Early mobilization in patients on venoarterial extracorporeal membrane oxygenation: A scoping review

Table 4 Characteristics of included studies

Authors/date/study type/appraisal	Sample/reason for VA-ECMO	Mobilization and PT	Frequency	Results	Critique	Complications during mobilization
Abrams et al[30]; retrospective cohort study; NOS: 6; separate data on VA-ECMO: No	A total of 100 ECMO patients. A total of 35 patients were immobilized (12 VA-ECMO patients/23 VV-ECMO patients), 5 VA-ECMO patients and 14 VV-ECMO patients for transplantation. A total of 7 VA-ECMO patients and 9 VV-ECMO patients for recovery	No mobilization or passive range of motion of extremities; turning in bed (including active-assisted range of motion of extremities); sitting in bed with the head of bed elevated; sitting on the edge of the bed with feet on floor; sitting in a chair; standing; marching on the spot; ambulation	7.2 ± 6.5 PT sessions while on ECMO; 2.8 PT sessions per week	During PT sessions, 18 patients (51%) ambulated [Distance: 53.34 m (IQR 11.43-86.87)]. During ECMO, 23 (66%) patients were liberated from invasive mechanical ventilation. Of the 16 recovery patients, 14 (88%) survived to discharge; 10 transplant patients (53%) survived to transplantation. 90% of survivors were discharged. In total, of the 23 survivors, 13 (57%) went home, 8 (35%) to acute rehabilitation, and 2 (9%) to subacute rehabilitation	Mobilization of patients on ECMO is safe and contributes to faster weaning from invasive mechanical ventilation and faster recovery	There were no PT-related complications
Abrams et al[2]; retrospective cohort study; NOS: 6; separate data on VA-ECMO: No	A total of 511 ECMO patients (184 VA-ECMO patients and 327 VV-ECMO patients). A total of 177 patients were immobilized, 33/177 VA-ECMO patient with femoral cannula. A total of 124/177 for transplantation and 53/177 for recovery	Nothing (lying in bed); sitting in bed; passively moved to chair; sitting over edge of bed; standing weight bearing through the feet in the standing position; transferring bed to chair; marching on spot; walking with assistance of 2 or more people; walking with assistance of 1 person; walking independently with a gait aid; walking independently without a gait aid	A total of 2.706 PT sessions; 108 (61%) patients, who walked participated in 1.284. The 34 patients, with femoral cannulas, participated in 250 sessions	BTT (OR = 17.2, 95%CI: 4.12–72.1), VV-ECMO (OR = 2.83, 95%CI: 1.29–6.22) and higher Charlson comorbidity index (OR = 1.53, 95%CI: 1.07–2.19) were associated with increased odds of achieving out-of-bed exercises vs in-bed PT. Invasive mechanical ventilation (OR = 0.11, 95%CI: 0.05–0.25) and femoral cannulation (OR = 0.19, 95%CI: 0.04–0.92) were associated with decreased odds of performing out-of-bed activities. IMS score on ECMO: BTT 7 (5–9); bridge to recovery 3 (1–5), (P= 0.001)	ECMO patients’ mobilization is safe. VenoVenous ECMO, and higher Charlson comorbidity index were associated with increased odds of achieving out-of-bed vs in-bed PT. However, invasive mechanical ventilation and femoral cannulation were associated with decreased odds of performing out-of-bed activities	A total of 13 isolated bleeding events at the cannula insertion site, (10 involved femoral cannulas. Stroke in 2 patients cardiac arrest in 1 VV-ECMO patient
