Discussion: mobilization for mechanically ventilated patients

Discussion: mobilization for mechanically ventilated patients ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: mobilization for mechanically ventilated patients Can you help me understand this Health & Medical question? Discussion: mobilization for mechanically ventilated patients see attachment. .needs to be APA style. 300 words and list references Should early mobilization for mechanically ventilated patients be routinely utilized? When should early mobilization not be used? Does your hospital follow this practice? Summarize the discussion session in your own words from the Schmidt et al., article. should_early_mobilization_be_routine_in_mechanically.pdf expert_consensus_and_recommendations_for_mobilization.pdf Should Early Mobilization Be Routine in Mechanically Ventilated Patients? Ulrich H Schmidt MD PhD MBA, Lauren Knecht MD, and Neil R MacIntyre MD FAARC Introduction Early Mobilization: The Case for Routine Application in Mechanically Ventilated Patients The Supporting Evidence Base How Early, How Often, How Long? Early Mobilization: Concerns and Reasons for Caution Are the Results of the Many Positive Trials Overstated? Early Mobility Entails Patient Risk Early Mobility Programs Require Additional Resources Other Logistical Challenges Conclusions ICU-acquired weakness is a major complication of critical illness requiring mechanical ventilation. Early mobilization has been shown to decrease the negative consequences of ICU-acquired weakness. However, early mobilization might entail risks to the patient. Additional staffing needs might have a negative financial impact. This review examines whether early mobilization should be routinely performed in mechanically ventilated patients. Key words: mobilization; weakness; mechanical ventilation. [Respir Care 2016;61(6):867–875. © 2016 Daedalus Enterprises] Introduction Deconditioning and weakness are prevalent problems in survivors of critical illness requiring mechanical ventilation. Intensive care unit (ICU) acquired weakness is characterized by fatigue and profound neuromuscular weak- Drs Schmidt and Knecht are affiliated with the Department of Anesthesiology, University of California, San Diego, California. Dr MacIntyre is affiliated with the Department of Medicine, Duke University, Durham, North Carolina. Discussion: mobilization for mechanically ventilated patients The authors have disclosed no conflicts of interest. Dr MacIntyre presented a version of this paper at the 54th RESPIRATORY CARE Journal conference, held June 5–6, 2015, in St. Petersburg, Florida. Correspondence: Ulrich H Schmidt MD PhD MBA, Department of Anesthesiology, University of California, 200 West Arbor Drive, Room 8770, San Diego, CA 92103-8770. E-mail: [email protected] DOI: 10.4187/respcare.04566 RESPIRATORY CARE • JUNE 2016 VOL 61 NO 6 ness that can cause serious functional disability in survivors.1,2 Herridge et al3 performed a prospective study of 109 subjects with ARDS. These subjects had significant physical disability 1 y after hospital discharge, with ?50% of subjects back at work because of persistent fatigue, weakness, and poor functional status.3 The disease pathogenesis is complex and multifactorial but is known to be associated with the inflammatory response from severe sepsis and systemic inflammatory response syndrome. Independent of critical illness, bed rest has been shown to increase reactive oxygen species and inflammatory mediators, causing muscle atrophy and protein catabolism, ultimately leading to disuse atrophy, weakness, and functional disability.4 Fink et al5 showed in a preclinical rat model that both immobilization and inflammation cause muscle weakness and are additive in their effects. ICUacquired weakness could therefore be described as a result of a combination of insults leading to a cycle of inflammation, disuse, and muscle breakdown, ultimately leading to functional disability (Fig. 1). 867 EARLY MOBILIZATION IN MECHANICALLY VENTILATED PATIENTS Fig. 1. Mechanisms of ICU-acquired weakness. LOS ? length of stay. ICU-acquired weakness is known to be associated with increased duration of mechanical ventilation, immobilization, and increased ICU and hospital length of stay (LOS). Discussion: mobilization for mechanically ventilated patients The incidence of ICU-acquired weakness has been reported by observational studies to be as high as 57%, depending on the ICU population studied.6 Therefore, ICU-acquired weakness impairs many ICU survivors and is a major public health issue. Given the deleterious consequences of ICU-acquired weakness, it is not surprising that early mobilization has been promoted to minimize the negative outcome