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Centene I'm happy here to discuss my.experiences with implementing an early.mobility program and what I've learned.about it over the last couple years my.objectives for this presentation are to.talk about some of the challenges and.some of the symptoms presented with post.intensive care syndrome we're going to.discuss problems with having our.patients immobilized in the ICU some.diagnostic approaches to recognizing ICU.aquired weakness I'm going to look at.some safety data for early mobility.programs review the outcomes based.research for OB.early mobility and describe how to.implement a early mobility program so.real briefly gonna disk over give you an.overview of my experience with an early.mobility program prior to coming to.Providence Everett I was at Harborview.for 20 years.Harborview is a trauma center in Seattle.Washington and they had decided to.implement an early mobility program and.I was tasked to be a part of the.implementation team it was very.interesting work it was novel to me at.the time and I learned a lot of the.barriers the nuances and the challenges.to trying to start this new process in.the ICU but we're first you have to.understand is a kind of a newer concept.is post intensive care syndrome post.intensive care syndrome is something.that we are that you are seen in.patients who have survived critical.illness with the improvements in.technology and our understanding of.critical care and improve strategies.such as lung protective ventilation we.are seeing patients with worsening.outcomes after they survive their.critical illness these outcomes and crew.deficiencies and the physical mental and.cognitive abilities in many cases the.research shows that these deficiencies.can and will go on for years.some of the more specific values is.we've seen that PFT values are reduced.in patients with a RDS and with critical.illness we see reductions in in Spiteri.muscle strength you see reduction in.hand grip strength which is often used.as a sort of a mana as a value to look.at how a patient strength has been.lessened in the ICU we see reductions in.six-minute walk test and ICU survivors.we also see limitations in their.returning through their activities of.daily living including driving and.working what we've under begin to.understand is even though that patients.can survive a significant critical.illness they don't always return to.their baseline work status and this.includes people who were quite.functioning in society before their.episode of a RDS or their episode of.sepsis.we know that cognitive impairment is.pretty common including a up to half of.people who survived an acute lung injury.we'll have it up to one year and we see.that anxiety and depression and.post-traumatic stress disorder are.pretty common in survivors so patients.who are weaker they have poorer outcomes.we know that they will spend longer time.in the ice use that they will be on the.ventilator for a longer period of time.they are most likely to need.reintubation due to acute respiratory.failure as they are weaker they are.unable to explorations they're less.mobile and they will often go to a.skilled nursing facility prior to.returning home and they will experience.a long time in rehabilitation so what we.see is that even though they survived.again to recap they have deficiencies.and their physical abilities and.sometimes cognitive abilities and for.and a lot of them have high levels of.anxiety so as.you see these patients that have.long-term issues the thought process.begins to look at what is happening in.the ICU that we are are we causing this.and predominantly in the ICU stay we at.least when I started in critical care.when we had patients who were in a RTS.or sepsis we would do everything we.could to sedate and keep them immobile.and this was thought that by doing so.that we were treating the patient better.reducing oxygen consumption keeping them.still where their body recovered but we.see a cute deconditioning happen QD.conditioning which we see changes from.just to several days two weeks after a.couple weeks we'll see chronic.deconditioning and thus deconditioning.can impact their mood their ability to.coordinate their body their muscle.strength and their ability to walk their.gait their physical ability their.balance so even though with even a short.stay in an ICU we see some.deconditioning and their physical.ability just some reminders that we can.see muscle atrophy much relaxed if II.can lose one to one and a half percent.per day with strict bed rest and even.from what we know from other medicine.like if you cast a limb your skeletal.muscle strength will decline by five to.six percent per day and these are the.prominent muscles that are used to.approach gravity so we consider when we.take their ICU patients and place them.in bed rest for even up to a week that.we can cause acute muscle atrophy when.we look at some of the diagnoses for.people who are in bed rest to kind of.specific diagnoses emerge from the.literature one is critical illness.polyneuropathy and critical illness.polyneuropathy is what we see