Ask the Experts

Hemodynamic Instability: Is It Really a

Barrier to Turning Critically Ill Patients?
Please give us the guidelines on turning and
repositioning hemodynamically unstable patients,
patients with an intra-aortic balloon pump, and
patients receiving vasopressors.

Kathleen M. Vollman, RN,

MSN, CCNS replies:

Specific studies that address the

direct questions of how and with
what frequency to turn and reposition
critically ill patients with hemodynamic instability, whether the
Author
Kathleen M. Vollman has lectured, consulted,
and published nationally and internationally
on a variety of topics related to pulmonary,
critical care, prevention of hospital-acquired
injury, and professional nursing. From 1989
to 2003, she was a clinical nurse specialist
for the medical intensive care units at Henry
Ford Hospital in Detroit, Michigan.
Currently her company, Advancing Nursing LLC, is focused on creating empowered
work environments for nurses through the
acquisition of greater skills and knowledge.
Corresponding author: Kathleen M. Vollman, RN, MSN,
CCNS, FCCM, FAAN, Advancing Nursing LLC, 17139
Victor Drive, Northville, MI 48168 (e-mail: kvollman
@comcast.net).
To purchase electronic and print reprints, contact
The InnoVision Group, 101 Columbia, Aliso Viejo,
CA 92656. Phone, (800) 899-1712 or (949) 362-2050
(ext 532); fax, (949) 362-2049; e-mail, reprints
@aacn.org.
2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ccn2012765

patients are receiving vasoactive medications or intra-aortic balloon pump

therapy, have not been published.
However, a body of evidence is available from which inferences can be
made to develop recommendations
for safely turning and repositioning
hemodynamically unstable patients.
The evidence comes from 3 areas.
The first area describes the impact
of prolonged bed rest and/or space
flight research where bed rest was
used to simulate weightlessness and
the effect that motion has on the
cardiovascular system in healthy
adults, elderly persons, and patients
with diabetes.1-25 The second area is
research performed on coronary
bypass patients and other critically
ill patients that examines the impact
of a lateral turn and dangling the
patients legs on cardiovascular
response and recovery.21,22,26-32 The
third body of evidence is the most
recent and includes studies of early
mobility in critically ill patients that
included data on feasibility, safety,
and processes of care.33-49

Cardiovascular Response
to Bed Rest and Posture
Change
Critically ill patients spend a
significant amount of time in bed.
The changes in the cardiovascular
system related to bed rest are significant. The act of lying down shifts
11% of the total blood volume away
from the legs, with most going to
the chest. Within the first 3 days of
bed rest, an 8% to 10% reduction in
plasma volume occurs, with the loss
stabilizing to 15% to 20% by the
fourth week.1-5 These changes result
in increased cardiovascular workload, elevated resting heart rate,
and a decrease in stroke volume
with a reduction in cardiac output.
The heart muscle deconditions
with bed rest. A recent study demonstrated that cardiac atrophy occurs
during prolonged bed rest related to
the physiological adaption to reduced
myocardial load and work.6,7 In
healthy persons on 5 days of bed rest,
insulin resistance and microvascular
dysfunction are seen.3
Orthostatic tolerance deteriorates rapidly with immobility, with
the maximum effect seen at 3 weeks.
Baroreceptor dysfunction, changes
in autonomic tone, and fluid shifts
are thought to be the cause.8-15 Bed
rest lessens carotid-cardiac baroreflex

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responsiveness, contributing to postural hypotension and tachycardia

as a result of reductions in stroke
volume and cardiac output.8,9 Head
motion alone can reduce cardiac
reflex response to central stimulation of the carotid baroreceptors by
30%.8 Low vasoconstrictive reserve
can occur because of the hypovolemia
and lead to a lower capacity to buffer
orthostatic changes.9,10
Researchers recently examined
whether the dysfunction in the
baroreceptors that occurs with bed
rest is due to hypovolemia or is a
unique adaptation of the autonomic
nervous system to bed rest deconditioning. The results showed that the
abnormality was partially normalized by plasma volume restoration.12
The baroreceptor mechanism plays
a critical role in adaptation to posture
change, and the adaptation is performed in concert with vestibular
or inner ear response. The vestibular system has an important sympathetic and parasympathetic influence
in the regulation of cardiovascular
function during movement and
change in posture. Removal of
vestibular input in an animal model
affects regulation of blood pressure
during gravitational changes.17 Fullbody rotational stimulation of the
inner ear can induce hypotension
primarily associated with relaxation
of vasoconstriction (parasympathetic influences).16-18
Hemodynamic instability may
occur for many reasons. The critically ill patient may start out with
poor vascular tone, a dysfunctional
autonomic feedback loop, and/or
low cardiovascular reserve.19 The
patients illness and how care is structured may lead to an imbalance of
oxygen supply and demand, creating

