There is an increasing interest in postintensive care syndrome: new or worsening impairment in physical, cognitive, or mental health arising after intensive care unit (ICU) and persisting beyond acute care hospitalization.1 The provision of rehabilitation for survivors of critical illness as a result of improved survival rates and reports about the long-standing functional limitations that negatively affect their health-related quality of life (QOL).2 Thus, physical therapists and critical care physicians are challenged to prevent and treat the long-term consequences of critical illness.3 One common problem of survivors of critical illness is ICU-acquired weakness caused by deconditioning from immobilization.4 This can result in limited physical function, increased length of ICU and hospital stay, increased medical care costs, and decreased QOL.5 According to recent studies, early physical therapy (PT) in ICU is increasingly recommended6–8 because it has a lot of beneficial effects on muscle strength, physical function, health-related QOL, ventilator-free days, and lengths of stay in ICU and hospital as well.9
Extracorporeal membrane oxygenation (ECMO) is a life-sustaining therapy for patient with refractory heart or lung failure that is curable or transplantable.10 Patients on ECMO often have many contraindications for mobilization and PT, such as bleeding from cannulation area, open sternum status, and delirium.11 Thus, many physicians are reluctant to perform active PT for their ECMO patients. However, all patients may need physical rehabilitation. Recently, the techniques, devices, and knowledge of ECMO have been advanced that it is possible for patients to ambulate while receiving ECMO support.12–14 The purpose of this study was to review our experience of early PT for patients on ECMO in terms of its safety and feasibility.
Materials and Methods
A retrospective investigation was performed on eight patients who received PT while on ECMO at Samsung Medical Center from May 2013 to December 2013. Patients were selected by multidisciplinary ICU rehabilitation team consisted of intensivists, rehabilitation physicians, thoracic surgeons, physical therapists, respiratory care practitioner, and ICU nurses. Our inclusion criteria of ECMO rehabilitation were alert and cooperative patient, stable vital signs (MAP > 60 mm Hg, respiratory rate less than 30 beats/minute, arterial oxygen saturation higher than 95%), and stable cannulation site. Exclusion criteria were coagulopathy, bleeding from cannulation site, use of vasopressor, open surgical wound, and unstable ECMO flow. The patients’ algorithm selection is shown in Figure 1.
Once a candidate was selected, physical therapist conducted physical evaluation. For safety, before the PT, nurses in charge assured all intravenous lines, arterial lines, and ECMO cannulas to remove extraneous connections. Respiratory specialist ensured appropriate oxygen supply and respiratory conditions. As needed, perfusionist checked ECMO circuit. While PT was in session, responsibilities for patients’ safety included the following: monitoring vital signs by an intensivist, monitoring ECMO circuit integrity by a perfusionist, and oxygen therapy or ventilator by a respiratory therapist.
From Monday to Friday, multidisciplinary ICU rehabilitation roundings were held to discuss the patient’s physical status and progress with the mobilization. Physicians adjusted narcotic, anxiolytic, and analgesia medications to optimize patient’s mental status for participation. Nurses also assisted during PT sessions by temporarily disconnecting any unnecessary lines, holding enteral nutrition, and assisting with mobilization. As necessary, ECMO perfusionist adjusted ECMO setting to regulate blood and sweep gas flow per physician’s order. The criteria of early termination of PT were: systolic blood pressure > 180 mm Hg, mean arterial blood pressure < 60 mm Hg, heart rate < 40 beats/minute; >130 beats/minute, peripheral oxygen saturation < 90%, respiratory rate > 45 per minute, or Richmond agitation sedation scale > +2. When the patient met the criteria for early termination of PT, intensivists reevaluated the patient and made a confirmative decision on PT. In general, intensivists gave a 2 minute interruption and checked patient’s condition and vital signs.
Physical therapies or mobilization were achieved for patients receiving ECMO at the following conditions: 1) passive range of motion (PROM) of extremities and electrical muscle stimulation (EMS) in supine, 2) sitting in reclined bed with the head and trunk upright or on the edge of the bed, 3) strengthening using elastic band in sitting position, 4) standing out of bed or marching in place with or without device, and 5) walking with assistance (Figure 2).
Descriptive statistics was used to summarize ECMO setting, ventilator status, and other lines during PT sessions. Implemented PT sessions, vital signs, and safety events were also reported using descriptive statistics. Paired t-test was used to compare ECMO blood flow rate and sweep gas flow rates of before PT and during PT.