is.impaired oxygen and nutrient delivery to.the nerves and this is caused frequently.by sepsis and hyperglycemia.hyperglycemia the the nerves do not.do well with high levels of glucose and.it makes them leaky and as they get.leaky we see direct damage to nerves by.cytokines as another distinct process we.see critical illness myopathy and this.is increase in proteins breakdown by.inflammatory cytokines and collectively.we will call the critical illness.myopathy and critical illness.polyneuropathy I see you acquired.weakness which i think is the more.common term that you will see in the.literature and in discussions what are.the risk factors for ICU acquired.weakness there there are plenty sepsis.is a big one multi organ failure again.hyperglycemia catecholamine.administration duration of mechanical.ventilation the being a female gender.and corticosteroids and neuromuscular.blocking agents have long been.identified as significant risk factors.for polyneuropathy what we see here is a.sort of a breakdown a graphic of the.different mechanisms that can lead to.ICU acquired weakness we see significant.cytokine production which can lead to.micro vascular changes metabolic.derangements and electrical alterations.and we can see that all these will.impair these micro circulation impair.the specific humor balances in the body.and which will eventually lead to ice.you acquired weakness and you can review.this at your leisure.it is quite there's many pathways that.can cause I see you acquired weakness.and not one specific how does one.diagnose ice you acquired weakness in.the ICU I would say there's a couple of.different strategies you can take.physical exam being probably the.simplest however it requires an awake.and cooperative patient so when you.think about your.work in the ICU many of our patients are.sedated or they are delirious and.they're unable to cooperate with the.exam and the exam requires them to be.able to lift their arm opposed to lift.their arm or post resistance and how.strong they can do it other options are.electrophysiological electrophysiologic.testing this is where you may stick a.needle into the nerve into the muscle.electro myelogram and and see if there's.changes you can detect changes 24 to 40.hour 8 48 hours after the onset of the.critical illness however the test.requires specialized knowledge to.conduct and it is the quality is.impacted by several factors most.significant of which is being limo Dima.you have to get the needle precisely.placed into muscle and nerves and having.a demitasse limbs can make that.difficult and also local temperature at.the limb level may also impact that test.muscle biopsy probably is our definitive.diagnosis for myopathies because then.you can examine the muscle directly.however that is the most invasive in the.ICU so most often what we will see is.that I see you acquired weak illness or.weakness will be diagnosed empirically.and this is a graphic showing the.electoral myelogram and on the bottom of.the screen you'll see that the we would.see is a normal test where you are.sending an impulse into the nerve and.you're measuring the muscle and you see.that as the impulse goes through the.nerve we have the same amplitude of.impulse at them at the muscle and when.we have neuropathy when we deliver the.the impulse to the nerve that is.attenuated but we will still see a when.we stimulate the muscle we'll still see.a nice spike and in myopathy we will see.ten you a Tanner stimulation as well as.in ten you ated muscle stimulation again.this is another and from the same.article from Lipshutz in anesthesiology.that looks how you may approach.diagnosing ICU weakness in the ICU again.you know you there's you look at trying.to rule out other factors if they have.MRIs brain issues and then look at nerve.conduction studies and then possible.nerve biopsy or muscle biopsy and.oftentimes again I see I think that most.people given the complexity of the.diagnostic procedures and the treatment.options will just opt to diagnose it.empirically so a more practical approach.that was presented by jolly in 2016 was.to change to obtain a history before.their diagnosis oftentimes from family.early stage consider doing muscle test.if they are able to participate and.consider doing specialized diagnostic.tests if the patient is non.participatory and this is the.electrophysiologic testing muscle.ultrasounds which is a newer diagnostic.test and then post ICU after their.extubated more cooperative you can do.the handgrip strengths the tests for.other higher assess higher level of.activities and these are interval tests.and then after the ICU it can continue.to do those a tests and assess for their.return to their activities and baseline.activities of daily living and if they.can return to baseline and what you will.typically see is as the patient has is.you acquired weakness you're monitoring.for their ability to return to their.baseline levels.next I'd like to move on to reviewing.the safety data for an early mobility.program so give you sort of a context.when I first heard about doing the icy.mobility program as many of us who.worked