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Recap from ISHLT 2016: Ambulatory ECMO in Adults - We Like to Move It, Move It

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Keith M. Wille, MD, MSPH
Univeristy of Alabama at Birmingham
Birmingham, AL, USA

Worldwide, the use of extracorporeal life support has exploded onto the scene in recent years, with more centers now offering extracorporeal membrane oxygenation (ECMO) to select patients with advanced heart and/ or lung failure. ECMO may be performed as a bridge to transplantation or destination therapy, as a bridge to deciding on transplant candidacy, as a bridge to recovery of organ function, or as a means of support for post-transplant complications, such as primary graft dysfunction. The increase in ECMO use is likely related to several newer developments, such as improved technology, device performance, and safety; advances in patient management; and improvements in overall patient outcomes. Moreover, ECMO patients can more easily ambulate when supported by either a dual lumen access cannula (typically placed in the right internal jugular vein) or by central cannulation. Coupled with prior studies describing functional disability and neuro-cognitive impairment following prolonged hospitalization for acute respiratory distress syndrome (ARDS), ECMO may now offer patients the advantage of maintaining physical capability while minimizing the sedation requirements.

In this ISHLT session, Christian Benden opened by reviewing the neonatal and pediatric ECMO experience. He described in particular the experience with lung transplant procedures performed in children on intra-operative ECMO support, noting the safety and favorable outcomes of the technique. Keith Wille followed with an update of the medical considerations when ambulating ECMO patients, including patient selection, benefits, safety concerns, and potential complications. He noted the importance of securing and maintaining proper cannula position during ambulation to reduce complications such as: arrhythmias, bleeding, cannula malposition, or changes in blood flow and hemodynamics. Avoidance of hemolysis, as measured by elevated plasma free hemoglobin, was also associated with improved ECMO outcomes. Next, Bryan Boiling offered a nursing perspective on the practical considerations regarding the resources for a successful ambulatory ECMO program. Ambulating a patient while on ECMO, he noted, typically requires several support personnel, namely a combination of nurses, physical therapists, perfusionists, and / or respiratory therapists. Attention must also be given to a patient's hemodynamic status, oxygen requirement, and level of mentation and cooperation. Finally, Kate Hayes addressed the physical benefits and specific complications related to mobilizing ECMO patients. While the survival rate after ECMO for patients with reversible refractory hypoxemia can be high, long-term survivors may suffer from reduced mental health, general health and social function, with little chance of returning to work. She highlighted the need for long-term follow-up and support for these patients after discharge, and the need for longer-term end points in future clinical studies.

As advancements in the delivery of extracorporeal life support continue, several issues will need to be addressed. These include: refining candidate selection guidelines; defining optimal dosing of anticoagulation; establishing transfusion thresholds to minimize sensitization risk; enhancing safety; reducing device-related complications; and identifying those patients most able to participate in and benefit from early ambulation. Finally, the expanding international interest of ECMO has coincided with Erick Morillo's - Reel 2 Real song "I Like to Move It" from 1994 only to become an international hit perpetuated by Dreamworks computer-animated comedy series - Madagascar with the latest premiere in 2012, Madagascar 3: Europe's Most Wanted and Madagascar 4 due in 2018. Indeed, like the song and animated series, our most wanted desire for patients on ECMO is to have them "Move It, Move it." ■

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

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