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1. SYSTEM EXAMINATION OF SURGICAL ICU PATIETNS: DR.MAHNOOR MALIK DPT,MS-CPPT

2. Renal system: The kidneys have a vital role in homeostasis. They are responsible for excretion of waste products of metabolism including drugs, production of hormones, control of the extracellular fluid composition which influences intracellular volume, osmolality and acid-base status. Haematological /immunological system: The haematological and immunological stability of a patient is often overlooked during the physiotherapy assessment. However, these systems may produce strong contraindications for physiotherapy. Patients with sepsis are often complicated by abnormal coagulation. Prolonged dotting times coupled with low platelet counts may lead to spontaneous bleeding from both mucous membranes and the respiratory tract. Physiotherapy may aggravate bleeding. Patients who are immunocompromised either through primary disease processes (e.g. malignancy), drug therapy (e.g. use of steroids) or as a complication of sepsis are particularly at risk from nosocomial infections (hospital acquired) and cross-infection.

3. The haematological and immunological stability of a patient is often overlooked during the physiotherapy assessment. However, these systems may produce strong contraindications for physiotherapy. Patients with sepsis are often complicated by abnormal coagulation. Prolonged dotting times coupled with low platelet counts may lead to spontaneous bleeding from both mucous membranes and the respiratory tract. Physiotherapy may aggravate bleeding. Patients who are immunocompromised either through primary disease processes (e.g. malignancy), drug therapy (e.g. use of steroids) or as a complication of sepsis are particularly at risk from nosocomial infections (hospital acquired) and cross-infection.

4. Considerations tor physiotherapy: • Appropriate care must be taken to minimize cross-infection (see Ch. 4) with respect to local health and safety recommendations. Most ICUs advocate the use of a clean apron and gloves for each patient. Masks may be worn if indicated (e.g. open tuberculosis). While suctioning (p. 287), a sterile or second glove should be worn and goggles may be recommended. Gastrointestinal system: A patient who has sustained a large gastrointestinal bleed may become hypovolaemic due to blood loss. A metabolic acidosis may be evident from arterial blood gas analysis. The patient may adopt an abnormal breathing pattern in an attempt to 'blow off carbon dioxide and therefore reduce overall acidity. Nutritional support is an important aspect of the care of the critically ill patient. Adequate nutrition is essential to prevent the loss of lean body tissue, provide material for repair and to facilitate recovery. Poor nutritional status, particularly deficits of magnesium and phosphates, may contribute to respiratory muscle weakness and delayed weaning from the ventilator

5. Routes of administration: Routes of administration: • Enteral - rube feeds directly into the gastromtestinal tract, e.g. nasogastric feeds or gastrostomy / jejunostomy • Parenteral - intravenous feeding via central or peripheral line • Oral — usually with supplementation. Considerations for physiotherapy • Ventilated patients with a reduced level of consciousness and a poor gag reflex may be prone to pulmonary aspiration if the endotracheal tube is uncuffed or the cuff deflated. Overfeeding may result in increased C0 2 production especially in patients with respiratory failure

6. Musculoskeletal system: It is beneficial to know the patient's state of preadmission mobility. It is unlikely that a patient who does not have musculoskeletal complications will require regular passive movements but it is important to assess this regularly as the critically ill patient may develop musculoskeletal problems. Patients who have sustained musculoskeletal trauma, have pre-existing pathology or who have been ventilated for a prolonged time will require an in-depth assessment and appropriate treatment. Positioning. The frequent turning of a patient will not only benefit the musculoskeletal system and aid pressure relief, but will also enhance the respiratory system. A change of position may have several effects, assisting the drainage of secretions, improving ventilation- perrusion relationships, and increasing functional residual capacity. Beds. A wide variety of specialist beds are available to assist in the turning and positioning of the critically ill patient (Birtwistle 1994). It is essential for any patient, but imperative for the multi-trauma patient, to be assessed adequately for the appropriate specialist bed

7. Considerations for physiotherapy: The unstable patient may not tolerate a change in position MECHANICAL VENTILATION (IMPLICATIONS FOR PHYSIOTHERAPY): Mechanical ventilation is used in patients undergoing a general anesthetic and in most patients requiring intensive care. Modern ventilators provide a wealth of different modalities to cater for patients from the most critically ill, through the weaning process to extubation . At every different stage, a full assessment must be undertaken to identify the presence of any physiotherapy problems. Physiotherapy may need to be modified depending on a patient's ventilatory requirements and during the weaning process.

