Presentazione sul tema: "MOBILIZZAZIONI E ATTIVITÀ MOTORIA NEL PAZIENTE CON INFARTO MIOCARDICO ACUTO E CON INSUFFICIENZA CARDIACA REFRATTARIA Premesse fisiopatologiche Alessandra."— Transcript della presentazione:
1MOBILIZZAZIONI E ATTIVITÀ MOTORIA NEL PAZIENTE CON INFARTO MIOCARDICO ACUTO E CON INSUFFICIENZA CARDIACA REFRATTARIA Premesse fisiopatologiche Alessandra Chinaglia UTIC Ospedale Maria Vittoria, ASLTO2
2Riposo a letto: è un trattamento benefico ? Fino agli anni ‘50 trattamento di scelta per infarto miocardico ed altre patologieJ A M A 1944The evil sequelae of complete bed rest.
339 trials sul riposo a letto 15 patologia differenti (5777 pazienti) Cardiologiche: IMA e post cateterismoIn nessun trial miglioramento clinico con il riposo a letto(o nessun miglioramento clinico o peggioramento)Allen,Lancet 1999; 354: – 3 3
5ATROFIA MUSCOLARE DA INATTIVITA’ ProteolisiRidotta sintesi proteica da inibizione dei fattori di iniziazionePerdita di massa muscolareRiduzione dello spessore delle fibreRiduzione della capacità muscolarePassaggio da fibre muscolari lente (resistenti alla fatica) a fibre muscolari velociVariazione del metabolismo (da acidi grassi a glucosio)
6L’attività muscolare svolge un ruolo antiinfiammatorio ImmobilitàAumento delle citochine circolantiStato pro infiammatorioPerdita di tessuto muscolare
7Forza di estensione del ginocchio -13.2% p =.004 IMPATTO FUNZIONALE DEL RIPOSO A LETTO PER 10 GIORNI IN ADULTI SANI ANZIANI11 uomini e donneetà 67 +/- 5 anniriposo a letto per 10 giornidieta normocaloricaForza di estensione del ginocchio % p =.004Potenza nel salire le scale % p =.01Capacità massimale aerobica -12% p =.04Kortebein P J Gerontol A Biol Sci Med Sci 2008; 63:
8Capacità muscolarePerdita di forza del quadricipite dell’1% - 1.5% per ogni giorno di riposo a letto (individui sani)Negli anziani ulteriore peggioramentoDonne: 36.3%Età media: anniMediana (range 25-75°): 72 (61-80) anniEtà > 75 anni: 38.9% dei pazienti3
9Densità osseaL’osso viene continuamente rimodellato in base al carico meccanico (forza di gravità e sollecitazioni meccaniche muscolari)Il riposo a letto comporta riduzione nella densità ossea della colonna lombare, testa del femore, e calcagno.dopo la ripresa della mobilizzazione il recupero della densità ossea è lentorischio di fratture (particolarmente nelle donne anziane)
10Effetti del riposo a letto prolungato sulle strutture osteomuscolari del tronco Dolore lombareAllungamento della colonnaAtrofia della muscolatura spinaleAumento dell’altezza dei dischi intervertebraliAlterata composizione dei dischi intervertebraliLe alterazioni della morfologia dei dischi intervertebrali persistono per 5 mesi dopo riposo a letto per 21 giorni.Hides, Eur Spine J (2011) 20:808–818
11Ulcere da decubitoIl processo che porta alle ulcere inizia dopo poche ore di immobilitàRiguarda le zone sottoposte a pressione in corrispondenza di prominenze osseeFacilitato da barelle troppo strette per permettere i movimenti, età avanzata, sedazione, incoscienza, immobilità prolungata
12Effetti dell’allettamento sul polmone Ridotta espansione polmonareRidotta capacità respiratoriaAtelettasiePolmoniti
13Effetti dell’allettamento sul sistema cardiovascolare Riduzione della compliance delle vene delle gambePerdita di fluidi che determinano ipotensione ortostatica, tachicardia, riduzione della gittata cardiaca, della portata cardiaca e delle resistenze vascolariDisfunzione microvascolare
14Disfunzione microvascolare da inattività Hamburg, Arterioscler Thromb Vasc Biol. 2007;27:
15Malnutrizione40% dei pazienti ospedalizzati sono già denutriti al momento del ricoveroI pazienti ricoverati in terapia intensiva ricevono meno del 60% del loro fabbisogno caloricoSpesso la denutrizione è prevalentemente proteicaLa perdita di proteine viene controbilanciata utilizzando prevalentemente proteine muscolari