in critical care back at the time.we were very concerned about the safety.of doing this modality when you consider.all the lines IVs and specialty.equipment not to include the mechanical.ventilator and the endotracheal tube to.mobilize patients was we thought was.very risky and and the initial study is.looking at mobilizing patients really.looked at could we do this safe safely.and one of the earliest published.studies back in 2007 wasn't from a 8 bed.respiratory care intensive unit that.included patients that were in.mechanically ventilated for over four.days and they began to do increases in.their progression in their mobility and.they had them sit in the bed sit on the.chair and they emulated twice a day and.this was a team of physical therapy rest.rapists nurses and bedside assistance.staff and the outcome is could they.emulate the patient's 100 feet and that.was what their goal was they were.working to and what they found is even.though out of over 1,400 events.it was pretty safe they had relatively.few safety concerns and most of those.safety concerns were small in nature.they had a couple patients that fell to.their knees there was some blood.pressure changes four of which were due.to orthostatic changes and there was.some desaturation zall of which were.quickly resolved and then there was one.instance of a feeding tube being removed.so when you consider that over 1,400.events they had only those few safety.concerns and and most of which were not.very.significant it's sort of demonstrated.that you could do an early mobility.program safely at least from this.initial study so in another study that.looked at the early study looked at.early mobility they were asking could we.does an early mobility program increase.the number of patients in an ICU.receiving physical therapy and this is.back I would say prior to this when in.the old state physical therapy may do.range of motion changes or Mait range of.motion therapy but didn't we're very.active with patients on mechanical.ventilation and so they developed a.protocol to increase the intensity of.physical therapy with patients and their.outcome was the portion of hospital.survivors receiving physical therapy and.this is the approach that they use to.increasing physical therapy for.mechanically ventilated patients and.what's significant about this is even.though as early the knowledge about.early mobility has evolved in the last.decade the protocol that most facilities.employ is pretty much similar to this.and what we see here is level one is we.have an unconscious patient and.non-participatory patient and they would.receive passive mode range of motion.three times a day the bedside staff.still turns the patient every two hours.and then we move on to sort of if they.can do this then let's move them on to.the next level if they are conscious.when we can continue to do some passive.range motions and we continue to turn.them but we can do some active.resistance physical therapy and we place.the patients in the sitting position and.if they can go to the sitting position.then we can move them to the next step.which is if they can sit then let's have.them sit on the edge of the bed and then.dangle their feet and this allows them.to move their limbs and their legs.against gravity and we take that for.granted but moving our limbs tore.against gravity.maintain a significant amount of.strength and resist that muscle atrophy.from the pulmonary standpoint even if.they can do just that level of activity.that benefits us because that helps them.maintain their core strengths and their.thoracic strength which will help their.coffin their pulmonary toilet post.extubation if they can sit on the edge.of the bed then we consider having them.stand so that's the next step if they.can do all that above then we can have.them stand and if they can stand let's.have them transfer to another chair and.if they can stand transfer to another.chair let's consider having them walk.and on the right-hand side of the screen.as safety criteria which is is the rest.or a therapist or bedside nurse you.always want to be cognizant that your.facility has developed some safety.criteria to either monitor either you if.you for example you have a peep of 15.and 80 percent or you're on hyper-v.settings maybe you don't want to have.your patient do that much activity but.there if they're on moderate settings.and they're not on vasopressors you may.consider that they are safe to do this.this type of activity but if you want to.have some criteria that if there are.changes they become hypoxic or they.become hypotensive that you limit the.stop the therapy stop the progression.and have them rest so in this particular.study they did see that they were able.to increase the amount of physical.therapy that patients received in the.ICU so Moorman patients were seen by PT.in the hospital they had more sessions.and what was interesting is that because.of this because PT began working with.the patient sooner they were able to get.the patients out of bed sooner and in.this early study they showed a shortened.ICU stay in hospital lengths this day.but the duration