Safety of Nurse-Led Ambulation for Patients on Venovenous Extracorporeal Membrane Oxygenation

Effect of an evidence-based early rehabilitation program on adult patients with venovenous extracorporeal membrane oxygenation: A cohort study

OBJECTIVES

To assess the efficacy of early rehabilitation program for VV-ECMO patients and observe the influence on the respiratory and skeletal muscles.

DESIGN

A cohort study.

SETTING

The study was conducted with VVECMO patients in a comprehensive ICU with 32 beds.

MAIN OUTCOME MEASURES

Ultrasound measurements were performed on each patients on day 1, 4, 7, 10, and 14, including diaphragmatic excursion (DE), diaphragmatic thickening fraction (DTF), intercostal muscle thickening fraction (ICMTF), thickness of the rectus femoris (RF), thickness of vastus intermedius (VI), and rectus femoris cross-sectional area (RF-CSA). Data on basic characteristics, results of ultrasound measurements, patients outcomes and adverse events were collected.

RESULTS

22 patients received usual rehabilitation measures were set as the control group and 23 patients underwent early rehabilitation program were set as the study group. There were no differences in diaphragmatic excursion, diaphragmatic thickening fraction, intercostal muscle thickening fraction, thickness of rectus femoris, thickness of vastus intermedius, rectus femoris cross-sectional area between two groups on day 1 after VV-ECMO treatment (P > 0.05). The variation of diaphragmatic thickening fraction and intercostal muscle thickening fraction decreased on the day 7 and 14 after treatment (P < 0.05). The variation of vastus intermedius thickness and rectus femoris cross-sectional area in the study group was less compared with those in the control group on day 4, 7, 10 and 14. The ECMO duration in the study group was shorter than that in the control group (12.00 [10.00-16.25] days vs. 8.00 [6.00-12.25] days, P = 0.002), but there was no difference in the duration of mechanical ventilation.

CONCLUSION

Early rehabilitation program can ameliorate muscle atrophy. We recommend implementation of our rehabilitation program in VV-ECMO patients. This program can improve skeletal muscle atrophy and dysfunction in patients with VV-ECMO effectively and perhaps improve quality of life for patients in the future.

IMPLICATIONS FOR CLINICAL PRACTICE

Early rehabilitation program put higher demands bedside nurses. It requires them to observe conditions of VVECMO patients closely, assess the feasibility of rehabilitation promptly, and monitor for any adverse reactions. Ultrasound measurement is a noninvasive and useful tool to assess muscle atrophy in ICU patients. Early rehabilitation program can improve skeletal muscle atrophy and dysfunction in patients with VV-ECMO effectively.

ECMOve: A Mobilization Device for Extracorporeal Membrane Oxygenation Patients

Extracorporeal membrane oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients with severe respiratory or cardiac failure. Studies demonstrated the feasibility of in-hospital mobilizing during and after ECMO treatment preventing neuromuscular weakness and impaired physical functioning. Despite more compact mobile ECMO devices, implementation of ambulatory ECMO remains labor-intensive, complex, and challenging. It requires a large multidisciplinary team to carry equipment, monitor and physically support the patient, and to provide a back-up wheelchair in case of fatigue. Moreover, there is no adequate solution to ensure the stability of the patient's cannula and circuit management during ambulation. We developed a system contributing to improvement and innovation of current ambulatory ECMO patient programs. Our modular cart-in-cart system carries necessary ECMO equipment, features an extendable walking frame, and contains a folding seat for patient transport. An adjustable shoulder brace with lockable tubing-connectors enables safe fixation of the blood tubing. ECMOve provides safety, support, and accessibility while performing ambulatory ECMO for both patient and caregiver. Prototype evaluation in a simulated intensive care unit showed feasibility of our design, but needs to be evaluated in clinical care.