of ICU-acquired weakness.7 Early mobilization might, however, have unintended risks leading to negative outcomes. The following review as a pro-con debate will provide the reader with the information to judge whether early mobilization should be routinely performed in mechanically ventilated patients. Early Mobilization: The Case for Routine Application in Mechanically Ventilated Patients The Supporting Evidence Base The benefit of physical movement in critically ill patients has been known for decades. In 1995, Griffiths et al7 documented the benefits of passive range-of-motion exercise in decreasing muscle atrophy in subjects with critical illness receiving neuromuscular blockade. The authors used continuous passive motion for 3-h intervals, compared with a control leg that received routine nursing care. In the continuous passive motion group, they reported less muscle atrophy and a 35% decrease in fiber area. The fact that passive range-of-motion exercise helps to reduce muscle atrophy led to changes in ICU protocols.Discussion: mobilization for mechanically ventilated patients ICU nurses in their facility are now required to do passive range-of-motion exercises. However, passive stretching in the bed did not solve the significant problem of protein catabolism. 868 In 2007, Bailey et al8 investigated whether it was safe and feasible to exercise critically ill subjects while receiving mechanical ventilation. Subjects were included who met the following criteria: ventilated for ?4 d and physiologically stable in 3 areas: neurologic (respond to command), respiratory (FIO2 ?0.6, PEEP ?10 cm H20), and circulatory (no orthostasis or catecholamine infusions). There were 3 goals of physical activity: sit on the edge of the bed, sit in a chair, or walk down the hall. The team consisted of nurses, respiratory therapists, physical therapists, and critical care technicians. During the study, 103 subjects were enrolled, and there were 1,449 activity events: 233 events were sitting on the edge of the bed, 454 were sitting in a chair, and 762 were recorded as ambulation. Forty-one percent of the events took place in intubated subjects, and 42% of those events were ambulation. There were ?1% associated adverse events, which included 5 falls to knees without injury, 4 systolic blood pressure readings ?90 mm Hg, 3 oxygen saturations ?80%, one feeding tube removal, and one systolic blood pressure ?200 mm Hg. There were no unplanned extubations, and none of the adverse events led to lengthened hospital stays or the need for additional therapy. Morris et al9 performed a prospective randomized trial investigating whether a protocol of early mobility (within 48 h of intubation) with a mobility team versus usual care improved patient outcomes and increased the frequency of physical therapy in ICU subjects. The mobility team consisted of a critical care nurse, nursing assistant, and physical therapist and was dedicated to performing the mobility protocol 7 d/week, whereas the usual care group received physical therapy at the attending physician’s discretion.Discussion: mobilization for mechanically ventilated patients The study included 4 levels of activity, and subjects progressed through them based on consciousness and increased strength, starting with passive range-of-motion exercises, sitting on the edge of the bed, transfers from bed to chair, seated balance exercises, pregait exercises, and ambulation. The results of this study showed decreased mortality in the protocol group compared with the usual care group (12% vs 18%), and there were no deaths, near-deaths, or cardiopulmonary resuscitation during physical therapy. There were no adverse events, such as removal of tubes or devices. There was no difference in ventilator-free days; however, ICU LOS for the protocol group was significantly shorter compared with the usual care group (5.5 d vs 6.9 d). Similarly, the hospital LOS was also decreased in the protocol group (11.2 d vs 14.5 d). The cost per subject was $3,000 less in the protocol group than in the usual care group. In 2009, Schweickert et al10 published a randomized controlled trial that compared scheduled early mobilization in ventilated subjects with physician-initiated mobility therapy. The primary outcome was the ability of subjects to perform the activities of daily living (independent RESPIRATORY CARE • JUNE 2016 VOL 61 NO 6 EARLY MOBILIZATION IN MECHANICALLY VENTILATED PATIENTS functional status) by hospital discharge. In addition, the authors included secondary outcomes, such as duration of delirium, number of ventilator-free days, and LOS in the ICU and hospital. The intervention group started physical therapy on the day of trial enrollment, whereas