847CHAPTER 69 Acute Rehabilitation and Early Mobility in the Pediatric Intensive Care Unit in play/leisure, feeding, self care, and returning to school and/or work To optimize development, prevent los[.]
CHAPTER 69 Acute Rehabilitation and Early Mobility in the Pediatric Intensive Care Unit in play/leisure, feeding, self-care, and returning to school and/or work To optimize development, prevent loss of skills, and to allow full return to those activities, it is crucial that an OT is involved in a child’s care plan early in the PICU admission In the ICU, a triad of conditions, medical devices, and prolonged hospitalization may have an impact on a child’s daily activities When a child requires deep sedation and immobility owing to a clinical condition, the OT’s interventions will focus on positioning and splinting (see Fig 69.1) Those interventions will help to promote musculoskeletal alignment and range of motion Furthermore, splinting helps to protect the wound as needed and gain function.26 Other benefits of positioning besides musculoskeletal alignment are increasing oxygenation and decreasing respiratory rate when a child is positioned prone.27 This collaboration with the OT may be a temporary solution for children with acute respiratory distress syndrome (ARDS) Repositioning is also crucial to prevent skin breakdown Another specialized occupational therapy intervention that is used in the ICU, especially for infants, is sensorimotor interventions, also known as oral motor stimulation The intervention involves providing stimulation to oral and perioral regions with tactile, kinesthetic, auditory, and olfactory systems.28 Prolonged intubation and/or prolonged ICU stay may impact the infant’s ability to feed by mouth Therefore, oral stimulation allows the infants to progress with oral motor skills and to prevent oral aversion during prolonged mechanical ventilation and ICU stay The benefits of oral stimulation are to help soothe infants as well as to promote physiologic stability, decrease length of hospital stay, and facilitate digestion.29 In addition, oral stimulation helps to transition infants to oral feeding much sooner.30 Role of Speech-Language Pathology in the Pediatric Intensive Care Unit SLPs work to prevent, diagnose, and treat persons with language, cognitive, and swallow disorders They receive a master’s degree and complete a 1-year clinical fellowship In the ICU, the role of the SLP is to assess and promote safe swallowing, help the child regain speech/language and provide assisted communication for the child based on the child’s medical status or limitations by medical interventions.31 Many postsurgical and medical procedures can affect a child’s swallowing and increase aspiration risk Therefore it is imperative that swallowing and speech be considered throughout the ICU stay as aspiration can increase the length of an ICU stay and lack of communication may increase agitation and prolong the need for sedation Rehabilitation may be established using compensatory or remedial strategies The SLP’s role in the ICU is focused on adaptation or recovery of speech, swallowing, and cognitive abilities Cognitive assessments may be warranted in the setting of neurologic injury or prolonged sedation In addition, the ability to communicate can be impacted; thus, speech pathologists may provide augmented or alternate communication access, such as use of an eye gaze system or Passy Muir valve (Passy Muir, Irvine, CA) in patients with a tracheostomy tube.32 Important Considerations for Mobility in the Pediatric Intensive Care Unit Pediatric Intensive Care Unit Environment The ICU environment can often be a barrier to early mobility owing to room setup, medical device locations (both in the 847 relation to the patient’s anatomy and in the room), medications, respiratory support and sometimes, most importantly, the overall mobility culture of the unit Prior to manipulation, the patient’s medical status and resources available need to be well understood by the interdisciplinary team involved in the mobilization For successful mobility, the rehabilitation therapist should be encouraged to discuss these barriers with the respiratory, medical, and nursing colleagues and adapt the room or devices if feasible and appropriate As vascular lines, tubes, and catheters are being placed or removed, the rehabilitation therapists can provide recommendations on a patient’s mobility or neurologic status to optimize function or neuromuscular recovery For early mobility, the room setup can affect whether a child can safely transfer to sitting on the edge of the bed or in a chair If the child’s pulmonary support is on one side of the bed and all intravenous pumps are on the other side, this can affect feasibility and safety Cardiac and Pulmonary Status and Complications Cardiac and pulmonary disease processes are the most common issues impacting rehabilitation during a prolonged PICU stay Positioning and mobilizing the critically ill patient is considered one of the most important ways of reducing the development of morbidity from ventilator-associated pneumonia (VAP).33 PTs and OTs intensely focus on optimizing positioning in the ICU Positioning in bed, or proning, is often used in the critically ill patient to optimize ventilation and has been demonstrated to decrease