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Early Physical Medicine and Rehabilitation management, in the Intensive Care Unit, the Intermediate Care Unit or the post-ICU Rehabilitation Department

Réponses rapides dans le cadre du COVID 19 - Posted on May 05 2020

Key points
 

  • Rapid response No. 1: The contagious nature of the SARS CoV2 coronavirus means that it is necessary to apply additional strict hygiene precautions tailored to the types of care and protocols in force in the department in which the patient is hospitalised. The objective is to protect caregivers and patients.
  • Rapid response No. 2: In patients hospitalised in intensive care and intermediate care units, the most severe deficiencies are respiratory, cardiovascular, hepatic and renal, neurological, cognitive, musculoskeletal, metabolic (undernutrition) and behavioural. The objectives or physiotherapy/rehabilitation at this stage are to prevent and limit the functional consequences of these deficiencies.
  • Rapid response No. 3: In intensive care and intermediate care units, physical medicine and rehabilitation (PM&R) management of the patient and physiotherapy/rehabilitation procedures are performed once vital signs have stabilised and in collaboration with the doctors responsible for the patient’s care. It is possible that conditioning may be required before the physiotherapy/rehabilitation session, in particular, modification of the ventilation mode, increase in oxygenation, or addition of analgesic treatment.
  • Rapid response No. 4: The continuous monitoring of vital signs is maintained in intensive care and intermediate care units during physiotherapy/rehabilitation; if any deterioration occurs, the physiotherapy/rehabilitation session must be adapted, or even stopped immediately, and intensive care treatments are adapted.
  • Rapid response No. 5: Physiotherapy/rehabilitation sessions are adapted to the clinical condition and capacities of patients. In sedated or unconscious patients, passive mobilisation and limb postures are aimed at limiting loss of joint range of motion and cutaneous complications. For conscious patients (ventilated or otherwise), physiotherapy/rehabilitation sessions also include active muscle exercises, cardiorespiratory reconditioning exercises, sitting and standing, and preparation for the resumption of functional activities.
  • Rapid response No. 6: The objective of respiratory rehabilitation is to improve ventilation quality in order to prepare for the withdrawal or assisted ventilation and low-intensity muscle effort.
  • Rapid response No. 7: Due to the risk of aerosolization, instrumental respiratory physiotherapy techniques, in particular lung clearance, are only used where essential and respecting additional hygiene precautions including "air"-type protection.

Context

The severe respiratory deficiency encountered in SARS CoV2 coronavirus may be associated with multi-organ failure and decompensation of comorbidities. In addition, ICU treatment usually involves mechanical ventilation, sedation and neuromuscular blocking and periods in the prone position, which can result in deficiencies that is necessary to prevent as far as possible and then try to improve. The possible sequelae are secondary to the specific damage caused by the viral infection, as well as complications inherent to acute respiratory distress system (ARDS), ICU-acquired complications and immobility.

The principles for rehabilitation in the ICU or intermediate care unit of patients infected with the SARS CoV2 virus are similar to those for patients with severe ARDS, with certain specific characteristics related to the contagious nature of the virus and the severity of the ARDS, with a high number of patients requiring neuromuscular blocking agents, placement in the prone position and long-term ventilation. Observation of the first patients leaving French intensive care units, a proportion of whom present complications, suggests that there may be a need for specific, long-term rehabilitation.

The specific characteristics of severe SARS CoV2 illness include:

  • bronchial obstruction that is uncommon in the initial phase;
  • a risk of sudden decompensation;
  • a dissociation between the severity of the hypoxaemia and the patient’s perceived dyspnoea;
  • a frequent need to place the patient in the prone position;
  • a high risk of thromboembolic complications;
  • the need for massive sedation and neuromuscular blocking agents;
  • increased incidence of intensive care delirium and cognitive disorders, manifested by disorientation on awakening.

The rules for prevention and protection of professionals during the contagious period of the virus are based on the recommendations of the Société française d'hygiène hospitalière (SF2H - French Hospital Hygiene Society, 28 January 2020).

These rapid responses are drafted on the basis of available knowledge on the date of publication and are liable to evolve on the basis of new data.

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