What are the guidelines for contraindications for physiotherapy sessions in an Intensive Care Unit (ICU) setting for patients on levophed (norepinephrine)?

Contraindications for Physiotherapy in ICU Patients on Levophed (Norepinephrine)

Patients on high doses of norepinephrine with hemodynamic instability are not candidates for aggressive mobilization due to the risk of adverse cardiovascular events during physiotherapy sessions. 1

Assessment Before Physiotherapy

Before initiating physiotherapy in ICU patients on norepinephrine, careful assessment is essential:

• Hemodynamic stability: Monitor blood pressure every 2-5 minutes during initial administration of norepinephrine until desired pressure is obtained 2
• Vasopressor dosage: Patients on medium to high doses of inotropes/vasopressors are at higher risk for adverse events 3
• Baseline cardiovascular status: Patients with unstable baseline hemodynamic values or previous cardiac comorbidities are at increased risk 3

Specific Contraindications

Absolute Contraindications:

• Severe hemodynamic instability requiring escalating doses of norepinephrine
• Dangerously high blood pressure from norepinephrine administration 2
• Patients with profound hypoxia or hypercarbia while on norepinephrine 2
• Patients receiving norepinephrine who have mesenteric or peripheral vascular thrombosis (due to risk of increasing ischemia) 2
• Patients with occlusive vascular diseases (atherosclerosis, arteriosclerosis, diabetic endarteritis, Buerger's disease) receiving norepinephrine infusions 2

Relative Contraindications:

• Patients on stable but moderate doses of norepinephrine
• Patients with cardiac arrhythmias while on norepinephrine
• Patients receiving concurrent medications that may interact with norepinephrine (MAOIs, tricyclic antidepressants) 2
• Elderly patients with decreased hepatic, renal, or cardiac function on norepinephrine 2

Safe Physiotherapy Approaches

For patients on low-dose, stable norepinephrine with adequate hemodynamic parameters:

1. Start with less demanding interventions:

   • Passive range of motion
   • Positioning (avoid right side lying which may cause cardiovascular deterioration) 3
   • Therapeutic touch and massage for anxiety management 1

2. Progress cautiously to more active interventions if tolerated:

   • Reduce active muscle mass involvement or exercise duration to lower metabolic demands 1
   • Consider electrical muscle stimulation as an alternative to active exercise 1
   • Gradually advance to sitting and standing activities if hemodynamically stable

3. Continuous monitoring during therapy:

   • Blood pressure should be monitored every 2-5 minutes during initial sessions 2
   • Heart rate and rhythm should be continuously monitored
   • Observe for signs of tissue perfusion changes
   • Have clear stopping criteria established before beginning therapy

Monitoring Parameters and Stopping Criteria

• Stop physiotherapy immediately if:
  • Decrease in blood pressure or new arrhythmia development
  • Signs of decreased tissue perfusion
  • Patient reports new symptoms (headache may indicate hypertension) 2
  • Increased vasopressor requirements during or after therapy

Evidence on Safety

Despite concerns, research shows that physiotherapy in ICU is generally safe with a low incidence of adverse events (0.2% in a multi-center study) 3. However, patients on medium to high doses of inotropes/vasopressors with unstable baseline hemodynamic values and previous cardiac comorbidities are at higher risk for adverse events 3.

Clinical Recommendations

• Assess patients individually before each physiotherapy session, as their condition may change rapidly in the ICU 1
• Document baseline vital signs and vasopressor requirements before initiating therapy
• Start with less demanding interventions and progress based on patient tolerance
• Ensure appropriate monitoring of vital functions during all physiotherapy interventions 1
• Consider using therapist-driven protocols to guide safe physiotherapy practice in the ICU 4

Remember that while physiotherapy is beneficial for preventing complications of prolonged ICU stay, the risk of moving a critically ill patient on norepinephrine should always be weighed against the risks of immobility 1.