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Early Mobilization and ECMO: It Takes an Army


Jacqueline Smith, PT, DPT
Temple University Hospital
Philadelphia, PA, USA
Jacqueline.Smith@tuhs.temple.edu



"Alone we can do so little; together we can do so much." - Helen Keller

If you asked me 8 years ago when I was applying to graduate school to become a physical therapist what patient population I would want to work with, I most likely would have responded with, "The Philadelphia Eagles." Yet, here I am 8 years later working with the most critically ill population and collaborating with a great team of medical professionals to make the impossible, possible.

At any given day in the Temple University Hospital Respiratory ICU, you can find an army of medical professionals parading medical equipment down the hallway. This army includes: physical therapy, occupational therapy, mobility aide, respiratory therapy, a perfusionist, and of course, a nurse. We have come together as a group to attempt to master early mobilization while on Extracorporeal Membrane Oxygenation (ECMO). While I know many hospitals with progressive transplant programs participate in this type of mobilization, it is something that we often take for granted and/or overlook benefits of for those patients on ECMO as a bridge to lung transplantation. When you really step back and take a moment to think that this machine is oxygenating someone's body, yet they are able to participate in a therapy program, while bringing a team of medical professionals together for the same cause, it is truly amazing.

Active rehabilitation during ECMO as a bridge to lung transplantation has demonstrated patients to have a shorter post-transplant hospital stay, a shorter post-transplant mechanical ventilation length, shorter ICU stays, and less incidences of post-transplant myopathy [1]. In addition, you may be surprised to learn that mobilizing patients while on ECMO significantly cuts costs hospital-wide. Patients who participated in ambulatory ECMO have shown to have 22% reduction in total hospital cost, 73% reduction in post-transplant ICU cost, and 11% reduction in total cost compared with non-ambulatory ECMO patients [2].

Of course, we must stop to consider the complications and logistics. We must take into account the time it takes, the critically ill level of the patients, and most importantly for physical therapists, the cannula placement. In most studies looking at ambulation while on ECMO, the upper body was the common site of cannulation, which allowed for increased mobility, less weakness, fewer mechanical ventilation days, less sedation, earlier rehabilitation, and shorter ICU stays compared to those with femoral cannulation [3]. Currently at Temple University, we have not initiated ambulating patients with femoral cannulation while on ECMO. Some of the reasons why include: difficulty for patient to go from supine to standing while not impeding the line and concern for safety of line placement with hip flexion and movement. However, a new study has shown it is feasible and safe to deliver early rehabilitation including standing and ambulation to patients on extracorporeal membranous oxygenation support in those with femoral cannulation sites with veno-arterial extracorporeal membranous oxygenation and veno-venous extracorporeal membranous oxygenation [3]. In this study, the cannulas are secured to the thigh using sutures and adhesive anchors by surgeons, and hip flexion is performed to 90 degrees to test the flow of the cannula prior to mobility by physical therapists. In addition, specialized hospital beds are available that go from supine to standing, allowing patients to avoid hip flexion/sitting to prevent compression or kinking of the femoral cannula. Safety of the patient undoubtedly comes first and the same study showed that 66 patients, out of a sample of 167, with at least one femoral line experienced no major adverse events while mobilizing, including standing and ambulation [3].

According to Wells et al., to achieve a successful early rehabilitation program, a well-trained multidisciplinary team is required to complement the work of the advanced ICU ECMO-trained physical therapist with competent clinical judgement, advanced practical skills, and ability to collaborate [3]. We hope to begin implementing these new findings at Temple University Hospital, as well as continuing our progressive mobilization with patients on ECMO. After all, physical therapists are constantly finding ways to safely and feasibly mobilize our critically ill patients, especially those on ECMO and those waiting for lung transplants. With collaboration of the multidisciplinary teams, it is indeed possible.

In closing, when I stop to think about my daily routine and about the accomplishments our team is able to achieve, this is just one example of how great things can be accomplished when there is collaboration with all members of the medical team and physical therapists. It ultimately creates improved outcomes for patients who are both pre- and post-lung transplantation. I know through this ongoing collaboration we will continue to make progress and improvements in what we are able to provide for our patients; however, it takes an army. ■

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


References:

  1. Kyle J. Rehder, David A. Turner, Matthew G. Hartwig, W. Lee Williford, Desiree Bonadonna, Richard J Walczak, R. Duane Davis, David Zaas and Ira M. Cheifetz. Active rehabilitation during ECMO as a bridge to lung transplantation. Respiratory Care December 2012, respcare.02155
  2. Jesse C Bain, David A Turner, Kyle J Rehder, Eric L Eisenstein, R Duane Davis, Ira M Cheifetz and David W Zaas. Economic Outcomes of Extracorporeal Membrane Oxygenation With and Without Ambulation as a Bridge to Lung Transplantation. Respiratory Care January 2016, 61 (1) 1-7
  3. Chris L. Wells; Jenny Forrester; Joshua Vogel; Raymond Rector; Ali Tabatabai; Daniel Herr. Safety and Feasibility of Early Physical Therapy for Patients on Extracorporeal Membrane Oxygenator: University of Maryland Medical Center Experience. Critical Care Medicine. 46(1):53-59, JAN 2018



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