakefulness Early Mobility Physical Therapy Delirium Treatment Serial Measures of Muscle Weakness: MRC, Strength, Function Serial Measures of Wakefulness, Sedation, Delirium 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.

  22. 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 care unit. Arch Phys Med Rehabil 1998; 79: 849-854.

  23. 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?

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