The document discusses the negative effects of prolonged bed rest in critically ill patients, including decreased mobility, respiratory function, cardiac output, and the development of ICU-acquired weakness. It then outlines a mobility protocol for critically ill patients with four levels of increasing activity from passive range of motion to ambulation, and provides criteria for assessing patient tolerance and safely progressing through the levels. Several studies are cited that demonstrate the benefits of early mobilization, such as shorter hospital and ICU stays, better functional outcomes, and no increase in adverse events.

1. The Nobility of Mobility
The Nobility of Mobility
Sandra Hess Hess RN CCRN
Sandra RN BSN BSN CCRN
University of Iowa Iowa HospitalsClinics
University of Hospitals and and Clinics

2. Bed rest is not a physiological
state
Negative Effects:
-Decrease in respiratory excursion
-Decrease in mobilization of
secretions
-Increase in atelectasis and
pneumonia
-Increase in dependent edema
-Fluid shifts from lower extremities
to the thorax. Volumes can
exceed 500cc.

3. - Decrease in plasma volume due to fluid
shifts, and onset of diuresis.
-Increased workload on the heart related
to fluid shifts.
-Gradual onset of tachycardia and hypotension due to diuresis
following fluid shifts.
-Decrease in cardiac output due to diuresis and venous pooling.
- Cardiac deconditioning with a gradual fall in O2 consumption.
-Neuromuscular polyneuropathies due to deconditioning, loss of
muscle mass, and release of cytokines in inflammatory
response. (Chobanian et al, 1974)

4. Critical Illness Polyneuropathy and Myopathy
A recent systematic review of 24 studies found that 46% of
critical illness survivors developed neuromuscular dysfunction.
This disability resulted in prolonged hospital length of stay and
extended rehabilitation. (Needham et al 2007)
In a study of long term outcomes after ARDs, critical care
survivors were only able to walk 66% of the predicted distance
of a 6 minute walk after one year.
Reasons for the deficit included
global wasting, weakness, foot drop,
joint immobility and dyspnea.
Only 49% of survivors were able to
return to work. (Herridge et al 2003)
Our patients survive
sepsis, systemic inflammatory
response syndrome, ARDs and
multi-organ failure and transfer
out to the floor unable to hold a
spoon, stand up from the bed,
Walk or even brush their teeth.

5. The patient on CLRT is ready to begin optional forms of
mobility when there is:
Improvement in the chest X-ray
Improved ABGs
Sedatives are decreased
Patient is able to move and turn self.
Criteria for Starting Upright Mobility
FIO2<.50
PEEP<8
P/F Ratio ALI >300 ARDs >200
S/F Ratio ALI >315 ARDs >235
De-conditioned by > than 3 days of immobility
Ready to begin ventilator weaning
Requiring orthostatic training to tolerate an upright position

6. During all mobility interventions, monitor the patient for
hemodynamic tolerance.
Vital signs: Watch continuously for Feelings of faintness dizziness,
the onset of hypertension or diaphoresis, shortness of breath or
hypotension, bradycardia or nausea.
tachycardia greater than 10% above Allow a 5 minute equilibration
resting heart rate. period after each position change to
SPO2 drop below 90%-Adjust FIO2 allow for the return of
up to maintain the O2 saturation hemodynamic stability.
above 90%
ECG-Watch monitor for any
dysrhythmias.
For hemodynamic intolerance to head up position changes, begin orthostatic
training with the reverse trendelenberg position. This position allows the baroreceptors
to respond to the changes in blood pressure, stimulating the central reflex mechanisms
that allow adjustments via heart rate changes, vasodilation and vasoconstriction.
( Stiller et al, 2004)

