Algorithmen zur Frühmobilisierung auf Intensivstationen

  • P. Nydahl
  • R. Dubb
  • S. Filipovic
  • C. Hermes
  • F. Jüttner
  • A. Kaltwasser
  • S. Klarmann
  • H. Mende
  • S. Nessizius
  • C. Rottensteiner
Pflege

Zusammenfassung

Die Immobilität von Patienten auf Intensivstation kann zu nachhaltigen physischen und kognitiven Nachteilen führen. In den letzten Jahren wurden Maßnahmenbündel zur Rehabilitation entwickelt, die u. a. auch die Frühmobilisierung beinhalten. Die deutsche Leitlinie zur Lagerungstherapie und Frühmobilisierung empfiehlt allgemein die Entwicklung stationsspezifischer Protokolle. Ziel dieser narrativen Übersichtsarbeit ist es, Empfehlungen zur Entwicklung eines Best-Practice-Protokolls im eigenen Arbeitsbereich zu geben. Es wird empfohlen, a) Frühmobilisierung als Teil eines Maßnahmenbündels unter Einbeziehung von regelmäßigem Screening und Management von Wachheit, Schmerz, Angst, Stress, Delir sowie der Gegenwart der Familie umzusetzen, b) spezifische Ein- und Ausschlusskriterien mithilfe eines Ampelsystems für die zu behandelnde Populationen in einem interprofessionellen Prozess zu entwickeln, c) Checklisten zur Risikoeinschätzung und Vorbereitung der Mobilisierung zu verwenden, d) die ICU Mobility Scale zur Zielsetzung und Dokumentation der Mobilisierung zu nutzen, e) relative Sicherheitskriterien für hämodynamische und respiratorische Veränderung sowie die Borg-Skala für eine subjektive Evaluation zu verwenden, f) die Mobilisierung sowie Barrieren, unerwünschte Sicherheitsereignisse und andere Parameter systematisch zu dokumentieren und zu evaluieren.

Schlüsselwörter

Rehabilitation Delir Physiotherapie Bewegungstherapie Beatmungstherapie 

Algorithms for early mobilization in intensive care units

Abstract

Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one’s own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient’s awareness, pain, anxiety, stress, delirium and family’s presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.

Keywords

Rehabilitation  Delirium Physical therapy modalities Exercise therapy Respiration therapy 

