Physiotherapy

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Browsing Physiotherapy by browse.metadata.advisor "Coetzee, Andre"

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    The effects of a lung recruitment manoeuvre before extubation on pulmonary function after coronary artery bypass surgery
    (Stellenbosch : Stellenbosch University, 2013-12) Nel, Stephanus Gerhardus; Hanekom, S. D.; Coetzee, Andre; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences.
    ENGLISH ABSTRACT: Aim: The aim of this study is to determine if the addition of a pre-extubation recruitment manoeuvre to standard care is safe and will improve lung compliance and subsequent PaO2/FiO2 (PF ratio) after extubation in postoperative coronary artery bypass graft surgery patients. Design: Prospective, triple blind, randomised, controlled trial. Method: This study was conducted in a private hospital in the Northern suburbs of Cape Town, South Africa. All patients admitted between 03/10/2010 and 22/11/2011, for uncomplicated elective coronary artery bypass graft (CABG) surgery were eligible for inclusion into the study. Patients were randomly allocated into either the intervention group or the control group. The intervention group received a gradual build-up lung recruitment manoeuvre (RM). The primary outcome was PaO2/FiO2 (PF ratio). The secondary outcomes were safety and static lung compliance. ICU length of stay (LOS) and hospital LOS were also recorded. The pre-RM hemodynamic stability of the patient was checked before the intervention and repeated at 5 minutes after the intervention by the nursing sister. Data to calculate static lung compliance was captured at the same time. Criteria for safety and discontinuation of the RM were monitored during the intervention by the principle investigator only. Results: Of the 69 patients eligible for the study 47 were randomly allocated into the intervention group (n=22) and control group (n=25) respectively. Groups were the same at baseline with regards to sex, pulmonary risk, sedation and surgical procedures. The RM could be completed in all patients. The prior defined criteria for discontinuation of the RM were not reached in any of the patients. No adverse effects were noted. The PaO2/FiO2 (PF ratio) decreased significantly in both groups from pre-surgery measurements compared to when measured before the RM (p<0.001). There was a tendency noted for the intervention group to return to pre-surgery measurements of PF ratio within 12 hours after extubation when compared to the control group. There was no significant difference between the groups from extubation to 24 hours (p = 0.6). The static compliance improved at 5 minutes following the RM (p<0.001) and remained improved until extubation (p<0.001) for the intervention group. No difference was noted in the static compliance of the control group over the same time period. The mean hospital length of stay for the intervention group was 8.61 (95% confidence interval 7.26 to 9.96 days) and 10.08 (95% confidence interval 8.52 – 11.63 days) for the control group. Conclusion: A gradual recruitment manoeuvre at 30cmH2O 30minutes before extubation significantly improved static lung compliance within 5 minutes with no adverse hemodynamic side effects. There was noted maintained improved PF ratio at extubation or immediately afterwards for the intervention group and no difference in the PF ratio between the intervention group and control group.
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    The implementation and evaluation of a best practice physiotherapy protocol in a surgical ICU
    (Stellenbosch : University of Stellenbosch, 2010) Hanekom, Susan; Louw, Q. A.; Coetzee, Andre; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Sciences
    ENGLISH ABSTRACT: Introduction: It is increasingly being recognized that how intensive care services are delivered may have a greater impact on patient outcome than the individual therapies. Uncertainty regarding the optimal physiotherapy service provision model in a surgical intensive care unit (ICU) exists. Methodology: The aims of this study were to 1) develop an evidence-based physiotherapy protocol; 2) validate the content of the protocol; and 3) conduct an explorative intervention trial to compare usual care to the estimated effects of providing a physiotherapy service guided by an evidence-based physiotherapy protocol by a dedicated physiotherapist. A systematic review process was used to synthesize the evidence in eight subject areas. The GRADE system was used to formulate best practice recommendations and algorithm statements. Forty-two experts from a variety of disciplines were invited to participate in a Delphi process. Finally, the evidence-based physiotherapy protocol was implemented in a surgical ICU over four three-week intervention periods by a group of research therapists. The outcomes measured included ventilator time, ventilation proportions, failed extubation proportions, length of ICU and hospital stay, mortality, functional capacity, functional ability