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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 122-125

Physiotherapy during and after extracorporeal membrane oxygenation support


1 Post Graduate, Department of Physiotherapy, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
2 Associate Professor, Department of Physiotherapy, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission29-Aug-2019
Date of Decision04-Nov-2019
Date of Acceptance05-Nov-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Veena Kiran Nambiar
Department of Physiotherapy, M. S. Ramaiah Medical College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_67_19

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  Abstract 


Extracorporeal membrane oxygenation (ECMO) is a mechanical heart and/or lung support by a modified heart–lung machine, which enables blood circulation outside the body. The use of ECMO as rescue therapy for the patient in cardiac shock both before and following cardiac surgeries has been increasing over the past two decades. The purpose of this case study is to sensitize the role of the physiotherapist in interventions during and after ECMO in a postoperative cardiac surgery patient. Physical therapy interventions can be provided safely to patients on portable ECMO. These interventions were focused on preventing the negative sequelae of bed rest, improving strength and endurance, preventing ECMO complications as well as improving the level of consciousness and psychological well-being.

Keywords: Coronary artery bypass grafting, Extracorporeal membrane oxygenation, Physiotherapy


How to cite this article:
Bhat K, Nambiar VK. Physiotherapy during and after extracorporeal membrane oxygenation support. Indian J Phys Ther Res 2019;1:122-5

How to cite this URL:
Bhat K, Nambiar VK. Physiotherapy during and after extracorporeal membrane oxygenation support. Indian J Phys Ther Res [serial online] 2019 [cited 2020 Jun 1];1:122-5. Available from: http://www.ijptr.org/text.asp?2019/1/2/122/273727




  Introduction Top


The incidences of myocardial dysfunction are about 3%–5% after cardiac surgeries. There are an increasing number of cardiac surgeries being performed in elderly individuals. In this population, improving function and quality of life are more pressing goals than prolonging life.[1],[2] These patients could wean from cardiopulmonary bypass with inotropes or intra-aortic balloon counterpulsation majorly. However, 1% of these patients still have refractory cardiac and/or pulmonary dysfunction and need advanced mechanical circulatory support.[1]

Extracorporeal membrane oxygenation (ECMO) is a mechanical circulatory support given after treatment, which provides blood flow support and extracorporeal gas exchange at the same time. These circuits can even replace the function of the heart and lungs for a considerable period.[3]

As ECMO technique is more widely applied, physiotherapists may be required to treat these patients in an intensive care unit (ICU) during and after ECMO support therapy.[4]

Muscle weakness due to prolonged immobility, critical illness or femoral vessel cannulation and lower-limb sequelae, vascular injuries, sensory deficits, spinal cord ischemia, or infarct can be the possible complications after ECMO therapy.[4],[5],[6]

Attachments such as ECMO cannula may limit treatment options, depending on insertion location.[5] Physiotherapy interventions in respiratory failure on ECMO are supported by literature, but the role of a physiotherapist is not well-sensitized postcardiac surgeries or cardiac arrest.[7],[8],[9]

The role of a physiotherapist during Phase 1 cardiac rehabilitation is well documented and protocol based. However, the recent emerging techniques of application such as ECMO on cardiac patients are on the rise in India. There is scarce evidence and protocol in literature about physiotherapy application when a patient is on ECMO. Hence, through this case report, a few highlights of patient management when a cardiac patient is on ECMO have been focused upon.


  Case Report Top


A 62-year-old male admitted with a history of acute onset of moderate retrosternal nonradiating chest discomfort with sweating and easy fatigue, which lasted for 25–40 min. Recurrence of a similar episode with exertional dyspnea (New York Heart Association III) of 25–30 min was reported on the day of admission. The patient was a known case of type 2 diabetes mellitus and hypertension with no history of smoking or alcohol consumption.

On examination, the patient was conscious, cooperative, moderately built, nourished with blood pressure (BP) of 100/70 mm Hg, pulse rate of 100/min, respiratory rate (RR) of 21/min, with no sign of pallor/icterus/clubbing/edema.

Cardiac investigation revealed sinus rhythm and ST elevation in V1–V3 leads in electrocardiography. Echocardiography showed mild left ventricular (LV) ejection fraction of 40%. Angiogram revealed triple-vessel coronary artery disease. The patient had ventricular tachycardia (VT) and cardiac arrest for which cardiopulmonary resuscitation was started. The patient was intubated and put on ventilator and intra-aortic balloon pump support. For the total occlusion of LAD, angioplasty was done with Promus PREMIER 2.5 mm × 38 mm. The patient persisted to be in cardiogenic shock with ill-sustained VT for which the patient was initiated on venoarterial ECMO support (vascular access through the right femoral artery and right femoral vein, respectively).

Ultrasonography showed mild pleural effusion. As the patient was getting hemodynamically stable, ECMO and Intra aortic balloon pump (IABP) were weaned off and removed. Toe discoloration was noted despite no significant obstruction in color Doppler. However, blood culture sensitivity tests showed the presence of Klebsiella pneumoniae. The patient had recurrent sustained VT with LV dysfunction. Hence, cardioverter-defibrillator was implanted, and rehabilitation was started on the third postoperative day.

The key findings considered were:

  • Medications – heparin, mild sedatives, and inotropes
  • For Hemodynamic stability, parameters like heart rate (HR), BP, and relative risk inotropes were considered. HR was maintained between 85 and 99 beats/min, BP at 110/70–130/80 mm Hg, and RR 20–34 breaths/min.
  • Activated clotting time was between 400 and 500 s.
  • ECMO flow and oxygen sweep rate was changed as per the medical concerns.
  • X-ray findings were considered periodically.


