Early mobility in the hospital setting is getting more scrutiny and study – there are several recent articles in the NYT as well including one here. My CI suggested that I look at the literature on it and do an inservice on ambulation on ventilators, which they would like to start doing. This is Part I of III – I will post the rest in the next week, and also give my view of PT, acute care, and being a student in acute care (Photo credit – Acute Care, originally uploaded by HelloMokona).
Result of inactivity/ bedrest
- 4 hrs of bed rest: muscles deteriorate
- 8 hrs: contractures start
- 48 hrs: reduced perfusion, increased hemodynamic instability, increased risk for ischemia and injury
- 1 week: 10% loss of strength in HEALTHY volunteers
- Muscles – sarcomeres shorten, reducing contracting force and strength; slow fibers convert to fast
- Inflammatory diseases – can cause diaphragmatic contractile dysfunction
- Unloading/ resting diaphragm = decreased endurance
- Sensory deprivation – anxiety, depression, disturbed sleep (therefore medicated)
- Sense of fatigue – leads to self-limitation
Critical Illness Neuromyopathy
- Develops during ICU (vs GB or myasthenia gravis)
- Cardinal locomotor sign – proximal weakness, grossly symmetrical
- Scored by a MMT sum of arm abd, elbow flex, wrist ext, hip flex, knee ext, DF, with 0 = no visible contraction, 1 = visible but no movement, 2 = active but not AG, 3 = active, AG, 4 = active, AG and resistance (NOTE: doesn’t say how much resistance!), 5 = normal power
- <48 – significant weakness; may have sensory, DTR, muscle mass loss
- Can be diagnosed with EMG which shows reduced action potential, and spontaneous activity occurring, but noted to not always be feasible
- Pts with CINM – increased days on vent, longer weaning, immobility
Outcomes of prolonged ventilation
- DVT’s, pneumonia
- Residual weakness (12 months after admission, still have significant residual weakness – 66% of NV in 6 min walk test)
- Sensory deficits (Study: vented >28 days: 59% with motor or sensory deficits, 95% with EMG evidence of chronic partial denervation)
- Increased mortality (Study: PMV 98-00 – 1yr mortality 58%, 22% died in hospital, 36% died within 1 yr of d/c, 57% of survivors got off the vent)
- Discharge location (Study: d/c disposition: 17% home, 35% to rehab, 23% to SNF. Study: >96hrs on vent 45% to SNF, median time to home 7 months 53% had 1 or more re-admits within 12 months
- Cognitive deficits (Reports of 27% d/c with cognitive deficits)49% of survivors return to work at 1 yr
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