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Moving Forward: Safely Walking Patients on ECMO


Bryan Boling, RN, CCRN-CSC, CEN
University of Kentucky
Lexington, KY, USA
bryanboling@uky.edu

Katie Burns, RN, BSN, CCRN
University of Kentucky
Lexington, KY, USA
klburn4@uky.edu



Venovenous extracorporeal membrane oxygenation (ECMO) is an effective and often necessary therapy for end-stage pulmonary disease patients awaiting lung transplant [1]. Even though newer cannulation techniques, such as the use of a dual lumen cannula in the internal jugular vein, allow for greater patient mobility, ambulation of patients on ECMO remains rare. Immobility of critically ill patients, particularly those with pulmonary disease, is a significant problem, often leading to physical deconditioning [2], prolonged mechanical ventilation [3], and skin breakdown [4].

Despite the benefits of mobility, there are safety concerns regarding the ambulation of patients on extracorporeal support. In our experience, staff concern for patient safety presents the largest barrier to ambulation of these patients in many institutions. However, this can be done safely. In the Cardiothoracic and Vascular Intensive Care Unit (CTVICU) at the University of Kentucky Hospital, we have been ambulating ECMO patients for three years with great success [5].

Initially, there was significant resistance on the part of the CTVICU nursing staff towards the ambulation of ECMO patients. Fears of decannulation, major bleeding, falls, and other patient safety issues were the primary concerns expressed by the nurses. From talking with staff at other centers, these fears are a common impediment to the routine ambulation of ECMO patients nationwide. With time, our experience has shown these fears to be unwarranted and ECMO ambulation is now a commonly accepted standard of practice in our institution [5].

Proper planning and execution are essential to ambulating these patients safely. The use of a multidisciplinary team, led by the CTVICU nurses and consisting of physical therapy, perfusion, and respiratory therapy, ensures that all needed support is available. In addition to our team, we also employ special equipment such as a self-contained mobile ECMO cart and specialized thoracic walker to ensure the safety of the patient.

Prior to being ambulated patients are classified as either high or low-risk based on a number of factors, including their ability to bear weight independently, hemodynamic stability, and the distance they are able to walk without seated rest periods (see Box). Those patients who are physically debilitated to the point they require two or more people to assist them with walking are also considered to be high-risk.

At least two nurses, typically the patient's nurse and the ICU charge nurse, accompany all high-risk patients with additional nurses and/or nursing care technicians assisting as needed. In addition to the nurses, either the cardiac perfusionist or ECMO specialist accompanies the patient and is responsible for the ECMO cart and protection of the integrity of the ECMO circuit. If the patient needs manual ventilation via bag valve mask or if they are receiving inhaled nitric oxide, one or more respiratory therapists may be involved. Physical therapy staff may also assist, if available. To ensure that the cardiothoracic surgeons and operating room staff are available, should there be the need for any emergent surgical intervention, these high-risk patients are only ambulated during the hours of 0700-1900.

Low-risk patients, however, may be ambulated at any time, provided the needed staff and resources are available. Because these patients are more independent and require less physical support, the additional staff is often unnecessary and only two nurses are required to accompany the patient. While one of the nurses assists and monitors the patient, the second is charged solely with managing the ECMO cart and monitoring the securement of the cannulas.

The primary nurse works with the patient to determine the optimal time for ambulation and then coordinates with the rest of the team. Each session is tailored to the needs and abilities of the individual patient, but frequently consists of distances up to 300 feet or more, with many patients walking two or three times per day. Patients are ambulated both within the CTVICU and in the adjacent hallways outside the unit. In some cases, staff or family members may push a recliner chair behind the patient to allow for seated rest periods. In addition to the ECMO pump and circuit being contained on the mobile cart, a special thoracic walker that facilitates optimal patient positioning, along with providing attachment for oxygen tanks, chest tubes, foley catheter drainage bags, portable monitors and other equipment, is used.

In the past three years, we have successfully ambulated over 50 patients undergoing ECMO therapy without any major adverse events [5]. We attribute this outstanding safety record to good planning, proper equipment, and a dedicated staff willing to move beyond traditional thinking in order to provide the best care for our patients. Ambulating ECMO patients is safe, if done correctly, and we feel that it ultimately leads to improved outcomes. ■

Box - Classification of ECMO Patients

High-Risk

  • Requires > 1 person to assist with ambulation (independent of ECMO)
  • Unable to ambulate > 100 ft or requires frequent seated rest periods
  • Becomes unstable with exertion requiring additional support (i.e. vent, bagging, etc.)

Low-Risk

  • Patient currently ambulating >100 ft. with minimal difficulty
  • Able to bear weight and ambulate with ≤ 1 assist (independent of the ECMO)
  • Hemodynamically stable

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Hoopes CW, Kukreja J, Golden J, et al. Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg. 2013;145:862-867.
  2. de Jonghe B, Lacherade JC, Durand MC, et al. Critical illness neuromuscular syndromes. Crit Care Clin. 2007;25:55-69.
  3. de Jonghe B, Lacherade JC, Sharshar T, et al. Intensive care unit-acquired weakness: risk factors and prevention. Crit Care Med. 2009;37:S309-315.
  4. Clements L, Moore M, Tribble T, et al. Reducing skin breakdown in patients receiving extracorporeal membrane oxygenation. Nurs Clin North Am. 2014;49:61-68.
  5. Dennis DR, Boling B, Tribble TA, et al. Safety of Nurse Driven Ambulation for Patients on Venovenous Extracorporeal Membrane Oxygenation. Poster presented at: International Society for Heart & Lung Transplantation 34th Annual Meeting and Scientific Sessions; April 10-13, 2014; San Diego, CA



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