Early Mobilization for a Patient With a Right Ventricular Assist Device With an Oxygenator: A Case Report : Journal of Acute Care Physical Therapy

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CASE REPORT

Early Mobilization for a Patient With a Right Ventricular Assist Device With an Oxygenator

A Case Report

MacFarlane, Sheena; Lee, Vanessa; Simonds, Adrienne H.; Alvarez, Samantha; Carty, Samantha; Ewers, Kevin H.; Kelly, Victoria R.; Linden, Parker; Moskal, Amanda L.

Author Information
Journal of Acute Care Physical Therapy 14(1):p 45-51, January 2023. | DOI: 10.1097/JAT.0000000000000198

Abstract

Early mobilization (EM) is a commonly used intervention for critically ill patients, which involves progressive functional mobility that is initiated as soon as medically feasible.1 Despite guidelines for the initiation of EM, challenges to mobilizing intensive care unit (ICU) patients continue to affect patient care; some of these include lack of adequate staffing and equipment, line placement and management, sedative practices, and hemodynamic instability.2–4 Common interventions associated with EM include sitting upright in bed, sitting out of bed in a chair, standing activities, and ambulation.1,5 EM appears effective at reducing ICU-acquired weakness, shortening the time on mechanical ventilation, and improving functional capacity.6

Patients with severe cardiac and/or pulmonary failure may require mechanical circulatory support (MCS), which is used to maintain adequate circulation and respiratory function. Patients on MCS are typically candidates for EM when medically feasible.5,7 Extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) are examples of MCS device categories.8 Use of MCS devices is becoming more common; the use of ECMO alone has increased 3-fold in the United States from the year 2010 to 2019.9 A variety of cannulation sites and circuit configurations can be used to individualize the support provided to the patient; however, the most common cannulation sites for ECMO use single or double lumen peripheral cannulae at the femoral or jugular vessels. Upper body cannulation sites tend to facilitate mobility while femoral cannulation sites can be a barrier to mobility.5,8,10 Central cannulation, which requires a sternotomy and uses large blood vessels in the thorax, is less common and can be used for multiple MCS device configurations.11,12 A right ventricular assist device with an oxygenator (Oxy-RVAD) is a configuration of MCS components, which can be implemented via peripheral cannulation or via central cannulation and provides support for respiratory function and the right ventricle.10–12

Providing EM to patients with MCS devices requires advanced clinical expertise due to need for continuous advanced patient monitoring and clinical decision-making, especially in light of the inherent risks unique to this population, which include the potential for cannula kinking, fracture, or dislodgement.8,13 There are no formal clinical practice guidelines for EM for patients on MCS devices; however, some eligibility requirements have been published.14 Additionally, a consensus from Eden et al3 in 2017 describes best practice when providing EM for patients on ECMO, including description of pretreatment safety considerations and a rehabilitation protocol. A consensus of agreement from the literature is that the provision of EM for patients on MCS devices requires a multidisciplinary team to optimize feasibility and mitigate adverse events.1,3,5,7,14,15 Few previously published studies describe EM for patients with MCS via central cannulation.5 The purpose of this case report is to describe the clinical course and functional outcomes of EM for a patient with Oxy-RVAD via central cannulation awaiting a heart-lung transplant while in the ICU.

CASE DESCRIPTION

A 40-year-old African American man with a medical history significant for sickle cell trait, β thalassemia, left hip avascular necrosis surgically managed with a left hip arthroplasty, and spontaneous pneumothorax presented to an urban university hospital emergency department with complaints of chest pain and dyspnea. Prior to hospitalization, the patient was independent with community-level mobility and activities of daily living (ADL) and enjoyed recreational basketball with friends and family. For the 2 years prior to admission, he reported occasional shortness of breath with a dry cough, which worsened in the month prior to admission. His initial workup included a chest computed tomography (CT) Scan, which demonstrated extensive bilateral interstitial lung disease of unknown etiology and a large left-sided pneumothorax. An echocardiogram showed dilated cardiomyopathy with biventricular systolic dysfunction and a left ventricle ejection fraction of 30% to 35%. During the first 2 weeks of his admission, the patient remained independent with functional mobility and ADL including hallway ambulation. He required medical management for heart failure and persistent pneumothorax. Conservative management of his pneumothorax was ineffective, and the patient underwent left video-assisted thoracic surgery with apical bullectomy and mechanical pleurodesis on hospital day 9.