16Allettamento richiede terapia antitrombotica ! Prevenzione emboliaSanguinamentoQuesti obiettivi debbono essere conseguiti senza pagare un prezzo eccessivo in termini di complicanze emorragicheinvasiveconservativeBeneficioRischio16
19Mobilizzazione precoce, riabilitazione e fisioterapia Surviving the intensive care: residual physical, cognitive, and emotional dysfunction.I pazienti ricoverati per malattie acute e critiche possono soffrire di problemi fisici, psicologici e cognitiviDepressione secondaria alla sensazione di dipendenza anche nelle più elementari attività, allo stress per la gravità della malattia, alla consapevolezza della vulnerabilitàMobilizzazione precoce, riabilitazione e fisioterapiaJones, Thorac Surg Clin 2012 Nov;22(4):509-16
20Mr E, a 56-year-old man with severe chronic obstructive pulmonary disease and acute renal failure, ambulating on day 4 after admission to the medical intensive care unit while receiving mechanical ventilation via an oral endotracheal tube.Needham, JAMA. 2008;300(14):
21CONTROINDICAZIONI:frequenza cardiaca > 110/min a riposopressione arteriosa media < 60stato di shocknecessità di FiO2 > 60%aritmie ventricolari subentrantiLa mobilizzazione precoce in pazienti critici con insufficienza respiratoria non è solo fattibile e sicura ma previene le complicazioni neuromuscolariAmerican Journal of Critical Care, 2009;18:
24team multidisciplinare Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings.16 letti Adult Medical/Surgical ICU /26 letti Adult Intermediate Care Unit (IMCU)team multidisciplinarealgoritmo per indirizzare la valutazione della potenziale mobilitàDaily Ambulation Status Reports rivalutato ogni mattina per determinare il livello di mobilizzazione.Nei 3 mesi precedenti la mobilizzazione entro 72 ore è avvenuta nel 6.2% dei pazienti ICU e 15.5% dei pazienti IMCUNei 6 mesi dopo nel 20.2% dei pazienti ICU e 71.8% dei pazienti IMCU.Drolet A,Phys Ther Sep 13
25E’ sufficiente fare esercizi al letto ? Non controbilanciano gli effetti avversi del riposo a letto, in particolare l’accumulo di liquidi nel torace rispetto agli arti inferiori per l’assenza di gravitàNei piani di assistenza sulla mobilizzazione è quindi raccomandata la posizione ortostatica
26MOBILIZZAZIONE PRECOCE Early mobilisation for patients following acute myocardiac infarction: a systematic review and meta-analysis of experimental studiesMortalità per tutte le cause o reinfarto a un anno dall’IMA.14 studi (13 pubblicati prima del 1983).MOBILIZZAZIONE PRECOCE(1541)CONTROLLO(1518)MORTE149 (9,3%)179 (11.6% )RR=0.85, 95% CI 0.68, 1.05REINFARTO82 (5,2%)80 (5.3%)RR=1.02, 95% CI 0.75, 1.39Cortes, Int J Nurs Stud Nov;46(11):
27Mobilizzazione post IMA: controindicazioni: i pazienti con disfunzione ventricolare sinistra devono inizialmente restare a letto per escludere scompenso precoce ed aritmie.nei casi non complicati il paziente può sedersi fuori dal letto in I giornata, utilizzare la comoda, lavarsi e nutrirsi da solo.si può iniziare precocemente a camminare (in particolare nei pazienti trattati per via radiale)i pazienti con complicazioni devono essere mantenuti a letto e la loro attività fisica deve riprendere in funzione dei sintomi e dell’entità del danno miocardico.Mobilizzazione post IMA: controindicazioni:scompenso cardiaco instabile e incontrollabiledolore toracico persistentePA instabile, shocktachicardia inappropriataaritmie persistenti e severe
28E I PAZIENTI CON SCOMPENSO ? Eur J Heart Fail January; 12(1): 58–65
29Esercizio fisico nel paziente con scompenso cardiaco Cardiol Res Pract. 2011; 2011:
30Attività muscolare: riflesso dal muscolo al sistema cardiovascolare e respiratorio Riflesso esagerato nei pazienti con scompenso cardiacoRiflesso causa attivazione del sistema simpaticoAttivazione esagerata del sistema simpatico: riduce la dilatazione arteriolare portando a una ridotta perfusione del muscolo.
