**4. Early mobility in ECMO**

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

**3. Skin integrity implications in ECMO patients**

receiving ECMO support to prevent HAPU.

Hospital-acquired pressure ulcers (HAPUs) are seen often in the intensive care setting and continue to be a significant financial burden within the healthcare system. The costs range anywhere from \$500 to \$70,000 per pressure ulcer and can cause length of stay (LOS) to increase by as much as 11 days [26]. While incidence of pressure ulcer development ranges per hospital and patient population, in a database of 710,626 patients, an estimated 3.6% of all patients within the adult critical care and step-down units developed a HAPU [31]. In the acute care setting, a range from 0.4 to 12% has been found [31]. Within the cardiac surgery patients which comprise a portion of patients on ECMO, pressure ulcer incidence as high as 29.5% occurs [26]. The consequences of these pressure ulcers often include infection leading to sepsis, increased pain, further disability, and sometimes death [26]. Although general risk factors such as age, immobility, poor nutritional status, altered sensory perception, moisture, diabetes mellitus, vascular disease, and other comorbidities have been identified, patients receiving ECMO support are also at an increased risk for pressure ulcer development due to multiple factors unique to this population [7, 26]. If patients do undergo cardiothoracic surgery, factors that increase the likelihood of a HAPU include cardiopulmonary bypass time, vasopressor therapy, and body temperature while in the operating room [26]. While on ECMO support, hemodynamic instability related to turning can inhibit appropriate prevention measures, leading to higher incidence of skin breakdown. Nurses can experience apprehension related to routine turning due to the potential of accidental decannulation or risk of worsening hemodynamic instability. High doses of multiple vasopressors that are utilized in patients newly placed on ECMO can lead to decreased peripheral perfusion and have also been shown to increase risk of HAPU. These risk factors make it essential to establish a dedicated skin care regimen for patients

Skin care goals for patients receiving ECMO support should largely be similar to any patient that is in the intensive care setting. "At-risk" patients are identified by using a standardized risk screening tool such as the Braden Scale score and treated with stratified skin care interventions implemented based on severity of risk. Patients with a Braden Scale score of 14 or less (moderate to high risk) receive maximum interventions [31]. Patients need to be turned and repositioned every 2 h as tolerated. Turns should be scheduled and require a multidisciplinary team to ensure patient safety (perfusionist or respiratory therapist to hold ECMO cannulas, nurse for lines, etc.). For patients who do not tolerate a full turn, such as those who are hemodynamically unstable on ECMO, specialty beds have been shown to be very effective in reducing HAPU [20]. These rotation and pressure redistribution beds can be set to rotate every 30 min to different ranges as patients tolerate. Even subtle and small frequent position changes have been shown to reduce HAPUs [7]. Many facilities also use fluidized repositioning devices to offload pressure [31]. Silicone gel adhesive dressings should be utilized when possible and can be applied on the sacrum, elbows, and heels. Specialized heel-protective boots can also be used if available. Nutritional status also has a significant impact on the body's ability to repair wounds. This makes dietitians an essential part of the treatment team to ensure these patients receive adequate nutrition in order to prevent skin breakdown

There are multiple factors all contributing to this patient population's increased risk of HAPU. Staff education, awareness, and motivation are essential in delivering the proper skin care measures in ECMO patients. When possible, a multidisciplinary skin care team can address each of the challenges present in this population

to ensure that adequate prevention measures are being implemented.

**16**

and promote healing.

Early physical rehabilitation and mobility implemented in patients receiving ECMO support have been shown to significantly improve patient outcomes, including decreased LOS in the ICU and hospital, decreased rate of delirium, shorter durations of mechanical ventilation, decreased time to ambulation, increased function, and increased likelihood of returning home to family versus a rehabilitation facility [1, 36]. In spite of the obvious importance of early mobility in ECMO patients, there are limitations to this, particularly hemodynamic instability. The first 24–48 h after the initiation of ECMO are typically the most critical and often do not allow for aggressive physical therapy regardless of the type of ECMO. Most patients during this time are requiring the maximum amount of ventilatory and circulatory support. Eligibility for physical therapy is based upon hemodynamic stability and degree of mechanical and pharmacological support and is specific to each patient case.

