Extracorporeal membrane oxygenation and rehabilitation in patients with COVID-19: A scoping review.

BACKGROUND AND PURPOSE: The coronavirus diseases 2019 (COVID-19) pandemic posed severe difficulties in managing critically ill patients in hospital care settings. Extracorporeal membrane oxygenation (ECMO) support has been proven to be lifesaving support during the SARS-CoV-2 outbreak. The purpose of this review was to describe the rehabilitative treatments provided to patients undergoing ECMO support during the COVID-19 pandemic. METHODS: We searched PubMed and Scopus for English-language studies published from the databases' inception until June 30, 2021. We excluded editorials, letters to the editor, and studies that did not describe rehabilitative procedures during ECMO support. We also excluded those articles not written in English. RESULTS: A total of 50 articles were identified. We ultimately included nine studies, seven of which were case reports. Only two studies had more than one patient; an observational design analyzing the clinical course of 19 patients and a case series of three patients. Extracorporeal support duration varied from 9 to 49 days, and the primary indication was acute respiratory distress syndrome COVID-19-related. Rehabilitative treatment mainly consisted of in-bed mobilization, postural transfers (including sitting), and respiratory exercises. After hospital discharge, patients were referred to rehabilitation facilities. Physiotherapeutic interventions provided during ECMO support and after its discontinuation were feasible and safe. CONCLUSION: The physiotherapeutic treatment of patients undergoing ECMO support includes several components and must be provided in a multidisciplinary context. The optimal approach depends on the patient's status, including sedation, level of consciousness, ECMO configuration, types of cannulas, and cannulation site.

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.

Multidisciplinary approach utilizing early, intensive physical rehabilitation to accelerate recovery from veno-venous extracorporeal membrane oxygenation.

This case demonstrates the benefits of our early, intensive physical rehabilitation intervention to prevent the natural sequelae occurring from prolonged bed rest. This minimizes neuromuscular weakness and optimizes strength, endurance and cardiorespiratory function, thus accelerating recovery from a long duration of femorally cannulated veno-venous extracorporeal membrane oxygenation.

Continuous renal replacement therapy during extracorporeal membrane oxygenation: why, when and how?

PURPOSE OF REVIEW: The use of extracorporeal membrane oxygenation (ECMO) is increasing rapidly. Patients on ECMO have a high risk of developing acute kidney injury (AKI) and needing renal replacement therapy (RRT). The aim of this review is to describe different strategies of combining RRT and ECMO and to outline their advantages and drawbacks. RECENT FINDINGS: Fluid overload is the most common indication for RRT during ECMO, and continuous renal replacement therapy (CRRT) is the most commonly used modality. The optimal timing for initiation of CRRT should be individualized based on degree of fluid overload and severity of AKI-related metabolic derangements. In ECMO patients, CRRT can be provided via an integrated approach (i.e. in-line haemofilter or a fully integrated CRRT device) or a parallel system with separate ECMO and RRT circuits. In-depth knowledge of the resulting intra-circuit pressure changes, risks of air entrapment and haemolysis, and implications for ultrafiltration and solute clearance are essential. There is no evidence that the different methods of combining ECMO and CRRT impact mortality. SUMMARY: In patients on ECMO, CRRT can be provided via an integrated approach or independently via parallel systems. An in-depth understanding of the advantages and drawbacks of the different techniques is required.

Safety and Feasibility of Early Physical Therapy for Patients on Extracorporeal Membrane Oxygenator: University of Maryland Medical Center Experience.

OBJECTIVES: To examine the feasibility and safety of mobilizing patients while on extracorporeal membranous oxygenation support. DESIGN: Retrospective cohort study. SETTING: Medical and Surgical ICUs in a large tertiary care hospital in the United States. PATIENTS: Adults supported on extracorporeal membranous oxygenation from January 2014 to December 2015. MEASUREMENTS AND MAIN RESULTS: We reviewed the medical records from physical therapy, perfusion, and intensivists to obtain the number and type of physical therapy interventions and discharge status; extracorporeal membranous oxygenation type and description of support, cannulation sites; and risk management details of adverse effects, if any. Of 254 patients supported on extracorporeal membranous oxygenation, 167 patients (66.7%) received a total of 607 physical therapy sessions while on extracorporeal membranous oxygenation support. In this cohort, 134 patients (80.2%) had at least one femoral cannula during physical therapy intervention. Sixty-six of the 167 patients (39.5%) were supported on extracorporeal membranous oxygenation with bifemoral cannulas, and 44 (26.3%) were on veno-arterial extracorporeal membranous oxygenation. A dual lumen catheter was only used in five cases. Twenty-five patients (15%) (13 bifemoral cases) participated in standing or ambulation activities. Seventy-five patients (68.8%) who were successfully weaned from extracorporeal membranous oxygenation were discharged to a rehabilitation facility; 26 patients (23.8%) went home. Three minor events (< 0.5%) involving two episodes of arrhythmias and a hypotension event interrupted the therapy sessions, but mobility activities and exercises resumed that day. No major events were reported. CONCLUSIONS: With a highly trained multidisciplinary team and a focus on restoring function, it is feasible and safe to deliver early rehabilitation including standing and ambulation to patients on extracorporeal membranous oxygenation support even those with femoral cannulation sites with veno-arterial extracorporeal membranous oxygenation and veno-venous extracorporeal membranous oxygenation.