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Prolonged gravitational equilibrium

Gravity
Cardiac baroreflex
Heart rate

Sympathetic activity
Vasoconstriction reserve
Orthostatic stability

Blood volume
Stroke volume and perfusion
Maximum
oxygen
consumption

Figure Impact of bed rest on the cardiovascular system.

Adapted from Convertino,12 with permission.

a situation where any care activity

(demand) overstretches supply, creating instability.20-22 As we age, the
responsiveness of our autonomic
nervous system to gravity-related
fluid shifts is diminished, placing us
at higher risk for cardiac instability.
This response may be in part related
to an impaired baroreflex function
that causes inappropriate autonomic
response.23,24 Critically ill patients with
a history of diabetes may be at a
higher risk for hemodynamic instability. Autonomic dysfunction increases
as diabetic complications worsen.25
Another reason for hemodynamic
instability in critically ill patients
can be inferred from the research on
gravity and space flight. Cardiovascular instability during a position
change is often seen after patients
spend prolonged lengths of time in
a stationary position. When people
change their gravitational reference
from a lying to sitting position, the
body goes through a series of physiological adaptations to maintain
cardiovascular homeostasis.16 Critically ill patients may experience a
similar adaptation when turning

laterally, dangling the legs, or

standing. With changes in gravitational plane (position change), the
stretch receptors read the shift in
plasma volume, the inner ear
responds, and information is sent
to the autonomic nervous system
to adapt accordingly.19
With prolonged bed rest, a number of the normal compensatory
mechanisms to posture change are
disrupted.10,15 Astronauts, as an
example, must be able to adapt to
changes in gravitational planes in
order to maintain an effective circulating volume while in space.
Extensive training occurs to ensure
tolerance of gravitational changes
on carotid-cardiac baroreflex and
vestibular response. This training
ensures that the astronauts experience cardiovascular adaptation
when in space (see Figure).
A similar concept may apply
with critically ill patients who have
hemodynamic instability (regardless
of whether they are taking vasopressors) that occurs with a manual turn.
If we train patients to turn, thus
preventing prolonged gravitational

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equilibration or remaining in a stationary position for extended periods, less instability with position
changes may result. Commonly,
patients are unstable when turned
after long intervals in a stationary
position in the operating room,
intensive care unit (ICU), emergency
department, and computed tomography scanner, regardless of whether
the patient is having vasoactive
agents infused. Such patients may
benefit from a course of training
using continuous rotational therapy.
As stated earlier, the vestibular system influences many components
of the autonomic nervous systems
adaptation to posture change. A
manual turn is usually accomplished rapidly, making vestibular
adjustment much more difficult.
Rotational therapy can gradually
retrain patients to tolerate turning
or we can slow down the patients
movement during the mobility
technique to allow adaptation and
increase the frequency.

Response and Recovery

From a Lateral Turn or
Dangling Legs of Critically
Ill Patients
The second body of evidence is
drawn from observing the response
of mixed venous oxygen saturation
(SvO2) to position change in patients
recovering from open heart surgery
and the effect of mechanical ventilation on cardiovascular response
during position change. SvO2 is an
indirect reflection of the relationship
between oxygen supply and demand.
Researchers in several studies
have examined the impact of a lateral turn on SvO2 in coronary bypass
graft patients and other critically ill
patients with and without vasoactive