Historically, a dual-lumen ECMO catheter would occupy one vessel, usually the internal jugular vein, and provide veno-venous (VV)-ECMO through one cannulation site, allowing bridge-to-transplant patients to participate in early mobility more easily. This was optimal for ambulation because both lower extremities were free and the patients were seen as less high risk for accidental decannulation. However, recently there has been a significant push to mobilize all types of ECMO patients whether they are bridge-to-transplant patients or bridge-to-recovery patients, despite the location and type of cannulation. Whatever the level of physical therapy the patient can tolerate, whether this is passive range of motion or ambulation in the hallway has been shown to improve patient outcomes [1]. Typically, VV-ECMO patients are more stable than VA-ECMO patients, and thus bedside nurses are more comfortable with early mobility in these patients. Patients on VA-ECMO with bifemoral cannulation are some of the most difficult to ambulate. Fear of accidental decannulation, risk of hemodynamic instability, and lack of training in the physical rehabilitation of these patients have all been barriers to early mobilization. However, the study at the University of Maryland demonstrates that physical mobility is safely possible regardless of the type of ECMO or cannulation site [36].

Many institutions who have an established ECMO program have developed a dedicated multidisciplinary team highly trained in the initiation of physical therapy for ECMO patients [36]. These teams typically include a physical therapist, one to two critical care nurses, a perfusionist or respiratory therapist, and a critical care attending physician. When assessing for eligibility, it is helpful to have a standardized screening tool [36]. The University of Maryland developed a protocol for the initiation of ECMO physical therapy [36]. The initial screening was composed of two parts: a medical screening and a physical therapy assessment [36]. The medical screening criteria included hemodynamic stability specific for each patient, coagulopathy: no bleeding at the cannulation site, stable ECMO flows with RN activities, a RASS goal of −1 to 0 with a range (−2 to +2), and stability of cannulation position [36]. The physical therapy assessment included vital signs, assessment of mental status, ECMO flow remaining stable (hip flexion with femoral cannulated lower extremities), and documented ECMO cannulation position [36]. If both of these screens were passed, then the patient met the criteria for further rehabilitation as tolerated [36]. The common physical therapy progression included bed activities/ bed mobility such as passive range of motion and resistive training [36]. If that was well tolerated, then patients progressed to the edge of bed activities including balance training and pre-transfer activities [36]. Following this were sit-to-stand transfers, standing and pre-gait activities, and lastly ambulation [36]. Stabilization devices to secure the ECMO cannulas are recommended before physical therapy is

initiated [1]. Adjustments on the sweep gas flow rates and increased oxygenation settings can be used during physical therapy based on clinician assessment [1].

In the aforementioned study, 167 of the 254 patients supported on ECMO received physical therapy [36]. One hundred and thirty-four of those patients had at least one femoral cannula, while 66 patients had two, 44 of which were on VA-ECMO and 39 of whom were on VA-ECMO with bi-femoral cannulas. Only five patients had a dual-lumen catheter. Only three minor events were recorded during physical therapy: one episode of hypotension and two episodes of arrhythmias. Of the patients who received physical therapy, 109 patients survived hospital discharge, and 26 of those patients were discharged home. The patients who received physical therapy while on ECMO scored higher on their ICU mobility scale (IMS) than the ones who only received physical therapy after decannulation [36]. It is important to note that this was only possible due to a dedicated team of individuals specifically trained for the initiation and completion of physical therapy and mobility in ECMO patients and that the resources necessary to develop this type of team may not exist at all institutions who utilize ECMO support [36].

The Society of Critical Care Medicine developed the ABCDEF (**A**ssess, prevent, and manage pain; **B**oth spontaneous awakening and breathing trials; **C**hoice of analgesia and Sedation; **D**elirium assess, prevent, and manage; **E**arly mobility and exercise; **F**amily engagement/empowerment) bundle as an ICU Liberation Collaborative [25]. A recent study measured the success of this bundle on over 15,000 patients spread across 68 academic, community and federal intensive care units. Patients who received more of the ABCDEF bundle each day showed lower delirium rates, less use of physical restraints, decreased length of mechanical ventilation, avoidance of ICU readmission, increased instances of being discharged to home, and ultimately decreased mortality rates [25]. The significance of this bundle is that it can be applied to every ICU patient regardless of their diagnosis, including the ECMO patient population. Implementing the ABCDEF bundle on ECMO patients potentially increases the likelihood of returning to their baseline function sooner.
