Impact of the Chelsea critical care physical assessment (CPAx) tool on clinical outcomes of surgical and trauma patients in an intensive care unit: An experimental study

Exploring Peripheral and Respiratory Muscle Weakness and Functional Impairments in ICU Patients: Insights From a Resource-Constrained Setting

IMPORTANCE AND OBJECTIVES

The aim of this study was to explore peripheral and respiratory muscle structure and strength from unit admission to hospital discharge among ICU patients in a resource-constrained setting.

DESIGN

Prospective, observational study.

SETTING

Tertiary academic hospital.

PARTICIPANTS

Newly intubated critically ill adults admitted to the medical and surgical ICUs and expected to be mechanically ventilated for more than 48 hours were included in the study.

MAIN OUTCOMES AND MEASURES

Ultrasonography of the right hemi-diaphragm and quadriceps muscles were taken at admission for 3 consecutive days. Respiratory and peripheral muscle strength were evaluated using the Medical Research Council-Sum Score, dynamometry and maximal inspiratory pressure (MIP) at awakening, ICU discharge and hospital discharge.

RESULTS

Forty-five participants were included, with a median (interquartile range) age of 34.5 (24.3-47.4) years and 73% were male. Most of the change in diaphragm thickness was observed on day 3, with 5 (22%) participants showing a decrease of more than 10% from baseline. Minimal changes in rectus femoris cross-sectional area were noted during the first 3 days. Eleven participants (44%) presented with ICU-acquired weakness at awakening, which decreased to 7 (29%) participants at ICU discharge and 5 (24%) participants at hospital discharge. The mean ± sd percentage of predicted quadriceps force was 22.2 ± 5.1 N at hospital discharge. The mean ± sd percentage of predicted MIP scores was 29.6% ± 10.5% at ICU discharge and 29.1% ± 8.6% at hospital discharge.

CONCLUSIONS AND RELEVANCE

Patients discharged from the ICU in a resource-constrained setting presented with peripheral and respiratory muscle weakness, with minimal change in muscle structure shown by ultrasonography, despite short ICU stays, low Acute Physiology and Chronic Health Evaluation II scores, and a relatively young age. Future research should explore whether these findings indicate a distinct phenotype of critical illness in such environments.

Physical function and activity of patients after open abdominal surgery: a prospective cohort study comparing the clinimetric properties of two outcome measures

OBJECTIVES

To measure and compare the clinimetric properties of the Chelsea Critical Care Physical Assessment (CPAx) and Physical Function in Intensive Care Test-scored (PFIT-s) for assessment of physical function and activity.

DESIGN

Prospective cohort design using crossover-randomisation of the sequence in which participants were assessed with CPAx and PFIT-s.

SETTING

Surgical and transplant intensive care units (ICU) in an academic hospital.

PARTICIPANTS

Adults who underwent elective open abdominal surgery. Consecutive sampling was used to enrol 69 participants.

INTERVENTIONS

Physical function and activity were assessed on ICU days one, three, five and at ICU discharge using the CPAx and PFIT-s in random order.

MAIN OUTCOME MEASURES

Responsiveness to change, minimal clinically important difference (MCID), floor and ceiling effect, and convergent validity.

RESULTS

CPAx demonstrated a large responsiveness (effect size index (ESI)= 0.83) and PFIT-s moderate responsiveness (ESI=0.73) to change in scores. MCID for CPAx was 2.1 (standard error of measurement (SEM) 1.1) and for PFIT-s 0.6 (SEM=0.3). CPAx had no floor effect and a small ceiling effect (9%, n = 6) at ICU discharge compared to 2% (n = 1) floor and 48% (n = 32) ceiling effects of PFIT-s. Moderate convergent validity was found for both tools at ICU admission (n = 67, r = 0.62, p < 0.001) and discharge (n = 67, r = 0.51, p < 0.001).

CONCLUSION

CPAx is most responsive to changes in physical function and activity scores, has no floor and limited ceiling effects and moderate convergent validity, and is recommended for similar cohorts. CONTRIBUTION OF THE PAPER.

Physiotherapy management of patients with trunk trauma: A state-of-the-art review

BACKGROUND

Trauma injury remains a significant health risk for all on a global level. Patients with trunk trauma suffer blood loss, inflammation and hypoxia and are at risk of developing respiratory and musculoskeletal complications during their recovery. Physiotherapists are an integral part of the interprofessional team that manages patients who sustain trunk trauma.

OBJECTIVES

To describe the physiotherapy management of adult patients with trunk trauma, their quality of life, post-discharge rehabilitation service provision, and outcome measures used in the physiotherapy management.

METHOD

A non-systematic narrative review of published literature was performed.

RESULTS

Mobilisation, functional exercises, deep breathing exercises and active coughing are used to optimise patients' respiratory and musculoskeletal functioning. Some physiotherapists educate patients on the use of pain management strategies to reduce discomfort from rib fractures, surgical sites and intercostal drainage bottle tubing. Survivors of trunk trauma experience limitations in physical function up to two years. Little is known about post-discharge rehabilitation service provision to these patients after discharge. Few physiotherapists use outcome measures as part of their daily clinical practice.

CONCLUSION

Physiotherapy management of patients with blunt or penetrating trunk trauma during hospitalisation and after discharge is a field of clinical practice that is rich for high-quality research related to service provision, cost analysis and interventions used.

CLINICAL IMPLICATIONS

Physiotherapy clinicians and researchers can use the findings of this review as a guide to their management of adult patients recovering from trunk trauma.