Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3
Mobilization in Indian intensive care units: Where do we stand? Sir, We read with the great interest the article by Rajesh Chawla et al. (2014) surveying the mobilization, analgesic, and sedative practises in Indian intensive care units (ICUs). [1] We appreciate the authors for the greater efforts in evaluating the intensive care practises at a larger scale. Though the response rate was poor (11%), the study paves way for utilization of several standardization procedures including therapeutic practises in ICUs. Especially the study has demonstrated mobilization practices in Indian ICUs. Mobilization is a standard practice in western ICUs. Earlier research had elaborated effects of early mobilization in maintenance of muscle mass, thus preventing critical illness myoneuropathy, increasing functional capacity, early functional independence, early weaning, reduction of ventilator‑associated pneumonia and critical illness, reduction of intensive care, and hospital stay, improving neuropsychiatric outcomes such as ICU delirium, reduction of caregiver stress, and health resource utilization.[2‑7] Western literature including meta‑analysis and systematic reviews are available stating significant evidence in mobilization of critically ill patients.[2,5,7] In the article by Rajesh Chawla (2014), we are not surprised by the fact that out of 94% (614 physician responders), only 13% (90 physicians) were in favor of mobilizing critically ill patients with equipments (ventilators and tubes).[1] Western literature supports mobilization of intensive care patients with ventilators and assistive devices.[8,9] Safety in mobilizing intensive care patients with ventilators and tubes are proved earlier. [10,11] We disagree the author in holding only physician apprehension as responsible for poor mobilization practises in Indian ICUs. This may be due to lack of infrastructure, expertise training in handling mobile ventilators, and mobilizing aids, such as mechanical hoists (passive transfer using mechanical aids) ,[12] lack of therapist’s and nurse’s knowledge of initiating and progressing early mobilization in ICU, criteria for termination of mobilization, screening for risk stratification during mobilization, knowledge about mobility aids, and safe handling techniques.[10,11] New promising researches are put forward depicting the 188
positive attitude of mobilizing patients in Indian ICUs in past few years.[13‑15] We recommend future trials in elucidating the effects of early mobilization in intensive care outcomes in Indian medical pitch. Apart from the study mentioned, limitation, such as the poor response rate poor responders, few other setbacks prevent from generalization of the study results in Indian clinical arena.[1] First, majority of the responders are age below 40 (59%) and ICU practising experience below 5 years (41%). Since this survey partially depends on the experience of the practising intensivists, the practise patterns elaborated in the study are questionable to certain extent. Second, the majority of the responders are from institutions with less than 20 ICU beds (77%). Though the bed strength falls within the standardization of Indian Society for Critical care medicine (ISCCM), the systematic mobilization program may not be implemented at ease within the constrained perimeter of the ICUS included in the present study. Further, the current survey could have inclusions of various ICUs such as cardiology, neurology, post‑surgical and traumatic practice patterns differing between ICUs within an Insitution itself which may question the applicability of the results in Indian clinical arena. Other than the above limitations, the study adds evidence to the current therapeutic practises, newer association between sedation and mobilization and neuropsychiatric outcomes such as delirium in Indian intensive care settings. We appreciate once again the authors for demonstrating lag of current ICU practices behind the standard guidelines of therapeutic applications in Indian ICUs.
Baskaran Chandrasekaran, Senthil S. Kumar, Chandra S. Sekar
Department of Pulmonary and Critical Care Medicine, Peelamedu Samanaidu Govindarajulu Hospitals, Coimbatore, Tamil Nadu, India
Correspondence: Mr. Baskaran Chandrasekaran, Department of Pulmonary and Critical Care Medicine, PSG Hospitals, Peelamedu, Coimbatore - 641 004, Tamil Nadu, India. E‑mail: [email protected]
References 1.
2. 3. 4.
Chawla R, Myatra SN, Ramakrishnan N, Todi S, Kansal S, Dash SK. Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2014;18:575‑84. Adler J, Malone D. Early mobilization in the intensive care unit: A systematic review. Cardiopulm Phys Ther J 2012;23:5‑13. Kress JP. Clinical trials of early mobilization of critically ill patients. Crit Care Med 2009;37:S442‑7. Engels PT, Beckett AN, Rubenfeld GD, Kreder H, Finkelstein JA, da Costa L, et al. Physical rehabilitation of the critically ill trauma patient in the ICU. Crit Care Med 2013;41:1790‑801.
Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3 5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15.
Casey CM. The study of activity in older ICU patients: An integrative review. J Gerontol Nurs 2013;39:12‑25. Vollman KM. Understanding critically ill patients hemodynamic response to mobilization: Using the evidence to make it safe and feasible. Crit Care Nurs Q 2013;36:17‑27. Kalisch BJ, Dabney BW, Lee S. Safety of mobilizing hospitalized adults: Review of the literature. J Nurs Care Qual 2013;28:162‑8. Dong ZH, Yu BX, Sun YB, Fang W, Li L. Effects of early rehabilitation therapy on patients with mechanical ventilation. World J Emerg Med 2014;5:48‑52. Abrams D, Javidfar J, Farrand E, Mongero LB, Agerstrand CL, Ryan P, et al. Early mobilization of patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. Crit Care 2014;18:R38. Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD, Needham DM. Safety of physical therapy interventions in critically ill patients: A single‑center prospective evaluation of 1110 intensive care unit admissions. J Crit Care 2014;29:395‑400. Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, et al. Early mobilization of mechanically ventilated patients: A 1‑day point‑prevalence study in Germany. Crit Care Med 2014;42:1178‑86. Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care 2010;16:138‑46. Kumar J, Maiya A, Periera D. Role of Physiotherapists in intensive care units of India – A Multicenter survey. Indian J Crit Care Med 2008;11:198‑203. O’Connor ED, Walsham J. Should we mobilise critically ill patients? A review. Crit Care Resusc 2009;11:290‑300. Pattanshetty RB, Gaude GS. Critical illness myopathy and polyneuropathy – A challenge for physiotherapists in the intensive care units. Indian J Crit Care Med 2011;15:78‑81. Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152782
Hyponatremia management in critically ill: Food (protein) for thought Sir, Hyponatremia is the most common disorder of body fluid and electrolyte balance encountered in clinical critically ill patients and associated with increased morbidity and mortality. A wide range of conditions can cause hyponatremia and, as a result, it is being managed by clinicians from a variety of backgrounds with a variety of approaches to its diagnosis and management. Adding to the complexity is the available treatment options, which
includes normal saline, hypertonic saline, fluid restriction, drugs (demeclocycline and vaptans) and increasing intake of solutes like urea/protein. Treatment decision is based on multiple factors like severity and symptoms of hyponatremia, onset of hyponatremia, underlying disease, and associated illness. Rate of correction and overcorrection are important factors to consider. The decision to administer normal saline or hypertonic saline to patient with hyponatremia is quite clear and easy to practice. Except the use of saline and vaptans, rest of the treatment options are infrequently practiced, sometimes difficult to apply in critically ill patients especially with regard to fluid restriction. Management of the hyponatremia should ensure patient management rather than simply looking at the sodium level. If hyponatremia is serious and symptomatic, it is life‑threatening. In this situation, the first line of treatment will be prompt intravenous infusion of hypertonic saline. For patients with reduced circulating volume, extracellular volume should be replaced with intravenous infusion of 0.9% saline. If the cause is apparent, reversing it may lead to correction as restricting water intake in psychogenic polydipsia, giving glucocorticoid/thyroid replacement in deficient, stopping hypotonic fluids or medications like selective serotonin reuptake inhibitors, nonsteroidal anti‑inflammatory drugs, thiazides or desmopressin and optimization of Congestive heart failure (CHF), hepatic or renal failure. For patients with the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), which constitutes about 40% of hyponatremia cases and with moderate or profound hyponatremia, first‑line treatment is fluid restriction. Equal second‑line treatments are increasing solute intake. For moderate or profound hyponatremia, there is no recommendation for the use of lithium, demeclocycline, and even vasopressin receptor antagonist. Overcorrection is major reasons against vaptans.[1] There are not good outcome data either, with vaptans in form of improved survival or improved quality of life.[2] The lack of outcome data also applies to other treatments of hyponatremia. There are a vast majority of hyponatremic patients in the Intensive Care Unit (ICU) who are neither volume deficient nor they have profound and symptomatic hyponatremia. There are also patients in critical care unit where it is difficult to implement fluid restriction. 189