31Riposo a letto CONTRO PRO decondizionamento Aritmie riduzione della mobilitàdepressione dell’umoreAtrofia muscolareUlcere da decubitoAtelettasie polmonariDemineralizzazione osseainvecchiamentoPROAritmieScompenso refrattarioischemia
32La riduzione della VO 2max dopo 40 anni di vita (da 20 a 60) era comparabile a quella dopo 3 settimane di riposo a letto all’età di 20 anni !Journal of Gerontology: Vol. 64A, No. 2, 293–299
33Mobilizzazione precoce vuole dire iniziare la mobilizzazione quando il paziente: Xè completamente autonomonon necessita di supplemento di O2non necessita di terapia infusionaleè emodinamicamente stabileè in grado di collaborarenecessita di livelli di O2 accettabili
34What Are the Barriers to Mobilizing Intensive Care Patients? Audit prospettico di 4 settimanePazienti mobilizzati in 176 (54%) di 327 giorni paziente.Eventi avversi: 2 /176 mobilizzazioni (1.1%)Cause di non mobilizzazione:Device con accesso vascolare femoraleProcedureAgitazione o stato di coscienza alteratoInstabilità emodinamicaMANCANZA DI RISORSE(INFERMIERI; FISIOTERAPISTI)Cardiopulmonary Physical Therapy Journal Vol 23 March 2012
35Crescita culturale riguardo ai potenziali benefici della mobilizzazione precoce e impegno da parte delle figure professionali coinvolte.
37Mortalità cardiovascolare - ospedalizzazione per scompenso Keteyian, J Am Coll Cardiol 2012;60:1899–905)
38Mitochondrial oxidative capacity is impaired due to decreased oxidative enzyme activity, mitochondrial volume density andbiogenesis, as well as increased reliance upon glucose rather than fatty acid oxidation. Thereis a shift from fatigue-resistant type I fibers that primarily rely on mitochondrial oxidativephosphorylation to generate ATP to type II fibers that have a higher glycogen content andderive most of their energy from glycolysis. Additionally, skeletal muscle in heart failurepatients has decreased capillary density6, which correlates with maximal VO2 and totalexercise time7. Fiber atrophy and decreased muscle mass also occur, and have beendemonstrated to account for much of the variability in peak VO2.
39Endotheliumderivednitric oxide-mediated vasodilation is decreased in the peripheral, coronary, andpulmonary circulations of patients with HF.14–16 The inability of the peripheral vasculatureto respond physiologically to variations in cardiac output, peripheral blood flow andpositional changes results in increased peripheral vascular resistance and imbalance in bloodpressure regulation in patients with advanced heart failure.
40Exercise training was shown to induce increased mitochondrial volume density as well as a shift from type II back to type I fibers.26Insulin resistance, which is commonly seen even in nondiabetic patients with heart failure,has also been associated with reduced exercise capacity.28. One proposed explanation for theprevalence of insulin resistance has been functional resistance to adiponectin, an insulinsensitizingadipocytokine. Van Berendoncks et al. studied heart failure patients whounderwent 4 months of combined endurance and resistance exercise training and found, atbaseline, a negative correlation between levels of adiponectin mRNA in skeletal muscle andVO2 peak and muscle strength, as well as a positive correlation between measures ofexercise capacity and mRNA expression of the skeletal muscle receptor for adiponectin,
41There has long been evidence that measures of cardiac function such as ejection fraction and cardiac output only poorlycorrelate with a patient’s capacity to exercise, suggesting the involvement of factors otherthan those impacting the central circulation. Furthermore, many studies of the effects ofexercise in patients with heart failure have failed to demonstrate improvements in cardiacoutput, stroke volume, or ejection fraction, despite showing gains in exercise capacity andpeak oxygen uptake (VO2),4 which has been validated as an excellent isolated predictor ofoutcome in this population5. The lack of a close correlation between central hemodynamicsand exercise tolerance has led to investigations into alterations in the periphery, such asabnormalities in vascular endothelial function, hyperactivation of the sympathetic nervoussystem, and changes in structure and oxidative capacity of skeletal muscle, which are oftenseen in patients with heart failure
