The effect of a therapeutic early mobility position on the haemodynamic stability in a critically ill patient population.

Conradie, Elmarie (2016-03)

Thesis (MScPysio)--Stellenbosch University, 2016.

Thesis

ENGLISH ABSTRACT: Introduction Bed rest is routinely prescribed during critical illness which leads to significant inactivity in an adult critically ill population. Survivors will possibly encounter difficulties in their health related quality of life (HRQoL) and physical functioning. The therapeutic use of positioning in the management of an adult critically ill population could minimise the negative effects of bed rest. Method A scoping review was conducted to describe the therapeutic use of positioning in the management adult of critically ill patients. Six electronic data bases were searched by two researchers using specific search strategies. Papers were identified and included using predefined inclusion criteria. Data was extracted into an Excel spreadsheet. Data describing the therapeutic use of positioning was reported in a scoping review and the focussed review explored the effect of the semi-recumbent position on a critically ill patient population. This information was used in planning of the primary study. A non-randomised experimental design was used to evaluate the feasibility of using an adapted early mobility readiness protocol (protocol) to identify patients who could tolerate the therapeutic early mobility position (testing position). We reported on the effect of the testing position on two haemodynamic parameters including the mean arterial pressure (MAP) and the percentage central venous oxygen saturation (ScvO2%). The secondary aim was to describe the current nursing positions used in the surgical and respiratory units (the units) and to describe any adverse events. Twice weekly, all patients nursed in the units were screened with the inclusion/exclusion criteria and the protocol. The patients included were tested in the baseline nursing position followed by the testing position. The MAP and ScvO₂% were measured at 0 minutes, 3 minutes and 10 minutes. Data were described using repeated measures of ANOVA. A 5% significant level (p < 0.05) was used. If data were skewed, medians ranges 95% confidence intervals (CI), mean differences and 95% CI of mean differences were used. Results Nine hundred and thirty-six full text papers were assessed for inclusion into the review. One hundred and thirty-four papers described the therapeutic use of positions. Twelve papers, of which six papers described the effect of the semi-recumbent position and six papers described the clinical outcome of the semi-recumbent position, were included in the focussed review. Uncertainties still surround the haemodynamic stability and the ability of a patient to maintain the 45⁰ semi-recumbent position. A longer period in the 45⁰ semi-recumbent position is needed to evaluate the dynamic interaction of variables like the MAP and ScvO2%. We screened 138 patients using the inclusion/exclusion criteria which 82 patients failed. Eleven (7.9%) patients passed the protocol: male/female (9/2) with a median (range) age of 47 (20-67) years. The placement from the baseline nursing position to the testing position resulted in a mean difference (95% CI) of 2.03 (-1.12 - 5.18) in the MAP and a mean difference (95% CI) of 0.79 (-3.15 - 4.74) in the ScvO2%. Both did not reach statistical significance. Conclusion Guidelines for the use of the 45⁰ semi-recumbent position as a preventative intervention for ventilator associated pneumonia and aspiration do exist but therapeutic use of a position as an early mobility position still needs investigation. The protocol was not able to adequately identify patients who would be able to tolerate the testing position. Further work is needed to refine the criteria of protocol. Our data can inform the process. The outcome of patients nursed in this position needs further investigation.