8. Intubation: The decision to intubate and ventilate a patient is never taken lightly, as this procedure in itself has an associated level of morbidity and mortality. Endotracheal tubes come in a variety of types and sizes. Most of those routinely used for adults have a high-volume, low-pressure cuff to limit tracheal damage. Considerations for physiotherapy: When assessing the mechanically ventilated patient it is important to note the ventilation requirements and to understand their implication. The level of stability of both the cardiovascular and respiratory systems must be established. A patient with an unstable respiratory system requiring high levels of oxygen (Fi02 > 0.6) and /or high levels of PEEP (> 10 cmH2 0) should have an absolute indication for treatment before physiotherapy is undertaken. • If manual hyperinflations are indicated in a patient requiring a high level of PEEP, a PEEP valve should be used

9. When assessing the mechanically ventilated patient it is important to note the ventilation requirements and to understand their implication. The level of stability of both the cardiovascular and respiratory systems must be established. A patient with an unstable respiratory system requiring high levels of oxygen (Fi02 > 0.6) and /or high levels of PEEP (> 10 cmH2 0) should have an absolute indication for treatment before physiotherapy is undertaken. • If manual hyperinflations are indicated in a patient requiring a high level of PEEP, a PEEP valve should be used (p. 286). • The inspiratory : expiratory (I : E) ratio can be altered in mechanical ventilation to meet an individual patient's needs. A prolonged expiratory time or an expiratory pause can be used in patients with chronic airflow limitation. A prolonged inspiratory time (inverse ratio ventilation) improves oxygenation in ARDS. An altered I : E ratio may be vital to maintain good oxygenation. In this situation, manual hyperinflation may not be tolerated.

10. When positioning the mechanically ventilated patient it must be remembered that the physiological factors affecting ventilationperfusion matching are altered. The application of positive pressure leads to non-dependent areas of lung being preferentially ventilated. Therefore as perfusion is influenced by gravity some degree of inequality is always present. For example in right side lying, the right lung is dependent and therefore preferentially perfused, whereas the left lung is non-dependent, thus preferentially ventilated. As this mismatching occurs in all positions, frequent changes of position are essential. Use of the prone position has been shown to be of benefit in some patients with severe lung disease ( Pappert et al 1994). • When assessing a patient who requires an unconventional form of ventilation, e.g. highfrequency ventilation and/or nitric oxide (p. 94), and in whom physiotherapy is indicated, it is advantageous to discuss the plan of treatment with the medical staff.

11. Weaning: Weaning is the process of reducing or removing ventilatory support. As soon as the patient's condition stabilizes, weaning can start. Influences on the weaning process Neurological system. A reduced level of consciousness is not a direct contraindication to weaning as airway patency and protection can be maintained with an endotracheal or tracheostomy tube. The patient must be able to sustain adequate spontaneous ventilation. Sedative drugs need to be reduced during the weaning process. Pathology such as Guillain-Barré syndrome and myasthenia gravis may require weaning to take place during the daytime as fatigue and poor diaphragmatic function may lead to nocturnal hypoventilation. Cardiovascular system. A stable cardiovascular system is necessary for successful weaning. Reduced cardiac output due to hypovolemia or arrhythmias may potentially result in respiratory muscle oxygen deprivation. Respiratory system. The patient must be able to initiate an adequate respiratory drive during each stage of the weaning process. Any primary lung pathology should have resolved significantly to allow for improved respiratory function Respiratory system. The patient must be able to initiate an adequate respiratory drive during each stage of the weaning process. Any primary lung pathology should have resolved significantly to allow for improved respiratory function.

12. It is necessary that adequate oxygenation can be sustained with reducing levels of oxygen and PEEP. In the final stages of weaning, patients must be able to generate adequate minute volumes to maintain their PaC02 within the normal range. Acid-base balance. It should be noted that the weaning process can be complicated in patients with an abnormal acid-base balance, e.g. severe metabolic acidosis will induce a raised respiratory rate, whereas metabolic alkalosis may lead to hypoventilation. Renal system. Electrolyte balance is imperative to prevent excessive respiratory muscle fatigue. Acute renal failure with fluid overload will make weaning more difficult Nutrition. Adequate nutritional support is essential during weaning to help prevent muscle weakness and fatigue. Infection. Overwhelming sepsis can cause impaired gas exchange with an increased 02 consumption and CO: production which may delay weaning (Browne 1988a).

13. Methods of weaning: In the uncomplicated postoperative situation the whole process of weaning may only take a short period. As the patient regains consciousness and breathes spontaneously, rapid extubation can take place. In the long-term ventilated patient, the weaning process is started by reducing sedation and positioning for optimal diaphragmatic excursion. Modern ventilators have an extensive range of weaning modalities. The patient is encouraged to self-ventilate on an assisted mode, e.g. synchronized intermittent mandatory ventilation (SIMV), while still receiving additional support for each spontaneous breath, e.g. inspiratory pressure support (IPS)

14. Considerations for physiotherapy: • In the weaning phase a patient on assisted ventilation may have a high spontaneous respiratory rate. Manual hyperinflation may cause the patient distress and may be ineffective if only small tidal volumes are achieved. If a primary respiratory problem is causing the high respiratory rate, physiotherapy is indicated. It is important to start manual hyperinflation matching the patient's own respiratory rate and depth. By slowly increasing the tidal volume, the PaCO : levels can be lowered, temporarily inhibiting the patient's respiratory drive and allowing effective manual hyperinflations. • When a patient has been weaned on to CPAP, it is important that adequate physiotherapy input continues. Good positioning is essential to maximize further weaning potential. If sputum is present airway clearance techniques should be utilized

15. Extubation : Although successful weaning culminates in extubation , the two processes must be assessed independently. Extubation should not be considered until the patient can protect his own airway, and can cough and swallow Minitracheostorny tube: The sole purpose of the minitracheostorny is access for the removal of excess bronchial secretions. It can also be used in the decannulation process of a tracheostomy tube. It is important to remember that a mini tracheostomy offers no airway protection