42in skeletal muscle, hyperventilation is another consequence of the exaggerated EPR during exercise, both of which accentu- ates the symptoms of exercise intolerance. It is important to understand how the exaggerated EPR contributes to the exer- cise intolerance in CHF patients. Furthermore, the exaggerated sympatho-excitation that occurs during exercise also increases the risk of experiencing myocardial ischemia, myocardial infarction, cardiac arrest, and/or stroke during or immediately after exercise in these patients. As exercise intolerance and exaggerated sympatho-excitation are important clinical features in these patients, therapeutic inter- ventions are largely aimed at improving these symptoms. A particular interest has recently been directed toward the exagger- ated EPR in CHF (Piepoli et al., 1996, 1999; Khan and Sinoway, 2000; Piepoli, 2006;Wang et al., 2010b, 2012). Once thought to be contraindicated in patients with CHF, long-term regular exercise training (ExT for at least 8 weeks) as a non-pharmacological treat- ment for CHF is now commonly employed in these patients, and has been shown to increase the quality of life as well as survival (Belardinelli et al., 1999; Piepoli et al., 2004; Smart and Marwick, 2004; Jankowska et al., 2007; Wisloff et al., 2007; Flynn et al., 2009; O’Connor et al., 2009). The beneficial effects of ExT include improved autonomic balance, reduced neurohumoral activation, increase in exercise capacity and ameliorated myopathy in CHF patients and animals (Pliquett et al., 2003; Roveda et al., 2003; Rondon et al., 2006; Jankowska et al., 2007; Mueller, 2007b; Negrao and Middlekauff, 2008). Adequate discussion of the ben- eficial effects of ExT in CHF is a large endeavor and beyond the
43ESERCIZIO FISICO E SCOMPENSO CARDIACO (CHF) FunzioneAutonomaFunzionemetabolicaFunzionemuscolareFunzioneendotelialeAumentata tollerabilità all’esercizio fisico e ridotta ventilazione sottosforzoBenesseregeneraleQualitàdella vitaG.I.C.R.- IACPR43
44Coronary blood flowHambrecht R. et al. NEJM 2000;342:454
45in compensated stable CHF pts Exercise Trainingin compensated stable CHF ptsimproves peripheral vascular, muscular and metabolic functionimproves respiratory and autonomic functionthese effects lead to a significant improvement in exercise tolerance and quality of lifeno significant deterioration in central hemodynamicsattenuation of unfavorable LV remodeling
46Il training fisico: effetti fisiologici INCREMENTA:Il flusso muscolare e l’estrazione di O2Il rilascio dell’ NOLa capacità aerobicaLa soglia ischemicaLa capacità lavorativaIl colesterolo HDLRIDUCE:Il VO2 miocardicoLa FC e la PA a riposo e durante sforzoLa produzione muscolare di acido latticoLa trigliceridemiaL’aggregabilità piastrinicaLa produzione di catecolamine
47Result FiltersDisplay Settings:AbstractSend to:Am J Med May 15;116(10):Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N.SourceDepartment of Epidemiology and Public Health, University of Birmingham, Birmingham, United Kingdom.PURPOSE:To review the effectiveness of exercise-based cardiac rehabilitation in patients with coronary heart disease.METHODS:A systematic review and meta-analysis of randomized controlled trials was undertaken. Databases such as MEDLINE, EMBASE, and the Cochrane Library were searched up to March Trials with 6 or more months of follow-up were included if they assessed the effects of exercise training alone or in combination with psychological or educational interventions.RESULTS:We included 48 trials with a total of 8940 patients. Compared with usual care, cardiac rehabilitation was associated with reduced all-cause mortality (odds ratio [OR] = 0.80; 95% confidence interval [CI]: 0.68 to 0.93) and cardiac mortality (OR = 0.74; 95% CI: 0.61 to 0.96); greater reductions in total cholesterol level (weighted mean difference, mmol/L [-14.3 mg/dL]; 95% CI: to mmol/L [-24.3 to -4.2 mg/dL]), triglyceride level (weighted mean difference, mmol/L [-20.4 mg/dL]; 95% CI: to mmol/L [-34.5 to -6.2 mg/dL]), and systolic blood pressure (weighted mean difference, -3.2 mm Hg; 95% CI: -5.4 to -0.9 mm Hg); and lower rates of self-reported smoking (OR = 0.64; 95% CI: 0.50 to 0.83). There were no significant differences in the rates of nonfatal myocardial infarction and revascularization, and changes in high- and low-density lipoprotein cholesterol levels and diastolic pressure. Health-related quality of life improved to similar levels with cardiac rehabilitation and usual care. The effect of cardiac rehabilitation on total mortality was independent of coronary heart disease diagnosis, type of cardiac rehabilitation, dose of exercise intervention, length of follow-up, trial quality, and trial publication date.CONCLUSION:This review confirms the benefits of exercise-based cardiac rehabilitation within the context of today's cardiovascular service provisi