On hospital day 14, the patient had an acute onset of respiratory distress. Urgent medical workup included a venous ultrasound, which showed an acute left lower extremity deep venous thrombosis and chest CT angiogram, which revealed an acute pulmonary embolism that extended from the inferior vena cava to the pulmonary artery. A transesophageal echocardiogram showed worsening left ventricular ejection fraction to 20% to 25%. He required supplemental oxygen via a nonbreather mask to maintain adequate oxygenation. The next day, he underwent a pulmonary thromboendarterectomy via a sternotomy while on cardiopulmonary bypass support. Following clot retrieval, the patient continued to exhibit hypoxia and low mean arterial blood pressure, which correlates to intraoperative transesophageal echocardiogram findings of severe right ventricle hypokinesia and bilateral ventricular dilation. The patient required placement of MCS support via an Oxy-RVAD with central cannulation to achieve hemodynamic stability.

Following Oxy-RVAD placement, the patient underwent separate emergent pulmonology and cardiology medical workups. Both groups of physicians determined the patient was a candidate for a heart-lung transplant. On hospital day 26, the 11th day of MCS, he underwent a heart-lung transplant. This case study focuses on the EM course for the time the patient was on an MCS device, prior to his transplant.

Early Mobilization

Clinical decision-making regarding EM eligibility was made by the multidisciplinary team prior to each session. Physical therapists (PT) and occupational therapists (OT) were consulted on the day of surgery and attempted to examine the patient on post-Oxy-RVAD days 1 and 2; however, both days he was ineligible to participate in the session because he was sedated and requiring 2 vasopressor medications. Additionally, on hospital day 21, EM was held due to desaturation and increasing supplemental oxygen requirements at rest. A summary of best practice recommendations applied to clinical decision-making regarding EM eligibility for this case is captured in Table 1.

TABLE 1. - Case-Specific Decision-Making Framework for Early Mobilization Eligibilitya
Factors Early Mobilization Eligibility Status
Green Yellow Red
Neuromuscular system
Mental status14,22 Awake, alert, following commands Alert but limited command following4 Not alert and receiving sedative medication
Cardiovascular system
Mean arterial blood pressure14,26 65-90 mm Hg 55-64 or 90-119 mm Hg <55 or >120 mm Hg
Systolic blood pressure14,26 90-160 mm Hg 80-89 or 160-179 mm Hg <80 or >180 mm Hg
Heart rate4 60-120 beats/min <60 or 121-140 beats/min >150 beats/min
Vasopressor requirement3,4,14
  • Stable or decreasing

  • Low dose of 0-1 medications

  • Stable requirement

  • Moderate doses of 1-2 medications

  • Increasing requirement

  • Moderate or high doses of >2 medications

Pulmonary system
Respiratory rate 10-30 breaths/min14 >30 breath/min4
Breathing pattern22 Comfortable Increased work of breathing at rest or use of accessory muscles Respiratory distress
Oxygen saturation4 >90% <90%
Supplemental oxygen4
  • FiO2<60%

  • Stable over last 24 hours

  • FiO2≥60%

  • Recent minimal increase required in FiO2 or ventilator settings

Saturation >90% but recent significant increase in FiO2 or ventilation settings
MCS device considerations
Cannula sites3,5 Intact, no bleeding Minimal oozing noted
  • Bleeding

  • Decreased integrity of MCS device components

MCS device flow rates5 Stable over past 24 hours adequate flow Kinking or drop in flow with specific positions or activities9 Significant drop in flows (cut-off per physician guidance specific to patient)
Other considerations
Interdisciplinary team3,5 All necessary early mobility team members present If perfusionist not present—in-bed activity only
FiO2, fraction of inspired oxygen; MCS, mechanical circulatory support; min, minutes.
aEarly mobilization (EM) eligibility status is coded as green, yellow, or red. Green status = the patient is eligible for EM with low risk for adverse events. Yellow status = the patient is a potential EM candidate, but there is a need to weigh risk-benefit ratio of EM (the accumulation of multiple yellow criteria might cause the risks of EM to outweigh the benefits). Red status = the patient is likely ineligible to participate in EM. The categories with relevant clinical factors provide a framework for clinical decision-making and interdisciplinary team conversations on EM eligibility for patients on MCS.