mechanical ventilation.was not significantly different what's.important to note is in this early event.is that they saw no increase in costs.where you would likely see your increase.in cost in the facility would be that.you have to hire more staff to deliver.this type of care and they were in this.small study they were able to deliver.the care with the existing staffing.model that they had so there was no.increase significant increasing costs.and there was no also no adverse events.in a more larger study looked at just.specifically looked at safety doctor.ngaidol and published in 2017 looked at.the reports of adverse events in early.mobility and what you can see is out of.quite a few early mobility sessions the.reported event rate was significantly.lower but I think it's a I did the math.and there's about 2.6 percent adverse.event rate per early mobility and when.you consider that we have done thousands.of early mobility events and this is.having patients set up having patients.sit on the edge of the bed and have them.walk that the event rate the adverse.event rate is actually pretty low so.what are the outcomes for having an.early mobility program there are several.now larger randomized controlled trials.that have looked at having an early.mobility program swagger doctor Spiker.in 2009 published one of the earlier.ones and this one they looked at MICU.patients that require mechanical.ventilation for more than 72 hours they.implemented a early exercise a mobility.program that coupled the daily.interruption of sedation maybe with the.usual PT ot and their primary outcome.was how functional independently or how.physically functional these patients.were at discharge and they were looking.at six specifically ADL's and there were.other outcomes was a reduction in.delirium and hopefully a reduction in.duration of mechanical ventilation the.idea being if they.tane the patient's functional status.they could get the patients off the.ventilator sooner and what we see in the.outcomes and this is a relatively small.study 50 about 5050 about a total of 100.patients 50 in control of 55 or 55 and.control 49 in intervention and we see.that in the intervention they received.physical therapy much sooner the other.significant outcome of this was the.intervention groups they repaired more.returns to their activities of daily.living at discharge so they were more.functional at hospital discharge another.interesting outcome is that they were.able to walk a greater distance at.hospital discharge as compared to the.control group and when you look at.milestones they were faster to these.milestones than the control group they.were sooner to get out of bed they were.sooner to be able to stand they were.sooner marching in place getting to.another chair and walking and when he.knew this makes intuitive sense that if.you begin the therapy sooner if you.provide better care to the patient even.when they're intubated they may reach.these milestones sooner other outcomes.that were of note they're more patients.were able to return to independent.functional status at discharge so they.did not have to go to skilled nursing.facilities so that has some community.health benefits there was fewer ICU.delirium there was less time with.delirium and in this particular study.there were fewer mechanical ventilation.days they were able to get the patients.off the ventilator sooner.and this is a graph showing that their.ability to return to functional status.was significantly higher and then the.control group so this study resulted in.some benefits to patients just simply.being more functional at discharge.following their critical illness this.study was followed up by another one.again kind of a smaller study a total of.50 patients their primary outcome was.using a physical function test the s.sf-36 telephone quest which is a.questionnaire that's done over the phone.post discharge and they had some.secondary outcomes using a MCR MRC score.and measures some cytokines so again.this was where they did more intensive.study and we can see in the graph here.that the patients who received exercise.had better physical function better.physical role less bodily pain a better.emotional role but it also is of.interesting note they had differences in.their inflammatory markers most.significant of which was the il-6 one of.the larger studies was done by Morris.that was published in JAMA two years ago.this was over 300 patients pretty good.size at 150 in control and in this.particular one the standard rehab.therapy was normally what was done the.ICU was compared to progressive physical.therapy with increasing intensity and.the primary outcome and this one was.Hospital length of stay there were other.secondary outcomes included ventilator.length the stay physical outcome at.discharge and a mentee mini-mental State.Exam what's interesting to note in this.particular study is that the usual care.did not result in much improvement.over the more intensive physical therapy.on these outcomes it's a big slide.apologize for having a lot of the data.but not a lot of significant values in.this particular graph and and