Distress during Physiotherapy

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Distress during Physiotherapy

• Dr Lisa Salisbury
• Research Physiotherapist
• The University Of Edinburgh
• Ian Cornwall
• Clinical Specialist Physiotherapist
• Edinburgh Royal Infirmary

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Is Physiotherapy in ICU distressing?
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Content

• Sedation in intensive care
• Scottish Survey of Sedation Practice among
  Physiotherapists in ICU
• Observational study of distress during
  Physiotherapy
• Implications for future practice

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Consequences of over and under-sedation

• Under-sedation
• Anxiety/agitation
• Extubation
• Lines
• Drains etc
• High oxygen consumption
• Myocardial ischaemia

• Over-sedation
• Delayed wakening
• Prolonged ventilation
• Ventilator-associated pneumonia
• Prolonged ICU and hospital stay
• Higher hospital costs

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Sedation what are the issues?
Anxiety Pain Ventilator synchrony
Sedation requirements typically high
Acute period
Conscious level Agitation Delirium/confusion Muscl
e strength
Sedation requirements lower Agitation/delirium
common
Weaning period
Cognitive function -Impairment -Delirium -PTSD
Uncertain if ICU sedation practice impacts on
long term sequelae
Rehabilitation period
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Monitoring of Sedation

• None
• Physician Orders
• Clinical Judgement
• Clinical Sedation Scales
• Sedation Monitors

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Payen et al (2007)
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A Survey of Sedation on Scottish ICUs

• Postal survey sent to senior physiotherapists in
  22 ICUs across Scotland
• Response rate of 100
• Questions included a VAS rating of the importance
  of sedation assessment and exploration of the
  methods of sedation assessment.

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Survey Results

• Visual Analogue Scale (VAS) demonstrated
  moderate/high levels of importance attached to
  the assessment of sedation (7.981.89)
• Over 80 of respondents always used patient
  observation, physiological trends, liaison with
  nursing staff and examination of previous
  physiotherapy notes.
• Only 46 used a validated sedation scoring system

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Sedation Work at Edinburgh Royal Infirmary

• Led by Professor Tim Walsh and in collaboration
  with GE Healthcare.
• Development of a sedation monitoring system to
  ensure that patients receive optimal sedation
  levels.
• What about when somebody becomes distressed while
  on ICU?

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Distress during Physiotherapy

• Methods
• Observational study
• Patients receiving mechanical ventilation and
  physiotherapy
• Data collection during one physiotherapy session
  only (Patient unknown to treating
  physiotherapist)
• Aiming for at least 50 participants

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• Methods (cont)
• Physiological parameters of Mean Arterial
  Pressure, Systolic and Diastolic pressure and
  Heart Rate.
• Collected continuously
• 30 mins prior to physio starting (baseline)
• Throughout physiotherapy
• Further 35 minutes after physiotherapy

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• Methods (cont)
• Clinical measurement of distress (BPS)
• Clinical measurement of sedation level (RASS).
• BPS RASS collected prior to physio starting
  (baseline), during each physiotherapy
  intervention and at 5 mins and 35 mins after
  physio completed.

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Richmond Agitation-Sedation Score (RASS)
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Behavioural Pain Score (BPS)
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• Results
• Results from 10 participants will be presented.
• Baseline values from the first 30mins were
  calculated for MAP, systolic and diastolic
  pressures and heart rate.
• Changes in values in relation to the baseline
  were explored.

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Results Mean Arterial Pressure
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Results Mean Arterial Pressure
BPS increase 2 points (0 to 3) RASS increase 3
levels (-1 to 6)
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Results - Systolic
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Results - Systolic
BPS increase 2 points (0 to 3) RASS increase 3
levels (-1 to 6)
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Results - Diastolic
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Results - Diastolic
BPS increase 1 point (0 to 3) RASS increase 2
levels (-1 to 6)
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Results Heart Rate
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Results Heart Rate
BPS increase 1 point (0 to 3) RASS increase 1
level (-1 to 6)
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Summary

• Only a small group and further analysis of all
  participants needs to be undertaken.
• Pressures affected more than heart rate by
  distress
• Observable changes seen in RASS/BPS

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Observations

• Nursing staff sometimes used a physiotherapy
  treatment session as an opportunity to leave the
  bed space e.g. get equipment, drug checks, ABGs
  etc
• Physiotherapists didnt routinely seek additional
  boluses of sedation to manage distress.

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Clinical Implications

• Should distress be an acceptable part of
  physiotherapy or managed better?
• Importance of communication and joint working
  between professions when managing distress in
  ICU.
• Value of valid/reliable tools that improve
  communication and aid best practice.
• Hopefully better patient management!!

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Acknowledgements

• GE Healthcare
• Kirsty Everingham
• Participants
• Physiotherapy team in 118
• Professor Tim Walsh

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• Further information contact
• Lisa.Salisbury_at_ed.ac.uk
• Or
• Ian.Cornwall_at_luht.scot.nhs.uk