Considerations & Contraindications

Inclusion/Exclusion algorithm to guide clinical reasoning (Linke et al., 2020)

Image used with permission from the author

General Exclusion Criteria

(Brummel et al., 2012; Engel et al., 2013; Hodgson et al., 2014; Holm, 2017; Linke et al., 2020; Mendez-Tellez & Needham, 2012)

When reviewing the patient’s chart, you want to look out for things including hemodynamic instability (vitals, labs, ICP, respiratory support/vent settings), emergent surgical interventions, and active seizures. The following values are guidelines in which to defer or consult with the team before therapy. But it’s important that you complete a safety screening prior to each therapy session, as the patients status may change. If any of these apply to the patient, they’re likely not appropriate to participate.

    • Symptomatic drop in MAP when not in supine

    • MAP >110 mmHg or <65 mmHg

    • BP change from baseline:

      • >20 systolic or

      • >10 diastolic

    • Systolic BP >200 mmHg or <90 mmHg

    • Increase in the dose of vasopressors in the previous 2 hours

    • >130 or <30-40 bpm for ≥ 5 minutes

    • Unstable arrhythmias

    • >40 or <5 breaths/min for ≥ 5 minutes

    • Inability to maintain oxygen saturation of arterial blood >90% with activity; pulse oximetry <88%

      • ≥ 5 minutes

      • case dependent

    • FiO2 >0.80 (80%)

    • PEEP >14 cm H2O

    • Inadequately secured or unstable airway

    • Evidence of elevated ICP or

    • An ICP > 20

    • New and/or active bleeding that requires further medical workup or treatment 

    • Agitation (RASS + 2 to + 4)

    • Presence of a femoral vascular device (no exercises on affected side; no sitting, standing, or ambulating)

    • Open chest/abdomen

    • Unstable fracture

    • Acute change in neurological status or evolving neurological event (i.e., CVA, SAH, ICH)

      • Including altered mental status, new/worsening of extremity weakness, facial weakness, sensory changes, vision changes, dizziness, speech difficulty, swallowing difficulty, new-onset/worsening of headache, and/or seizure activity

General “Yield” Criteria

(Hodgson et al., 2014; Linke et al., 2020)

When reviewing the patient’s chart, some general criteria which may cause you to pause or “yield” include comorbid conditions (fracture that requires fixation), sedatives (How much? Can they be paused or decreased for therapy?), and “Storming”. The following values are guidelines are “Yield” criteria and warrant further discussion with the interdisciplinary team. But it’s important that you complete a safety screening prior to each therapy session, as the patients status may change. If any of these apply to the patient, they may or may not be not be appropriate to participate.

  • Single vasopressor with titration OR multiple vasoactive medications without titration

  • ICP 10-20 at rest

  • Active vent adjustments within 1 hours of therapy session

  • SBP <80

  • MAP <65

  • HR <50 or >110 at rest

  • PEEP 10-14 at rest

  • RR >30 at rest

  • Stable fracture

Criteria to Stop Treatment Session

(Brummel et al., 2012; Hodgson et al., 2014)

When working with your patient in the ICU, vitals and symptoms should be monitored throughout the treatment session. The following are general guidelines for terminating a therapy session.

  • Symptomatic drop in MAP (i.e., dizziness, light-headed, syncope)

  • HR <40 or > 130 bpm*

  • RR < 5 of > 40 breaths/min*

  • SBP >180 mmHg*

  • SpO2 <88%*

  • Marked ventilator dyssynchrony*

  • Patient distress (i.e., nonverbal cues, gestures, physical combativeness)

  • New arrhythmia

  • ETT removal

  • Fall to knees

*Monitor for up to 5 minutes for resolution of symptoms. Decision to proceed is at the discretion of the therapist

Other General Considerations

 

  • *Not yet treated with anticoagulants

    • Occurs when a blood clot forms in a deep vein, usually the lower leg, thigh, pelvis, or arm (Centers for Disease Control [CDC], 2020).

    • Signs and symptoms: pain and swelling distal to the thrombus, localized redness and warmth, low-grade fever, and dull ache or tightness in the region of the DV

    • Diagnostic testing includes: UE/LE non-invasive study (LENIS/UENIS)

    • The patient may require an inferior vena cava (IVC) filter if there is a high risk for pulmonary embolism (PE)

    • Clarify plan for medical management. The patient may be appropriate for treatment if on Lovenox or another form of anticoagulation (i.e., Fragmin, low molecular weight Heparin, Coumadin, etc.) or if they have an inferior vena cava (IVC) filter 

  • *Not yet treated with anticoagulants

    • Complication of DVT where part of clot breaks off and travels through the blood stream to the lungs causing a blockage (CDC, 2020).

    • Signs and symptoms: tachycardia, possible chest pain, rapid onset of tachypnea, anxiety, lightheadedness, dysrhythmia, hypotension, and decreased oxygen saturation

    • Clarify plan for medical management. The patient may be appropriate for treatment if on Lovenox or another form of anticoagulation (i.e., Fragmin, low molecular weight Heparin, Coumadin, etc.) or if they have an inferior vena cava (IVC) filter 

  • With most patients, the earlier that rehabilitation efforts start the better. The following indications can be used to assess readiness for OT evaluation in the ICU.

    • Is the ICP controlled? If the patient has a bolt, ICP is usually not controlled. However, some neurosurgeons may allow therapy/mobilization with close monitoring

    • BP must be stable at rest, knowing there will likely be fluctuations with activity

    • Sedation: weaned, lightened, or turned off during evaluation

    • Medical confounders are being treated

    A few factors that might indicate the patient is not ready or appropriate for therapy:

    • Persistent ICPs >25 with active hyperosmolarity therapy

    • Medically paralyzed

    • Team/nursing concerns regarding medical status

    • Specific orders prohibiting sedation lightening

    • Scheduled or plan to schedule a family meeting to address goals of care or comfort measure only option with anticipated change in code status

    • Be cautious when progressing activity during weaning period as the patient may be less tolerant to exercise as the demand on the respiratory system increases.

