ECMO

It sounds like a fuzzy lovable Sesame Street character, but this big boy ain’t no joke. ECMO or Extracorporeal Membrane Oxygenation is basically a lung outside the body. Blood passes through it. CO2 is removed and oxygen is introduced. It sounds simple, but that is the furthest thing from the truth. This is really advanced care and should only be provided by very skilled rehab providers and their teams. I’m going to stay relatively superficial here and focus on information only. These patients are not coming home on ECMO, but there are some factors that may be relevant to your evaluation and treatment of a patient who has recently been on ECMO.

Just like we have patients we can provide external kidney function through hemodialysis and external cardiac function through cardiac bypass, we can provide support for the lungs, also. ECMO also does the pumping of the reoxygenated blood back in to the body, so it functions as a heart, too. You don’t hear much about ECMO in the rehab world, and especially not in the general public and daily conversation. But lately, thanks to COVID-19, that is changing. So, here are the basics of what you need to know about ECMO and what to consider if your patient is coming to you after a stent with the ECMO monster.

My first experience with ECMO was during my time as a heart and lung transplant educator. One of my long time patients had been pre-habbing toward bilateral lung and vasculature transplant due to pulmonary hypertension and COPD. I visited her in the hospital after her transplant was completed and she was on ECMO. The tower next to the bed was breathing for her instead of her own brand spanking new lungs. Large plastic hoses were running out from under the sheets into the machine and then from the machine back in to her. It was a startling sight. Thankfully, the next time I saw her was in her home, and she was sitting up and singing just like she had been before the transplant.

Basically, ECMO is a last-ditch effort, a last resort. If mechanical ventilation isn’t working, even at the highest settings considered safe, ECMO may be brought in. This takes a huge effort, a large team, and round-the-clock monitoring of the machine and the patient. Typically, only very highly skilled teams and facilities are able to provide ECMO. ECMO is by no means a highly successful intervention. A recent study of patients with COVID-19 demonstrated less than 50% of people who were placed on ECMO survived (21 of 58). And let’s not forget that “survival” doesn’t mean they popped up and raced home to their family. ECMO also extends the road to recovery for most patients. However, that could be seen as a percentage of people who survived that would have otherwise died on the ventilator, so we can definitely see the benefit.

So why isn’t every patient failing mechanical ventilation, whether it be due to new onset GBS or succumbing to viral overload, given ECMO? We don’t have the resources. We don’t have the people. Like I said above, utilizing this device takes a team. This team includes twenty-four hour monitoring, usually in the room, by a respiratory therapist or registered nurse who specializes in pulmonary care. A surgeon and surgical team are required to implant the hoses in to the patient’s vasculature (no small feat). Several physicians also must come together to make the decisions on when is the right time, who are the right patients, and who has the best chance of survival. These are just the extras. This is all in addition to the already stretched team of nurses, nursing assistants, hospitalists, social workers, and rehab therapists that are working with the patient. And, prior to COVID-19, we didn’t have hundreds of patients at a single hospital going in to ARDS at one time, so we don’t have that many ECMO machines sitting around.

You can see more about the guidelines for use of ECMO here:

Now, down to the meat and potatoes. What does rehab look like with ECMO? It depends (of course). Many times, patients are heavily sedated while on ECMO. But, sometimes, they aren’t. Sometimes they are able to be functional and awake and they need you so much at that point in time. Placing and managing ECMO takes a team, but so does rehab during ECMO. I want you to know what it looks like to ambulate a patient on ECMO, so please watch the video at this link.

Things you need to consider when evaluating a patient who has recently had ECMO:

Wounds. Several vascular access sites will still be healing. You may find them in the neck, chest, or upper thighs. Access can be placed in the femoral veins or jugular veins depending on the needs of the patient and the machinery available. These wounds place the patient at an increased risk of sepsis so they need to be carefully monitored for healing and/or signs of infection, dehiscence, or delayed healing. If they were on ECMO, odds are they had several other support devices in place (you saw those pictures and videos), so there will be several other vascular access sites not for ECMO and the same considerations apply. I’ve seen IV sites become infected and cellulitis spread through an arm because of it. Venipuncture sites matter just as much as surgical wounds. More research coming out is showing soft tissue infections as one of the main factors for returning to the hospital after discharge.

Profound Weakness. I’m not talking your average deconditioning. These patients were likely “under water” and/or sedated for several weeks, being completely dependent for all movement. Specifically for patients with COVID-19, the small muscles (intrinsics, muscles of the lower arm and legs) and core musculature seem to be greater challenged than the large musculature. Their diaphragms have done NOTHING for a long time and their cardiac function has been so chemically modified that the muscles don’t even know what to do anymore. Don’t forget about your tools like IMT and PEP to help with this! Supplemental oxygen can typically be run through these devices if needed.These patients need a greater level of reconditioning, a longer timeframe of overall recovery, and they are starting from an even further place than their non-ECMO cohorts with COVID-19. They need coordination training for the muscles of breathing and the cardiac system and they need to take it low and slow. You can find more information about that here.

Delirium. Just mechanical ventilation can cause delirium. Just ARDS can cause delirium. A hypoxic state can cause delirium. So imagine if you have all of those things and then you get put WAY WAY under so that a machine can oxygenate your body. The delirium is going to be there and it’s going to hang on for a while. There are many measurement tools that can be appropriate for establishing level of delirium, but the important thing is that you quantify a baseline so you can show improvement in delirium over time. Keep in mind that there may be little to know carryover or ability to generalize any skills instructed due to the “fog” still present. It has been postulated that these patients present very much like patients after traumatic brain injury and that the Richmond Agitation and Sedation Scale (RASS) used frequently in ICU settings may line up well with the Ranchos Los Amigos Scale/Levels of Cognitive Functional Scale (RLAS/LCFS) used in patients with TBI. It has been noted by several ICU practitioners that these patients really do present as if they have experienced a traumatic brain injury. Based on this, you have to modify your lens through which you view the patient, their participation, your activities, and your therapeutic goals. Those Neuro skills are really going to come in handy!

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What was your reaction when you first saw an ECMO machine attached to a patient? Tell me about it in the comments!

References

Boyles, S. (2020). Critically ill COVID-19 patient better after ECMO treatment – experts offer guidance on ECMO use in pandemic setting. MedPage Today. Retrieved from https://www.medpagetoday.com/infectiousdisease/covid19/86003

Lin K, Wroten M. Ranchos Los Amigos. [Updated 2019 May 29]. In: SatPearls. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448151/

Mayer, K., Engel, H., Falvey, J., Ricard, P. (2020). COVID-19: ICU to Home Transitions. [Webinar] Home Health Section of the American Physical Therapy Association. Retrieved from https://aptahhs.memberclicks.net/assets/5-16-20%20ICU%20Webinar%20Recording.pdf

Seethala, R. & Keller, S. P. (2020). ECMO resource planning in the setting of pandemic respiratory illness. ANNALSATS Articles in Press. American Thoracic Society. doi: 10.1513/AnnalsATS.202003-233PS. Retrieved from https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.202003-233PS

The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RKAm J Respir Crit Care Med. 2002 Nov 15; 166(10):1338-44. https://pubmed.ncbi.nlm.nih.gov/12421743/

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