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2025 PACUPrep BCCCP Preparatory Course Immobility and Early Mobilization Supportive Care Measures and Management of Complications

Lesson 78, Topic 4

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Supportive Care Measures and Management of Complications

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Supportive Care Measures and Management of Complications in the ICU

Supportive Care Measures and Management of Complications

Objective

Recommend appropriate supportive care and monitoring to manage complications associated with ICU immobility and its pharmacologic management.

1. Supportive Care Goals and Safety Principles

Early mobilization hinges on preserving physiologic stability, optimizing pain and sedation, and preventing secondary injury. Protocols should be individualized based on a patient’s hemodynamic, respiratory, and neurologic reserves.

Key Pearls: Mobilization Safety

Mobilization requires a stable sedation level (Richmond Agitation-Sedation Scale [RASS] –1 to +1) and sufficient analgesia without causing respiratory depression.
Pre-mobilization checklists standardize team roles, ensure equipment readiness, and have been shown to reduce adverse events.

1.1 Preparing the Patient and Environment for Mobilization

Patient Assessment: Review current sedation (RASS), analgesia effectiveness, ventilator settings, and the stability of all lines and drains.
Environment Safety: Secure all devices (IV lines, catheters), engage bed and chair brakes, and apply gait belts or harnesses as needed.
Equipment Staging: Clear overhead space and pathways. Stage portable pumps, oxygen tanks, and physical therapy aids within reach.
Staffing: Ensure adequate staffing for the planned activity; a minimum of two skilled personnel is recommended for high-dependency patients.
Pharmacologic Planning: Consider temporary holds on continuous sedation infusions or using easily titratable agents like dexmedetomidine to facilitate patient engagement.

1.2 Interprofessional Communication and Checklists

Structured communication is vital. A pre-mobilization huddle using a standardized format like SBAR (Situation, Background, Assessment, Recommendation) ensures the entire team is aligned.

Figure 1: Pre-Mobilization Communication Workflow. A structured huddle using a safety checklist and clear role assignments, followed by documentation, improves team coordination and patient safety.

2. Mechanical Ventilation Optimization for Mobilization

Ventilator settings must balance adequate support for gas exchange with the promotion of respiratory muscle activity during mobilization.

Key Pearls: Ventilator Management

Begin with Pressure Support Ventilation (PSV) targeting a rapid shallow breathing index (RSBI) of less than 105 breaths/min/L.
Establish clear abort criteria: SpO₂ < 90%, respiratory rate > 35/min, or any signs of patient fatigue or hemodynamic compromise.

2.1 Ventilator Mode Adjustments

Pressure Support Ventilation (PSV): Start with moderate support (e.g., 10–14 cm H₂O) and decrease by 2–4 cm H₂O per session as tolerated, ensuring tidal volumes remain ≥6 mL/kg of predicted body weight.
Continuous Positive Airway Pressure (CPAP): Transition to CPAP when minimal support is tolerated. This mode promotes alveolar recruitment without delivering mandatory breaths, encouraging spontaneous effort.

2.2 Monitoring During Mobilization

Continuously monitor key respiratory parameters during and after activity:

Gas Exchange: SpO₂ and end-tidal CO₂.
Respiratory Effort: Respiratory rate, tidal volumes, and accessory muscle use.
Overall Tolerance: RSBI and patient-reported dyspnea. Intervene immediately if abort criteria are met.

3. Hemodynamic Support

Cardiovascular stability during activity requires vigilant perfusion monitoring and careful titration of vasoactive agents.

Key Pearls: Hemodynamic Stability

The dose of norepinephrine should be stable or decreasing for at least 2 hours before attempting mobilization.
Serial lactate trends are a valuable guide to assess readiness for activity; a declining or stable lactate suggests adequate tissue perfusion.

3.1 Vasopressor and Inotrope Titration

The primary goal is to maintain a mean arterial pressure (MAP) of ≥65 mmHg. An arterial line is essential for real-time monitoring.

Common Vasoactive Agents and Mobilization Considerations
Agent	Typical Dose Range	Clinical Considerations
Norepinephrine	0.01–3 µg/kg/min	First-line vasopressor. Ensure dose is stable or weaning prior to mobilization.
Vasopressin	0.01–0.04 units/min	Adjunctive therapy. Avoid bolus doses. Dose should be stable.
Dobutamine	2–20 µg/kg/min	For low cardiac output with adequate MAP. Monitor for tachyarrhythmias.