7. Criteria
-FIO2 > .50
Level 1 -PEEP>8
Passive ROM -P/F Ratio ARDs <200
ALI <300
CLRT -S/F Ratio ARDs <235
ALI <315
Manual turning -Lobar collapse, atelectasis,
-Excessive secretions
Boots or splints to -Hemodynamic instability with
prevent contractures turning
-Increased sedation or
paralytics needed to ventilate
-Requirement of 2 or more
pressors
-Progressing to maximal
ventilatory support
-Oscillator vent

8. Level 2 ( Includes Level 1 interventions )
HOB up 45 degrees 20 -30 minutes. Passive ROM
HOB up 45 degrees, legs dependent for 20-30
minutes. Passive ROM. Assess for active
participation.
HOB up 65 degrees, feet and legs dependent for
20-30 minutes( Cardiac chair position)
Assess patient for ability to do active ROM

9. Level 3 ( Includes Level 1 & 2 interventions)
Dangle at side of bed with feet supported on a stool. Assess
ability to hold self upright and move extremities against gravity
in sitting.
Standing trial: Can lift buttocks partially off bed without
assistance. Then move to a full upright stand.
Step in place ( march) at the bedside 3 times without
assistance. If able to do this , step forward and backward once
with each foot.
Transfer to a recliner at bedside 20-30 minutes.
Level 4 ( Includes levels 1, 2, & 3 interventions)
Ambulation with assistance using assistive devices as needed.
Patient is monitored throughout ambulation to assess tolerance.
(Ahrens et al, 2005; Kubo, 2008 )

10. Review the patient’s medical history and current conditions.
Past history to include:
-Medical history of cardiovascular disease
-Recent symptoms of CV/Respiratory dysfunction
Medications:
Pressors Inotropes Beta blockers
Sedatives Analgesia
Review the current drip rates. When a patient needs pressors to
maintain an adequate B/P at rest, this is a sign of possible
hemodynamic instability with activity.
Assess for sensory losses or abnormalities that need correction
such as vision, hearing or neuropathies.
(Kubo, 2008)

11. Ideally, a resting heart rate that is less than
50% of the age predicted maximal heart rate is
optimal. Critically ill patients with a high
resting heart rate may have limited cardiac
reserve to tolerate activities that will further
increase the rate. If tachycardic, consider
treatable causes e.g. pain, fever, volume status
or the presence of inotropes.
( Stiller et al, 2004)

12. Age Target HR Zone 50–85 % Average Maximum Heart Rate
20 years 100–170 beats per minute 200 beats per minute
25 years 98–166 beats per minute 195 beats per minute
30 years 95–162 beats per minute 190 beats per minute
35 years 93–157 beats per minute 185 beats per minute
40 years 90–153 beats per minute 180 beats per minute
45 years 88–149 beats per minute 175 beats per minute
50 years 85–145 beats per minute 170 beats per minute
55 years 83–140 beats per minute 165 beats per minute
60 years 80–136 beats per minute 160 beats per minute
65 years 78–132 beats per minute 155 beats per minute
70 years 75–128 beats per minute 150 beats per minute
(American Heart Association)

13. Variability of B/P- Not more than a 20%
deviation from recent trends.
ECG shows no ischemic changes or arrythmias
affecting cardiac output e.g. A-fib with RVR.
Patient is not currently in a R/O MI protocol.
All other cardiac conditions excluded.
(Stiller et al, 2004)

14. P/F ratio ALI > 300 ARDs >200
S/F Ratio ALI >315 ARDs >235
SPO2 > 90 with no recent drops in O2 Saturation
Stable respiratory pattern with no dyspnea or
tachypnea.
If ventilated, ability to maintain mechanical
ventilation throughout the trial.
Stable blood gases when ABGs are available.
(Stiller et al, 2004)

15. Hemoglobin stable and greater than 7.0
Platelet count stable and greater than 20,000
Body temperature < 38.5 C. ( Elevations > 38.5 greatly
increase O2 demands)
Patient not overtly fatigued or in pain.
No recent acute change in consciousness level.
Suspicion of DVT or PE ruled out or current order to
ambulate from physician.
If obese, able to be safely managed.
Adequate staff and level of expertise to be able to
manage equipment and monitor patient response.
( Stiller 2007)