mortality in patients with severe ARDS.34 The Centers for Disease Control and Prevention (CDC) and other international medical organizations have identified a semi-recumbent position with the head of the bed elevated to be effective in preventing VAP.35 Proper positioning allows for improved ventilation by optimizing diaphragmatic and accessory muscle use in patients who are able to work on increasing active or passive participation, such as putting the bed in chair position or getting out of bed to a chair.36 Appropriate and safe seating can be a challenge in the PICU setting as a wide range of ages, level of participation, and safety can make standard chairs inappropriate Seating devices that can be adapted for children of various sizes and level of support allow for more diverse use and decrease space for storage Sedation Sedation approaches are key factors in facilitation of early mobilization in critically ill patients A randomized controlled trial in critically ill adults demonstrated that early physical activity and decreased sedation was safe, well tolerated, associated with less delirium, fewer days on the ventilator, and improved functional outcomes.37 In the pediatric population, decreasing sedation can be more challenging owing to concern for patient agitation and risk of inadvertent removal of life-supporting devices, caregiver or provider anxiety, or difficulty with appropriate communication The RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) study38 demonstrated no increase in unplanned endotracheal tube or invasive line removal in the intervention group who received targeted sedation and routine arousal assessments As such, in many instances, the OT and SLP can provide and optimize access to augmented communication to allow the patient to “voice” needs to decrease agitation Utilization of the rehabilitation therapist may be valuable in quality improvement initiatives aiming to decrease overall sedation use Documentation 848 S E C T I O N V I Pediatric Critical Care: Neurologic of the current and goal level of sedation so that all multidisciplinary team members can speak the same language is critical Use of validated delirium screening tools (Pediatric Confusion Assessment Method for the Intensive Care Unit [pCAM-ICU],39 Preschool Confusion Assessment Method for the ICU [psCAM-ICU],40 or Cornell Assessment of Pediatric Delirium [CAPD]41) and sedation scores (State Behavioral Score42 or Richmond Agitation-Sedation Scale [RASS]43) allows for more informed resource utilization Using validated tools, the rehabilitation therapist can determine whether the child is adequately sedated to avoid unsafe situations, including mobilizing a delirious child or when active mobility or strengthening is futile in an oversedated child Including the rehabilitation team in quality improvement initiatives focused on sedation is integral to the interdisciplinary process of mobilization within the PICU.44 Intensive Care Unit–Acquired Weakness A prolonged stay in an ICU has profound repercussions on strength in the critically ill adult population.45 ICU-acquired weakness (ICU-AW) is a well-documented complication.46–48 In adults, ICU-AW is multifactorial, with myopathy and neuropathy components, and is associated with morbidity, increased length of stay, and a decline in physical function.49,50 ICU-AW in pediatrics is less well studied and may be underreported Field-Ridley et al used a national PICU database to determine the level of reported cases of ICU-AW in 203,875 PICU admissions.51 In this study, they found that ICU-AW was associated with respiratory or infectious diagnoses in pediatric patients Further, ICU-AW was associated with poorer outcomes and the need for higher levels of care postdischarge, often requiring an admission to an inpatient rehabilitation facility Facilitating Infant Neurodevelopment During Critical Illness With continued medical advancements, more infants and young children are surviving with complex medical conditions requiring prolonged or frequent PICU stays.52,53 As such, developmentally based intervention is critical to minimize delays in development due to prolonged and/or recurrent PICU admission and hospitalization As previously discussed in this chapter, the environment of the ICU can be detrimental to fostering development owing to poor sleep/wake cycles, including inability to turn off lights when critically ill, more interruptions for care/medical interventions, fewer opportunities to play given the confined space, and poor access or variability in age-appropriate stimuli Owing to the focus on acute resuscitation in the PICU, children are usually either over- or understimulated According to the Synactive Theory of Development,54 the infant’s development is directly related to experiences and input received from the environment This theory considers all the systems that optimize development and includes the following: autonomic response, motor, regulation between states, attention/interaction, and selfregulation Each system is crucial for typical development and can be directly influenced by the medical culture of an ICU, which can effect “typical” interactions that will impact the child’s development For instance, the infant who has a bright light flashed in the face will learn to keep the gaze away from the midline—and