Promotion of progressive mobility activities with ventricular assist and extracorporeal membrane oxygenation devices in a cardiothoracic intensive care unit.

BACKGROUND: Progressive mobility (PM) is a clinical intervention that influences complications experienced throughout critical illness. Early PM is a relevant topic in critical care practice literature and was principle to introducing a PM care guideline in an acute cardiothoracic/cardiovascular intensive care unit. PURPOSE: A noted challenge in the cardiothoracic/cardiovascular intensive care unit is caring for acute cardiac and pulmonary failure. Often, these patients require prolonged mechanical circulatory support via extracorporeal mechanical oxygenation or a ventricular assist device. This article describes safe and effective progressive mobilization for patients experiencing MCS in a case study format. This article also highlights how a multidisciplinary clinical team supports mobility practice in specific critical care roles. CONCLUSIONS: Post-intensive care syndrome is composed of various health implications that occur following critical illness. Recent data suggest improved care outcomes when critically ill patients are awake and participate in active physical rehabilitation as early as clinically possible. The case studies presented indicate that mobility, to the point of ambulation, is a feasible clinical expectation when patients present with substantial acute respiratory and cardiac failure and are managed with MCS. CLINICAL IMPLICATIONS: Development of a PM guideline uses a critical appraisal of practice evidence, highlights multidisciplinary collaboration, and increases progression to ambulation. Mobility for complex patients is attainable, as demonstrated in the postguideline outcomes. The PM guideline provides structure to primary caregivers and promotes safe practices. The PM guideline facilitates an advanced level of care, promotes safe practices, champions holistic recovery, and encourages active patient involvement, goals satisfying to both patients and staff.

Feasibility and Safety of Early Physical Therapy and Active Mobilization for Patients on Extracorporeal Membrane Oxygenation.

Physical therapy (PT) and early mobilization for critically ill patients have been popularized to decrease the length of hospital stay and to improve the quality of life after discharge. We reviewed our experience of PT and active mobilization for patients on extracorporeal membrane oxygenation (ECMO) in terms of its technical feasibility and safety. Study endpoints were safety events during PT and PT interruptions due to unstable vital signs. Of the eight patients, one patient (12.5%) had venoarterial ECMO, seven patients (87.5%) had venovenous ECMO. Among total of 62 sessions including 31 sessions (50%) of passive range of motion and electrical muscle stimulation, 17 sessions (27.4%) were performed for patients who were sitting in bed or on the edge of bed, two sessions (3.2%) were for strengthening in sitting, 11 sessions (18%) were for standing or marching in place, one session (2%) was for walking. Eight sessions (13%) of sitting were supported with invasive mechanical ventilation. Three sessions (5%) were stopped due to tachycardia (n = 1) and tachypnea (n = 2). There was no clinically significant adverse event in patients. Thus, early PT and mobilization for patients on ECMO might be feasible and safe at an experienced ECMO center.

Early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study.

INTRODUCTION: Critical illness is a well-recognized cause of neuromuscular weakness and impaired physical functioning. Physical therapy (PT) has been demonstrated to be safe and effective for critically ill patients. The impact of such an intervention on patients receiving extracorporeal membrane oxygenation (ECMO) has not been well characterized. We describe the feasibility and impact of active PT on ECMO patients. METHODS: We performed a retrospective cohort study of 100 consecutive patients receiving ECMO in the medical intensive care unit of a university hospital. RESULTS: Of the 100 patients receiving ECMO, 35 (35%) participated in active PT; 19 as bridge to transplant and 16 as bridge to recovery. Duration of ECMO was 14.3 ± 10.9 days. Patients received 7.2 ± 6.5 PT sessions while on ECMO. During PT sessions, 18 patients (51%) ambulated (median distance 175 feet, range 4 to 2,800) and 9 patients were on vasopressors. Whilst receiving ECMO, 23 patients were liberated from invasive mechanical ventilation. Of the 16 bridge to recovery patients, 14 (88%) survived to discharge; 10 bridge to transplant patients (53%) survived to transplantation, with 9 (90%) surviving to discharge. Of the 23 survivors, 13 (57%) went directly home, 8 (35%) went to acute rehabilitation, and 2 (9%) went to subacute rehabilitation. There were no PT-related complications. CONCLUSIONS: Active PT, including ambulation, can be achieved safely and reliably in ECMO patients when an experienced, multidisciplinary team is utilized. More research is needed to define the barriers to PT and the impact on survival and long-term functional, neurocognitive outcomes in this population.