and cost (using nursing workload as proxy). Results: Fifty-three research reports in eight subject areas were identified, 23 draft best-practice recommendations and 198 algorithm statements were formulated. The draft protocol consisted of five clinical management algorithms. Fifteen international research experts and twelve national academics in the field of critical care agreed to participate in the Delphi process. Consensus was reached on the formulation of 87% (20/23) recommendations and the rating of 66% (130/198) statements. The risk of an adverse event during the protocol care intervention period was 6:1000 treatment sessions (p=0.34). Patients admitted to the unit during the protocol care intervention period were less likely to be intubated (RR 0.16 95%CI 0.07 – 0.71; RRR 0.84 NNT 5.02; p=0.005) or fail extubation (RR 0.23 95%CI 0.05 – 0.98; RRR =0.77 NNT 6.95; p=0.04). The mean difference in the daily unit TISS-28 score between the two condition periods was 1.99 95%CI 0.65 – 3.35 (p=0.04). Patients managed by the protocol tended to remain in the hospital for a shorter time after unit discharge (p=0.05). There was no difference in the time spent on the ventilator (p=0.50), mortality (p=0.52) or in the six minute walk distance (p=0.65). In addition there was no difference in the proportion of patients who reached independence in any of the Barthel Index activities measured within 48 hours of discharge from the unit. Conclusions: The use of an evidence-based physiotherapy protocol for the comprehensive physiotherapeutic management of patients in a surgical ICU was feasible and safe. The preliminary results of this study suggest that a physiotherapy service, which is guided by an evidence-based protocol and offered by a dedicated unit therapist, has the potential to lower the cost of ICU care and facilitate the functional recovery of patients after unit discharge. This information can now be considered by administrators to optimize the physiotherapy service provided in ICU.
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    The profile of a surgical ICU in a public sector tertiary hospital in South Africa
    (Stellenbosch : University of Stellenbosch, 2004-12) Hanekom, Susan; Faure, M.; Coetzee, Andre; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
    ENGLISH ABSTRACT: Objective: To describe the baseline data of a surgical ICU in South Africa before the implementation of an evidence-based physiotherapy practice protocol. Design: Prospective cohort observational study Setting: Ten-bed closed surgical unit in a university affiliated tertiary hospital. Patients: All adult ICU admissions from 16 June - 30 September 2003. Measurements: The patient’s clinical data including demographic information, admission diagnosis, surgery classification and co-morbidities were recorded on admission to the unit. APACHE II score was calculated. The physiotherapy techniques, positions and functional activities used, the frequency and duration of physiotherapy treatment sessions, the provision of after-hours service and the diagnosis of pulmonary complications were also recorded daily. The time of mechanical ventilation was calculated and the number of re-intubations documented. The ICU length of stay or mortality was recorded. Results: 160 patients were admitted. Patients were 49 +/- 19.95 years of age. The mean APACHE II score was 12.3 +/ 7.19 and a 12.3% mortality was observed. Thirty seven percent of patients were admitted to the unit following elective surgery. Patients stayed in the unit for 5.94 +/- 6.55 days. Hypertension was the most frequent co-morbidity found in this cohort (42%), and 21% of patients tested, tested positive for HIV. Co-morbidities had no significant association with ICU LOS or mortality. Nine hundred and twenty seven physiotherapy records were obtained. Students were responsible for 39% (n=366) of treatment sessions, the unit therapist for 34% (n=311) and the on-call therapists for 27% (n=250). Despite routine daily physiotherapy for all patients in the unit, 39% (n=62) developed excessive secretions, 30% (n=48) of patients developed pneumonia and 27% (n=43) of patients were diagnosed with basal atelectasis. Nineteen patients (12%) died in the ICU. Patients spent a mean of 5.94 (SD 6.55) days in the unit. One hundred patients (63%) were ventilated. Almost a third of ventilated patients (31%) were intubated more than once. The patients spent a mean time of 3.8 days (SD 6.30) on the ventilator every time they were re-intubated. The development of pulmonary complications significantly increased the time on the ventilator and the LOS. Conclusions: This baseline study of a surgical ICU presents a picture of a unit providing care comparable to first world environments. The picture of the physiotherapy service provided in this unit is of a “traditional” service based neither on the available evidence regarding the prevention or management of pulmonary complications, nor on the incorporation of early rehabilitation into the management of mechanically ventilated adult patients in ICU.