one of.them I might say one of the criticisms.or the biases of that study is when we.look at how care has been provided we.may be teaching the nursing staff and.the respiratory therapy staff to be more.assertive in doing early mobility.programs so even though you may not have.physical therapy coming to the bedside.that the other bedside caregivers are.doing more therapy with those patients.so that may have biased the results.another study this is a matter of.analysis that looked at several.randomized control trials looked at.physical therapy versus the usual care.and when we look at these randomized or.these meta-analysis we want to look at.the diamond and some of these don't.include a lot of studies but we see that.the meta-analysis are favoring the early.rehabilitation for different groups when.you look at the different slices of the.study which is less clear is are they.able to make a difference on having.delirium free days or mental health.related outcomes and so what we're.seeing from some of this is that we are.definitely making an impact on the.physical outcomes less clear on the.mental health related outcomes and some.of the other based on how they slice the.data health-related scores and some.other physical scores so what are the.costs associated with having an early.mobility program oftentimes there is.concern from the card of the c-suite.that having an early mobility program is.is expensive because you have to have.more staff doing time intensive therapy.and this was the post analysis of.particular studies looked at the cost of.having early mobility programs and.differences in the outcome so they.looked at two different studies they.signed some costs to the more study and.another rosenbaum study and they showed.that in the in the morris study that.with the early mobility program the cost.of care was around forty one thousand.American dollars as opposed to forty.four thousand dollars when you had the.usual care and what we can kind of see.is that when you have no early mobility.program you will have more time spent in.the ICU or it's perceived that you will.have more time spent in the ICU which is.the most expensive place to care for the.patient with an early mobility program.presumably the patients will spend less.time in the ICU and they will be more.functional as they are discharged and.will have lower costs and on the table.on the right-hand side of the slide.there demonstrates that an estimated.emissions per year based off of this.analysis the hospital saving so an.estimated savings if you have 2,200.emissions per year you would save about.$34,000 and as the admissions go up so.do the cost savings so the argument for.having an early mobility program is yes.you are spending more intensive time.with the patients in the ICU but they'll.be in the ICU for a lesser amount of.time and they will require less.intensive therapy as they progress.through the healthcare continuum next I.would like to talk a little bit about.implementing early mobility program kind.of what you need to be successful and.maybe hopefully learn from some of my.experiences.what you would definitely need to be.successful is you need to have.administrative buy-in there are.sometimes considerations for having more.staff particularly more physical therapy.staff the is more time intensive for.nursing for respiratory therapy so.making sure that as everyone is very.concerned about their productivity and.that their expenses that you have.administrative buy-in to begin the.program and then give you the.opportunity to demonstrate the benefits.of the program and so that you can.demonstrate the cost savings to the.c-suite.another key element is you have to have.a physician champion the physician.champion is essential to negotiating.with the other attendings to.successfully implement the program they.have to help educate everybody and be.that sort of go-to person to champion.the cause and you need to have a.multidisciplinary approach it is not it.is best that if it's not just nursing.not just physicians not just physical.therapy or not just respiratory therapy.that this is a true multidisciplinary.approach and spend a lot of time.overcoming misconceptions about early.mobility when I started my first when I.I didn't start it but when I was a part.of starting our first early mobility.program there were a lot of conceptual.barriers to overcome and we were.struggling with why we could not get the.patients up and moving and what we.finally decided on doing was we set up.specific rounds in our medical ICU to.round on the patient's for the express.purpose of discussing what were the.barriers to early mobilization and what.was so functional beneficial about this.is it was a physician a nurse champion a.rust or a therapist champion a.position a psychiatrist who was an.expert in delirium and when we ran when.we rounded with the bedside staff we.would often run into misconceptions.about early mobility or I would say most.significantly was delirium we had.learned that we were frequently over.sedating our patients miss diagnosing.delirium and causing them to fail from.that angle so we spent