Early rehabilitation and mobilisation of neonatal and paediatric extracorporeal membrane oxygenation patients: A UK and Ireland consensus document

Despite increasing early rehabilitation and mobilisation (ERM) in paediatric intensive care, current evidence for ERM of neonatal and paediatric patients receiving extracorporeal membrane oxygenation (ECMO) is limited. The proposed benefits of ERM in neonatal and paediatric ECMO patients are multifaceted, including reduced immobility related issues and maintenance of functional ability. However, ECMO presents additional safety and logistical challenges, and currently there are no published neonatal or paediatric guidelines. A consensus document was developed to provide guidance for ERM with neonatal and paediatric ECMO patients. The document was developed by specialist physiotherapists from nine ECMO centres within the UK and Ireland, together with the UK Paediatric Critical Care Society ECMO group and members of the multidisciplinary team. The document covers key considerations and practicalities for completing ERM in this population including, acuity level measurement, activity level guidance, safety and risk assessment, and goal setting. Risk assessment and safety checklist bedside tools are also included and designed to be adapted as required to meet specific unit policies and protocols.

Developing a competency framework for extracorporeal membrane oxygenation nurses: A qualitative study

AIM

To develop a competency framework applicable to Chinese extracorporeal membrane oxygenation (ECMO) nurses.

DESIGN

A qualitative study was performed following the consolidated criteria for reporting qualitative research.

METHODS

Semi-structured interviews based on the critical incident technique were conducted among 21 ECMO care providers recruited from five well-known ECMO centres in Guangzhou, China. Interview transcripts were coded and analysed using the constant comparative method. The data collection period lasted from November 2021 to April 2022.

RESULTS

A competency framework for ECMO nurses was identified. It included four domains: knowledge, skills, behaviours and attitudes, containing 33 subcompetencies and 66 items.

RELEVANCE TO CLINICAL PRACTICE

This framework can be a reference for the assessment and training of ECMO nurses.

An Interprofessional Approach to Mobilizing Patients With COVID-19 Receiving Extracorporeal Membrane Oxygenation

OBJECTIVE

To assess survival outcomes with the intervention of an interprofessional mobilization program for patients with COVID-19 who were receiving venovenous extracorporeal membrane oxygenation (VV-ECMO).

DESIGN

Preintervention and postintervention retrospective cohort study.

METHODS

Survival outcomes of nonmobilized, adult patients (n = 16) with COVID-19 who were receiving VV-ECMO (May 2020 through December 2020) were compared with those of 26 patients who received a mobility care plan (January 2021 through November 2021). In the preintervention group, full sedation and paralysis were used. In the postintervention group, an early mobilization strategy involving interprofessional collaboration was introduced.

RESULTS

The postintervention group had improved survival (73.1% vs 43.8%; P < .04); fewer days of receiving paralytics, fentanyl, and midazolam (P < .01 for all); but more days of dexmedetomidine, morphine, and ketamine administration (P < .01 for all). Concomitantly, more patients in the postintervention cohort received oral or transdermal analgesics, oral anxiolytics, and oral antipsychotics (P < .01 for all), and also required more VV-ECMO cannula adjustments (P = .03).

CONCLUSION

Early mobilization of patients with COVID-19 who were receiving VV-ECMO improved survival rates but led to more cannula adjustments.

Awake extracorporeal life support and physiotherapy in adult patients: A systematic review of the literature

OBJECTIVE

The Awake Extracorporeal Life Support (ECLS) practice combined with physiotherapy is increasing. However, available evidence for this approach is limited, with unclear indications on timing, management, and protocols. This review summarizes available literature regarding Awake ECLS and physiotherapy application rates, practices, and outcomes in adults, providing indications for future investigations.

METHODS

Four databases were screened from inception to February 2021, for studies reporting adult Awake ECLS with/without physiotherapy. Primary outcome was hospital discharge survival, followed by Extracorporeal Membrane Oxygenation (ECMO) duration, extubation, Intensive Care Unit stay.