3.2 Perfusion Goals and Monitoring

Lactate Clearance: A plateau or decline in serum lactate over 6–12 hours is a strong indicator of adequate global perfusion.
Invasive Monitoring: Central venous pressure (CVP) trends can help assess preload. Advanced monitoring (e.g., pulse contour analysis) may be used if available to track cardiac output changes.
Experimental Monitoring: Near-infrared spectroscopy (NIRS) is an emerging technology that can provide non-invasive, real-time data on regional tissue oxygenation.

4. Prevention of Immobility Complications

A proactive, risk-stratified approach is necessary to prevent venous thromboembolism (VTE), pressure ulcers, and atelectasis alongside mobilization efforts.

Key Pearls: Complication Prevention

Low-molecular-weight heparin (LMWH) is the preferred agent for VTE prophylaxis in most ICU patients unless contraindicated.
A Braden Scale score of ≤12 indicates a very high risk for pressure ulcer development, mandating intensified preventive strategies.

4.1 Venous Thromboembolism (VTE)

Use a validated risk assessment tool, such as the Padua Prediction Score (score ≥4 indicates high risk), to guide prophylaxis decisions.

Pharmacologic VTE Prophylaxis Options
Agent	Typical Dosing	Key Considerations
Enoxaparin (LMWH)	40 mg SC daily	Preferred due to predictable pharmacokinetics and lower risk of HIT. Requires dose adjustment for severe renal impairment.
Unfractionated Heparin (UFH)	5,000 units SC q8-12h	Use if high bleeding risk (short half-life) or severe renal impairment (CrCl < 30 mL/min).

Mechanical Prophylaxis: Sequential compression devices (SCDs) should be used when pharmacologic prophylaxis is contraindicated (e.g., active bleeding, severe thrombocytopenia). Ensure correct sizing and continuous use for efficacy.

4.2 Pressure Ulcer Prevention

Assess risk on admission and daily using the Braden Scale. For high-risk patients (score ≤12), implement:

Repositioning: Turn patient at least every 2 hours.
Support Surfaces: Use high-density foam or alternating-pressure mattresses.
Skin Care: Keep skin clean and dry; use moisture barriers as needed.

4.3 Pulmonary Atelectasis Prevention

Positioning: Elevate the head of the bed to 30°–45° and perform lateral turns every 2 hours to recruit dependent lung areas.
Lung Expansion: In cooperative patients, encourage 10–15 maximal inspiratory efforts hourly using an incentive spirometer. Chest physiotherapy (percussion and vibration) can also be beneficial.

5. Management of Iatrogenic Complications

Early detection and targeted therapy are crucial to minimize harm from pharmacologic interventions used to support critically ill patients.

Key Pearls: Iatrogenic Complications

In suspected Heparin-Induced Thrombocytopenia (HIT) with a 4Ts score ≥4, discontinue all heparin products immediately and initiate a non-heparin anticoagulant.
Reserve antipsychotics for severe ICU delirium where non-pharmacologic measures have failed and patient safety is at risk.

5.1 Heparin-Induced Thrombocytopenia (HIT)

HIT is a prothrombotic, antibody-mediated reaction. Use the 4Ts score to estimate pretest probability.

Figure 2: Diagnostic and Management Algorithm for Suspected HIT. A 4Ts score helps stratify risk and guides immediate management decisions, including cessation of heparin and initiation of alternative anticoagulation.

Alternative Anticoagulants for Confirmed or Suspected HIT
Agent	Dosing & Titration	Key Considerations
Argatroban	Start 2 µg/kg/min infusion. Titrate to aPTT 1.5–3x baseline.	Metabolized by liver; reduce dose in hepatic impairment. Falsely elevates INR.
Bivalirudin	Start 0.15 mg/kg/h infusion. Titrate to aPTT 1.5–2.5x baseline.	Cleared by kidneys; reduce dose in renal impairment. Less effect on INR.