17. A nurse to manage the IV lines and drips, the cables, and
to monitor the patient tolerance and vital signs.
A physical therapist to assist with proper transfer
techniques and to assess the ability of the patient to meet
physical directions.
A respiratory therapist to manage the ventilator, provide
the manual resuscitation bag, and make ventilator changes
as necessary to meet the physical demands of the patient.
And if the activity includes ambulation ,
A nursing assistant to follow along with a wheelchair to
provide assistance if the patient becomes weak or fatigued.
(Morris et al, 2008)

18. Good Tolerance
Appropriate rise in heart rate—not greater than 10% of
resting heart rate, allowing 2 to 5 minutes to equilibrate.
Appropriate rise in systolic B/P from the recent baseline,
with a stable or slight increase in diastolic B/P.
Sinus rhythm maintained including baseline rhythm of
sinus tachycardia.
P/F ratio is greater than 250 at start of intervention.
No tachypnea, dyspnea, increase in accessory muscle
use, nasal flaring or facial expression of distress.
Color good, skin warm and dry, no chest pain, faintness
or diaphoresis.

19. Uncertain of Tolerance
Excessive increase in heart rate greater than 10% of the resting
heart rate.
Rising B/P –Systolic and diastolic with a greater than 20% rise in
systolic B/P above baseline.
Increasing ectopic beats with arrythmias.
Experiencing dyspnea and/or tachypnea.
Patient looks distressed.
Maneuvers:
1. Increase the FIO2
2. Decrease or stop the intervention and wait for the patient to
stabilize.
If the reaction doesn’t improve, stop the intervention and seek a
medical evaluation if necessary.

20. Poor Tolerance
Excessive rise in heart rate and B/P plus signs of cardiac stress
e.g. ST depression on monitor, chest pain, multifocal ectopic
beats, new onset arrythmias, and hemodynamic instability
OR
No change or decrease in heart rate but exhibiting signs of
cardiac stress as listed above.
Fall in B/P ( Either systolic or diastolic or both) of greater than
20% indicating hemodynamic intolerance.
Decrease in baseline SPO2 greater than 4% and not corrected by
an increase in FIO2.
If the patient experiences any of the above physical signs and
develops faintness, dizziness or chest pain, diaphoresis, or
nausea, Stop the intervention and seek a medical evaluation.
( Stiller, 2007)

21. The previous slides are guidelines. Patient
assessments are highly individualized and
should be made by the team members with
each new intervention.
A signal is needed if the patient is intubated or
has a trach so that the team can be alerted
when the patient needs to stop. The approach
always needs to be patient focused to bring
about positive outcomes.
Goals can be reviewed daily with the patient
and family and listed on the white board for
communication.

22. Schweickert et al Lancet ( 2009)
Randomized controlled trial of 104 functionally independent ICU patients in
respiratory failure. Participants were randomized < 72 hours after intubation.
The intervention group underwent early physical and occupational therapy.
The control group received usual ICU care.
The primary endpoint was a return to functional independence at hospital
discharge, including the ability to bathe, dress, eat independently, groom,
transfer from the bed to chair, toilet and walk independently.
Days until start of physical therapy: Study group-1.5; Control-7.3
Independent functioning at discharge: Study group-59%; Control- 35%.
Unassisted ambulation: Study group 110 feet; Control- 0 feet.
Ventilator free days: Study group-21.1; Control-23.5
Duration of ICU delirium: Study group- 2 days; Control group-4 days.
Adverse events were 4% for all reasons.