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Mobilization in Indian intensive care units: Where do we stand? Sir, We read with the great interest the article by Rajesh Chawla et al. (2014) surveying the mobilization, analgesic, and sedative practises in Indian intensive care units (ICUs). [1] We appreciate the authors for the greater efforts in evaluating the intensive care practises at a larger scale. Though the response rate was poor (11%), the study paves way for utilization of several standardization procedures including therapeutic practises in ICUs. Especially the study has demonstrated mobilization practices in Indian ICUs. Mobilization is a standard practice in western ICUs. Earlier research had elaborated effects of early mobilization in maintenance of muscle mass, thus preventing critical illness myoneuropathy, increasing functional capacity, early functional independence, early weaning, reduction of ventilator‑associated pneumonia and critical illness, reduction of intensive care, and hospital stay, improving neuropsychiatric outcomes such as ICU delirium, reduction of caregiver stress, and health resource utilization.[2‑7] Western literature including meta‑analysis and systematic reviews are available stating significant evidence in mobilization of critically ill patients.[2,5,7] In the article by Rajesh Chawla (2014), we are not surprised by the fact that out of 94% (614 physician responders), only 13% (90 physicians) were in favor of mobilizing critically ill patients with equipments (ventilators and tubes).[1] Western literature supports mobilization of intensive care patients with ventilators and assistive devices.[8,9] Safety in mobilizing intensive care patients with ventilators and tubes are proved earlier. [10,11] We disagree the author in holding only physician apprehension as responsible for poor mobilization practises in Indian ICUs. This may be due to lack of infrastructure, expertise training in handling mobile ventilators, and mobilizing aids, such as mechanical hoists (passive transfer using mechanical aids) ,[12] lack of therapist’s and nurse’s knowledge of initiating and progressing early mobilization in ICU, criteria for termination of mobilization, screening for risk stratification during mobilization, knowledge about mobility aids, and safe handling techniques.[10,11] New promising researches are put forward depicting the 188
positive attitude of mobilizing patients in Indian ICUs in past few years.[13‑15] We recommend future trials in elucidating the effects of early mobilization in intensive care outcomes in Indian medical pitch. Apart from the study mentioned, limitation, such as the poor response rate poor responders, few other setbacks prevent from generalization of the study results in Indian clinical arena.[1] First, majority of the responders are age below 40 (59%) and ICU practising experience below 5 years (41%). Since this survey partially depends on the experience of the practising intensivists, the practise patterns elaborated in the study are questionable to certain extent. Second, the majority of the responders are from institutions with less than 20 ICU beds (77%). Though the bed strength falls within the standardization of Indian Society for Critical care medicine (ISCCM), the systematic mobilization program may not be implemented at ease within the constrained perimeter of the ICUS included in the present study. Further, the current survey could have inclusions of various ICUs such as cardiology, neurology, post‑surgical and traumatic practice patterns differing between ICUs within an Insitution itself which may question the applicability of the results in Indian clinical arena. Other than the above limitations, the study adds evidence to the current therapeutic practises, newer association between sedation and mobilization and neuropsychiatric outcomes such as delirium in Indian intensive care settings. We appreciate once again the authors for demonstrating lag of current ICU practices behind the standard guidelines of therapeutic applications in Indian ICUs.
Baskaran Chandrasekaran, Senthil S. Kumar, Chandra S. Sekar
Department of Pulmonary and Critical Care Medicine, Peelamedu Samanaidu Govindarajulu Hospitals, Coimbatore, Tamil Nadu, India
Correspondence: Mr. Baskaran Chandrasekaran, Department of Pulmonary and Critical Care Medicine, PSG Hospitals, Peelamedu, Coimbatore - 641 004, Tamil Nadu, India. E‑mail: [email protected]
References 1.
2. 3. 4.
Chawla R, Myatra SN, Ramakrishnan N, Todi S, Kansal S, Dash SK. Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2014;18:575‑84. Adler J, Malone D. Early mobilization in the intensive care unit: A systematic review. Cardiopulm Phys Ther J 2012;23:5‑13. Kress JP. Clinical trials of early mobilization of critically ill patients. Crit Care Med 2009;37:S442‑7. Engels PT, Beckett AN, Rubenfeld GD, Kreder H, Finkelstein JA, da Costa L, et al. Physical rehabilitation of the critically ill trauma patient in the ICU. Crit Care Med 2013;41:1790‑801.
Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3 5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15.
Casey CM. The study of activity in older ICU patients: An integrative review. J Gerontol Nurs 2013;39:12‑25. Vollman KM. Understanding critically ill patients hemodynamic response to mobilization: Using the evidence to make it safe and feasible. Crit Care Nurs Q 2013;36:17‑27. Kalisch BJ, Dabney BW, Lee S. Safety of mobilizing hospitalized adults: Review of the literature. J Nurs Care Qual 2013;28:162‑8. Dong ZH, Yu BX, Sun YB, Fang W, Li L. Effects of early rehabilitation therapy on patients with mechanical ventilation. World J Emerg Med 2014;5:48‑52. Abrams D, Javidfar J, Farrand E, Mongero LB, Agerstrand CL, Ryan P, et al. Early mobilization of patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. Crit Care 2014;18:R38. Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD, Needham DM. Safety of physical therapy interventions in critically ill patients: A single‑center prospective evaluation of 1110 intensive care unit admissions. J Crit Care 2014;29:395‑400. Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, et al. Early mobilization of mechanically ventilated patients: A 1‑day point‑prevalence study in Germany. Crit Care Med 2014;42:1178‑86. Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care 2010;16:138‑46. Kumar J, Maiya A, Periera D. Role of Physiotherapists in intensive care units of India – A Multicenter survey. Indian J Crit Care Med 2008;11:198‑203. O’Connor ED, Walsham J. Should we mobilise critically ill patients? A review. Crit Care Resusc 2009;11:290‑300. Pattanshetty RB, Gaude GS. Critical illness myopathy and polyneuropathy – A challenge for physiotherapists in the intensive care units. Indian J Crit Care Med 2011;15:78‑81. Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152782
Hyponatremia management in critically ill: Food (protein) for thought Sir, Hyponatremia is the most common disorder of body fluid and electrolyte balance encountered in clinical critically ill patients and associated with increased morbidity and mortality. A wide range of conditions can cause hyponatremia and, as a result, it is being managed by clinicians from a variety of backgrounds with a variety of approaches to its diagnosis and management. Adding to the complexity is the available treatment options, which
includes normal saline, hypertonic saline, fluid restriction, drugs (demeclocycline and vaptans) and increasing intake of solutes like urea/protein. Treatment decision is based on multiple factors like severity and symptoms of hyponatremia, onset of hyponatremia, underlying disease, and associated illness. Rate of correction and overcorrection are important factors to consider. The decision to administer normal saline or hypertonic saline to patient with hyponatremia is quite clear and easy to practice. Except the use of saline and vaptans, rest of the treatment options are infrequently practiced, sometimes difficult to apply in critically ill patients especially with regard to fluid restriction. Management of the hyponatremia should ensure patient management rather than simply looking at the sodium level. If hyponatremia is serious and symptomatic, it is life‑threatening. In this situation, the first line of treatment will be prompt intravenous infusion of hypertonic saline. For patients with reduced circulating volume, extracellular volume should be replaced with intravenous infusion of 0.9% saline. If the cause is apparent, reversing it may lead to correction as restricting water intake in psychogenic polydipsia, giving glucocorticoid/thyroid replacement in deficient, stopping hypotonic fluids or medications like selective serotonin reuptake inhibitors, nonsteroidal anti‑inflammatory drugs, thiazides or desmopressin and optimization of Congestive heart failure (CHF), hepatic or renal failure. For patients with the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), which constitutes about 40% of hyponatremia cases and with moderate or profound hyponatremia, first‑line treatment is fluid restriction. Equal second‑line treatments are increasing solute intake. For moderate or profound hyponatremia, there is no recommendation for the use of lithium, demeclocycline, and even vasopressin receptor antagonist. Overcorrection is major reasons against vaptans.[1] There are not good outcome data either, with vaptans in form of improved survival or improved quality of life.[2] The lack of outcome data also applies to other treatments of hyponatremia. There are a vast majority of hyponatremic patients in the Intensive Care Unit (ICU) who are neither volume deficient nor they have profound and symptomatic hyponatremia. There are also patients in critical care unit where it is difficult to implement fluid restriction. 189
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