RESULTS

Twenty-nine observational studies and one randomized study were selected, including 1,157 patients (males n = 611/691, 88.4%) undergoing Awake ECLS. Support type was reported in 1,089 patients: Veno-Arterial ECMO (V-A = 39.6%), Veno-Venous ECMO (V-V = 56.8%), other ECLS (3.6%). Exclusive upper body cannulation and femoral cannulation were applied in 31% versus 69% reported cases (n = 931). Extubation was successful in 63.5% (n = 522/822) patients during ECLS. Physiotherapy details were given for 676 patients: exercises confined in bed for 47.9% (n = 324) patients, mobilization until standing in 9.3% (n = 63) cases, ambulation performed in 42.7% (n = 289) patients. Femoral cannulation, extubation and V-A ECMO were mostly correlated to complications. Hospital discharge survival observed in 70.8% (n = 789/1114).

CONCLUSION

Awake ECLS strategy associated with physiotherapy is performed regardless of cannulation approach. Ambulation, as main objective, is achieved in almost half the population examined. Prospective studies are needed to evaluate safety and efficacy of physiotherapy during Awake ECLS, and suitable patient selection. Guidelines are required to identify appropriate assessment/evaluation tools for Awake ECLS patients monitoring.

Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support

The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.

Ambulatory Extracorporeal Membrane Oxygenation: Times Are Changing

During the past century, medical technology has evolved to enhance quality and quantity of life. Medications, surgeries, and implantable devices have been developed and enhanced to reduce complications and improve patient outcomes. The use of extracorporeal membrane oxygenation is one of the most substantial advances in life-saving modalities. Extracorporeal membrane oxygenation has been widely used for patients with heart or lung failure across the lifespan. Expansion and simplifications of extracorporeal membrane oxygenation circuit designs have informed changes in patient treatment (from bed confinement to ambulatory) and shifted many clinical staffing structures (from cardiovascular perfusionist to nurse-managed care). Highly skilled registered nurses and advanced practice registered nurses are increasingly involved in managing extracorporeal membrane oxygenation in the critical care setting. The purpose of this article is to highlight the technological evolution of extracorporeal membrane oxygenation and the corresponding patient care that bedside registered nurses and advanced practice registered nurses provide.

Perception of other healthcare professionals about the nurses' role and competencies in veno-venous extracorporeal membrane oxygenation care: A qualitative study

Aim

This study aimed to explore the perception of other healthcare professionals, including the doctors, physiotherapists and perfusionists, about the nurses' role and competencies in veno‐venous extracorporeal membrane oxygenation.

Background

Extracorporeal membrane oxygenation is considered as a challenging clinical activity that requires critical decision and rapid response from nurses, particularly in emergencies. It was observed that nurses are primarily responsible for bedside management of these patients, and teamwork was found helping the nurses to manage this high‐acuity care. However, little is known on the perception of other healthcare professionals about the nurses' roles and competencies, which would contribute to further improvements in quality extracorporeal membrane oxygenation care.

Design

This was a qualitative descriptive study.

Methods

One‐to‐one in‐depth interviews were conducted with nine healthcare professionals working in extracorporeal membrane oxygenation care in an adult intensive care unit of a general hospital in Kuwait.

Results

Participants reported that nurses play critical and multiple roles and responsibilities in the insertion, maintenance, weaning, and retrieval of extracorporeal membrane oxygenation, plus providing general nursing care, and performed their roles competently. Heavy workload, less recognition and support, and individual differences in competence were reported as possible barriers to the nurses' performance.

Conclusion

Other healthcare professionals recognize continuous training, having experience, teamwork, and increased staffing as measures that can promote the nurses' role in extracorporeal membrane oxygenation.

Rehabilitation of adult patients on extracorporeal membrane oxygenation: A scoping review

OBJECTIVES

The objective of this study was to conduct a scoping review to comprehensively map the breadth of literature related to the rehabilitation of adult patients whilst on extracorporeal membrane oxygenation (ECMO) and identify gaps and areas for future research.

REVIEW METHOD USED

This review was conducted using recommended frameworks for methods and reporting including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

DATE SOURCES

We searched seven databases from inception to June 2021 and included all study designs and grey literature.