AFRIKAANSE OPSOMMING: Inleiding Bed rus word gewoonlik voorgeskryf tydens die mediese versorging van kritieke siek pasient. Dit lei tot onaktiwiteit van kritieke siek pasiënt. Pasiënte sal moontlik probleme teëkom in hul gesondheidsverwante lewenskwaliteit en fisiese funksionering na hul herstel. Die negatiewe gevolge van bed rus kan moontlik verminder word en daarom word n beter begrip van die terapeutiese gebruik van posisionering in die hantering van volwasse pasiente in n kritieke siektetoestand benodig. Metode ’n Literatuur oorsig is gedoen om die terapeutiese gebruik van posisies te beskryf in volwasse kritieke siek pasiente. Ses data basisse is ondersoek deur twee navorsers met behulp van spesifieke soekstrategieë. Relevante artikels is geïdentifiseer en ingesluit aan die hand van vooraf gedefinieerde kriteria. Data is onttrek en opgesom in 'n self-ontwikkelde datablad. Data wat die terapeutiese gebruik van posisionering beskryf is in die oorsig studie beskryf en die gefokusde studie rapporteer die effek van die semi-geligte posisie op kritieke siek pasiente. Hierdie inligting is gebruik om te help in die beplanning van die primêre studie. 'n Nie-ewekansige eksperimentele studie is gebruik om die toepaslike gebruik van 'n aangepaste vroeë mobiliteits-gereedheidsprotokol te evalueer en om moontlike pasiënte te identifiseer wat die terapeutiese vroeë-mobiliteitsposisie kan verdra. Die primere doel was om die uitwerking van die toetsposisie op twee hemodinamiese parameters, die gemiddelde arteriele druk (MAP) en die sentrale veneuse suurstof persentasie (ScvO2%), te beskryf. Die beskrywing van die huidige verpleegsposisies in die eenhede en die newe-effekte wat daarmee gepaard gaan was die sekondere doel. Alle pasiënte wat in die chirurgiese en respiratoriese eenhede verpleeg word, is twee maal per week gëevalueer met die insluiting- en uitsluiting kriteria. Indien hul ingesluit is, is hul verder gëevalueer met die protokol. Pasiënte, wat dan slaag, is getoets in die basislyn-verplegingsposisie, gevolg deur die toetsposisie. Die MAP en die ScvO₂% is gemeet by 0, 3 en 10 minute. Data is beskryf deur middel van herhalende metings van ANOVA en n p-waarde van 5% is gebruik (p < 0.05) Data is beskryf met mediane (rykwydtes) en 95% vertrouensintervalle, gemiddelde verskille sowel as 95% vertrouensintervalle van gemiddelde verskille tydens skewe distribusie. Resultate 936 volledige teks dokumente is uitgelig vir insluiting. 134 dokumente is gevind wat die terapeutiese gebruik van posisies beskryf. Twaalf dokumente is in die gefokusde literatuur oorsig ingesluit waarvan ses die effek van die semi-geligte posisie beskryf en ses die kliniese uitkoms van die semi-geligte posisie beskryf. Die hemodinamiese stabiliteit en die vermoë van 'n pasiënt om die 45⁰ semi-geligte posisie te verdra word bevraagteken. 'n Langer tydperk in die 45⁰ semi-geligte posisie is nodig om die dinamiese interaksie van veranderlikes, die MAP en die ScvO2%, te evalueer. 138 pasiënte is gëevalueer met die insluitings en uitsluitings kriteria waarvan 82 pasiente nie geslaag het nie. Daarna is die oorblywende 46 pasiente gëevalueer met die protocol. Elf (7.9%), manlike / vroulike (9/2) pasiente met 'n mediaan (rykwydte) ouderdom van 47 (20-67) jaar, slaag die protokol. Die gemiddelde verskil van die MAP (95%CI) was 2.03 (-1.12 – 5.18) tydens posisionering vanaf die basislynverplegingsposisie na die toetsposisie en dit was nie statisties beduidend nie. Die gemene verskil van die ScvO2% (95%CI) was 0.79 (-3.15 - 4.74) tydens posisionering vanaf die basislynverplegingsposisie na die toetsposisie was ook nie statisties beduidend nie. Gevolgtrekking Riglyne bestaan wel vir die gebruik van die 45⁰ semi-geligte posisie vir die voorkoming van ventilator geassosieerde pneumonie en aspirasie van maag inhoud. Die gebruik van hemodinamiese parameters om die veiligheid en toepaslikheid van 'n vroeë mobiliteitsposisie te bepaal is nie ten volle beskryf nie. Die aangepaste vroeë mobiliteits-gereedheidsprotokol kon nie daarin slaag om toepaslike pasiente te identifiseer wat in die toets posisie geplaas kon word nie. Ons stel voor dat kriteria van die protokol verfyn word voor verdere gebruik. Ons data kan hierdie proses inlig. Die uitkoms van pasiënte wat vir n langer periode verpleeg word in hierdie posisie, benodig verdere ondersoek.

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