bright light is often used in the PICU to perform neurologic exams When the only touch that a child receives is directly related to line placements, blood pressure checks, or resistance from restraints, that child will learn that touch is typically negative and can demonstrate changes in state, such as agitation In the PICU, children are in a confined space, such as a crib or bed; this confinement can cause very limited opportunity to mobilize and lead to fewer opportunities to play or engage with caregivers, especially if the child is receiving paralytics or sedation medications.55 The frequent sounds of medical device alarms may lead to either a hyper- or hyporeaction to external sounds When infants are critically ill in the PICU, proper positioning is the primary initial intervention that can foster typical development Positioning is important, as postural alignment promotes comfort, neuromotor development, and physiologic stability Infants with long periods of oxygen dependence often exhibit increased active cervical and truncal extension with shoulder elevation in order to use accessory muscles for respiration This prolonged posture leads to motor asymmetries, resulting in less variety in the child’s motor repertoire and fewer opportunities for play, a direct cause of delayed motor skills To decrease asymmetry in motor skills, the optimal positioning for infants less than months of age is the in utero fetal position (Fig 69.3) The infant should be positioned in physiologic flexion with upper extremities and lower extremities flexed and head to midline If medically appropriate, the hands should be positioned toward the face to allow opportunities for self-calming This containment, not immobilization, allows proprioception awareness, selfstimulating of the mouth for feeding readiness, and helps regulate behavioral states Beyond impacting a child’s motor and sensory development, immobility affects other aspects of typical early infancy Craniofacial deformities, respiratory status, and parent-child bonding can all be directly influenced Cranial deformities, including plagiocephaly and brachycephaly, are not only important from a cosmetic perspective but changes in head shape have been found to have an impact on motor skills.56 To prevent development of abnormal head shape, repositioning with emphasis on changing positioning from supine, side lie, and prone should be integrated into infant care Prone positioning in critically ill infants has been found to increase oxygenation, decrease respiratory rate, and alleviate reflux.27,57 Frequent changes in developmentally appropriate positions helps to strengthen cervical, truncal, and upper extremity musculature and provides proprioceptive input in order to develop awareness of the body in space.58 Another well-studied method of promoting mobility in infants is kangaroo care,59 which emphasizes skin-to-skin contact by having the child positioned directly on the caregiver’s chest The benefit of kangaroo care is not exclusive to changes in position; rather, it has long-term benefits in cognition and parent-child interaction up to the age of 10 years.60,61 As the PICU is often a stressful time for both the infant and parents, at least hour of kangaroo care can decrease stress hormones, while increasing oxytocin, in both parents and infant.62 Communication Speech may be disrupted due to airway instability, pulmonary function, neurologic condition, and/or preexisting conditions The airway may be compromised due to craniofacial surgery, intubation, tracheostomy, or vocal cord paralysis.63 When a child’s communication is impaired, it can impact the child’s ability to cope with being in the hospital because of the inability to express emotions or wants and needs Furthermore, there is a high risk CHAPTER 69 Acute Rehabilitation and Early Mobility in the Pediatric Intensive Care Unit 849 • Fig 69.3 Optimal positioning for motor skills in infants ,3 months of misinterpretation, as the child’s nonverbal expressions or behaviors may be interpreted as pain rather than anxiety or fear It is challenging for family and hospital caregivers not to be able to verify the child’s ability to understand In general, losing communication can be one of many ways that children lose control and normalcy during a hospital stay In order to address the communication barriers for children in the ICU, augmentative and assistive communication can be a solution There are three main levels of communication in the PICU.63 Initially, communication may be basic, with simple “yes” or “no” answers when the patient is emerging from sedation, shaking or nodding of the patient’s head or using the colors green for yes and red for no Lower levels of sedation may be better tolerated if communication needs are addressed, as there is increased wakefulness Simple communication techniques can allow access to basic care, such as a blanket, suction, repositioning, and alleviating pain Augmentative and assistive communication (AAC) is any strategy, tool, or technology that replaces speech or writing.63,64 Even texting on a mobile phone is considered to be an AAC technique AAC systems can be low technology, which is simply writing or using a communication chart, or high technology, which uses switches, an eye gaze system, or tablet communication apps Provision of an