several weeks.re-educating the nursing staff the rest.for a therapy staff the bedside staff.about delirium trying to limit.benzodiazepines overcoming barriers such.as you would have a patient that the.staff would decide was too sick to do.any movement on and then reeducate them.well this is actually quite safe and you.can go ahead and set them up you can go.ahead and have them sit at the edge of.the bed and a lot of I would say.reassurance to the bedside staff but.really having discussions about what are.the perceptions to the barriers what is.your level of comfort or education so.I'd say a lot of re-education on what.the actual mechanics of a program are.there are a lot of safety concerns there.are a lot of concerns over accidentally.discharge mentum of the medical devices.the endotracheal tube being most.significant vascular devices.you know compile complications from.increased activity with hypoxemia.hemodynamic and patient comfort and.these are often the perceptions of the.bedside staff not necessarily the.caregivers themselves and we've actually.did a lot of early mobilization with.endotracheal tubes and you know the rest.are a therapist can guard and be aware.of the endotracheal tube I does not come.out you can guard the IV or the central.line and it does not come out there have.been case reports of patients being.actively mobilized while they're even on.ECMO using an Avalon catheter they can.be safely mobilized so if you are.mindful if you were.in your approach if you secure the.device appropriately before you leave.the bedside then these are not really.barriers these are just concerns and.things to watch sedation and delirium.this is a significant barrier if you are.not actively assessing for delirium in.your ICU and you hear a lot of.conversations about the ABCDE bundle.early mobility is a part of the ABCDE.bundle but so as delirium if your.patients are over delirious they will.not be able to actively participate in.the mobility program and initially that.was the buzz saw that we ran into when I.was a Harborview when we implemented the.program is that the many of the patients.were just too sedated.there were too delirious and we were not.accurately assessing the delirium so we.had to do a lot of reeducation.re-education around using the cam tool.and once we were able to get a handle on.that we were able to begin the activity.and decrease those barriers for the.staff again cost is an issue it's not.really an issue unless you're hiring.more staff but from the perception of.the staff this requires more of their.time they feel that say sometimes have.less time for other patients and you.each facility needs to address this on.their own if you're only mobilizing.walking one or two patients a day that's.not a significant increase to the.workload but if you're walking 10.patients a day that may be an increase.so another kind of barrier that I was.unaware of is that some early components.of an early mobility program may not be.skilled therapy for physical therapy and.so in those cases you have to train the.nursing staff in the RT staff enough.that they can do the the mobilization of.the patients again it's not a barrier.you don't need a PT person to sit up a.patient in bed or have them dangle their.feet you may need some assistance to.have patience.initially walk but if they don't need.skilled therapy you don't need to have.the physical therapist present in one.case an instant I recall caring for a.cystic fibrosis patient who was.essentially ventilator dependent and and.they were awaiting a lung transplant as.part of their plan to improve their.health for the lung transplant the.patient was very motivated and began.sort of their own activity routine and I.will say that they were quite mobile.there we would routinely actually go for.walks around the hospital on the.ventilator PT was not present at that it.was just the rest rapist a nurse and.some members of the patient family again.go through the progression so there is.sort of a standard process to having an.early mobility program it's not all.about just walking it's about increasing.the activity for the patients you want.the patient to sit up in bed you want.them to be able to dangle their feet on.the edge of the bed have them if they.can do that then have them stand up and.bear weight if unable to bear weight.move or if unable to bear weight you can.move them to the cardiac chair and.assess for reasons that they can't bear.their weight if they can move to the.cardiac chair move them to the commode.if they can move back and forth to see.if they can ambulate with a walker or a.portable ventilator and if they could do.this stuff you can take small steps have.them walk across the room and back to.their bed each of these is sort of a.progression and increasing ability and.as you can increase this ability you can.also increase the frequency of the.mobility oftentimes I think I use an.analogy that you don't just have.somebody go to the gym and start bench.pressing you know 300 pounds they have.to work their way up to it it is very.similar for patients working they are.patients living or critical illness