Literatur

  1. 1.
    Abrams D, Javidfar J, Farrand E et al (2014) Early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study. Crit Care 18:R38CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Adler J, Malone D (2012) Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 23:5–13PubMedPubMedCentralGoogle Scholar
  3. 3.
    Amidei C (2012) Measurement of physiologic responses to mobilisation in critically ill adults. Intensive Crit Care Nurs 28:58–72CrossRefPubMedGoogle Scholar
  4. 4.
    Bailey P, Thomsen GE, Spuhler VJ et al (2007) Early activity is feasible and safe in respiratory failure patients. Crit Care Med 35:139–145CrossRefPubMedGoogle Scholar
  5. 5.
    Balas MC, Vasilevskis EE, Olsen KM et al (2014) Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 42:1024–1036CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Berry A, Beattie K, Bennett J, Cross Y, Cushway S, Hassan A, Longhurst E, Moore R, Phillips D, Plowman E, Scott J, Thomas L, Elliott D (2014) Physical activity and movement: a guideline for critically ill adults. Agency for Clinical Innovation, ChatswoodGoogle Scholar
  7. 7.
    Borg G (2004) Anstrengungsempfinden und körperliche Aktivität. Dtsch Arztebl 101:1016–1021Google Scholar
  8. 8.
    Bourdin G, Barbier J, Burle JF et al (2010) The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care 55:400–407PubMedGoogle Scholar
  9. 9.
    Brower RG (2009) Consequences of bed rest. Crit Care Med 37:422–428CrossRefGoogle Scholar
  10. 10.
    Charansonney OL (2011) Physical activity and aging: a life-long story. Discov Med 12:177–185PubMedGoogle Scholar
  11. 11.
    Clark DE, Lowman JD, Griffin RL et al (2013) Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. Phys Ther 93:186–196CrossRefPubMedGoogle Scholar
  12. 12.
    Davis J, Crawford K, Wierman H et al (2013) Mobilization of ventilated older adults. J Geriatr Phys Ther 36:162–168CrossRefPubMedGoogle Scholar
  13. 13.
    Dubb R, Nydahl P, Hermes C et al (2016) Barriers and strategies for early mobilization of patients in intensive care units. Ann Am Thorac Soc 13(5):724–730. doi:10.1513/annalsats.201509-586cme CrossRefPubMedGoogle Scholar
  14. 14.
    Felten-Barentsz KM, Haans AJ, Slutsky AS et al (2015) Feasibility and safety of hydrotherapy in critically ill ventilated patients. Am J Respir Crit Care Med 191:476–477CrossRefPubMedGoogle Scholar
  15. 15.
    Filipovic S (2012) Das Marburger Stufenkonzept. Pflegen Intensiv 9:22–27Google Scholar
  16. 16.
    Gaertner J, Siemens W, Daveson BA et al (2016) Of apples and oranges: lessons learned from the preparation of research protocols for systematic reviews exploring the effectiveness of specialist palliative care. BMC Palliat Care 15:43CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Genc A, Ozyurek S, Koca U et al (2012) Respiratory and hemodynamic responses to mobilization of critically ill obese patients. Cardiopulm Phys Ther J 23:14–18PubMedPubMedCentralGoogle Scholar
  18. 18.
    Gosselink R, Bott J, Johnson M et al (2008) Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 34:1188–1199CrossRefPubMedGoogle Scholar
  19. 19.
    Hanekom S, Louw QA, Coetzee AR (2013) Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units. Physiotherapy 99:139–145CrossRefPubMedGoogle Scholar
  20. 20.
    Haugdahl HS, Storli SL, Meland B et al (2015) Underestimation of patient breathlessness by nurses and physicians during a spontaneous breathing trial. Am J Respir Crit Care Med 192:1440–1448CrossRefPubMedGoogle Scholar
  21. 21.
    Hodgson C, Needham D, Haines K et al (2014) Feasibility and inter-rater reliability of the ICU Mobility Scale. Heart Lung 43:19–24CrossRefPubMedGoogle Scholar
  22. 22.
    Hodgson CL, Stiller K, Needham DM et al (2014) Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 18:658CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Hopkins RO, Spuhler VJ, Thomsen GE (2007) Transforming ICU culture to facilitate early mobility. Crit Care Clin 23:81–96CrossRefPubMedGoogle Scholar
  24. 24.
    Intensivmedizin DGFaU (2015) Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen FunktionsstörungenGoogle Scholar
  25. 25.
    Intensivmedizin DGFRaSU (2015) S3-Leitlinie Analgesie, Sedierung und Delirmanagement in der Intensivmedizin (DAS-Leitlinie 2015) (http://www.awmf.org/uploads/tx_szleitlinien/001-012l_S3_Analgesie_Sedierung_Delirmanagement_Intensivmedizin_2015-08_01.pdf)Google Scholar
  26. 26.
    Kayambu G, Boots R, Paratz J (2013) Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med 41:1543–1554CrossRefPubMedGoogle Scholar
  27. 27.
    Klein K, Mulkey M, Bena JF et al (2015) Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study. Crit Care Med 43:865–873CrossRefPubMedGoogle Scholar
  28. 28.
    Li Z, Peng X, Zhu B et al (2013) Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil 94:551–561CrossRefPubMedGoogle Scholar
  29. 29.
    Mcwilliams D, Weblin J, Atkins G et al (2015) Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: a quality improvement project. J Crit Care 30:13–18CrossRefPubMedGoogle Scholar
  30. 30.
    Meyer MJ, Stanislaus AB, Lee J et al (2013) Surgical Intensive Care Unit Optimal Mobilisation Score (SOMS) trial: a protocol for an international, multicentre, randomised controlled trial focused on goal-directed early mobilisation of surgical ICU patients. BMJ Open 3:e003262CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Morris PE, Goad A, Thompson C et al (2008) Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 36:2238–2243CrossRefPubMedGoogle Scholar
  32. 32.
    Needham DM, Korupolu R (2010) Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehabil 17:271–281CrossRefPubMedGoogle Scholar
