Stiller Article

Question 1

What are the general aims of mobilization?

Answer 1

1. Improving respiratory function by optimizing ventilation/perfusion
   matching, increasing lung volumes, and improving airway clearance
2. Reducing the adverse effects of immobility
3. Increasing levels of consciousness
4. Increasing functional independence
5. Improving cardiovascular fitness
6. Increasing psychological well being

Question 2

How can mobilization specifically benefit the critically ill patient?

Answer 2

Mobilization may…
Reduce the incidence of pulmonary complications
Hasten recovery
Decrease the duration of mechanical ventilation
Decrease the length of ICU or hospital stay

Question 3

What were the major findings by Stiller & Phillips After mobilizing 31 ICU patients?

Answer 3

Mobilization resulted in significant increases in
HR and BP, and a nonsignificant fall in SpO2

Deterioration in status required intervention in 4.3% of occasions -> mobilization was a safe intervention
for most subjects.

Question 4

What intrinsic factors should be assessed in determining if mobilization is appropriate for a patient in the ICU?

Answer 4

Medical background and current condition
Cardiovascular reserve
Respiratory reserve
Hematology and metabolism
Other

Question 5

What is considerd in the medical background and current condition when determining if mobilization is appropriate for a patient in the ICU?

Answer 5

Medical hx
Medications
Previous activity and exercise capacity
Current condition

Question 6

True of false, formal exercise testing to establish exercise tolerance is contraindicated in the ICU setting

Answer 6

True, use other, indirect measures (look for the other card on this subject)

Question 7

What should PTs rely on when determining exercise tolerance in the ICU setting?

Answer 7

How well the patient has tolerated other recent interventions and ascertain which systems, if any, limited these interventions. Thus, the patient’s response to these interventions provides an indirect exercise test

Question 8

True or false, a resting HR of more than 50% of age-predicted max contraindicates mobilization in the ICU

Answer 8

False, mobilization is still well tolerated by most of these patients

While these patients may have a limited cardiac reserve, resting HR should not (usually) be the sole factor considered when considering mobilization

Question 9

Name some CV signs that a patient is not tolerating mobilization well

Answer 9

Abnormally high increase in HR, particularly if it does not stabilize
Marked fall in HR
Shortness of breath
Clamminess, faintness, or chest pain
Excessive increase in BP
Fall in BP

Question 10

What is the normal response of SBP and DBP to exercise? (typical, healthy patient)

Answer 10

SBP: Initial rise followed by increase that correlates linearly with intensity

DBP: Remain stable or increase slightly (at higher intensity levels)

Question 11

What is the normal response of an ICU patient’s SBP and DBP to exercise?

Answer 11

Data suggests that both SBP and DBP rise significantly

Question 12

While the evidence is not strong, what are some guidelines for using a patient’s BP to judge the appropriateness and effectiveness of mobilization in the ICU patient?

Answer 12

Stability of BP may be more useful than an absolute value - change > 20% may indicate hemodynamic instability and may contraindicate mobilization

If inotropes (epi, NE, DA) are required to maintain BP, mobilization may be contraindicated

Question 13

The ACSM lists cardiac conditions that contraindicate exercise testing. The authors suggest that these same conditions may be used as relative or absolute contraindications to mobilization in critically ill patients. What are these conditions?

Answer 13

Recent significant change in the resting ECG, suggesting significant ischemia, recent MI, or other cardiac event
Unstable angina
Uncontrolled cardiac arrhythmia causing symptoms or hemodynamic compromise
Severe symptomatic aortic stenosis
Uncontrolled symptomatic heart failure
Acute (PE) or pulm infarct
Acute myocarditis or pericarditis
Suspected or known dissecting aneurysm
Acute infections

Question 14

True or false, ECG is a useful, though not a mandatory, tool for monitoring ICU patients during mobilization

Answer 14

False, it is mandatory - provides an instantaneous measurement of HR and allows the detection of arrhythmias

Question 15

True or false, the authors recommend using partial pressure of oxygen in the arterial blood (PaO2) to monitor oxygenation and respiratory reserve

Answer 15

False the authors recommend PaO2/FIO2

FIO2 is the inspired fraction of oxygen

Question 16

How do the authors group PaO2/FIO2 values into categories and what does each mean?