the control group received standard therapy according to physician order. Physical therapy progressed from passive range-ofmotion exercises to more active bed exercises and further on to activities of daily living and walking. The intervention group began therapy 1.5 (range 1–2.1).Discussion: mobilization for mechanically ventilated patients d after intubation, whereas the control group did not start therapy until 7.4 (range 6 –10.9) d after intubation. Return to independent functional status was achieved more commonly in the intervention group, 59% of subjects compared with only 35% in the control group. The intervention group also had more ventilator-free days (23.5 d vs 21.1 d) and fewer days of delirium (2.0 d vs 4.0 d). Serious adverse events were uncommon: one event in 498 physical therapy sessions (desaturation ?80%). Morris et al11 looked at hospital readmissions within 1 y, in subjects who had been discharged after hospitalization with acute respiratory failure. They used hospital databases and responses from letters mailed to 280 survivors to determine what factors influenced readmission. Among many variables that predicted readmission and death was the lack of early ICU mobility in those subjects. This supports the notion that early mobility helps to decrease hospital costs. Hospital readmissions are a huge burden on yearly hospital cost and an issue that hospitals take great strides to reduce. Early mobilization protocols, if instituted nationwide, could cut readmission costs greatly, decreasing overall hospital costs. Hodgson and co-workers12 addressed whether early mobilization plays a role in decreasing longer-term mortality following a stay in the ICU. These authors observed the current mobilization practice in 12 Australian hospitals, looking at strength of subjects at discharge as well as outcomes at 3- and 6-month follow-up.12 Of 192 subjects enrolled, 147 survived to discharge, and 122 subjects (63.5%) did not receive any early mobilization. The main reported barriers were intubation and sedation. On followup, subjects who had received early mobilization had higher muscle strength as measured by the Medical Research Council Manual Muscle Test Sum Score compared with subjects who did not receive early mobilization (50 ? 11 vs 42 ? 10, P ? .003). Discussion: mobilization for mechanically ventilated patients These studies provide substantial evidence that a protocol for early mobilization is possible and safe, while reducing mortality. When begun early, patients are more likely to return to their independent functional status, with fewer days on the ventilator and a shorter length of ICU delirium. RESPIRATORY CARE • JUNE 2016 VOL 61 NO 6 Table 1. Reported Complications Associated With Early Mobility From 7 Trials Sessions Desaturations Patient-ventilator asynchrony Falls/unsteadiness High blood pressure Arrhythmias Gastrostomy tube loss Low blood pressure Vascular access loss Endotracheal tube loss Achilles rupture 8,942 27 19 15 13 12 7 6 3 1 1 How Early, How Often, How Long? There is no consensus among experts as to the best time to implement early mobility. Many studies have used inclusion criteria based on a mechanical ventilation time of ?48 h to ?4 d (either length of time on the ventilator or length of time anticipated on the ventilator).8,12,13 Although studies looking at this issue use the duration of mechanical ventilation as an inclusion criterion, there is no common, predefined, or agreed upon time (in days from admission or intubation) by which physical therapy must be implemented to classify it as early mobilization. Experts agree upon the necessity of patients to meet appropriate physiologic parameters before starting physical therapy. These parameters include the ability to follow commands, stable ventilator settings, and hemodynamic stability.14 Because early mobilization has provided benefits in the ICU setting, a continuation of the therapy after transfer out of the ICU seems a logical step. However, the impact of this remains unknown because most studies on early mobilization have concentrated on the ICU setting and have not continued the therapy to the floor. Early Mobilization: Concerns and Reasons for Caution The evidence base supporting benefits from early mobilization above is compelling. Discussion: mobilization for mechanically ventilated patients The following discussion is more of a cautionary tale, things to be aware of when trying to understand and implement an early mobilization protocol. Are the Results of the Many Positive Trials Overstated? There are several reasons to be cautious about overinterpreting the multiple positive trials. First, true equipoise was probably lacking in many study sites that