Critical care clinics
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Critical care clinics · Jan 2007
ReviewSafety issues that should be considered when mobilizing critically ill patients.
Mobilization is often used by physiotherapists for managing critically ill patients with the aim of treatment including improving respiratory function, level of consciousness, functional ability, and psychological well being, and reducing the adverse effects of immobility. In addition, mobilization may decrease the duration of mechanical ventilation and length of ICU or hospital stay. This article provides ICU practitioners with comprehensive guidelines that can be used to assess the safety of mobilizing critically ill patients. The main safety factors that should be addressed include intrinsic factors related to the patient (eg, medical background, cardiovascular and respiratory reserve, and hematological considerations) and factors extrinsic to the patient (eg, patient attachments, environment, and staffing).
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Growing interest in reducing costs for patients requiring long-term mechanical ventilation has led to development of different care delivery models. This article describes the development and implementation a respiratory care process model focusing on best practices and improvement in care, including early mobility. ⋯ ICU culture was transformed in a way that resulted in improved and consistent care, including early mobility, while stabilizing or even decreasing cost. Involvement of front-line staff in early mobility and other components of the care process model resulted in the development of a culture of safety and teamwork.
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In the previous articles in this issue of Critical Care Clinics, care of the critically ill patient was explored from the viewpoint of how intensive care unit (ICU) mobilization may benefit patients, and how our usual practice may impede the delivery of early mobilization. In this article, the authors discuss future directions in this area under the following headings: current limitations in understanding the effect of immobility on muscle and nerve, uncertainty about the risks and benefits of early mobility, how to implement early mobility programs, and ICU process of care issues required to facilitate early mobilization. Finally, we present a "roadmap" outlining future directions moving toward the development and testing of early ICU mobility therapies.
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Critical care clinics · Jan 2007
ReviewMobilizing the patient in the intensive care unit: the role of early tracheotomy.
A large number of studies have evaluated the benefits of early tracheotomy. Heterogeneity in the various studies reviewed in this article is apparent, with early tracheotomy ranging from one to several days, and benefits regarding incidence of pneumonia and mortality are variable. ⋯ A close look at the studies with the least confounding variables suggests that early tracheotomy has some merit. Most studies suggest that time in the ICU, on mechanical ventilation, and in the hospital is reduced.
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Critical illness neuromyopathy (CINM) is the most common peripheral neuromuscular disorder encountered in the ICU. Bilateral diffuse weakness predominant in the proximal part of the limbs after improvement of the acute phase of the critical illness is highly suggestive of CINM. ⋯ Respiratory muscles also are involved, and CINM may cause delayed weaning and prolonged MV. Besides muscle immobilization and prolonged sepsis-induced multiple organ failure, which are both strong contributors to CINM, hyperglycemia and use of corticosteroids also might have a deleterious effect on the neuromuscular system in critically ill patients.