5.2 Sedative-Related Delirium

The primary strategy is prevention and non-pharmacologic management. This includes frequent reorientation, providing sensory aids (glasses, hearing aids), promoting normal sleep-wake cycles, and minimizing noise.

Pharmacologic therapy is reserved for severe agitation or psychosis that poses a safety risk.

Pharmacologic Options for ICU Delirium
Agent	Typical Dosing	Key Considerations
Haloperidol	0.5–2 mg IV/PO q4-6h PRN	Monitor QTc interval for prolongation. Risk of extrapyramidal symptoms (EPS).
Quetiapine	25–50 mg PO/NG q12h	Monitor for sedation, orthostatic hypotension, and QTc prolongation. Less EPS risk.

6. Multidisciplinary Goals-of-Care Conversations

Shared decision-making is essential to align mobilization plans and other interventions with the patient’s values, prognosis, and overall treatment goals.

6.1 Roles of the Multidisciplinary Team

Physicians: Assess medical stability, identify contraindications, and lead goals-of-care discussions.
Nurses: Monitor patient tolerance during activities, manage lines and devices, and provide real-time feedback.
Pharmacists: Optimize sedation, analgesia, and prophylaxis regimens; screen for drug interactions and adverse effects.
Physical/Occupational Therapists: Prescribe and progress mobility activities, assess functional status, and recommend assistive devices.

6.2 Ethical Considerations and Shared-Decision Making

Discussions must transparently balance the potential benefits of mobilization against the risks, including pain, fatigue, and device dislodgement. It is critical to incorporate the patient’s advance directives and involve family members or surrogate decision-makers in setting realistic goals.

7. Monitoring and Reassessment

Continuous tracking of safety events and performance metrics is the foundation of quality improvement in any early mobilization program.

7.1 Safety Event Tracking and Tolerance Metrics

Systematically document all mobilization sessions and any associated events:

Adverse Events: Track desaturation (SpO₂ <90%), significant hypotension (e.g., MAP drop >20% or requiring vasopressor increase), falls, and line/tube dislodgements.
Tolerance Metrics: Record the duration of the session, level of assistance required, distance traveled, and patient-reported outcomes like exertion or dyspnea.

7.2 Continuous Quality Improvement (CQI) Loops

A successful program relies on a robust CQI process:

Audit Performance: Regularly review data on mobilization frequency, complication rates, and adherence to safety checklists.
Analyze Events: Conduct root-cause analyses for any significant adverse events to identify systems issues.
Provide Feedback: Share data and findings with frontline staff to celebrate successes and target areas for improvement.
Refine Protocols: Use the data to iteratively refine protocols, checklists, and abort criteria.

References

Devlin JW, Skrobik Y, Gelinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825–e873.
Zhang L, Hu W, Cai Z, et al. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One. 2019;14(10):e0223185.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.
Cuker A, Arepally GM, Chong BH, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv. 2018;2(22):3360–3392.
Marini I, Cuker A, Linkins L, et al. Management of heparin-induced thrombocytopenia: a systematic review and meta-analysis. Haematologica. 2022;107(6):1264–1277.

2025 PACUPrep BCCCP Preparatory Course

Pulmonary

Participants 432

Supportive Care Measures and Management of Complications

Objective

1. Supportive Care Goals and Safety Principles

1.1 Preparing the Patient and Environment for Mobilization

1.2 Interprofessional Communication and Checklists

2. Mechanical Ventilation Optimization for Mobilization

2.1 Ventilator Mode Adjustments

2.2 Monitoring During Mobilization

3. Hemodynamic Support

3.1 Vasopressor and Inotrope Titration

3.2 Perfusion Goals and Monitoring

4. Prevention of Immobility Complications

4.1 Venous Thromboembolism (VTE)

4.2 Pressure Ulcer Prevention

4.3 Pulmonary Atelectasis Prevention

5. Management of Iatrogenic Complications

5.1 Heparin-Induced Thrombocytopenia (HIT)

5.2 Sedative-Related Delirium

6. Multidisciplinary Goals-of-Care Conversations

6.1 Roles of the Multidisciplinary Team

6.2 Ethical Considerations and Shared-Decision Making

7. Monitoring and Reassessment

7.1 Safety Event Tracking and Tolerance Metrics

7.2 Continuous Quality Improvement (CQI) Loops

References