CARDIOLOGY ICU

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CARDIOLOGY ICU
Natalia Fernandez, BPT, MSc, MS, CCS.
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Implementation

• Process towards early mobility implementation
• In-services presented at clinical quality
  meetings
• Benefits of early mobility
• Clinical research
• Various initiatives of early mobility projects in
  other areas in the hospital

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Implementation

• Plan
• Formulated plan with CCU Clinical Quality Team
  for implementation of changes for improvement in
  early mobility in the CCU.
• Physicians, nursing and PT leadership addressed
  barriers identified.

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Implementation

• Outcomes
• Assigned PT
• Improved communication
• Decreased resistance
• Positive culture change
• Increased appropriate PT consults

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Consult Process

• Prior to the early mobility implementation
• No formal PT consult process.
• PT consulted at the discretion of patient
  physician.
• PT received approximately 4 consults/month.
• Physical therapists faced various barriers in the
  CCU.

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Consult Process

• Consults received via Carelink
• No standing consults in the CCU
• Flash rounds physician discretion

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Common Diagnoses

• Primary
• Acute on Chronic, Chronic Heart Failure
• Cardiomyopathy
• Heart transplant rejection (Acute vs. Chronic)
• Cardiogenic shock
• Hypotension
• Ventricular tachycardia
• Cardiac arrest / Cardio respiratory arrest
• NSTEMI / MI/CAD
• Severe aortic stenosis
• Pulmonary Hypertension

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Common Diagnoses

• Secondary
• Transplant work up / VAD work up
• Respiratory failure
• Acute kidney injury
• Diuresis

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Common Diagnoses

• New York Heart Association Functional
  Classification
• Class I (mild) No limitation of physical
  activity. Ordinary physical activity does not
  cause undue fatigue, palpitation, or dyspnea
  (shortness of breath).
• Class II (mild)Slight limitation of physical
  activity. Comfortable at rest, but ordinary
  physical activity results in fatigue,
  palpitation, or dyspnea.

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Common Diagnoses

• New York Heart Association Functional
  Classification
• Class III (Moderate) Marked limitation of
  physical activity. Comfortable at rest, but less
  than ordinary activity causes fatigue,
  palpitation, or dyspnea.
• Class IV (Severe) Unable to carry out any
  physical activity without discomfort. Symptoms of
  cardiac insufficiency at rest. If any physical
  activity is undertaken, discomfort is increased.

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Common Diagnoses

• Angina scale
• 1 Light, barely noticeable
• 2 Moderate, bothersome
• 3 Severe, very uncomfortable
• 4 Most severe pain ever experienced

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Triage Process

• Rehab techs
• Discussion with nursing
• Consult MD
• Chart Review
• Carelink
• Lab values
• Flow Sheet
• Yellow Sheet

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Lab Values

• Cardiac Specific lab values
• Cardiac Enzymes
• Troponin (TROPS)
• Creatine Kinase (CK)
• Creatine phosphokinase (TCK)
• Myoglobin (MYO)
• Lactic Dehydrogenase (LDH isoenzyme 1)
• Asparate Aminotransferase ( AST)

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Lab Values

• Cardiac Specific lab values
• Digitalis (Digitoxin/ digoxin)
• Brain Natriuretic Peptide (BNP)

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Possible Exclusions

• IABP Intra-aortic balloon pump
• Intubated and sedated
• Femoral lines
• Swan catheters
• Dysrhythmias
• Hemodynamic instability lab values
• Recent MI
• Unstable angina
• variable per physician orders

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Barriers To Mobility

• HR lt40, gt120
• Systolic BP gt 160, lt 80
• Diastolic BP gt 100
• MAP lt 60
• Pulse oximetry lt 90
• High vent settings
• Agitation / combative

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Precautions to Mobility

• Oxygen requirements
• Edema
• Agitation
• Somnolence
• Encephalopathy
• Hypersensitive airway
• Unstable lines

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Risk vs. Benefit

• CRRT with unstable access
• Swan with unstable access
• Agitated / combative
• Nitric oxide
• FiO2 100, high PEEP, high ventilator
• New onset arrhythmia
• Femoral lines
• Runs of Vtach recently

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Treatment

• Evaluation
• Bed exercises
• Bed-in-chair position
• Edge of bed
• Standing
• Weight shifting
• Pre-gait
• Chair transfer
• Interval walking

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Safeguards

• Nurse aware of treatment plan
• Monitoring of vital signs
• Disconnect non-essential lines prior to mobility
• Careful planning for contingencies

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Absolute Contraindications for Exercise/ Mobility

• A recent significant change in the resting EKG
  suggesting significant ischemia, recent MI or
  acute cardiac event
• Unstable angina
• Uncontrolled dysrhythmias causing symptoms or
  hemodynamic instability
• Symptomatic severe stenosis compromises

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Absolute Contraindications for Exercise/ Mobility

• Uncontrolled symptomatic heart failure
• Acute myocarditis or pericarditis
• Suspected or known dissecting aneurysm
• Acute pulmonary embolus or pulmonary infarction
• Acute systemic infection, accompanied by fever,
  body aches, or swollen lymph glands.

