Çocuk Yoğun Bakımda Erken Mobilizasyon

Öz

ÖZET Çocuk yoğun bakım ünitesine yatırılan çocuklar çeşitli nedenlerle uzun süre hareketsiz kalmakta ve taburcu olduktan sonra bile hayatı etkileyen kalıcı sorunlarla mücadele etmektedir. Bu olumsuz sonuçlardan dolayı hastaların yoğun bakım sürecinde rehabilitasyonu ve erken mobilizasyonu önem kazanmıştır. Mobilizasyon aktiviteleri hekim, fizyoterapist, pediatrik ergoterapist, aile işbirliği ile disiplinler arası, hemşire odaklı bir protokol oluşturularak planlı yürütülmektedir. Erken mobilizasyon protokolü hastanın uyku hijyeni, ağrı, deliryum ve sedasyon değerlendirmelerinin yapıldığı, hastaya özgü bireyselleştirilmiş mobilizasyon hedeflerinin belirlendiği kademeli bir sistemdir. Yatak içi aktif ve pasif Range of motion egzersizleri, yatak kenarında oturma, top fırlatma, yatak içi bisiklet ergometrisi, yürüme gibi çeşitli mobilizasyon aktiviteleri hastanın klinik durumu ve toleransına göre planlanmaktadır. Yapılan klinik çalışmalarda erken mobilizasyon protokolü kullanımı ile mobilizasyon aktivitelerinin uygulandığı hasta ve mobilizasyon aktivitesi sayısının arttığı, hastaların hastanede kalış süresinin azaldığı, günlük yaşam aktivitelerinin iyileştiği ve yoğun bakımda edinilen morbiditelerin azaldığı bildirilmiştir. Hemşireler tüm gün yanında olduğu için mobilizasyon aktivitelerini günlük bakıma kolaylıkla entegre edebilir. Güncel çalışmalar erken mobilizasyon aktivitelerinin kritik çocuk hastalarda uygulanabilir ve güvenli olduğunu göstermektedir. Ancak çocuk yoğun bakım ünitelerinde standart bir mobilizasyon protokolünün olmaması, bilgi eksikliği, güvenlik endişeleri, ekipman ve personel yetersizliği erken mobilizasyonun uygulanmasının önünde engellerdir. Bu derlemede erken mobilizasyonun tanımı ve önemi, çocuk yoğun bakımda uygulama örnekleri ve güncel klinik çalışmaların sonuçlarına yer verilmiştir.

Anahtar Kelimeler

• Çocuk yoğun bakım
• Erken mobilizasyon
• Hemşirelik
• Rehabilitasyon
• Çocuk hasta

Early Mobilization in Pediatric Intensive Care Unit

Öz

ABSTRACT Children admitted to the pediatric intensive care unit remain immobile for long periods of time for various reasons and struggle with permanent problems that affect life even after discharge. Due to these negative outcomes, rehabilitation and early mobilization of patients during the intensive care period have gained importance. Mobilization activities are carried out in a planned manner by creating an interdisciplinary, nurse-focused protocol with the cooperation of the physician, physiotherapist, pediatric occupational therapist and family. The early mobilization protocol is a gradual system in which the patient's sleep hygiene, pain, delirium and sedation are evaluated and individualized mobilization goals specific to the patient are determined. Various mobilization activities such as in-bed active and passive Range of motion exercises, sitting on the edge of the bed, throwing a ball, in-bed bicycle ergometry, and walking are planned according to the clinical condition and tolerance of the patient. In clinical studies, it has been reported that with the use of early mobilization protocol, the number of patients and mobilization activities increased, the length of hospital stay of patients decreased, daily living activities improved, and morbidities acquired in intensive care decreased. Nurses can easily integrate mobilization activities into daily care because they are with the patient all day. Current studies show that early mobilization activities are feasible and safe in critically ill pediatric patients. Furthermore, the lack of a standard mobilization protocol in pediatric intensive care units, lack of information, safety concerns, and inadequate equipment and personnel are barriers to the implementation of early mobilization. In this review, the definition and importance of early mobilization, examples of application in pediatric intensive care and the results of current clinical studies are discussed.