medications. A mean decrease in

SvO2 of 8% to 11% immediately after
position change that returned to baseline within 5 minutes was reported.
In some studies, the reduction was
as high as 22% in patients with low
cardiac reserve.20,21,26-30
Gawlinski and Dracup27 studied
the effect of positioning on SvO2 in
critically ill patients with ejection
fractions less than 30%. They found
statistically significant differences
in SvO2 among all 3 positions (left,
right, supine). The greatest difference occurred within the first 4 minutes after the position change and
also in the left lateral position. A
stepwise regression analysis showed
that oxygen consumption (demand)
accounted for a greater amount of
the variance in SvO2 during position
change than oxygen delivery (supply).
Skeletal muscle movement
causes an increase in peripheral use
of oxygen that is reflected in the
SvO2.20,26 Similar results have been
demonstrated when initiating the
dangling posture in critically ill
patients.31-33 In the most recent study,
Price32 examined the impact of sitting on the side of the bed on heart
rate, blood pressure, SvO2, and oxygen saturation in 55 men who had
undergone coronary artery bypass
surgery. The results showed that most
patients experienced an increase in
heart rate, decreased blood pressure,
and a reduction in SvO2 that returned
to baseline levels (for supine position) within 10 minutes.32
Patients receiving mechanical
ventilation have additional factors
that may influence the supply side
of the supply/demand equation.
Relative hypovolemia can occur
with positive pressure ventilation,
as a result of a reduction in venous

return relative to an increase in

intrathoracic pressure.34 The addition of positive end-expiratory pressure can worsen that effect.35 In one
study, the impact on size and shape
of the inferior vena cava was examined in response to position change
in people without cardiac disease.
The results showed a decrease in
vessel diameter and area in both
lateral positions versus the vessel
dimensions in supine patients. The
smallest diameter of the inferior vena
cava occurred when persons were in
the left lateral position.36 This finding is most likely due to the greater
number of structures within the
thoracic cavity that may create a
larger compression effect while the
person is in the lateral position.34,37
Critically ill patients are hemodynamically affected by a position
change. These effects can be mitigated by the careful planning of
nursing care activities to reduce
excess oxygen demand on the
patient outside of the demand that
will occur during a position change.
By allowing for physiological rest
before an increase in oxygen
demand, the ability to tolerate the
activity increases.20-22 The evidence
supports that most of the hemodynamic instability is transient.26-30 To
balance the risk and benefits of
turning critically ill patients, the
care should include the following
steps: determining the timing of the
position change in relation to other
care activities, monitoring for tolerance after 5 to 10 minutes in a new
position, and (if the left lateral position is used) being aware of the
potential for greater cardiovascular
compromise necessitating a temporary decision to keep the patient
supine or in the right lateral position

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until the patient can tolerate lying

on the left side.

Feasibility, Safety, and

Processes of Care
Additional challenges for in-bed
mobilization of critically ill patients
include concerns about the safety
of the endotracheal tube, catheters,
and other invasive devices; amount
of personal and equipment resources
needed; the patients size, pain, and
discomfort; and the time, valuing,
and priority of turning and repositioning.38-42
Studies that provide direction
on how to safely turn and position
patients with an intra-aortic balloon
pump in place are lacking. The
hemodynamic concerns are similar
to the concerns in patients with low
cardiac reserve. The structural goal
in positioning patients with an
intra-aortic balloon pump is to prevent kinking of the device during
turning. The use of log rolling and
foam wedges to hold the body in
alignment has been suggested.43,44
Winkelman and Peereboom41
conducted 49 separate interviews
with 33 nurses identifying barriers
and facilitators to mobility of patients
in and out of bed. From the 49 activity descriptions, 41 related to in-bed
activity. Fifty-nine percent of the
nurses stated that unstable vital
signs prevented in-bed mobilization,
whereas 46% stated that low respiratory and energy reserves were also a
part of the decision not to perform
in-bed mobilization. Thirty-four
percent of the nurses stated safety
issues, which included loss of tubes
or catheters and potential injury of
the patient or staff. The authors
reported that the number of staff,
presence of physical therapy or

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nursing assistants, and the admitting diagnosis were not associated

with the success of mobilization.
What facilitated success with in-bed
or out-of-bed mobilization was the
presence of a protocol, Glasgow
coma score greater than 10, beds
that provided a chair position, or a
physicians order.
Safety regarding the activity
event and the patients ability to
hemodynamically tolerate the
movement may be the most significant. A prospective cohort study45
of 103 patients receiving mechanical
ventilation helped to evaluate the
safety of mobilizing critically ill
patients. During the study, 1449
activity events were performed and
the percentage of adverse events
was recorded. The activity events
included sitting on the bed, sitting
in the chair, and ambulating. The
adverse events were defined as fall
to the knees, catheter/tube removal,
systolic blood pressure exceeding
200 mm Hg, systolic blood pressure
less than 90 mm Hg, oxygen desaturation less than 80%, and extubation.
The results showed adverse events
in less than 1% of patients, and 69%
of the patients ambulated at least
100 feet (30 m) at discharge from
the respiratory care ICU.45 This
study was conducted on critically ill
patients who had received 4 days or
more of mechanical ventilation.
Can those same safety results be
seen mobilizing patients with inbed and out-of-bed activity in less
than 24 hours of intubation?
Pohlman and colleagues46 examined the feasibility of early physical
and occupational therapy on 49
patients receiving mechanical ventilation within a mean of 1.5 days
from intubation. At least one of the