Early mobilization, consisting of physical therapy and occupational therapy examinations followed by cotreatment sessions, began on hospital day 18, which was post-Oxy-RVAD day 3 following pulmonary thromboendarterectomy and Oxy-RVAD placement. The cardiothoracic surgery team requires sternal precautions to be followed for patients with sternotomies. Additionally, facility protocol and published best practice require a perfusionist or ECMO specialist to be present for functional mobility sessions when a patient has an oxygenator (ECMO or Oxy-RVAD) to monitor and manage the circuit, lines, and flows.3,7

During examination, the arterial line, telemetry, and Oxy-RVAD flow rates were used for continuous hemodynamic monitoring. His resting vital signs included a blood pressure of 107/52 mmHg, heart rate 87 beats per minute, oxygen saturation of 100% on 9 L of supplemental oxygen via high-flow nasal cannula (57% fraction of inspired oxygen [FiO2]), and a stable Oxy-RVAD flow (3.45 liters per minute). The patient's Oxy-RVAD cannulas were fixed to the patient's lower abdomen and upper thighs with sutures. Other observations included swelling in the patient's left lower extremity consistent with his diagnosis of left lower extremity deep vein thrombosis and mild forward shoulder posture. He was alert and oriented x4 and followed 100% of multistep commands. He demonstrated decreased bilateral lower extremity strength (assessed functionally due to pain and limited tolerance of testing positions, which did not allow for formal manual muscle testing) and impaired balance requiring minimal assistance to maintain static balance in sitting. Poor activity tolerance limited the therapists' ability to complete formal examination of endurance although this was assessed indirectly during functional mobility.

Functional mobility examination started with a supine position to sitting at the edge of the bed transfer, which resulted in a brief kinking of the Oxy-RVAD cannulae. A potential adverse event was avoided by reclining the patient to a recumbent sitting position (hip flexion less than 60°) for all future sessions. The patient initially required maximum assistance of 2 people to transfer from the supine to sit position and moderate assistance of 2 people to transfer from the sit to supine position due to 5/10 pain (on the visual analog scale), decreased muscle performance, and difficulty maintaining sternal precautions. The patient tolerated standing for 3 minutes and walked 5 ft with a rollator and minimal assistance of 2 people. Throughout the session the patient required multiple rest breaks between activities. These rest breaks occurred while reclined at the edge of the bed with trunk support or in static standing. Three outcome measures were used at each session to capture functional mobility status: ICU Mobility Scale (IMS), John Hopkins Highest Level of Mobility (JH-HLM), and Functional Status Score for the ICU (FSS-ICU). Vital signs and MCS device flows were continuously monitored. The patient experienced no major adverse events.

The main impairments identified by the PT included: decreased endurance/aerobic capacity (metabolic equivalent intensity lower than 2), decreased activity tolerance (requiring multiple rest breaks during the session), increased pain (5/10 on the visual analog scale), decreased muscle performance/strength (requiring assistance for transfers), and biomechanical disadvantage during reclined sitting (required to avoid kinking of the cannula). Functional mobility was affected by these impairments resulting in an increase in the level of assistance the patient required to participate in functional tasks. Impairments identified by the OT included: decreased upper extremity strength and decreased cardiopulmonary endurance impacting his overall independence, specifically with self-care tasks.

The recommended plan of care for EM consisted of physical therapy and occupational therapy six times per week. The plan of care for occupational therapy included therapeutic exercises in the supine and standing position, functional mobility training, and education regarding positioning, safety, sternal precautions, and energy conservation. The OT facilitated participation in ADL tasks (dressing, grooming, and toileting) in varied positions, and leisure tasks, including simulated standing basketball, which focused on balance and standing tolerance. An example of the standing leisure task, ring toss, is depicted in Supplemental Digital Content Video 1 (available at: https://links.lww.com/JACPT/A9). Toileting occurred in a recumbent sitting position with a bedpan at the edge of bed. Specifics of each session (including both physical therapy and occupational therapy interventions) are reported in Table 2.