Anahtar Kelimeler

• Pediatric intensive care unit
• Early mobilization
• Nursing
• Rehabilitation
• Pediatric patient

Kaynakça

1. 1. Knoester H, Bronner MB, Bos AP. Surviving pediatric intensive care: physical outcome after 3 months. Intensive Care Medicine. 2008;34,1076-1081.
2. 2. Pereira GA, Schaan CW, Ferrari RS. Functional evaluation of pediatric patients after discharge from the intensive care unit using the Functional Status Scale. Rev Bras Ter Intensiva. 2017;29(4):460-465.
3. 3. Wieczorek B, Burke C, Al-Harbi A, Kudchadkar SR. Early mobilization in the pediatric intensive care unit: a systematic review. Journal of Pediatric Intensive Care. 2015;4:129-170.
4. 4. Rahmaty Z, Manning JC, Macdonald I, Perez M, Ramelet AS. Post‑intensive care syndrome in pediatrics-enhancing understanding through a novel bioecological theory of human development lens. Intensive Care Medicine-Paediatric and Neonatal. 2023;1(9):1-8.
5. 5. Herbsman JM, D’Agati M, Klein D, et al. Early mobilization in the pediatric ıntensive care unit: A quality ımprovement ınitiative. Pediatric Quality and Safety. 2020;5(1):1-8.
6. 6. Manning JC, Pinto NP, Rennick JE, Colville G, Curley MA. Conceptualizing post intensive care syndrome in children the pics-p framework. Pediatric Critical Care Medicine. 2018;4:298-300.
7. 7. Ekim A. The post-intensive care syndrome in children. Comprehensive Child and Adolescent Nursing. 2020;43(1):15-21.
8. 8. Woodruff AG, Choong K. Long-term outcomes and the post-ıntensive care syndrome in critically ıll children: a north american perspective. Children. 2021;8(4):254-260.