AAC system can be facilitated by an SLP and/or PT with additional collaboration from a child life specialist when available The SLP and/or PT determine appropriate access to the communication system based on the child’s function or need for adaptation, cognitive level, medical condition, and family support Once the child is progressing with communication, AAC can be expanded to a more broad and diverse system in which the goal is for the patient to converse in a manner similar to speech There are many benefits of AAC.63,65,66 AAC can help nurses, families, and providers understand a patient’s basic needs Optimizing communication enables more open dialogue and allows the child to express feelings and needs AAC also helps to decrease anxiety during the stressful hospital stay and medical interventions Acute Rehabilitation Across the Intensive Care Unit Continuum In an acute care setting, the role of the rehabilitation therapist is dependent on two main components: the age of the child and level of medical fragility Most children who spend multiple days in an ICU, despite medical status, would benefit from early PT and/or OT consultation (within 72 hours) to assess current functional status, prevent regression of skills, and facilitate acquisition of new skills.7 Acute rehabilitation is not exclusive to PTs, OTs, and SLPs Physicians, nurse practitioners, nurses, respiratory therapists, child life specialists, and families are all key partners in early mobility Patient Selection: Age-Based Factors For children from birth to years old, PT and OT evaluations and treatment plans enable maintenance or acquisition of developmentally appropriate skills Prolonged PICU stays can affect the child’s ability to develop self-soothing skills, decrease developmentally appropriate positioning and a child’s tolerance for touch overall, which can then increase the need for and amount of sedative medications.55,67 PTs and OTs play an important role in educating PICU medical team members and families on the promotion of developmentally appropriate skills in the high-acuity medical setting For patients older than years, the PT’s role in the PICU involves promoting the child’s individual functional baseline based on the child’s current medical status Patient Selection: Acuity of Illness Medical status drives the rehabilitation therapist’s interventions in PICU settings Immobility and inflammation related to critical illness increases muscle wasting.68 Critically ill children demonstrate prolonged functional deficits to months after discharge from the PICU.18,68 Therefore, early physical and occupational therapy, plus speech language pathology interventions, are critical to prevent or reduce these effects A tiered approach is necessary 850 S E C T I O N V I Pediatric Critical Care: Neurologic to monitor mobility progression and ensure that interventions are optimized early in the PICU stay.12 For the patients with the highest acuity of illness and medical instability requiring high levels of respiratory and/or medical support, out-of-bed mobility may be contraindicated However, for these high-risk patients, physical and occupational therapy can work closely with the multidisciplinary team to optimize other feasible and beneficial interventions OTs will monitor joint integrity and optimal alignment, often providing splints and positioning devices to preserve range of motion (ROM) and to maintain skin integrity For patients with diminished pulmonary status, there is a benefit to prone positioning related to improvement in ventilation/perfusion matching, with improved recruitment in nondependent lung regions.69 Positioning devices can be fabricated by the OT to allow full diaphragmatic expansion to maximize aeration when prone Physical therapy should focus on preventing the effects of muscle wasting due to critical illness and immobility, with the focus on positioning, ROM exercises, and educating family and nursing on these areas For the more medically stable and less tenuous PICU patients, PTs and OTs can begin to focus on early mobilization with emphasis on building functional endurance, optimizing pulmonary function, and beginning to increase activities This stage often requires the most intensive multidisciplinary approach, as the child is still medically complicated but has the physical reserve to allow for initiation of mobility Physical therapy interventions can include active exercises in bed, developmental positions other than supine, sitting on the edge of the bed and getting into a chair, and ambulating if functional mobility was previously tolerated without complication (see Fig 69.1).12 At this time, OTs should increase their involvement, focusing on promoting development, oral motor skills, fine motor coordination, vision therapy, and self-care For these patients, the OT will begin collaboration with the SLP to optimize communication based on the patient’s abilities, such as cognition, and existing medical interventions, such as an endotracheal tube Appropriate seating and mobility devices are often vital at this stage to begin to build cardiovascular endurance, improve pulmonary function, and increase overall cognitive arousal The more medically stable child—such as one admitted to the PICU for postoperative care after orthopedic, plastic, or otolaryngologic surgery—would