TABLE 2. - Early Mobilization Interventions Provided While on Oxy-RVAD
HD Outcome Measures Session Details EM Interventions Administered
IMS JH-HLM Session Length, min Supplemental Oxygen Bed Mobility Transfers: Sit-Stand Standing Duration Standing Therapeutic Exercise ADL Amb d, m Balance Training Education
18 4/10 5/8 55 9L 56% FiO2 HFNC X X 3 min D 1.5 m X
19 6/10 6/8 39 7L 48% FiO2 HFNC X X 4 min X D, G 4.3 m X
21 Early mobility session attempted. Patient ineligible due to desaturation with increasing oxygen requirement
22 6/10 5/8 25 20L 80%-100% FiO2 Aquinox/high-flow humidification system X X 4 min X D 0.9 m X X
23 7/10 6/8 55 10L 40%-100% FiO2 Aquinox/high-flow humidification system X X 10 min X D, G 7.3 m X
24 6/10 6/8 75 15L 40% FiO2 Aquinox/high-flow humidification system X X 11 min X D, G, F, T 3.0 m X
25 7/10 6/8 70 10L 40% FiO2 Aquinox/high-flow humidification system X X 10 min X D, G, F, T 10.7 m X
ADL, activities of daily living; Amb d, ambulation distance; D, dressing; EM, early mobilization; F, feeding; FiO2, fraction of inspired oxygen; G, grooming; HD, hospital day; HFNC, high-flow nasal cannula; IMS, Intensive Care Unit Mobility Scale; JH-HLM, Johns Hopkins Highest Level of Mobility; L, liters; Oxy-RVAD, right ventricular assist device with an oxygenator; T, toileting.

While the patient did not experience any major adverse events, the patient experienced desaturation during 2 of the 6 sessions, which was ameliorated by increasing in the FiO2 of the patient's high flow, high humidity oxygen delivery system, once from 80% to 100% and once from 40% to 100%. The facility protocol allows oxygen titration during mobility to be performed by any licensed member of the interdisciplinary team. For this case, titration was performed by the PT and the registered nurse (RN). In both instances, the desaturation resolved with titration of the FiO2, and the FiO2 was returned to his baseline requirements following the session.

Multidisciplinary Team

A multidisciplinary team of health care providers, including the PT, OT, RN, and perfusionist, coordinated their availability to participate in each of the 6 EM sessions. The PT was responsible for determining appropriate levels of mobilization and prescribing functional interventions and therapeutic exercises. The OT prescribed ADL to maximize independence with self-care tasks, provided therapeutic motivations, and prescribed individualized therapeutic activities. Perfusionists managed the Oxy-RVAD circuit and monitored flow rates.3,16 The RN was responsible for medication administration to allow for optimal pain management, as well as line management.3

OUTCOMES

The patient participated in 6 sessions of EM, which took place over 10 days administered by a multidisciplinary team; one EM session was held due to significant desaturation with increased oxygen requirement. The average session length was 53 minutes, and the patient participated in 100% of the sessions for which he was medically eligible. Further details are listed in Table 1.

Effectiveness of EM intervention was evidenced by the patient's improvements in functional capacity and functional outcome measures between the first and last EM sessions on Oxy-RVAD (see the Figure). Evidence of improved functional capacity can be seen in the patient's increase in standing duration (from 3 to 11 minutes) and ambulation distance (from 1.5 to 10.7 m). The change in IMS and JH-HLM scores was clinically significant. The 3.0-point improvement in the IMS from 4/10 to 7/10 exceeds the published minimally important difference value of 0.89 to 1.40.17 For the JH-HLM, there was a 1.0-point improvement from 5/8 to 6/8, which exceeds the published minimally detectable change value of 0.6.18 No change was observed on the FSS-ICU, 6/35, during the time on MCS.