Braune et al[26]; prospective observational study; NOS: 4; separate data on VA-ECMO: No	A total of 115 ECMO patients [VA-ECMO (n = 63), VV-ECMO (n = 26), veno-venous extracorporeal CO2 removal (n = 12), veno-arterial-extracorporeal CO2 removal (n = 10)]. A total of 43 patients mobilized, 17 VA-ECMO patients. Bridge for transplantation: 2 patients	Functional strengthening, breathing exercises, active upper and lower limb exercises, endurance exercises, and progressing functional mobility; IMS	Total mobilization sessions IMS ≥ 3, during ECMO: 72 sessions on VA-ECMO patients. Mobilization median IMS ≥ 3 was 130 minutes (IQR 44–215)	A total of 43 (37.4%) ECMO patients were actively immobilized, with an activity level on the IMS of ≥ 3. The 108 patients (93.9%) had femoral cannulation. Duration of activities (IMS ≥ 3): 130 minutes (IQR: 44–215). All mobilizations were applied by a multi-professional ECLS team. A total of 3 members involved (IQR: 3–4). Mobilization was significantly associated with the severity of illness (P ≤ 0.01)	ECMO patients’ early mobilization is safe and require multidiscipline team. Sedation was the main reason for non-mobilization	Bleeding from cannulation site during mobilization: 6.9%. During mobilization, one accidental episode of the femoral cannula displacement
Hayes et al[3]; pilot randomized controlled trial; PEDro scale: 7; separate data on VA-ECMO: Yes for the sessions frequency	A total of 15 ECMO patients [VA-ECMO (n = 10), VV-ECMO (n = 5)]. A total of 7 patients participated in an intense rehabilitation program and 8 in classic PT. Bridge for recovery	Intervention program: Progression of exercises to the highest level of mobility that the patient could tolerate. Classic PT program: Passive range of motion exercises to unstable or sedated patients. To the stable patients, rehabilitation consisted of resistance and active exercises and if was capable, sitting on the edge of the bed, standing and ambulation	The intervention program was applied for 7 days. Rehabilitation was applied for about 1 hour per day and there was a minimum of 20 minutes for passive exercise and 30 minutes for active exercise	There was no difference between the groups concerning the respiratory, hemodynamic, or ECMO parameters. The intensive rehabilitation group was exercised more than the standard care group (mean = 28.7 minutes vs 4.2 minutes, P < 0.0001). Treatment group [12.9 (7.2-16.7) days] had lower length of stay in relation with the standard care group [21.4 (15.5-38.5) days] (P= 0.05). Respiratory rate [r (SE): -1.4 (0.35)] and maximum tidal volume [r (SE): 137.34 (38.9)] during PT were significantly associated with the highest level of mobility (IMS) (P ≤ 0.002). The 43% of the intensive rehabilitation group was mobilized out of bed during ECMO in contrast to the standard care group, who was none. Higher mobility levels were also associated with lower noradrenaline dosage [r (SE): -1.49 (0.50)] (P = 0.04), less sedation [r (SE): 0.75 (0.09)] (P < 0.0001), longer exercise duration (mean: 28.7 minutes vs 4.2 minutes), and lower ECMO fresh gas flow [r (SE): -0.64 (0.22)] (P = 0.004)	The physiological parameters associated with the highest level of mobility (IMS) during PT, were respiratory rate and maximum tidal volume. Generally, early mobilization has low impact on physiological factors of ECMO patients	No complications mentioned
Ko et al[27]; retrospective study; NOS: 6; separate data on VA-ECMO: Yes	A total of 8 ECMO patients. A total of 8 patients were mobilized (1 VA-ECMO patient and 7 VV-ECMO patients). The 1 VA-ECMO (central) patients and 2 VV-ECMO for transplantation. A total of 5 VV-ECMO for recovery	A total of 62 sessions: 31 sessions (50%) of passive mobilization (VV-ECMO and VA-ECMO) and electrical muscle stimulation (VV-ECMO); 17 sessions (27.4%) of sitting in bed or on the edge of bed (VV-ECMO and VA-ECMO); 2 sessions (3.2%) of strengthening while sitting (VV-ECMO); 11 sessions (18%) of standing or marching in place (VV-ECMO); 1 session (2%) for walking (VV-ECMO)	A total of 62 sessions. The sessions’ frequency and duration it is not mentioned	The early mobilization