Mobilisation & Physiotherapy

Rehabilitation Guideline for patients on ECMO

This Guideline describes the skills and knowledge required to assess for, plan, implement and evaluate, safe and effective mobilisation and exercise provision for patients on ECMO.

A multidisciplinary team approach including physiotherapists, intensivists, ECMO clinical nurse specialist, and bedside nursing staff should be included in the planning and implementation of rehabilitation of patients on ECMO. It is recommended that out of bed rehabilitation of ECMO patients should include a Senior Physiotherapist (minimum Grade 2 with experience in mobilisation of patients on ECMO).

Senior Physiotherapist required knowledge and skills:

• A broad and coherent theoretical and technical knowledge of cardiorespiratory anatomy and physiology, relevant medical terminology and abbreviations for ECMO, cardiorespiratory dysfunction and physiotherapy treatment options
• Thorough working knowledge of indications, contraindications and precautions to mobilizing and exercising the critically-ill patient
• Thorough working knowledge of altering ventilator settings and alarm limits to allow for mobilizing and exercising the critically-ill patient including troubleshooting of ventilator during treatment, where patients are on mechanical ventilation
• Good working knowledge of the evidence base for mobilizing and exercising the critically-ill patient
• Good working knowledge of Alfred Health policies and procedures that relate to the physiotherapist’s role in mobilizing and exercising the critically-ill patient which include infection control protocols, OHS protocol analyse and evaluate information to complete mobilising and exercising the critically-ill patient in a safe and effective way
• Communicate effectively with patients, co-workers and supervisors
• Demonstrate clear and accurate documentation
• Manage risk to self and patient
• Identify any limitations to personal competence as it applies to the job role and consult with a more senior staff member as required
• Contraindications to rehabilitation of patients on ECMO:
• Haemodynamic or respiratory instability (Physiological parameters outside of set ECMO Daily Medical Orders on ICU Chart, serious arrhythmias (eg VT) or ventricular rate > 150, high inotrope requirements, SpO₂ < 90% at rest
• Bleeding at ECMO cannula site
• Poor stability at ECMO cannula site/evidence of movement of cannula
• Unstable ECMO flows with basic nursing care
• In addition: Out of bed mobilisation not to occur if RASS outside target (-1 to +1), lower limb strength ≤ 3/5, lack of independent sitting balance, patient delirium impacting on patients ability to follow commands

The “APLANB” approach is used for mobilisation of patients on ECMO.

A = Assessment

P = Preparation

L = Leader

A = Airway, ECMO and emergency equipment

N = Number of staff and skill mix

B = Backup plan

Assessment:

Screening for suitability for mobilisation and exercising the patient on ECMO:

• Haemodynamic and respiratory stability and targets set by ICU ward round (including but not limited to: HR and rhythm, inotropic support, MAP, RR, FiO₂, SpO₂, ABG’s). Review “ECMO Daily Medical Orders” for targets.
• ECMO type (VA versus VV) and cannulation site noted and assessed for no signs of bleeding at cannulation site
• Baseline ECMO settings and changes over past 24 hours (ECMO flow, FGF, FiO₂)
• Stable ECMO flows with nursing care/PAC/suction
• Stable ECMO flows with hip flexion to 90 degrees if femoral cannulation
• Assessment of clotting profile (APTT 50-70) and no active bleeding
• Assessment of sedation level (aiming for RASS -1 to +1)
• Delirium screening (CAM-ICU –ve)
• Assess premorbid mobility level, current strength (MRC) and bed mobility. For out of bed mobility, patients require independent sitting balance on the edge of the bed, and lower limb strength ≥ 3/5.

Preparation

• Case discussion with the MDT (agreement on suitability, arrangement of time for mobilisation, any necessary medications to be given prior to mobilisation, dressings or pads that need to be applied, team members required)
• Equipment (e.g. gait aide, tilt table, in-bed cycle, chair for behind patient, portable monitors)
• Physical environment ready
• Ensure treating ICU Medical team are in the unit at the time of intervention for out of bed mobilisation
• Patient aware of the plan before commencing mobilisation

Leader

Clear communication and designation of roles within the team is required. Physiotherapists will generally be responsible for assisting the patients with bed mobility, passive and active exercise programs, balance exercises, practice of transfers, marching on the spot and ambulation away from the bedside. Other team roles will include monitoring of vital signs and ECMO parameters, supporting the ECMO cannula, supporting other lines/mechanical ventilation and assisting with chair behind patient. Once all team members have indicated that they are ready for the mobilisation, the nurse that is monitoring the ECMO cannula should be the team member that prompts the commencement of mobilisation.

Airway, ECMO and emergency equipment:

• Designated staff members to the roles of airway (if mechanically ventilated) and ECMO cannula.
• Check that the airway and ECMO cannula are secure prior to mobilisation.
• All emergency equipment is present
• Provide suction prior to mobilisation as required

Number of Staff and right skill mix:

• Number of staff from the MDT available with required skill mix to allow continuous monitoring of the patient during mobilisation
• Clearly articulate and agree on target ranges for physiological parameters during mobilisation

Backup plan:

• Discussion with the MDT and patient regarding the plan prior to the commencement of mobilisation. Identify when cessation of mobilizing and exercising the patient within a session may be needed and take appropriate action

Treatment dosage and intensity should align with the specific goals of the treatment, whether this is enhanced respiratory status, maintenance of global function or recovery of strength, endurance or balance deficits.

Documentation: should include assessment findings as outlined above, including MRC and highest mobility level (IMS), treatment dosage and intensity (Borg RPE) and response to mobilisation.