common barriers to in-bed or outof-bed mobility (eg, the presence of

acute lung injury, vasoactive infusions, delirium, continuous renal
replacement therapy, or a body
mass index exceeding 30) was present in 89% of all activity encounters. Mobilization was interrupted
prematurely only 4% of the time,
and causes included agitation and
ventilator asynchrony. The patients
were able to perform upper and
lower extremity exercises 85% of the
time, side-to-side movement in 76%
of all sessions, and sitting on the
edge of the bed 69% of the time.
Fifty-three percent of the patients
had a positive ICU delirium score,
and the patients fraction of inspired
oxygen was greater than 60% in 35%
of all sessions. Seventeen percent of
patients were having 1 vasoactive
agent infused, and 14% were receiving infusions of 2 or more vasoactive
agents during in-bed or out-of-bed
mobility sessions.
Adverse events occurred in 16%
of all sessions and included desaturation of more than 5% in 6% of
patients, increase in heart rate
exceeding 20% in 4.2% of patients,
ventilator asynchrony in 4% of
patients, agitation in 25%, and
device removal (not life threatening) in 0.8%. During the therapy
session, most patients had 1 central
venous catheter (75%), the presence
of acute lung injury (58%), and
delirium (53%). This study affirms
that it is safe and feasible to perform in-bed and out-of-bed mobilization very early in a patients
ICU stay despite physiological and
structural challenges.
Safety can be ensured and the
risk of hemodynamic instability
can be reduced while turning and

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repositioning a critically ill patient

through inferences made from the
evidence.47,48 The following are recommendations for turning and
repositioning a critically ill patient
with or without a vasoactive infusion or the presence of an intraaortic balloon pump.
1. Critically ill patients who are
older, with comorbid conditions such
as diabetes and preexisting cardiac
disease and/or the presence of
vasoactive agents, will be at greater
risk for not tolerating in-bed mobilization. It is critical that the nurse
assess the risk factors and plan when
activity will occur to allow sufficient
physiological rest to meet the oxygen demand that positioning will
place on the body. A clinician may
also choose to preoxygenate before
position change to increase the oxygen supply side. When positioning
these high-risk patients, the right
lateral position should be used initially to prevent the hemodynamic
challenges reported with use of the
left lateral position. Last, consider
reducing the speed of the turn to
minimize the influence of inner ear
changes on cardiovascular response.
2. Prevent prolonged gravitational equilibrium by initiating a
turning schedule within hours of
admission to the ICU. Prolonged
periods in a stationary position result
in greater hemodynamic instability
when the patient is turned.
3. Toleration of a position change
should not be assessed for 5 to 10
minutes after a position change.

All the evidence indicates that critically ill patients require this
amount of time to equilibrate to
the new position.
4. If the patient does not tolerate
manual turning using the just-stated
recommendations, as evidenced by
a sustained decrease in blood pressure and oxygen saturation and/or
an increase in heart rate, the patient
should be returned to the supine
position and the nurse should consider the use of continuous lateral
rotational therapy in an effort to
train the patients body to tolerate
side-to-side movement. Continuous
lateral rotation therapy should be
managed by a protocol.
Significant problems are created
for ICU patients when they are not
mobilized effectively. The solution
rests in increasing the awareness of
the importance of early mobilization both in bed and out of bed. We
must shift the ICU culture from one
in which patients are on bed rest
and not moving as the norm, to one
in which mobilization enables the
prevention of complications and
faster healing and recovery.49 In-bed
mobility is a fundamental nursing
activity that requires knowledge and
skill to apply effectively and succeed
in mobilizing hemodynamically
unstable critically ill patients. CCN
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Financial Disclosures
None reported.

References
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CriticalCareNurse Vol 32, No. 1, FEBRUARY 2012 75

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Hemodynamic Instability: Is It Really a Barrier to Turning Critically Ill Patients?

Kathleen M. Vollman
Crit Care Nurse 2012;32 70-75 10.4037/ccn2012765
2012 American Association of Critical-Care Nurses
Published online http://ccn.aacnjournals.org/
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Critical Care Nurse is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published
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