Active rehabilitation during extracorporeal membrane oxygenation as a bridge to lung transplantation.

BACKGROUND: Patients with end-stage lung disease often progress to critical illness, which dramatically reduces their chance of survival following lung transplantation. Pre-transplant deconditioning has a significant impact on outcomes for all lung transplant patients, and is likely a major contributor to increased mortality in critically ill lung transplant recipients. The aim of this report is to describe a series of patients bridged to lung transplant with extracorporeal membrane oxygenation (ECMO) and to examine the potential impact of active rehabilitation and ambulation during pre-transplant ECMO. METHODS: This retrospective case series reviews all patients bridged to lung transplantation with ECMO at a single tertiary care lung transplant center. Pre-transplant ECMO patients receiving active rehabilitation and ambulation were compared to those patients who were bridged with ECMO but did not receive pre-transplant rehabilitation. RESULTS: Nine consecutive subjects between April 2007 and May 2012 were identified for inclusion. One-year survival for all subjects was 100%, with one subject alive at 4 months post-transplant. The 5 subjects participating in pre-transplant rehabilitation had shorter mean post-transplant mechanical ventilation (4 d vs 34 d, P = .01), ICU stay (11 d vs 45 d, P = .01), and hospital stay (26 d vs 80 d, P = .01). No subject who participated in active rehabilitation had post-transplant myopathy, compared to 3 of 4 subjects who did not participate in pre-transplant rehabilitation on ECMO. CONCLUSIONS: Bridging selected critically ill patients to transplant with ECMO is a viable treatment option, and active participation in physical therapy, including ambulation, may provide a more rapid post-transplantation recovery. This innovative strategy requires further study to fully evaluate potential benefits and risks.

Physical therapy and rehabilitation issues for patients supported with extracorporeal membrane oxygenation.

Extracorporeal Membrane Oxygenation (ECMO) is widely used to support patients who have failed conventional therapies for cardio-respiratory failure. Patient immobility during management of critical illness and ECMO support can result in physical impairment that can lead to prolonged hospitalization and poor functional outcomes for ECMO survivors. Although little information regarding the role of physical therapy in improving functional outcomes for ECMO patients is available, early intervention with physical therapy may decrease duration of hospitalization and improve functional outcomes for patients supported with ECMO.

Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach.

OBJECTIVE: Extracorporeal membrane oxygenation as a bridge to lung transplantation has traditionally been associated with substantial morbidity and mortality. A major contributor to these complications may be weakness and overall deconditioning secondary to pretransplant critical illness and immobility. In an attempt to address this issue, we developed a collaborative program to allow for active rehabilitation and physical therapy for patients requiring life support with extracorporeal membrane oxygenation before lung transplantation. DESIGN: An interdisciplinary team responded to an acute need to develop a mechanism for active rehabilitation and physical therapy for patients awaiting lung transplantation while being managed with extracorporeal membrane oxygenation. We describe a series of three patients who benefited from this new approach. SETTING: A quaternary care pediatric intensive care unit in a children's hospital set within an 800-bed university academic hospital with an active lung transplantation program for adolescent and adult patients. PATIENTS, INTERVENTIONS, AND MAIN RESULTS: Three patients (ages 16, 20, and 24 yrs) with end-stage respiratory failure were rehabilitated while on extracorporeal membrane oxygenation awaiting lung transplantation. These patients were involved in active rehabilitation and physical therapy and, ultimately, were ambulatory on extracorporeal membrane oxygenation before successful transplantation. Following lung transplantation, the patients were liberated from mechanical ventilation, weaned to room air, transitioned out of the intensive care unit, and ambulatory less than 1 wk posttransplant. CONCLUSIONS: A comprehensive, multidisciplinary system can be developed to safely allow for active rehabilitation, physical therapy, and ambulation of patients being managed with extracorporeal membrane oxygenation. Such programs may lead to a decreased threshold for the utilization of extracorporeal membrane oxygenation before transplant and have the potential to improve conditioning, decrease resource utilization, and lead to better outcomes in patients who require extracorporeal membrane oxygenation before lung transplantation.

[When the heart and/or the lung fails: the ECMO]. / Quand le coeur et/ou les poumons défaillent: oxygénation extracorporelle par "ECMO".

The Extra corporeal membrane oxygenation (ECMO) was initially proposed as a technique of respiratory support using an external membrane oxygenator. With time, it has also become a technique of cardiorespiratory support to ensure both gas exchange and organ perfusion until the restoration of organs function. This technical assistance can be central or peripheral and provides a partial or total circulatory support. The circuit includes a non occlusive centrifugal pump, an oxygenator for an enrichment of O2 and elimination of CO2 and cannulas for drainage and re-injection. Recently, the establishment of such assistance became possible percutaneously, allowing it to be initiated at the intensive care bedside or even before in-hospital admission.