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

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Abstract

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.

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Most cited references 24

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Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

Peter Morris, Amanda Goad, Clifton C. Thompson … (2008)

Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit. Prospective cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care. Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission: Protocol, n = 165; Usual Care, n = 165. An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated the protocol within 48 hrs of mechanical ventilation. The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge. Baseline characteristics were similar between groups. Outcome data are reflective of survivors. More Protocol patients received at least one physical therapy session than did Usual Care (80% vs. 47%, p < or = .001). Protocol patients were out of bed earlier (5 vs. 11 days, p < or = .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p < or = .001), and had similar low complication rates compared with Usual Care. For Protocol patients, intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care (p = .025); hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care (p = .006) (intensive care unit/hospital length of stay adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II, vasopressor). There were no untoward events during an intensive care unit Mobility session and no cost difference (survivors + nonsurvivors) between the two arms, including Mobility Team costs. A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care.

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Paresis acquired in the intensive care unit: a prospective multicenter study.

Bernard De Jonghe, Tarek Sharshar, Jean-Pascal Lefaucheur … (2002)

Although electrophysiologic and histologic neuromuscular abnormalities are common in intensive care unit (ICU) patients, the clinical incidence of ICU-acquired neuromuscular disorders in patients recovering from severe illness remains unknown. To assess the clinical incidence, risk factors, and outcomes of ICU-acquired paresis (ICUAP) during recovery from critical illness in the ICU and to determine the electrophysiologic and histologic patterns in patients with ICUAP. Prospective cohort study conducted from March 1999 to June 2000. Three medical and 2 surgical ICUs in 4 hospitals in France. All consecutive ICU patients without preexisting neuromuscular disease who underwent mechanical ventilation for 7 or more days were screened daily for awakening. The first day a patient was considered awake was day 1. Patients with severe muscle weakness on day 7 were considered to have ICUAP. Incidence and duration of ICUAP, risk factors for ICUAP, and comparative duration of mechanical ventilation between ICUAP and control patients. Among the 95 patients who achieved satisfactory awakening, the incidence of ICUAP was 25.3% (95% confidence interval [CI], 16.9%-35.2%). All ICUAP patients had a sensorimotor axonopathy, and all patients who underwent a muscle biopsy had specific muscle involvement not related to nerve involvement. The median duration of ICUAP after day 1 was 21 days. Mean (SD) duration of mechanical ventilation after day 1 was significantly longer in patients with ICUAP compared with those without (18.2 [36.3] vs 7.6 [19.2] days; P =.03). Independent predictors of ICUAP were female sex (odds ratio [OR], 4.66; 95% CI, 1.19-18.30), the number of days with dysfunction of 2 or more organs (OR, 1.28; 95% CI, 1.11-1.49), duration of mechanical ventilation (OR, 1.10; 95% CI, 1.00-1.22), and administration of corticosteroids (OR, 14.90; 95% CI, 3.20-69.80) before day 1. Identified using simple bedside clinical criteria, ICUAP was frequent during recovery from critical illness and was associated with a prolonged duration of mechanical ventilation. Our findings suggest an important role of corticosteroids in the development of ICUAP.

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Long-term complications of critical care.

Sanjay V Desai, Tyler Law, Dale M Needham (2011)

As critical care advances and intensive care unit mortality declines, the number of survivors of critical illness is increasing. These survivors frequently experience long-lasting complications of critical care. As a result, it is important to understand these complications and implement evidence-based practices to minimize them. Database searches and review of relevant medical literature. Critical illness and intensive care unit care influence a wide range of long-term patient outcomes, with some impairments persisting for 5-15 yrs. Impaired pulmonary function, greater healthcare utilization, and increased mortality are observed in intensive care survivors. Neuromuscular weakness and impairments in both physical function and related aspects of quality of life are common and may be long-lasting. These complications may be reduced by multidisciplinary physical rehabilitation initiated early and continued throughout the intensive care unit care stay and by providing patient education for self-rehabilitation after hospital discharge. Common neuropsychiatric complications, including cognitive impairment and symptoms of depression and posttraumatic stress disorder, are frequently associated with intensive care unit sedation, delirium or delusional memories, and long-term impairments in quality of life. Survivors of critical illness are frequently left with a legacy of long-term physical, neuropsychiatric, and quality of life impairments. Understanding patient and intensive care risk factors can help identify patients who are most at risk of these complications. Furthermore, modifiable risk factors and beneficial interventions are increasingly being identified to help inform practical management recommendations to reduce the prevalence and impact of these long-term complications.

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Author and article information

Contributors

Darryl Abrams

Jeffrey Javidfar

Erica Farrand

Linda B Mongero

Cara L Agerstrand

Patrick Ryan

David Zemmel

Keri Galuskin

Theresa M Morrone

Paul Boerem

Matthew Bacchetta

Daniel Brodie

Journal

Journal ID (nlm-ta): Crit Care

Journal ID (iso-abbrev): Crit Care

Title: Critical Care

Publisher: BioMed Central

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Print): 2014

Publication date (Electronic): 27 February 2014

Volume: 18

Issue: 1

Page: R38

Affiliations

[1 ]Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA

[2 ]Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA

[3 ]Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA

[4 ]Department of Clinical Perfusion, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA

[5 ]Department of Nursing, New York-Presbyterian Hospital, New York, NY, USA

[6 ]Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital, New York, NY, USA

[7 ]Division of Thoracic Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA

Article

Publisher ID: cc13746

DOI: 10.1186/cc13746

PMC ID: 4056162

PubMed ID: 24571627

SO-VID: 5694a1a4-b218-48b2-93be-5bbf482f67d7

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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

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Abstract

Introduction

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Results

Conclusions

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Irish Journal of Paramedicine

Most cited references 24

Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

Paresis acquired in the intensive care unit: a prospective multicenter study.

Long-term complications of critical care.

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