  33. 33.
    Needham DM, Korupolu R, Zanni JM et al (2010) Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 91:536–542CrossRefPubMedGoogle Scholar
  34. 34.
    Needham DM, Truong AD, Fan E (2009) Technology to enhance physical rehabilitation of critically ill patients. Crit Care Med 37:S436–441CrossRefPubMedGoogle Scholar
  35. 35.
    Nessizius S (2014) Aufgaben der Physiotherapie in der Intensivmedizin. Med Klin Intensivmed Notfmed 7:547–554CrossRefGoogle Scholar
  36. 36.
    Nessizius S, Rottensteiner C, Nydahl P (2016) Frührehabilitation in der Intensivmedizin. Elsevier, MünchenGoogle Scholar
  37. 37.
    Nickels M, Aitken LM, Walsham J et al (2016) Clinicians’ perceptions of rationales for rehabilitative exercise in a critical care setting: a cross-sectional study. Aust Crit Care. doi:10.1016/j.aucc.2016.03.003 PubMedGoogle Scholar
  38. 38.
    Nydahl P, Dewes M, Dubb R et al (2016) Frühmobilisierung: Kompetenzen, Verantwortungen, Zuständigkeiten. Med Klin Intensivmed Notfmed 111:153–159CrossRefPubMedGoogle Scholar
  39. 39.
    Nydahl P, Ewers A, Brodda D (2014) Complications related to early mobilization of mechanically ventilated patients on intensive care units. Nurs Crit Care. doi:10.1111/nicc.12134 Google Scholar
  40. 40.
    Nydahl P, Ruhl AP, Bartoszek G et al (2014) Early mobilization of mechanically ventilated patients: a 1‑day point-prevalence study in Germany. Crit Care Med 42:1178–1186CrossRefPubMedGoogle Scholar
  41. 41.
    Perme C, Nalty T, Winkelman C et al (2013) Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: a prospective observational study. Cardiopulm Phys Ther J 24:12–17PubMedPubMedCentralGoogle Scholar
  42. 42.
    Perme CS, Southard RE, Joyce DL et al (2006) Early mobilization of LVAD recipients who require prolonged mechanical ventilation. Tex Heart Inst J 33:130–133PubMedPubMedCentralGoogle Scholar
  43. 43.
    Pohlman MC, Schweickert WD, Pohlman AS et al (2010) Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med 38:2089–2094CrossRefPubMedGoogle Scholar
  44. 44.
    Schweickert WD, Pohlman MC, Pohlman AS et al (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373:1874–1882CrossRefPubMedGoogle Scholar
  45. 45.
    Skinner EH, Berney S, Warrillow S et al (2009) Development of a physical function outcome measure (PFIT) and a pilot exercise training protocol for use in intensive care. Crit Care Resusc 11:110–115PubMedGoogle Scholar
  46. 46.
    Sottile PD, Nordon-Craft A, Malone D et al (2015) Patient and family perceptions of physical therapy in the medical intensive care unit. J Crit Care 30:891–895CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Soysal P, Aydin AE, Koc Okudur S et al (2016) When should orthostatic blood pressure changes be evaluated in elderly: 1st, 3rd or 5th minute? Arch Gerontol Geriatr 65:199–203CrossRefPubMedGoogle Scholar
  48. 48.
    Stiller K (2013) Physiotherapy in intensive care: an updated systematic review. Chest 144:825–847CrossRefPubMedGoogle Scholar
  49. 49.
    Stiller K, Phillips A (2003) Safety aspects of mobilising acutely ill inpatients. Physiother Theory Pract 19:239–257CrossRefGoogle Scholar
  50. 50.
    Stiller K, Phillips A, Lambert P (2004) The safety of mobilisation and its effects on haemodynamics and respiratory status of intensive care patients. Physiother Theory Pract 20:175–185CrossRefGoogle Scholar
  51. 51.
    The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC) (2009) Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 30:2631–2671CrossRefGoogle Scholar
  52. 52.
    Tipping CJ, Bailey MJ, Bellomo R et al (2016) The ICU mobility scale has construct and predictive validity and is responsive: a multicenter observational study. Ann Am Thorac Soc 13(6):887–893. doi:10.1513/annalsats.201510-717oc CrossRefPubMedGoogle Scholar
  53. 53.
    Titsworth WL, Hester J, Correia T et al (2012) The effect of increased mobility on morbidity in the neurointensive care unit. J Neurosurg 116:1379–1388CrossRefPubMedGoogle Scholar
  54. 54.
    Wang YT, Haines TP, Ritchie P et al (2014) Early mobilization on continuous renal replacement therapy is safe and may improve filter life. Crit Care 18:R161CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Zafiropoulos B, Alison JA, Mccarren B (2004) Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient. Aust J Physiother 50:95–100CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • P. Nydahl
    • 1
  • R. Dubb
    • 2
  • S. Filipovic
    • 3
  • C. Hermes
    • 4
  • F. Jüttner
    • 5
  • A. Kaltwasser
    • 2
  • S. Klarmann
    • 6
  • H. Mende
    • 7
  • S. Nessizius
    • 8
  • C. Rottensteiner
    • 9
  1. 1.PflegeforschungUniversitätsklinikum Schleswig-Holstein, Campus KielKielDeutschland
  2. 2.Akademie der Kreiskliniken ReutlingenKreiskliniken Reutlingen GmbHReutlingenDeutschland
  3. 3.Abteilung PhysiotherapieUniversitätsklinikum MarburgMarburgDeutschland
  4. 4.Anästhesie und IntensivpflegeHELIOS Klinikum SiegburgSiegburgDeutschland
  5. 5.Anästhesie und IntensivpflegeAsklepios Paulinen Klinik WiesbadenWiesbadenDeutschland
  6. 6.Zentrale Einrichtung PhysiotherapieUniversitätsklinikum Schleswig-Holstein, Campus KielKielDeutschland
  7. 7.Klinik für Neurologie, Neurophysiologie, Frührehabilitation und SchlafmedizinChristophsbad GöppingenGöppingenDeutschland
  8. 8.Institut für Physikalische Medizin und Rehabilitation, Bereich Innere Medizin/IntensivstationLKH-Universitätskliniken InnsbruckInnsbruckÖsterreich
  9. 9.Universitätsklinik für Physikalische Medizin und Rehabilitation WienWienÖsterreich

Personalised recommendations