48Crit Care Med Aug;36(8):Early intensive care unit mobility therapy in the treatment of acute respiratory failure.Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E.SourceSection on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine, Winston Salem, NC, USA.AbstractOBJECTIVE:Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit.DESIGN AND SETTING:Prospective cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care.PATIENTS:Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission: Protocol, n = 165; Usual Care, n = 165.INTERVENTIONS:An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated the protocol within 48 hrs of mechanical ventilation.MEASUREMENTS AND MAIN RESULTS:The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge. Baseline characteristics were similar between groups. Outcome data are reflective of survivors. More Protocol patients received at least one physical therapy session than did Usual Care (80% vs. 47%, p < or = .001). Protocol patients were out of bed earlier (5 vs. 11 days, p < or = .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p < or = .001), and had similar low complication rates compared with Usual Care. For Protocol patients, intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care (p = .025); hospital length of stay for Protocol patients was 11.2 vs days for Usual Care (p = .006) (intensive care unit/hospital length of stay adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II, vasopressor). There were no untoward events during an intensive care unit Mobility session and no cost difference (survivors + nonsurvivors) between the two arms, including Mobility Team costs.CONCLUSIONS:A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care.
49Chest Dec;140(6):Implementing early mobilization interventions in mechanically ventilated patients in the ICU.Schweickert WD, Kress JP.SourceDepartment of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA.AbstractAs ICU survival continues to improve, clinicians are faced with short- and long-term consequences of critical illness. Deconditioning and weakness have become common problems in survivors of critical illness requiring mechanical ventilation. Recent literature, mostly from a medical population of patients in the ICU, has challenged the patient care model of prolonged bed rest. Instead, the feasibility, safety, and benefits of early mobilization of mechanically ventilated ICU patients have been reported in recent publications. The benefits of early mobilization include reductions in length of stay in the ICU and hospital as well as improvements in strength and functional status. Such benefits can be accomplished with a remarkably acceptable patient safety profile. The importance of interactions between mind and body are highlighted by these studies, with improvements in patient awareness and reductions in ICU delirium being noted. Future research to address the benefits of early mobilization in other patient populations is needed. In addition, the potential for early mobilization to impact long-term outcomes in ICU survivors requires further study.
50Crit Care Med Jan;35(1):Early activity is feasible and safe in respiratory failure patients.Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO.SourceDepartment of Medicine, Pulmonary and Critical Care Division, LDS Hospital, Salt Lake City, UT, USA.AbstractOBJECTIVE:To determine whether early activity is feasible and safe in respiratory failure patients.DESIGN:Prospective cohort study.SETTING:From June 1, 2003, through December 31, 2003, we assessed safety and feasibility of early activity in all consecutive respiratory failure patients who required mechanical ventilation for >4 days admitted to our respiratory intensive care unit (RICU). A majority of patients were treated in another intensive care unit (ICU) before RICU admission. We excluded patients who required mechanical ventilation for < or =4 days.PATIENTS:Eight-bed RICU at LDS Hospital.INTERVENTIONS:We assessed patients for early activity as part of routine respiratory ICU care. We prospectively recorded activity events and adverse events. We defined three activity events as sit on bed, sit in chair, and ambulate. We defined six activity-related adverse events as fall to knees, tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, oxygen desaturation <80%, and extubation.MEASUREMENTS AND MAIN RESULTS:During the study period, we conducted a total of 1,449 activity events in 103 patients. The activity events included 233 (16%) sit on bed, 454 (31%) sit in chair, and 762 (53%) ambulate. In patients with an endotracheal tube in place, there were a total of 593 activity events, of which 249 (42%) were ambulation. There were <1% activity-related adverse events, including fall to the knees without injury, feeding tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, and desaturation <80%. No patient was extubated during activity.CONCLUSIONS:We conclude that early activity is feasible and safe in respiratory failure patients. A majority of survivors (69%) were able to ambulate >100 feet at RICU discharge. Early activity is a candidate therapy to prevent or treat the neuromuscular complications of critical illness.