Everyday evaluation and treatment were planned which are described in [Table 1].
Table 1: Therapist driven protocol of care

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  Results Top


[Table 2] describes the brief outline of outcomes of clinical findings of the patient on ECMO.
Table 2: Brief outline of clinical findings of the patient on ECMO

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  Discussion Top


Rehabilitation was provided during and after ECMO therapy as a course of Phase 1 cardiac rehabilitation post-percutaneous transluminal coronary angioplasty (PTCA). We found a significant improvement in the hemodynamic parameters and ventilator weaning timings. Bronchial hygiene techniques and positioning were a major contributing factor to the improvement of respiratory parameters.

Unfortunately, in certain circumstances patients are not mobilized due to the lack of supportive evidence on early mobilization during ECMO treatment post cardiac surgeries and arrest [8] since mobilization and ambulation of patient was difficult with older generations of extracorporeal technology. In addition, traditional ECMO configurations involved femoral cannulation, which is larger and less flexible, so the chances of dislodgment are more. Femoral cannulation is not an absolute contraindication to ambulation, but it is certainly not optimal. The upper-body configuration is a feasible approach, which also facilitates mobilization by avoiding cannula complications and increases extracorporeal gas exchange efficiency.[7],[10]

ECMO patients are more likely to be sensitive to the oxygen demand required by position changes, so the chances of getting all these safety events are majorly in sitting or standing.[6],[11]

Planning for rehabilitation was based on guidelines given from the United Kingdom ECMO Physiotherapy Network, and post-ECMO removal treatment was planned according to the basic concept of postcardiac surgery rehabilitation and with some modification due to significant lower-limb weakness.[4],[3],[11],[12]

Auscultatory findings were the main indicator for early detection of recovery. It was noted that there was an association with delirium, which might be due to impaired functional status, prolonged hospitalization, and delayed patient recovery which justifies the adoption of strong measures for its prevention. It was seen that age, psychosocial factors also contribute to innate physical fitness which affects the ability and motivation of the patient to participate in regular physical activity.[2]

There is an increased interest and demand for early rehabilitation for patients in ICU. As portable awake ECMO used after cardiac surgeries is becoming more common, the need for mobilization with ECMO to maintain or improve functional and psychological well-being increases. This case demonstrated that with good teamwork, early rehabilitation in the patient with ECMO is safe and feasible. It was also noticed that the patient had greater motivation in the supervised exercise regimen over only the instruction or suggestion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Napp LC, Kühn C, Bauersachs J. ECMO in cardiac arrest and cardiogenic shock. Herz 2017;42:27-44.  Back to cited text no. 1
    
2.
Niemeyer-Guimarães M, Cendoroglo MS, Almada-Filho CM. Course of functional status in elderly patients after coronary artery bypass surgery: 6-month follow up. Geriatr Gerontol Int 2016;16:737-46.  Back to cited text no. 2
    
3.
Fiddler H, Williams N. ECMO: A physiotherapy perspective. Physiotherapy 2000;86:203-8.  Back to cited text no. 3
    
4.
Eden A, Purkiss C, Cork G, Baddeley A, Morris K, Carey L, et al. In-patient physiotherapy for adults on veno-venous extracorporeal membrane oxygenation – United Kingdom ECMO physiotherapy network: A consensus agreement for best practice. J Intensive Care Soc 2017;18:212-20.  Back to cited text no. 4
    
5.
Hayes K, Holland AE, Pellegrino VA, Leet AS, Fuller LM, Hodgson CL. Physical function after extracorporeal membrane oxygenation in patients pre or post heart transplantation – An observational study. Heart Lung 2016;45:525-31.  Back to cited text no. 5
    
6.
Ko Y, Cho YH, Park YH, Lee H, Suh GY, Yang JH, et al. Feasibility and safety of early physical therapy and active mobilization for patients on extracorporeal membrane oxygenation. ASAIO J 2015;61:564-8.  Back to cited text no. 6
    
7.
Munshi L, Kobayashi T, DeBacker J, Doobay R, Telesnicki T, Lo V, et al. Intensive care physiotherapy during extracorporeal membrane oxygenation for acute respiratory distress syndrome. Ann Am Thorac Soc 2017;14:246-53.  Back to cited text no. 7
    
8.
Polastri M, Loforte A, Dell'Amore A, Nava S. Physiotherapy for patients on awake extracorporeal membrane oxygenation: A systematic review. Physiother Res Int 2016;21:203-9.  Back to cited text no. 8
    
9.
Hodgson CL, Fan E. A step up for extracorporeal membrane oxygenation: Active rehabilitation. Respir Care 2013;58:1388-90.  Back to cited text no. 9
    
10.
Abrams D, Javidfar J, Farrand E, Mongero LB, Agerstrand CL, Ryan P, et al. Early mobilization of patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. Crit Care 2014;18:R38.  Back to cited text no. 10
    
11.
Lee H, Ko YJ, Suh GY, Yang JH, Park CM, Jeon K, et al. Safety profile and feasibility of early physical therapy and mobility for critically ill patients in the medical intensive care unit: Beginning experiences in Korea. J Crit Care 2015;30:673-7.  Back to cited text no. 11
    
12.
Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009;373:1874-82.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2]



 

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