Answer 16

Above 300: pt likely has sufficient respiratory reserve to tolerate mobilization well
200-300: Pt has marginal respiratory reserve
Below 200: Pt has minimal respiratory reserve

Question 17

True or false, lower PaO2/FIO2 values contraindicate mobilization

Answer 17

False, they indicate the need for extreme care, careful monitoring, and modification of intensity

Question 18

While the evidence is not strong, what are some guidelines for using a patient’s SpO2 to judge the appropriateness and effectiveness of mobilization in the ICU patient?

Answer 18

A SpO2 of 90% or more, accompanied by a recent

fluctuation of less than 4%, is likely to indicate sufficient respiratory reserve to tolerate mobilization

Question 19

What is hypercapnia?

Answer 19

elevated partial pressure of arterial CO2

Question 20

What might hyperapnia indciate

Answer 20

Acute respiratory failure

Chronically, hypercapnia should not affect ability to mobilize

Question 21

What is considered when determining if the patient has sufficient CV reserve for mobilization?

Answer 21

Heart rate
Blood Pressure
ECG
Cardiac status

Question 22

What is considered when determining if the patient has sufficient pulm reserve for mobilization?

Answer 22

PAO2/FIO2 and SpO2
Respiratory Pattern
Mechanical ventilation

Question 23

What ECG findings indicate that a patient may have sufficient cardiac reserve?

Answer 23

Absence of MI or arrhythmia

Question 24

What is observed when evaluating a patient’s respiratory pattern?

Answer 24

Respiratory rate
Asynchronous or paradoxical movement of the chest wall and abdomen
Overactivity of the accessory respiratory muscles Unduly prolonged expiration or wheezing

Question 25

If a patient has sufficient oxygenation (PaO2/FIO2, SpO2), does this indicate that their respiratory pattern will be satisfactory?

Answer 25

Not necessarily, the pt may only be able to do this at the expense of an increased work of breathing, reflected by a high respiratory rate and labored breathing.

In such a setting, the numbers may say ‘go’, but subjective observation suggests deferment, or at least caution, if attempting any mobilization.

Question 26

True or false, mechanical ventilation contraindicates mobilization

Answer 26

False, though these pts should be approached with extra care and caution during mobilization

Question 27

What is considered when determining if the patient has sufficient pulm reserve for mobilization?

Answer 27

Oxygenation
Hypercapnia
Respiratory Pattern
Mechanical ventilation

Question 28

What is considered when determining if the pts hematologic and metabolic status is appropriate for mobilization?

Answer 28

Hemoglobin
Platelet count 
White cell count
Body temperature
Blood glucose level

Question 29

True or false, Hg values outside of the normal range contraindicate mobilization

Answer 29

False

Side note: an acute fall in hemoglobin may be more clinically appropriate as an indication of active or recent bleeding, especially if it is associated with hemodynamic instability

Question 30

Why is platelet count considered in determining a pts appropriateness for mobilization?

Answer 30

Pts with a very low platelet count are at higher risk of microvascular trauma and bleeding, which in turn have the potential to result from any activity (such as mobilization) that significantly increases BP.

Question 31

What might an abnormal WBC count indicate

Answer 31

Both high and low WBC counts can indicate infection

Question 32

True or false, infection contraindicates mobilization

Answer 32

False

Question 33

Why does infection indicate that mobilization should be approached with caution?

Answer 33

Infection can increase the patient’s oxygen utilization, thus caution is required if undertaking activities that further increase oxygen demand

Question 34

What are other things should be considered besides Medical background and current condition
CV and pulm reserve, hematology, and metabolism
when determining appropriateness for mobilization?

Answer 34

Appearance of the patient
Neurological status
Presence of certain orthopedic conditions
Nutritional status