REVIEW METHODS

Eligibility screening was completed by two independent reviewers according to inclusion and exclusion criteria, with any disagreement resolved by consensus or with consultation with a third reviewer. Two independent reviewers extracted data related to intervention characteristics, patient outcomes, feasibility, safety, hospital outcomes, and mortality using a custom-designed piloted form.

RESULTS

Of 8507 records, 185 original studies met inclusion criteria, with the majority being small retrospective studies. Rehabilitation was more commonly reported in patients on veno-venous rather than veno-arterial ECMO. Ambulation was the most commonly reported intervention (51% of studies). Critical gaps were identified including incomplete reporting of the intervention along with heterogeneity in the type and timing of outcome measures. Less than 50% of patients met eligibility criteria to participate, but screening for eligibility was infrequently reported (9% of studies). Delivery of rehabilitation during ECMO may be facilitated by an expert multidisciplinary team, along with a strategy that targets low sedation levels and an upper body cannulation approach.

CONCLUSIONS

Rehabilitation during ECMO is an emerging area of research and mostly consisted of small retrospective single-centre studies. Future research requires more robust methodological designs that include comprehensive screening of potential candidates with reporting of eligibility, more detailed descriptions of the rehabilitation interventions, inclusion of a core outcome set with defined measurement instruments, and consistent timing of outcome measurement.

Mobilization of Patients Receiving Extracorporeal Membrane Oxygenation Before Lung Transplant

BACKGROUND

Extracorporeal membrane oxygenation is increasingly used to provide cardiopulmonary support to patients awaiting lung transplant. Although studies have shown that these patients benefit from early mobilization, the care team often has concerns about related complications, particularly for patients requiring femoral cannulation.

OBJECTIVE

To assess the safety of mobilizing patients receiving extracorporeal membrane oxygenation before lung transplant using a standardized mobility protocol.

METHODS

A retrospective review was performed of the electronic health records of patients receiving extracorporeal membrane oxygenation before or immediately after lung transplant who were mobilized according to a standardized protocol from April through October 2018. The setting was an 18-bed cardiothoracic intensive care unit in a Magnet-designated teaching hospital. Patients were helped to ambulate by an interdisciplinary team, with careful assessment for any related complications.

RESULTS

During the study period, 37 patients received extracorporeal membrane oxygenation, and 9 were mobilized. Two hundred forty-two therapy sessions were conducted involving 47 700 feet of ambulation. Patients experienced the following complications: chugging (1 patient), decrease in flow rate (2 patients), bleeding at the cannula site (2 patients), neck hyperextension (1 patient), fear/anxiety (1 patient), and shortness of breath (2 patients). Bleeding and neck hyperextension led to discontinuation of therapy until the problems were resolved. No changes were made to the protocol.

CONCLUSIONS

Patients receiving extracorporeal membrane oxygenation before lung transplant, including those with femoral cannulation, can be mobilized safely with the use of an interprofessional ambulation protocol. Further evaluation is indicated, including research on clinical outcomes.

Nurses' perception of their role in extracorporeal membrane oxygenation care: A qualitative assessment

BACKGROUND

Recently, there has been interest in the education of nursing personnel to provide veno-venous extracorporeal membrane oxygenation in Kuwait. There is need to understand the experience of nurses who take on this new role.

AIM

We aimed to explore the perspectives of nurses about their role, with a special focus on their competencies and the challenges faced while caring for patients who require extracorporeal membrane oxygenation.

METHODS

We used a qualitative descriptive approach, using in-depth individual interviews. Nineteen nurses working with veno-venous an extracorporeal membrane oxygenation machine in an adult intensive care unit of a general hospital in Kuwait were included in the study. Interviews were audio-recorded, transcribed verbatim, and analysed thematically.