of ECMO patients is safe and beneficial. It contributes to the better functionality and physical situation of the ECMO patients. The ECMO flow rate was higher during PT (2.53 ± 0.71) in contrast before (2.36 ± 0.65) (P = 0.013). However, the sweep gas flow rate of ECMO was not different before PT (4.89 ± 1.78) and during PT (4.90 ± 1.78) (P = 0.321)	The early mobilization of ECMO patients is safe and contributes to faster rehabilitation	Three sessions (5%) were interrupt due to tachycardia (n = 1) and tachypnea (n = 2). There was no clinically significant adverse event
Mayer et al[28]; retrospective study; NOS: 6; separate data on VA-ECMO: Yes for the sessions frequency	A total of 315 ECMO patients. A total of 218 patients were mobilized (venoarterial: 84 patients, venovenous single lumen: 53 patients, venovenous double lumen: 62 patients. Hybrid (venoarterial-venovenous): 19 patients). Bridge for recovery	IMS; nothing (lying in bed); sitting in bed; passively moved to chair; sitting over edge of bed; standing; transferring bed to chair; marching on spot; walking with assistance of 2 or more people; walking with assistance of 1 person; walking independently with a gait aid; walking independently without a gait aid	Sessions’ frequency: 4-7 times per week. Sessions’ average: 7.4 (SD: 12.7). Sessions’ frequency on ECMO: Mean: 0.41 (SD: 0.24). Occupational therapy: Session number on ECMO: Mean: 2.2 (SD: 5.5). Sessions’ frequency on ECMO: Mean: 0.24 (SD: 0.14)	A total of 218 patients (69%) had at least 1 PT session. A total of 70 patients (22%) received rehabilitation after ECMO therapy and 27 patients (9%) did not participate in rehabilitation. Survivors had mobility levels and more positive rate of change in mobility over the first 4 sessions than individuals who died in the hospital (2.8 vs 0.38, df = 199, t = 8.24, P < 0.001). The patients that could sit on the edge of the bed and walk for > 45 m were more likely to survive (47% vs 13%, χ2 = 156, P < 0.0001) than those who did not (26% vs 3.5%, χ2 = 80, P < 0.0001)	The ECMO survivors who participated in early rehabilitation achieved higher mobility levels and faster rehabilitation	No adverse events reported
Munshi et al[13]; retrospective cohort study; NOS: 5; separate data on VA-ECMO: Yes for the mobilization protocols	A total of 107 patients on ECMO. A total of 61 Acute Respiratory Distress Syndrome patients on ECMO. A total of 57 on VV-ECMO and 4 on V- VA-ECMO. A total of 50 patients (47 on VV-ECMO and 3 on VV-A-ECMO) were mobilized. Bridge: 61 patients for recovery	Passive mobilization; active mobilization; sitting; standing; IMS	It is not described	The 18 patients achieved an activity level of 2 or higher (active exercises in bed), and 8 patients achieved an activity level 4 or higher (actively sitting over the side of the bed). ICU physiotherapy (OR = 0.19, 95%CI: 0.04–0.98), Acute Physiology and Chronic Health Evaluation II score (OR = 1.13, 95%CI: 1.01–1.26), and sex (OR = 8.4, 95%CI: 1.71–41.7) were significantly associated with ICU mortality	The early mobilization of the ECMO patients is safe and was related with lower mortality	No adverse events reported
Pasrija et al[29]; retrospective study; NOS: 6; separate data on VA-ECMO: Yes	A total of 104 VA-ECMO patients. A total of 15 patients were mobilized out of bed. Bridge for recovery	Strength exercises; bed to chair transferring; walking	It is not described	Of the 104 VA-ECMO patients, 15 were immobilized with a femoral arterial cannula. Time duration from cannulation to out of bed exercises was 3 (0-26) days. Time duration from cannulation to initial mobilization was 4 (1-42) days. Median distance of the first postcannulation walk: 91.44 m. There wasn’t any decrease in ECMO flow and ECMO speed during or after ambulation. ICU stay: 12 days. Hospitalization: 21 days. One-year survival was 100% for ambulating patients	Selected VA-ECMO patients can be safely ambulated even though they have arterial cannulation	A total of 3 minor bleeding events (20%). There were no major bleeding episodes, vascular complications, or cannula displacement events related to mobilization