have long championed early mobility. This can lead to a subtle selection bias toward keeping “good” subjects in the treat- 869 EARLY MOBILIZATION IN MECHANICALLY VENTILATED PATIENTS Fig. 2. Color-coded symbols for mobilization safety criteria. From Reference 14, with permission. ment arm and removing “bad” subjects early. These studies are also unblinded by necessity, and this creates additional potential for bias. Specifically, “believers” may push more aggressive ventilator withdrawal strategies, sedation reduction strategies, and nutritional support and provide other forms of assistance to subjects randomized to early mobility. Indeed, some have suggested that the majority of the benefits attributed to early mobility programs are really a consequence of an aggressive sedation management program, a strategy well documented to facilitate ventilator withdrawal. One must also be cautious of interpreting the cost savings in these kinds of studies. These purported savings are usually calculated as a reduction in resource consumption due to shorter LOS. Unfortunately, shorter LOS can translate into significant cost reductions only if personnel and infrastructure elements are reduced or eliminated, something very difficult to do in busy ICUs with fixed space costs. Instead, the financial benefit to lower LOS reported in most studies must be tied to some kind of an increase in revenue resulting from more ICU bed availability, where additional patients can be admitted. Discussion: mobilization for mechanically ventilated patients These studies looking at financial benefits for early mobility programs presume that there will be more turnover and thus more revenue, something that probably occurs but may not. Early Mobility Entails Patient Risk Fig. 3. Respiratory considerations for early mobility. For color coding definitions, see Figure 2. From Reference 14, with permission. 870 Early mobility is not without its risks, and the complications are very real. One study carefully documented a number of important changes in physiological variables that occur after mobility procedures.15 These range from changes in heart rate of up to 15 beats/min, changes in breathing frequency of up to 6 breaths/min, changes in arterial pressure of up to 9 mm Hg, and drops in saturation ?1 point. Although these are not huge numbers, they do illustrate that early mobility is associated with physiologic stress. These changes can have important implications in ICU patients who already have limited reserves. RESPIRATORY CARE • JUNE 2016 VOL 61 NO 6 EARLY MOBILIZATION IN MECHANICALLY VENTILATED PATIENTS Fig. 4. Cardiovascular considerations for early mobility. IABP ? intra-aortic balloon pump, ECMO ? extracorporeal membrane oxygenation, DVT ? deep vein thrombosis, PE ? pulmonary embolism, EKG ? echocardiogram. For color coding definitions, see Figure 2. From Reference 14, with permission. These physiologic stresses can produce more serious problems, some of which have been noted above. A summary of 7 studies is given in Table 1 and shows that the most common problem that terminated a mobility procedure was arterial hemoglobin desaturations.16,17 Other im- RESPIRATORY CARE • JUNE 2016 VOL 61 NO 6 portant problems were arrhythmias, ventilator asynchrony, patient falls, blood pressure changes, loss of various catheters, and one Achilles tendon rupture. Discussion: mobilization for mechanically ventilated patients These only occurred in a very small number of sessions (?1%), but when they occur, they can be significant. As a consequence, monitoring 871 EARLY MOBILIZATION IN MECHANICALLY VENTILATED PATIENTS is critically important, and this must be performed by personnel trained to know how to respond. As a minimum, heart rate, pulse oximetry, ventilator settings, blood pressure, and alertness/agitation in patients must be carefully monitored during any mobility procedure. In 2008, the European Respiratory Society and European Intensive Care Medicine Task Force published guidelines for mobilization of patients in the ICU.18 These recommendations were based on observational studies and expert opinion. According to these guidelines, patients could only undergo physical therapy after passing a very long checklist of physiologic parameters. Therefore, if a patient falls outside of the list in one or a few areas, he or she is excluded from physical therapy at that time. However, Garzon-Serrano et al19 state that these strict barriers might hurt patients by not allowing them to start therapy at an earlier stage in their hospital stay. These authors advocate for allowing the patients to participate in therapy under the care of a health-care provider who can observe and maintain blood pressure, heart