      • Signs of distress include: autonomic changes, paradoxical breathing, tachypnea, agitation, panic, diaphoresis, cyanosis, angina, and arrhythmias

    • Patients who require prolonged MV are at risk for developing respiratory muscle atrophy, skin breakdown, contractures, and deconditioning.

  • General effects include:

    • Neurological: decrease in cortical and autonomic function

    • Cardiovascular: potential for arrhythmias, decreased BP, decreased myocardial contractility, and peripheral vascular resistance

    • Respiratory: decreased arterial oxygenation, decreased surfactant, decreased airway reflex

    Most common post-op complications include:

    • Neurological: delayed arousal, agitation, altered consciousness, cerebral edema, seizure, stroke, peripheral muscle weakness

    • Cardiovascular: hypotension, hypertension, dysrhythmia, MI, DVT, PE

    • Respiratory: airway obstruction, hypoxemia, hypercapnia, pulmonary edema

    • General: acute renal failure, urine retention, abdominal distention, hypothermia, sepsis, hyperglycemia, fluid imbalance, acid-base disorders, post-op pain

  • Difficulty with communication may be due to tubes obstructing the vocal cords (i.e., MV), pharmacologic intervention, neurological, or musculoskeletal impairments:

    • Factors influencing effective communication include: level of arousal, physical limitations, visual impairments, speech/language impairments, letter/number recognition, and ability to recognize familiar pictures. As well as the need for an interpreter for non-English speaking patients.

    • Alternative forms of communication may include: visual cues (communication board), nodding yes/no, hand gestures, and Passe-Muir valve (PMV) which allows a trached patient to speak through a one-way valve.

  • Can I see my patient? Are they:

    • “Sedated but arousable” [possibly appropriate, warrants further discussion with RN]

    • “Sedated but follows commands” [likely appropriate]

    • “Deep sedation” [likely not appropriate]

    • “Minimally sedated” [possibily appropriate, warrants further discussion with RN]

    • “Agitated, frequent pulling at lines” [likely not appropriate]

    • “Sedation increased to improve synchrony with the vent” [not appropriate]

References

Brummel, N. E., Jackson, J. C., Girard, T. D., Pandharipande, P. p., Schiro, E., Work, B., Pun, B. T., Boehm, L., Gill, T. M., & Ely, E. W. (2012). A combined early cognitive and physical rehabilitation program for people who are critically ill: The activity and cognitive therapy in the intensive care unit (ACT-ICU) trial. Physical Therapy, 92(12), 1580–1592. https://doi.org/10.2522/ptj.20110414

Centers for Disease Control. (2020, February 7). What is venous thromboembolism? Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/dvt/facts.html

Clark, K. (2017). Intensive Care Unit. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed., pp. 115–135). AOTA Press. https://library.aota.org/OT_in_Acute_Care_2e/134?highlightText=intensive%20care%20unit

Engel, H. J., Needham, D. M., Morris, P. E., & Gropper, M. A. (2013). ICU early mobilization: From recommendation to implementation at three medical centers. Critical Care Medicine, 41, S69–S80. https://doi.org/10.1097/CCM.0b013e3182a240d5

Giacino, J. T., Whyte, J., Nakase-Richardson, R., Katz, D. I., Arciniegas, D. B., Blum, S., Day, K., Greenwald, B. D., Hammond, F. M., Pape, T. B., Rosenbaum, A., Seel, R. T., Weintraub, A., Yablon, S., Zafonte, R. D., & Zasler, N. (2020). Minimum competency recommendations for programs that provide rehabilitation services for persons with disorders of consciousness: A position statement of the American congress of rehabilitation medicine and the national institute on disability, independent living and rehabilitation research traumatic brain injury model systems. Archives of Physical Medicine and Rehabilitation, 101(6), 1072–1089. https://doi.org/10.1016/j.apmr.2020.01.013

Hamby, J. (2017). The Nervous System. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed.). AOTA Press. https://library.aota.org/OT_in_Acute_Care_2e/134?highlightText=intensive%20care%20unit

Hodgson, C. L., Stiller, K., Needham, D. M., Tipping, C. J., Harrold, M., Baldwin, C. E., Bradley, S., Berney, S., Caruana, L. R., Elliott, D., Green, M., Haines, K., Higgins, A. M., Kaukonen, K.-M., Leditschke, I. A., Nickels, M. R., Paratz, J., Patman, S., Skinner, E. H., … Webb, S. A. (2014). Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical Care, 18(6), 658. https://doi.org/10.1186/s13054-014-0658-y

Holm, S. (2017). Early Mobility and Rehabilitation. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed., pp. 663–672). AOTA Press. https://library.aota.org/OT_in_Acute_Care_2e/134?highlightText=intensive%20care%20unit

Linke, C. A., Chapman, L. B., Berger, L. J., Kelly, T. L., Korpela, C. A., & Petty, M. G. (2020). Early mobilization in the ICU: A collaborative, integrated approach. Critical Care Explorations, 2(4), e0090. https://doi.org/10.1097/CCE.0000000000000090

Mendez-Tellez, P. A., & Needham, D. M. (2012). Early physical rehabilitation in the ICU and ventilator liberation. Respiratory Care, 57(10), 1663–1669. https://doi.org/10.4187/respcare.01931