Rinewalt et al[31]; case report; 18-criteria checklist by the Delphi panel: 4 yes; separate data on VA-ECMO: Yes	A total of 1 VA-ECMO patient. Bridge for heart transplantation	Standing and isometric upper body exercises according to his personalized program; flexion of the femoral region (sitting, walking) was avoided	It is not described	The patient underwent VA-ECMO as a bridge to heart transplantation. While on ECMO, he participated in a pt. program that included tilt bed with lower body support and excluded hip flexing to secure ECMO cannulas. The patient was discharged home 21 days after heart transplantation, due to his aggressive rehabilitation while he was on VA-ECMO support	Early mobilization contributed to the faster recovery of the transplanted patient	No complications mentioned
Shudo et al[32]; case report; 18-criteria checklist by the Delphi panel: 4 yes; separate data on VA-ECMO: Yes	A total of 1 VA-ECMO (central) patient. Bridge for heart and lung transplantation	Tilt Bed: Day 1: 45° incline and 40% weight bearing (30’). After 7 days: 180° incline and full weight bearing (30’). After 10 days: Standing and walking beside the bed with assistance. After 14 days: Walking (30’) with minimal assistance and strengthening exercises	19 days	Successful heart-lung transplant after 19 days of VA-ECMO support. Discharged from hospital 12 days after transplant	Mobilization led to better recovery of the patient after heart transplantation	No complications mentioned
Wells et al[35]; retrospective cohort study; NOS: 6; separate data on VA-ECMO: No	A total of 254 ECMO patients. A total of 167 patients were immobilized (98/167 on VV-ECMO and 69/167 on VA-ECMO). Bridge: 167/167 recovery	Range of motion strength and endurance exercises, stretching, breathing exercises. Mobilization in bed; activities and sitting at the edge of the bed; sitting, standing and transferring; transfers to other surfaces; standing activities; walking (gait training, speed, endurance)	A total of 268 therapeutic exercises; 170 bed mobilization; 100 bedside mobilization; 106 sitting–standing interventions; 39 standing– transfers; 98 standing activity interventions; 37 walking	The 667% of the ECMO patients were mobilized. A total of 607 physiotherapy sessions were performed. A total of 134 patients (80.2%) had at least one femoral cannula during their mobilization. A total of 25 patients (15%) participated in standing or walking. A total of 8 patients (4.8%) were ambulated 91.44 (9.144-304.8) m. A total of 75 patients (68.8%) who were successfully weaned from ECMO were discharged to a rehabilitation unit and another 26 patients (23.8%) went home	Early mobilization of ECMO patients is safe. Patients who were early mobilized had higher IMS scores and greater functional capacity during and after weaning from ECMO support compared to patients who started rehabilitation after ECMO weaning	There were 3 minor events (< 0.5%). A total of 2 arrhythmia episodes; 1 hypotension event

BTT: Bridge to transplant; ECMO: Extracorporeal membrane oxygenation; ICU: Intensive care unit; IMS: Intensive care unit mobility scale; IQR: Interquartile range; NOS: Newcastle Ottawa Scale; OR: Odds ratio; PT: Physical therapy; r: Regression coefficient; VA-ECMO: Veno-arterial extracorporeal membrane oxygenation; VV-ECMO: Veno-venous extracorporeal membrane oxygenation.