benefit from physical and occupational therapy to accelerate recovery of mobility and decrease the functional side effects of an ICU stay An SLP should be involved with the child if there is difficulty with communication or cognition, or if there is concern for dysphagia, requiring a swallow study to assess for aspiration Equipment The main objective of early mobility in the PICU is to maximize the patient’s current level of function while addressing patientspecific goals to promote age-appropriate developmental activities and positioning for development and musculoskeletal alignment.12 One of the major barriers to mobility in the PICU is the availability of appropriate equipment to meet mobilization goals for a heterogenous group of ages, sizes, and development Positioning Equipment When children are critically unstable and mobilization may cause more harm than benefit, positioning needs to be considered as the primary intervention The purpose of positioning is to optimize muscle length-tension relationships and to avoid asymmetric muscle activation that would limit appropriate strengthening and increase risk of skin breakdown.70 Some medical positioners are the Frederick T Frog positioning aid (Philips) and bendy bumpers for infants Foam wedges and Z-Flo fluidized positioners (Mölnlycke) for older children can also be helpful Based on the patient’s individualized needs and age, therapists may also fabricate positioners for custom fit using various densities of foam Nonmedical positioners, such as pillows and Boppy pillows, can also be effective Families should be cautioned that positioning devices that are used and provided in the hospital, while monitored, may not be appropriate at home and should be counselled on appropriate home crib setups Sitting Equipment The goal of sitting and bed mobility is to promote activation of muscles in order to prevent ICU-related weakness and improve pulmonary function Deconditioning in the ICU is often correlated with immobility Sitting is a functional position that allows the child to engage in activities and feeding Areas that need to be considered before determining appropriate equipment are core activation, level of arousal, and age For most infants and toddlers, bouncy chairs, tumble form chairs, floor activity mats, adaptable activity chairs that tilt in space, highchairs that recline, and personal strollers are appropriate Older children can use the cycle ergometer, which allows the child to cycle in or on the edge of bed, using the chair position in hospital beds, and out of bed to wheelchairs and bedside chairs Standing or Ambulation Equipment It is imperative to promote weight bearing in order to return to prior level of function and to promote development as soon as medically appropriate Weight bearing can maximize neurologic recovery and improve alertness Several factors need to be considered for weight bearing: age, pulmonary and neurologic status, and the amount and level of staff needed to assist Types of equipment to promote weight bearing for infants and toddlers (Fig 69.4) include standers that can be prone versus supine, child-size walkers, activity stations, cube chairs, and floor mats For school-age children: tilt table systems for body weight support (LiteGait), walkers, and electronic standing assist devices.71–74 Select orally or nasally intubated children who tolerate being awake with minimal sedation may also be candidates for ambulation, although this will be more resource intensive Decisions to ambulate intubated children should take place in a comprehensive, multidisciplinary discussion and scheduled to accommodate unit resources and acuity (Fig 69.5) Other Equipment Not all children in the PICU are ambulatory prior to admission, or their developmental level or physical function may necessitate alternate modes of activity Ride-on cars, wagons, tricycles, and scooters can also be a fun and creative way of facilitating mobility in the PICU if staff resources are available (Video 69.1) With PT and/or OT input, these activities can be facilitated by nursing, child life specialist, and/or family Some patients may even be able to travel off the unit to participate in activities in the physical therapy gym or to be exposed to direct sunlight (see Fig 69.5) Resource Utilization For an early mobility program to be effective, it cannot be driven solely by rehabilitation providers—nursing education is vital to maintain and promote early mobility To be effective, mobility CHAPTER 69 Acute Rehabilitation and Early Mobility in the Pediatric Intensive Care Unit • Fig 69.4 Various activities to facilitate upright posture and weight bearing • Fig 69.5 Ambulation in the pediatric intensive care unit 851 ... initiatives focused on sedation is integral to the interdisciplinary process of mobilization within the PICU.44 Intensive Care Unit–Acquired Weakness A prolonged stay in an ICU has profound repercussions... PICU database to determine the level of reported cases of ICU-AW in 203,875 PICU admissions.51 In this study, they found that ICU-AW was associated with respiratory or infectious diagnoses in pediatric... due to prolonged and/or recurrent PICU admission and hospitalization As previously discussed in this chapter, the environment of the ICU can be detrimental to fostering development owing to poor