RESULTS

The role of nurses was found to be diverse and challenging and involved engaging in multiple responsibilities. Nurses worked with other health care providers in a team, which facilitated their performance. Nurses viewed themselves as competent to perform their role and attributed their competency mainly to the training received and the experience spent providing extracorporeal membrane oxygenation care. In executing their role, nurses reported encountering significant challenges, including heavy workload, inefficient communication among colleagues, and a lack of an organized/supportive system.

CONCLUSIONS

This study suggests that nurses play an integral role in the management of patients on extracorporeal membrane oxygenation. An understanding of their role and their competence, the challenges they face with in the care setting, and providing a supportive environment is essential for transformation in the practice of extracorporeal membrane oxygenation nursing.

Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane Oxygenation Cannula Placement in the ICU-A Retrospective Review

OBJECTIVE

The most effective method of image guidance for venovenous extracorporeal membrane oxygenation is not known. The authors' objectives were to define the frequency of successful initial cannulation using echocardiographic guidance in the intensive care unit, as well as to determine the frequency of subsequent adjustments. Additional aims were to illustrate cannula malposition problems and to describe features associated with difficult cannulation.

DESIGN

Retrospective consecutive case series analysis.

SETTING

Single tertiary care university hospital.

PARTICIPANTS

Forty-five patients treated with venovenous extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The most common causes of respiratory failure were pneumonia, aspiration, and inhalational burn injury. Sixty-two percent survived to discharge. Initial cannulation was successful in 39 cases (87%). Adverse events included 5 cases of cannula malposition and 1 case of hemorrhagic shock. During the course of extracorporeal membrane oxygenation, 17 patients (38%) required echo-guided cannula position adjustments. There were no fatal complications. Factors associated with difficult cannulation included extremes of size, a prominent Eustachian valve, and an anterior guidewire bending in the right atrium. Younger age was associated positively with survival. There was no significant association between adverse events during cannulation and survival.

CONCLUSIONS

Dual-lumen venovenous extracorporeal membrane oxygenation cannulation in the intensive care unit under echo guidance has a high initial success rate, but many patients require subsequent repositioning. Echocardiography can define cannula position in sufficient detail to identify malposition precisely and to guide repositioning.

The early diagnosis and management of mixed delirium in a patient placed on ECMO and with difficult sedation: A case report

Delirium represents a serious problem that impacts the physical and cognitive prognosis of patients admitted to intensive care units and requires prompt diagnosis and management. This article describes the case and progress of a patient placed on Extracorporeal Membrane Oxygenation with difficult sedation criteria and an early diagnosis of mixed delirium. During the case report, we reflect on the pharmacological and non-pharmacological strategies employed to cope with delirium paying special attention to the non-use of physical restraint measures in order to preserve vital support devices (endotracheal tube or Extracorporeal Membrane Oxygenation cannula). The multimodal and multidisciplinary approach, focused on nursing interventions, strict Pain/Agitation/Delirium monitoring and pharmacological measures, as well as the implementation of measures according to the eCASH (early Comfort using Analgesia, minimal Sedatives and maximal Human Care) concept, were effective, resulting in a relatively short admission considering the severity of the patient's condition and the associated complications. Early independent ambulation was achieved prior to transfer to a hospitalisation unit.

In-patient physiotherapy for adults on veno-venous extracorporeal membrane oxygenation - United Kingdom ECMO Physiotherapy Network: A consensus agreement for best practice

Clinical specialist physiotherapists from the five severe respiratory failure centres in England where respiratory extracorporeal membrane oxygenation (ECMO) is practiced have established this consensus agreement for physiotherapy best practice. The severe respiratory failure centres are Wythenshawe Hospital, Manchester; Glenfield Hospital, Leicester; Papworth Hospital, Cambridge; Guy's and St Thomas' Hospital, London and The Royal Brompton Hospital, London. Although research into physiotherapy and ECMO is increasing, there is not a sufficient amount to write evidence-based guidelines; hence the development of a consensus document, using knowledge and experience of the specialist physiotherapists working with patients receiving ECMO. The document outlines safety aspects, practicalities and additional treatment considerations for physiotherapists conducting respiratory care and physical rehabilitation.