9. 9. Kyosti E, Peltoniemi O, Liisanantti JH, et al. School performance after pediatric intensive care association of mental well-being, chronic illnesses, and family socioeconomic status. Pediatric Critical Care Medicine. 2020;21(12):1099-1105.
10. 10. Piva TC, Ferrari RS, Schaan CW. Early mobilization protocols for critically ill pediatric patients: systematic review. Rev Bras Ter Intensiva. 2019;31(2):248-257.
11. 11. Kudchadkar S. PICU Up! A multicomponent early mobility intervention for critically ill children. ICU Management and Practice. 2019;19(2):80-83.
12. 12. Sönmez-Düzkaya D, Terzi B, Yakut T, Kızıl N. Basınç yarasında ne durumdayız? Pediatri yoğun bakım ünitemizdeki son bir yıllık veri. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi. 2014;17(4):239-244.
13. 13. Arslan İ, İrday-Demir K, Ekinci F, Özkale Y, Ece Ü. Çocuk yoğun bakımlarda bası yarası sıklığı ve risk faktörlerinin değerlendirilmesi: Çok merkezli bir çalışma. Journal of Pediatric Emergncy İntensive Care Medicine. 2022; 9(37):37-42.
14. 14. Ramos GW, Monteiro D da R, Rodrigues P de O, Wegner W, Breigeiron MK. Pressure ulcers in pediatric patients: causal factors and therapeutic management. Cogitare Enferm. 2023; https://doi.org/10.1590/ce.v28i0.90401
15. 15. Iqbal I, Qazi MF, Shah MA, Abbas A, Abbas Q, Rehman N. Incidence of new morbidity in children on discharge from pediatric intensive care unit of a developing country. Professional Medical Journal. 2023;30(10):1317-1323.
16. 16. Silver G, Traube C, Gerber LM, et al. Pediatric delirium and associated risk factors: A single-center prospective observational study. Pediatric Critical Care Medicine. 2015;16(4):303-309.
17. 17. Society of Critical Care Medicine. ICU liberation bundle. https://www.sccm.org/iculiberation/abcdef-bundles. Erişim tarihi: 25.11.2023.
18. 18. Smith HAB, Besunder JB, Betters KA, et al. Practice guidelines on prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ıll pediatric patients with consideration of the ıcu environment and early mobility. Pediatric Critical Care Medicine. 2022;23(2):74-110.
19. 19. Wieczorek B, Ascenzi J, Kim Y, et al. PICU up!: impact of a quality improvement intervention to promote early mobilization in critically ill children. Pediatric Critical Care Medicine. 2016;17(12): 559-566.
20. 20. Walker TC, Kudchadkar SR. Early mobilization in the pedaiatric intensive care unit. Translational Pediatrics. 2018;7(4):308-313.
21. 21. Morrow BM. Building a culture of early mobilization in the pediatric intensive care unit-a nuts and bolts approach. Translational Pediatrics. 2021;10(10):2845-2857.
22. 22. Choong K, Canci F, Clark H, et al. Practice recommendations for early mobilization in critically ıll children. Journal of Pediatric Intensive Care. DOI http://dx.doi.org/10.1055/s-0037-1601424
23. 23. 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):1-16.
24. 24. Morris PE, Berry MJ, Files DC, et al. Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: A randomized clinical trial. JAMA. 2016; 315(24): 2694-2702.
25. 25. Schaller J, Anstey M, Blobner M, Edrich T, Grabitz SD, Matis IG. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. The Lancet. 2016;388(10052):1377-1388.
26. 26. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF Bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Critical Care Medicine. 2019;47(1):3-14.
27. 27. Wangi L, Hua Y, Wang L, Zou X, Zhang Y, Ou X. The effects of early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis. Frontiers in Medicine. 2023. 10.3389/fmed.2023.1202754
28. 28. Cuello-Garcia CA, Mai SHC, Simpson R, Al-Harbi S, Choong K. Early mobilization in critically ill children: a systematic review. Journal of Pediatrics. 2018;203:25-33.
29. 29. Valla FV, Young DK., Rabilloud M, et al. Thigh ultrasound monitoring identifies decreases in quadriceps femoris thickness as a frequent observation in critically ill children. Pediatric Critical Care Medicine. 2017;18(8): 339-347.
30. 30. Adel TZ, Dijk M, Heer M, et al. Quality improvement intervention to stimulate early mobilisation of critically ill children. Nursing in Critical Care. 2023;28:545–553.
31. 31. Ista E, Scholefield BR, Mannings JC, et al. Mobilization practices in critically ill children: a European point prevalence study (EU PARK-PICU). 2020;24(368):1-11.
32. 32. Subaşı-Özçevik D. Pediatrik yoğun bakım ünitesinde deliryum: tanılama ve hemşirelik yönetimi. THDD. 2021;2(1):92-104.
33. 33. Betters K, Hebbar KB, Farthing D, et al. Development and implementation of an early mobility program for mechanically ventilated pediatric patients. Journal of Critical Care. 2017;41:303-308.
34. 34. Zheng K, Sarti A, Boles S, et al. Impressions of early mobilization of critically ıll children-clinician, patient, and family perspectives. Pediatric Critical Care Medicine. 2018;19(7):350-357.
35. 35. Kudchadkar S. Illness shouldn’t mean stillness: Let’s “PICU Up!” Tedx speaking videos. 2018. Erişim tarihi: 25.11.2023. Erişim adresi: https://www.ted.com/talks/sapna_kudchadkar_illness_shouldn_t_mean_stillness_let_s_picu_up?subtitle=en
36. 36. Amin FM, Ahmed GN, Said DA. Effectiveness of early mobilization protocol on critically ıll children outcomes and their activities of daily living. Egyptian Journal of Health Care, 2022;13(1):324-334.
37. 37. Abdulsatar F, Walker RG, Timmons BW, Choong K. “Wii-Hab” in critically ill children: A pilot trial. Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach. 2013; 6:193-202.
38. 38. Rogers T, Stram D, Fort V, Wang X, Ritterman-Weintraub M, Wong V, Boshuizen V. Pediatric ıntensive care unit early mobility program: ımpact on patient functional status. The Permanente Journal. 2023: https:// doi. org/ 10. 7812/ TPP/ 23. 010
39. 39. Thabet AM, Sayed ZA, Elsayed Y, Marzouk SA. Effect of early mobilization ıntervention on controlling acquired muscle weakness among pediatric critically ıll patients. 2020; 8(23):113-123.
40. 40. Rodriguez KM, Hollis T, Kalinowski V, Wilkerson M. Barriers to adherence of early mobilization protocols in the pediatric ıntensive care units. Journal of Pediatric Intensive Care. 2023; DOI https://doi.org/10.1055/s-0043-1771519.
41. 41. Kudchadkar SR, Nelliot A, Awojoodu R, et al. Physical rehabilitation in critically ill children: a multicenter point prevalence study in the United States. Critical Care Medicine. 2020;48(5):634-644.
42. 42. Hanna ES, Zhao S, Shannon CN, Betters KA. Changes in provider perceptions regarding early mobility in the PICU. Pediatric Critical Care Medicine. 2020;21(01):30-38.
43. 43. Ames SG, Alessi L, Chrisman M, Stanger M, Corboy D, Sinha A. Development and implementation of pediatric ICU-based mobility guidelines: A quality improvement ınitiative. Pediatric Quality and Safety. 2020;3(6):1-7.
44. 44. Kaplan E, Özakgül A, Sir Ö. Yoğun bakım hastası için erken mobilizasyonun önemi. Sakarya Üniversitesi Holistik Sağlık Dergisi. 2023;6(3):510-524.
45. 45. Stolldorf DP, Dietrich MS, Chidume T, Mclntosh M, Maxwell C. Nurse-initiated mobilization practices in two community ICUs:A pilot study. Dimens Critical Care Nursing. 2018;37(6):318-323.
46. 46. Chaiyakulsil C, Thippanate P. Nurse-driven early rehabilitation protocol for critically ill children. Pediatrics International. 2022;64:1-9.
47. 47. Aldaqiqi ASA, Albalawi MBF, Alanazi KİD, et al. Implementing early mobility protocols for ICU patients:An interprofessional approach with nurses, pysical therapists and laboratory technicians. 2022;19(82):390-398.