rate, and oxygen saturations within reasonable limits. They argue that patients should thus be evaluated on an individual basis rather than by strict exclusion criteria. More data are required to evaluate this. A more recent consensus group has put together recommendations on safety criteria to consider before embarking on active mobilization of mechanically ventilated, critically ill patients.14 These recommendations are presented as a series of color-coded green, yellow, and red situations (Fig. 2). Discussion: mobilization for mechanically ventilated patients Green means that the consideration should not be a major barrier to mobility, yellow means that specific monitoring strategies should be provided, and red means that the patient should not be subjected to mobility procedures. These are summarized in Figures 3– 6. Early Mobility Programs Require Additional Resources Most mobility programs involve several levels of progressive activity, as noted above. Level 1 is simply with the patient lying in bed, level 2 is with the patient sitting on the bed, level 3 is standing and pivoting, and finally level 4 is walking. These all require various levels of additional caregivers. If the patient is simply lying in the bed, most activities can usually be accomplished by the bedside nurse. However, once the patient is sitting on the bed, additional personnel are required. If the patient is standing, there may be more than one person required, and if the person is walking, especially with a ventilator, this may require multiple caregivers. To address these issues, additional resources are going to be required. Three large centers (Wake Forest University, John Hopkins University, and the University of California at San Francisco) reported the increased need for 872 Fig. 5. Neurological considerations for early mobility. RASS ? Richmond Agitation Assessment Scale, CAM-ICU ? confusion assessment method for the ICU. For color coding definitions, see Figure 2. From Reference 14, with permission. resources for carrying out mobility programs.20 At Wake Forest University, 7-d/week mobility is provided. To do this, one additional registered nurse, one additional nursing assistant, one additional physical therapist, and a manager were needed. At Johns Hopkins, which provides 6-d/week .. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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Discussion: mobilization for mechanically ventilated patients

Discussion: mobilization for mechanically ventilated patients ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: mobilization for mechanically ventilated patients Can you help me understand this Health & Medical question? Discussion: mobilization for mechanically ventilated patients see attachment. .needs to be APA style. 300 words and list references Should early mobilization for mechanically ventilated patients be routinely utilized? When should early mobilization not be used? Does your hospital follow this practice? Summarize the discussion session in your own words from the Schmidt et al., article. should_early_mobilization_be_routine_in_mechanically.pdf expert_consensus_and_recommendations_for_mobilization.pdf You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. ADDITIONAL INSTRUCTIONS FOR THE CLASS Discussion Questions (DQ) Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Weekly Participation Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. APA Format and Writing Quality Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. Use of Direct Quotes I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. LopesWrite Policy For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Late Policy The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Communication Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Should Early Mobilization Be Routine in Mechanically Ventilated Patients? Ulrich H Schmidt MD PhD MBA, Lauren Knecht MD, and Neil R MacIntyre MD FAARC Introduction Early Mobilization: The Case for Routine Application in Mechanically Ventilated Patients The Supporting Evidence Base How Early, How Often, How Long? Early Mobilization: Concerns and Reasons for Caution Are the Results of the Many Positive Trials Overstated? Early Mobility Entails Patient Risk Early Mobility Programs Require Additional Resources Other Logistical Challenges Conclusions ICU-acquired weakness is a major complication of critical illness requiring mechanical ventilation. Early mobilization has been shown to decrease the negative consequences of ICU-acquired weakness. Discussion: mobilization for mechanically ventilated patients Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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