F1
FIGURE.:
Change in Functional Outcomes From Examination Post-Oxy-RVAD to the Sixth Early Mobilization Session. FSS-ICU indicates Functional Status Score for the Intensive Care Unit; IMS, ICU Mobility Scale; JH-HLM, John Hopkins Highest Level of Mobility; MCS, mechanical circulatory support; MDC, minimal detectable change; MID, minimally important difference; Oxy-RVAD, right ventricular assist device with an oxygenator.

Following his heart-lung transplant, the patient continued to receive physical therapy and occupational therapy and showed continued functional improvement. The FSS-ICU values improved from 6/35 at PT and OT examinations to 31/35 at ICU discharge, 10 days following his heart-lung transplant. Twelve days after his heart-lung transplant, the patient achieved the maximum possible score on the FSS-ICU. Nineteen days post-transplant, on hospital day 44, the patient was discharged home.

DISCUSSION

This case study describes the EM course and functional outcomes of a patient with Oxy-RVAD with central cannulation. This patient made clinically significant improvements in the IMS and JH-HLM scores, both of which surpassed minimally important difference and minimal detectable change values. These improvements are similar to results reported by Wells et al5 and Lammers et al,19 who used the same measures. The patient continued to require assistance for functional tasks partly due to limitations associated with his cannulation sites. As a result, there was no improvement on the FSS-ICU. Outcome measures used in the ICU do not typically address the effect of lines and tubes, which limits the ability of these tools to differentiate between external limitations and actual functional mobility deficits. Although this report focuses on outcomes while on an MCS device, the patient's functional outcomes post-transplant and subsequent discharge home are consistent with previously published research. Specifically, patients who receive EM while on MCS have improved posttransplant outcomes as compared with patients who do not receive EM.20

There is heterogeneity in definitions, goals, and application of EM, despite EM is a widely used intervention.21 Few articles describe clinical decision-making for EM with general ICU patients.4,22 While safety considerations and eligibility criteria for EM in patients on MCS have been published,3,4,14 there is minimal information regarding clinical decision-making for the population. Patients on MCS may have vital signs and laboratory values fall outside of ideal ranges for mobilization. Consensus on EM eligibility among the interdisciplinary team should be reached to support the decision when the benefits of mobilization outweigh potential risks. Mobilization for these patients will require additional close monitoring and/or modifications to the EM session. Additionally, clinical decision-making may be a challenge for clinicians with limited ICU experience, those changing institutions, and/or involving a new population. More research is needed regarding clinical decision-making for EM for patients with MCS devices.

Documented progressions for EM interventions1,23 tend to emphasize early sitting at the edge of bed, transfer to a bedside chair, and ambulation. However, the patient in this case required modifications from this progression because he was unable to tolerate sitting upright. Progression of physical therapy interventions was achieved through increasing his standing duration and in-room ambulation distance. The OT progressed interventions using standing leisure activities and ADL training, similar to interventions described by Rahimi et al.24 In the authors' opinions, this collaboration between PT and OT improved patient engagement.

The lack of major adverse events in this case further supports the growing literature that EM for patients on MCS provided by an experienced multidisciplinary team is safe and feasible.1,3,5,7 Despite this, barriers related to risk for adverse events and perception of the safety of EM continue.2 One way to mitigate the risk for adverse events in patients on MCS is using a multidisciplinary team including an ECMO specialist or perfusionist when the patient is on ECMO or Oxy-RVAD. Another way is using appropriate clinical decision-making when monitoring hemodynamic values and patient responses and using that information to make clinical decisions regarding interventions, patient position, and/or titration of the FiO2 of the supplemental oxygen as needed.3,25

Generalizability with case reports is limited. This patient spent a relatively brief period (10 days) on MCS. EM outcomes for patients on MCS for longer periods may differ. The authors recommend that the PT and the OT advocate within the ICU, as key members of multidisciplinary teams to promote safe and effective EM for patients on MCS. Future research should focus on EM effectiveness and feasibility for patients on MCS devices with central cannulation and include a description of EM interventions and associated clinical decision-making. In conclusion, this case report illustrates the feasibility of EM, application of a decision-making framework for EM eligibility, reporting of physical therapy and occupation therapy EM interventions, and the demonstrating the effectiveness of these interventions using functional outcome measures.

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