Characteristics of subjects are summarized in Table 1. The mean age of subjects was 56.7 ± 10.7 years. There were seven males and one female. A total of seven venovenous ECMO and one venoarterial ECMO were included. In a total of 62 sessions, 31 sessions (50%) were conducted through PROM of extremities and EMS in supine, 17 sessions (27.4%) were conducted during sitting in bed with head and trunk upright or on the edge of the bed, two sessions (3.2%) were for strengthening using elastic band in sitting position, 11 sessions (18%) were performed for patients who were standing out of bed or marching in place with or without standing device, one session (2%) was performed for patients who were walking with assistance.
The mean ECMO blood flow rates and sweep gas flow rates before PT and during PT sessions are summarized in Table 2. The blood flow rate of ECMO was higher during PT than before PT (paired t; p = 0.013). However, the sweep gas flow rate of ECMO was not different before PT compared with during PT (paired t; p = 0.321). Eight sessions (13%) of sitting in bed with head and trunk upright or on the edge of the bed were supported with invasive mechanical ventilation while receiving ECMO. A total of 54 sessions (87%) were performed with arterial line, 14 sessions (23%) were with central line, and 26 sessions (42%) were with chest tube (Table 2). Three sessions (5%) were stopped due, one to tachycardia (132 beats/minute) and two to tachypnea (46 and 47 per minute, respectively; Table 3).
Advances in extracorporeal circuit and cannula technology have made ECMO therapy safer to support patient on ECMO for extended time periods.15 Like patients in ICU, patients on ECMO may also have benefit from mobilization and rehabilitation. We have conducted 31 sessions of mobilization including sitting, strengthening, standing or marching in place, and walking without any serious adverse event. Only three potential safety events (one tachycardia and two tachypnea) occurred during standing or marching in place. But they were recovered within 2 minutes after interrupting the PT sessions.
In experienced ECMO centers, PT including sitting and ambulation can be safely performed in patients on ECMO.15,16 Given the evidence of its effectiveness on ICU patients,3,5,17,18 implementing mobilization and PT in ECMO patients is also feasible and beneficial to improve their physical condition, functional activity, and QOL.19–22 However, patient safety is a critical issue in implementing PT intervention for patients on ECMO. Extracorporeal membrane oxygenation needs at least one large bore cannula and tubing lines. The flowmeter and the pump are sensitive devices. The change of gravity and angles of cannulae are also concerning.23 Any sudden change on the ECMO can be life threatening to patients who have poor native heart or lung function. Thus, monitoring of the patient on ECMO is very important. In our study, seven out of eight patients were on venovenous support. Generally, patients who have lung failure need more time to recover than patients on venoarterial support. Extracorporeal membrane oxygenation is also used as a bridge-to-transplantation for those who have a longer waiting time for lung donor allocation than for cardiac donor. Therefore, patients on venovenous ECMO may have more benefit from mobilization and PT.24
Only three safety events (5%) required interruption of PT during our study period. For successful PT, the most important key is to have a multidisciplinary team consisting of physicians, nurses, pharmacists, respiratory therapists, and physical therapists. The decision about which therapy and how much intensity of exercise would be implemented is a collaborative effort of all team members. Before initiating PT, present patient’s status including mental status, hemodynamics, and respiratory status should be screened. In addition, all possible incidents should be considered by team members. Although patient might be critically ill with a limitation of activity due to cannula, a team approach can lead to successful PT and mobilization.
Recently, several studies conducted PT, including mobilization in patients receiving ECMO.25–28 Rahimi et al.29 reported three cases of physical rehabilitation of patients in ICU requiring ECMO. Abrams et al. also reported successful early mobilization of 35 patients receiving ECMO. Their study described that they were successful in achieving standing and ambulation in two patients with femoral venous ECMO cannulae.28 Seven patients in our study had femoral venous ECMO cannulae, of which three patients achieved 11 sessions while standing, one patient completed one session while walking. There was no clinically significant adverse event in patients. Thus, we believe that femoral cannulation is not contraindicated to ambulation.
This study has a few limitations. This study was a small retrospective review of our early experience of rehabilitation for ECMO patients. Our experience may not be adapted for hospitals that do not have sufficient ECMO volume. We did not analyze the survival of our patients because the aim of the study was to determine the safety and feasibility of PT in ECMO patients.
In conclusion, it is feasible and safe to perform PT and mobilization for patients on ECMO in an experienced ECMO center. However, its benefit on survival should be further investigated in a larger prospective study in the future.
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