Effects of Early Rehabilitation During Intensive Care Unit Stay

Introduction

The patients in the intensive care unit experience physical, mental, and cognitive impairments. These affect the patient’s recovery and quality of life. The patients suffer for long periods even after surviving the critical illness. Early rehabilitation in the intensive care unit may reduce the risk of long-term impairments and improve the quality of life. Early rehabilitation should start earlier when the patient is on mechanical ventilation(machine-assisted breathing).

What Happens in the Intensive Care Unit?

The patients are bedridden for several months to years. Patients with critical illness will be under mechanical ventilation, deep sedation(controlled state of unconsciousness), and drugs. Long-term immobilization causes neuromuscular weakness and physical and non-physical impairments. More extended ICU stay increases the risk of intensive care unit-acquired weakness(ICU-AW).

What Is an Intensive Care Unit-Acquired Weakness?

The ICU-AW is a neuromuscular complication. It occurs due to multiple organ failure, restricted mobility, sepsis(extreme response of the body to infection), hyperglycemia (increased blood sugar), and the use of neuromuscular blocking agents or glucocorticoids. ICU-acquired weakness increases the duration of mechanical ventilation and hospital stay. The pathophysiology of ICU-acquired weakness is not entirely understood.

The diagnosis of the intensive care unit-acquired weakness involves:

• Respiratory muscles assessment.

• Peripheral muscles assessment.

What Are the NICE Guidelines for Early Rehabilitation?

The National Institute for Health and Care Excellence provides guidelines for early rehabilitation during the intensive care unit stay. The guidelines are as follows:

• During the intensive care unit stay, the service providers should conduct a short clinical assessment to determine the risk of the patients developing physical or non-physical morbidity.

• The health care professionals experienced in critical care and rehabilitation conduct comprehensive clinical assessments for patients at risk to determine the current rehabilitation needs of the patients.

• Short-term and medium-term rehabilitation goals are prepared for the patients according to their condition.

• The team should inform the patients and the caretakers about the possibility of morbidity and rehabilitation goals. The family members are involved because some patients remain unconscious and cannot sign the informed consent.

• The patient’s clinical records mention the comprehensive clinical assessment and rehabilitation goals.

• All the information about the patient's illness, treatments, equipment used in the intensive care unit stay, and possible morbidity, which may require rehabilitation, are mentioned in the clinical record of the patients.

What Are the Factors to Be Considered for Effective Early Rehabilitation?

Effective early rehabilitation for physical and mental impairments during the intensive care unit stay depends on the following factors.

• Early Rehabilitation for Physical Impairments depends on the following:

1. Potential barriers affecting the rehabilitation in ICU - Inadequate multidisciplinary team(MDT) and the reduced cooperation of the patients due to deep sedation jeopardize the success of early rehabilitation.

2. Feasibility - The availability of the patients is less due to many diagnostic tests and treatment procedures.

3. Benefits - Increased muscle function, physical strength, and quality of life. The early rehabilitation protocol should reduce hospital and ICU stays, thereby reducing the cost.

4. Safety - The early rehabilitation procedure should not have any adverse effects on the patients in ICU. One common problem found so far is reduced oxygen saturation.

5. Resources - In the intensive care unit, patients are connected to many devices, such as lines and tubes. So aids such as walkers, wheelchairs, portable ventilators, and oxygen source bags are needed.

• Early Rehabilitation for Mental Impairments needs more research. It requires the following interventions:

1. ICU diaries.

2. An earlier ICU psychological intervention.

3. Post-ICU coping skills and training.

What Are the Effects of Early Rehabilitation on Patients Who Suffer From a Stroke?

The main aim of the early rehabilitation program is to mobilize the patients early.

• Rehabilitation therapy focuses mainly on sitting, standing, and walking. The therapy team suggests short and more frequent mobilization.

• Physiotherapeutic approaches improve hand and leg movements.

• Non-invasive brain stimulation improves brain activity and motor functioning after a stroke.

• Speech therapy for patients with aphasia (a disorder that affects speech) to restore effective communication.

What Are the Effects of Early Cardiac Rehabilitation?

Early cardiac rehabilitation is for patients who suffered heart attacks or heart surgeries.

• The early rehabilitation begins within 2 to 5 days in the intensive care unit.

• The cardiac rehabilitation team checks the patient’s heart rate, blood pressure, and complete medical history.

• Acute care physical therapists give patients limited exercises, enabling them to go home.

What Are the Effects of Early Rehabilitation on Mechanical Ventilation?

The important goal of early rehabilitation is early mobilization. The benefits of early mobilization include the following:

• Reduces the duration of mechanical ventilation.

• Reduces the risk of ventilator-associated pneumonia.

• Improves muscle function.

• Increases the ability of the patients to perform daily activities of life.

The prolonged mechanical ventilation leads to dysfunction of the diaphragm (the primary breathing muscle). The diaphragm is examined by ultrasound scan. Early rehabilitation involves strengthening exercises to treat the diaphragm after mechanical ventilation. Early mobilization in the intensive care unit prevents deep vein thrombosis and venous stasis. Gradual physical activity improves the functions of the muscle and vascular structures.

What Are the Steps to Optimize the Effects of Early Mobilization and Rehabilitation in the ICU?

The effects of early mobilization and rehabilitation in the ICU are optimized by:

1. Create a multidisciplinary team to educate the patients and promote the mobilization of patients, which also improves the confidence and capabilities of the patients in critical care.

2. Identify and correct the patient-related, structural, procedural, and cultural barriers.

3. Measure the performance of the patients and ensure all the patients receive rehabilitation therapy.

4. Promote multi-professional communication.

5. Understand the short-term and long-term preferences of the patients.

6. Adopt safety criteria to ensure the safety of the patients during mobilization.

7. Take extra care of pain, sedation, delirium, and sleep, as they are closely associated with the effects of early rehabilitation.

8. Necessary assistive equipment to improve patient’s mobility and reduce the risk of injury.

9. Evaluate optimal timing for early rehabilitation to improve its effectiveness.

Conclusion

The main hindrance to providing early rehabilitation in the intensive care unit is medical devices and ventilators attached to the body of patients. So the rehabilitation team members hesitate to initiate rehabilitation in the ICU. The multi-disciplinary team evaluates and overcomes the barriers to provide early rehabilitation protocol.