52Crit Care Resusc. 2009 Dec;11(4):290-300. Should we mobilise critically ill patients? A review.O'Connor ED, Walsham J.SourceSt Columcille's Hospital, Loughlinstown, County Dublin, Ireland.AbstractBACKGROUND:Neuromuscular weakness, a frequent complication of prolonged bed rest and critical illness, is associated with morbidity and mortality. Mobilisation physiotherapy has widespread application in patients hospitalised with non-critical illness.OBJECTIVES:We reviewed the literature to evaluate the worldwide availability of mobilisation therapy in intensive care units and the role of mobilisation therapy in patients requiring medical or surgical high dependency or intensive care.METHODS:We searched PubMed (1980 to August 2009) using the MeSH terms "physiotherapy" and "intensive care". Additional keyword search terms, "mobilisation", "mobilization", and "fast-track", were used. In addition, we examined reference lists in recent studies and reviews.RESULTS:Routine mobilisation physiotherapy is least likely to be available in ICUs in the United States. Early mobilisation is appropriate for patients with pulmonary thromboembolic disease, community-acquired pneumonia and in elderly hospitalised patients. Although fast-track cardiac and noncardiac surgery with early ambulation is safe and reduces hospital length of stay, it does not alter postoperative mortality. Up to 25% of patients can be safely mobilised within 72 hours of ICU admission. This therapy may reduce hospital and ICU length of stay, shorten duration of mechanical ventilation, and improve muscle strength and functional independence scores. Pooled data show a nonsignificant mortality benefit in favour of early mobilisation (odds ratio, 0.77; 95% CI, ).CONCLUSIONS:The data in support of mobilisation therapy for perioperative and critically ill patients, while of a low level of evidence, are substantial. This justifies a paradigm shift in attitudes towards physiotherapy and the prevention of critical illness weakness.
53AMERICAN JOURNAL OF CRITICAL CARE, May 2009, Volume 18, No. 3
54heavy sedation, especially when they are mechanically ventilated . Continuous sedative infusions are widelyused  and associated with increased duration ofmechanical ventilation . Heavy sedation prevents patientsfrom participating in mobility activities. Daily interruption ofsedation infusions can result in decreased duration ofmechanical ventilation (4.9 days versus 7.9 days; P = 0.004)and ICU length of stay (6.4 days versus 9.9 days; P = 0.02). Use of lighter sedation also is potentially associatedwith decreased long-term psychologic disturbances such aspost-traumatic stress . Combined early mobility anddecreased sedation may have synergistic benefits.
55Patients undergoing uncomplicated successful reperfusion therapy should be kept in the coronary care unit for aminimum of 24 h, after which they may be moved to a step-down monitored bed for another 24–48 h.
57Bench-to-bedside review: Mobilizing patients in the intensive care unit – from pathophysiology to clinical trials
58Pathophysiologically important mechanisms for weakness include immobility, as well as local andsystemic inflammation, which act synergistically to promotesignificant muscle loss in the critically ill patient. prolonged bed rest associated with critical illness leads todecreased muscle protein synthesis, increased urinarynitrogen excretion (indicating muscle catabolism), anddecreased muscle mass, especially in the lower extremities. These changes lead to deleterious effects on muscleweakness, with 1% to 1.5% of quadriceps muscle strengthlost for each day of bed rest in healthy individuals [15,16].Both preclinical and clinical studies suggest a more profoundeffect of immobilization in the elderly, with a greater loss oflean body mass [14,17]. Additionally, the interaction of bedrest and critical illness appears to result in more significantmuscle loss than bed rest alone [18-21].
59Bed rest, and its associated mechanisms, may play an important role in the pathogenesis of neuromuscular weakness in critically ill patients. A new approach for managing mechanically ventilated patients includes reducing deep sedation and increasing rehabilitation therapy and mobilization soon after admission to the intensive care unit.
60ICU patients with sepsis, multiorgan failure, or prolonged mechanicalventilation, neuromuscular dysfunctionwas identified in 655 of 1421 patients(46%) and was associated withprolonged duration of mechanical ventilationand length of ICU and hospitalstay. One
61Costo energetico di alcune attività in MET (1 MET = 3.5 ml O2/kg/min) Posizione supina1.12.5Lavarsi viso e maniMangiare1.41.8Scrivere, leggere1.2Seduto in poltronaUso della comoda2.0Ortostatismo1.2Giannuzzi, Ignone.Riabilitazione nelle malattie cardiovascolari.UTET 1999