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Relative Contraindications for Exercise/ Mobility

• Left main coronary stenosis
• Moderate stenotic valular heart disease
• Electrolyte abnormalities (eg, hypokalemia,
  hypomagnesemia)
• Severe arterial hypertension at rest SBP
  gt200mmHg and or DP gt110
• Tachyarrythmias or bradyarrythmias

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Relative Contraindications for Exercise/ Mobility

• Hypertrophic cardiomyopathy
• Neuromuscular, musculoskeletal, or rheumatoid
  disorders that are exacerbated by exercise
• High degree atrioventricular block
• Ventricular aneurysm

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• Relative Contraindications for Exercise/ Mobility

• Uncontrolled metabolic disease
• Chronic infectious disease
• Mental or physical impairment
• Orthostatic hypotension

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• Relative Contraindications for Exercise/ Mobility

• PaO2lt60mmHg /or Oxygen saturation lt90
• Resting heart rate gt120 bpm
• Resting ST depression ( gt3mm)
• Respiratory rate of gt45
• Abnormal lab values

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Termination of Mobility/Exercise

• Physical or verbal manifestations of severe
  fatigue
• Patient requests to stop
• O2 Sat lt90
• Signs of poor perfusion
• Nausea/vomiting

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Termination of Mobility/Exercise

• Wheezing or leg cramps
• Peripheral ischemia ( level 8/10)
• SOB or Dyspnea ( level 2-5 /10 )
• Excessive BP rise ( SBP gt250mmHg, DBP gt115mmHg)
• Exercise hypotension

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Termination of Mobility/Exercise

• Failure of HR to increase with increasing
  activity
• Drop in HR gt 10 bpm
• Symptomatic supra-ventricular tachycardia
• ST displacement
• Ventricular Tachycardia

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Termination of Mobility/Exercise

• Altered heart sounds
• Pulmonary crackles
• Onset of Angina
• Noticeable change in heart rhythm

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Case Study - 1

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Case Study - 1

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Case Study - 1

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Case Study - 1

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Case Study - 1

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Case Study - 2

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Case Study - 2

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Case Study - 2

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Case Study - 2

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Case Study - 2

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References

-Winkelman, Chris. Ambulation With Pulmonary
Artery or Femoral Catheters in Place.
Ccn.aacnjournals.org. Critical Care Nurse, Oct.
2011. Web. Oct. 2011 -Gibbs, Simon R., Jennifer
Keegan, Christine Wrigh, Kim M . Fox, and Philip
A. Poole Wilson.Pulmonary Artery Pressure
Changes During Exercise and Daily Activities in
Chronic Heart Failure. Journal of the American
College of Cardiology, 151 (1990)52-61. -Rader,C
heryl., Melissa Nelson, Cindy Sobek, Michelle
Smith., Rose Gracia, Susan Wright, Kelly Moutray,
Sarah Shrum, and Nancy Richards. Cardiac Index
Based on Measurements Obtained in Bedside Chair
and In Bed .American Journal of Critical Care,
20.3 (2011)210-216.Print. - Adler, Joseph, and
Daniel Malone. Early Mobilization in the
Intensive Care Unit A Systematic Review.
Cardiopulmonary Physical Therapy Journal 23.1
(2012) 5-13. Print. - Cortes, Olga L., Juan C.
Villar, P.J. Devereaux, and Alba DiCenso. Early
Mobilization for Patients following Acute
Myocardiac Infarctions A Systematic Reivew and
Meta-analysis of Experimental Studies.
International Journal o Nursing Studies 46.11
(2009) 1496-504. Print.
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References

- Garzon-Serrano, Cheryl Ryan, Karen Waak, Ronald
Hirschberg, Susan Tully, Edward A. Bittner,
Daniel W. Chipman, Ulrich Schmidt, Georgios
Kasotakis, John Benjamin, Ross Zafonte, Matthias
Eikermann. Early Mobilization in Critically Ill
Patients Patients Mobilization Level Depends on
Health care Providers Profession. American
Academy of Physical Medicine and Rehabilitation 3
(2011) 307-13. Print. - Acute Care Perspective,
Appendix 3. Pg 15 Spring 2006 .  - Daniels, Rick,
Delmars guide to Laboratory and Diagnostic
Tests. Delmar-Thomson Learning. 2002.  -
Fischbach Frances, A manual of Laboratory
Diagnostic Tests. J.B. Lippincott Company.
1980.  - Schroeder, Seven A, et al, Current
Medical Diagnosis and Treatment. Appleton and
Lange. 1992. - ACSM Guidelines for Exercise
Testing and Prescription, 7th Ed. - Hillgrass
Essentials of Cardiopulmonary Physical Therapy,
3nd Ed, 2011.