23. Bailey et al Critical Care Medicine ( 2007)
103 participants; 1449 recorded mobility activities
Purpose of the study was to determine if early physical therapy was safe for ICU
patients with respiratory failure.
Activity events were defined as sitting on the edge of the bed without back support,
sit in a chair after transfer from a bed, and ambulate without assistance with a walker
or with support from the staff.
Goal: Would they improve to the point that most would ambulate by ICU discharge.
Results:
By activity level, on the last day of ICU admission, looking at survivor data only, 2.4%
had no activity, 4.7% sat on the bed, 15.3% sat in the chair, 8.2% ambulated < 100
feet and 69% ambulated > 100 feet. Age above 65 did not preclude participation in
the activities. Exclusions were patients who would be extubatesd < 4 days, coma
patients and palliative care patients. All others were assessed and started on activities
as soon as physiologically stable.
At discharge from the ICU, 69% ( majority ) were able to walk> 100 feet . ( mean
212+/- 18 feet.)
Adverse events were < 1% including one fall to knees without injury, one feeding
tube removal, one S B/P > 200 , one S B/P < 90 and one desaturation < 80. No
extubations.

24. Morris, et al Critical Care Medicine (2008)
370 patients with 165 enrolled in an early mobility protocol and
165 in usual care in ICU.
Formation of a mobility team consisting of a nurse, physical
therapist and a nursing assistant. Mobility protocol was initiated
within 48 hours of intubation, 72 hours in the ICU.
Time until PT initiated in the ICU: Protocol-91%; Usual care-13%
Results:
Time until out of bed: Protocol - 5 days; Usual care- 11 days
ICU LOS : Protocol 5.5 days ; Usual care 6.9 days.
Hospital LOS: Protocol 11.2 days; Usual care 14.5 days.
Use of a team did not increase hospital costs, and there were no
adverse events. The most frequent reason for ending a mobility
session was patient fatigue.

25. Burtin et al Critical Care Medicine ( 2009 )
RCT In a medical and surgical ICU in a university hospital.
90 patients were randomized to the study or control group.
Both groups received respiratory physiotherapy and standard passive ROM. In
addition, the study group received passive and active 20 minute sessions each day
pedaling on a bedside ergometer.
Results: Functional exercise capacity quadriceps force and self-perceived functional
status was higher at hospital discharge than with the control group. 73% of the study
group vs 55% of the control group could walk independently.
!7% of the control group was referred to a rehab center after discharge VS 10 % of the
study group.
74% of the treatment group v.s. 66% of the control group were discharged to home.
Thomsen et al Critical Care Medicine( 2008 )
Prospective study of 104 Ventilated respiratory failure ICU patients who
received an early mobility protocol after transfer to a unit where mobility
was a priority.
Within 2 days in there was a three fold increase in the number of patients
ambulating compared to pre-transfer rates.

26. FINIS

27. Aherns, T. et al ( 2005) Progressive mobility guidelines for critically ill patients(
electronic version) Website: Kathleen Vollman, Advancing Nursing. Retrieved,
November 2009
Chobanian, A.V. et al (1974) Metabolic and hemodynamic effects of prolonged
bedrest on normal subjects. Circulation (49) 551-559
Herridge MS et al (2003) One year outcome of survivors of the acute respiratory
distress syndrome. New England Journal of Medicine 348:683-693
Bailey, P. et al (2007) Early activity is feasible and safe in respiratory failure
patients Critical Care Medicine, 35(1) 139-145
Morris, P. et al (2008) Early intensive care mobility therapy in the treatment of
acute respiratory failure. Critical Care Medicine 36(8) 2238-2243
Needham, D. et al (2007) Neuromuscular dysfunction acquired in critical care: a
systematic review. Intensive Care Medicine 1876-189133:
Stiller, K. ( 2007) Safety issues that should be considered when mobilizing critically
ill patients. Critical Care Clinics, 23(1) 35-53
Stiller, K., Phillips, A., Lambert, P. (2004) The safety of mobilization and its
effect on hemodynamic and respiratory status of intensive care patients.
Physiotherapy Theory and Practice, 20, 175-185