in.the ICU they have to work their way up.to being mobile we sometimes lose sight.of just how deconditioned we make them.with our.critical-care so what is the role of.every clinician that supports the.program to make sure that we help screen.patients and encourage mobilization I.would see that would be the number one.be cognizant of the barriers of early.mobility and be actively working to.resolve them we want to ensure that our.spontaneous awaking trials our SBTs are.done daily we want to adhere to the.ABCDE bundle while we're mobilizing.patients we want to be monitoring the.patients for safety if they're having.any adverse changes and they're.hemodynamics d saturations we want to be.able to manage a mobile vent protect the.endotracheal tube and again you want to.document the patient progression we are.a participatory in the multi bit.disciplinary team and we want to.continue to hand off the information for.the shift before you leave you want to.make sure that you suction the patient.you give any bronchodilators if.indicated double-check your airway.double-check your equipment and discuss.what your mode of ventilation is there.is no set guidelines for a particular.mode of ventilation.however particular modes like the smart.care on the Drager are very beneficial.you want a ventilator mode that can.adapt to the patient's changes smart.care does that very nicely as the.metabolic demands increase and the.patient workloads increase it can.increase the level of support to meet.them and when they're done with their.mobility and they return back to.baseline it will also decrease the level.of support also consider increasing your.fio2 to help with the increased.metabolic demand and make sure that all.the equipment that you're leaving with.is functioning ventilators suction your.oxygen tanks monitoring equipment in.some instances especially with patients.who.long-term in the ICU and are really.debilitated they sometimes will go out.past the ICU we have taken ICU patients.to outside the hospital to the parking.lot again I had where there was one.patient that would literally try to do.laps around the hospital which also.brings up another kind of key safety.point that you can take my experience.yes patients can mobilize on this but.you have to keep in fact that there will.be somebody working hard to push a.ventilator behind them and I've seen.some caregivers actually get a better.workout than the patient trying to keep.the ventilator up so keep safety in mind.it's not useful to have somebody trying.to lift the ventilator over a street.curb and in some instances you may have.to investigate actually taking a patient.to a treadmill those cases are very rare.but it highlights the option that if you.are or highlights that if you have an.active mobility program that is.something that you may have a patient.who increases their mobility to that.level but can't come off the ventilator.are we going to limit their amount of.physical activity because they're simply.on a ventilator even though they.physically can do it these are things.you have to decide for yourself so what.does immobilization look like it's a.practical example these are some.pictures of patients early mobilising.this one here you can see that a.caregiver has the IV pole with some.pumps and then another caregiver is.having the ventilator behind them and is.watching the ventilator circuit and the.patient is mobilizing that is exactly as.they go down the hallway this is not in.a patient room consider the.psychological benefit to the patient.that even though they're on a ventilator.getting outside the room getting to.change their environment is mentally.beneficial to them they get to.participate in their care at this point.here's another example of a patient.ambulating while on a ventilator.again you see the caregivers around them.kind of being mindful of the patient and.the equipment so with two to three staff.it can be done very safely.so to summarize post intensive care.syndrome it's it's a now recognized.syndrome that is a consequence of.patients who have survived critical.illness it has physical cognitive and.mental alterations and the only real.treatment that we have for it there's no.medication that we give it but early.mobility is really the only potential.mitigation 2ic acquired weakness and.potentially to post intensive care.syndrome early mobility is safe for.patients who are receiving mechanical.ventilation the number of complications.or instances is very low outcomes for.early mobility is mixed I would say.because of the one large randomized.control trial didn't demonstrate benefit.but a lot of the smaller studies have.shown that early mobility does improve.functional get patients to a improved.functional status better and with.require more functional at discharge but.in order to have an essential program.clinician buy-in is imperative and you.have to keep looking for overcoming.those barriers and those misconceptions.good application of the ABC de bundle is.imperative maybe so thank you very much.cos for this great presentation.you.[Music].

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