When on ECMO: Awaken, Extubate and Mobilize

  • Rakesh C. Arora
  • Dave Nagpal
  • Yoan Lamarche
  • Rohan Sanjanwala
  • Andrea Szwajcer
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Background: The use of extracorporeal membrane oxygenation (ECMO) has increased significantly to support cardio-respiratory failure patients. The ECMO utilization has worsened immobility for the critically ill patients.

Objective: To evaluate the evidence for the effects of early mobilization in cardiothoracic surgery patients receiving ECMO on feasibility and safety, duration of ECMO utilization as well as ICU and hospital length of stay.

Methods: Using a combination of MeSH terms: “early mobilization” and “ECMO”, Medline: Ovid, Embase, Scopus and CINAHL databases were searched. Studies were evaluated to determine fit to the inclusion criteria. Considering the limited amount of high quality evidence found, the inclusion criteria were expanded to include studies evaluating sedation interruption, extubation and early mobilization in intensive care unit patients with/without ECMO.

Results: Eighteen studies were selected. The quality of the selected studies was assessed using the GRADE system. All the included studies reported on a multidisciplinary team implementing early mobilization which was feasible and safe in patients receiving ECMO. One study reported on reducing the duration of ECMO, two studies reported reducing ICU and hospital length of stay and reducing ICU and hospital mortality among ECMO patients receiving early mobilization.

Conclusions: An experienced, multidisciplinary team undertaking early mobilization seems feasible and safe. Early mobilization is beneficial in reducing critical care associated complications as well as reduces ICU and hospital length of stay in patients receiving ECMO.


VV ECMO VA ECMO Early mobilization Cardiothoracic surgery Post intensive care syndrome 



Acute respiratory distress syndrome


Extracorporeal membrane oxygenation


Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation


Intensive care unit


Post-intensive care syndrome


Prolonged ICU length of stay


Post-traumatic stress disorder


Society of Critical Care Medicine


Veno-arterial extracorporeal membrane oxygenation


Veno-venous extracorporeal membrane oxygenation


  1. 1.
    Webb SA, Pettila V, Seppelt I, for the ANZIC Influenza Investigators, et al. Critical care services and 2009 H1N1 influenza in Australia and New Zealand. N Engl J Med. 2009;361(20):1925–34.PubMedCrossRefGoogle Scholar
  2. 2.
    Zangrillo A, Biondi-Zoccai G, Landoni G, et al. Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO. Crit Care. 2013;17(1):R30.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Freed DH, Henzler D, White CW, et al. Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada. Can J Anaesth. 2010;57(3):240–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Sauer CM, Yuh DD, Bonde P. Extracorporeal membrane oxygenation use has increased by 433% in adults in the United States from 2006 to 2011. ASAIO J. 2015;61(1):31–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Lee H, Ko YJ, Suh GY, 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(4):673–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Munshi L, Kobayashi T, DeBacker J, et al. Intensive care physiotherapy during extracorporeal membrane oxygenation for acute respiratory distress syndrome. Ann Am Thorac Soc. 2017;14(2):246–53.PubMedGoogle Scholar
  7. 7.
    Chavez J, Bortolotto SJ, Paulson M, et al. Promotion of progressive mobility activities with ventricular assist and extracorporeal membrane oxygenation devices in a cardiothoracic intensive care unit. Dimens Crit Care Nurs DCCN. 2015;34(6):348–55.PubMedCrossRefGoogle Scholar
  8. 8.
    Abrams D, Javidfar J, Farrand E, et al. Early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study. Crit Care. 2014;18(1):R38.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Rahimi RA, Skrzat J, Reddy DRS, et al. Physical rehabilitation of patients in the intensive care unit requiring extracorporeal membrane oxygenation: a small case series. Phys Ther. 2013;93(2):248–55.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373 North American E(9678):1874–82.CrossRefGoogle Scholar
  11. 11.
    Schmidt M, Pellegrino V, Combes A, et al. Mechanical ventilation during extracorporeal membrane oxygenation. Crit Care. 2014;18(1):203.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351–63.PubMedCrossRefGoogle Scholar
  13. 13.
    Sklar MC, Beloncle F, Katsios CM, et al. Extracorporeal carbon dioxide removal in patients with chronic obstructive pulmonary disease: a systematic review. Intensive Care Med. 2015;41(10):1752–62.PubMedCrossRefGoogle Scholar
  14. 14.
    Buscher H, Vaidiyanathan S, Al-Soufi S, et al. Sedation practice in veno-venous extracorporeal membrane oxygenation: an international survey. ASAIO J. 2013;59(6):636–41.PubMedCrossRefGoogle Scholar
  15. 15.
    Langer T, Santini A, Bottino N, et al. “Awake” extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering. Crit Care. 2016;20(1):150.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Gay S, Durand M, Casez M, et al. O-18 extubation after minimal sedation of patients treated with ECMO. J Cardiothorac Vasc Anesth. 2011;25(3):S8.CrossRefGoogle Scholar
  17. 17.
    Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Li Z, Peng X, Zhu B, et al. Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil. 2013;94(3):551–61.PubMedCrossRefGoogle Scholar
  19. 19.
    Santos PMR, Ricci NA, Suster ÉAB, et al. Effects of early mobilisation in patients after cardiac surgery: a systematic review. Physiotherapy. 2017;103(1):1–12.CrossRefGoogle Scholar
  20. 20.
    Chen S, Su CL, Wu YT, et al. Physical training is beneficial to functional status and survival in patients with prolonged mechanical ventilation. J Formos Med Assoc. 2011;110(9):572–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Dong Z, Yu B, Zhang Q, et al. Early rehabilitation therapy is beneficial for patients with prolonged mechanical ventilation after coronary artery bypass surgery. Int Heart J. 2016;57(2):241–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Kayambu G, Boots R, Paratz J. Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomised controlled trial. Intensive Care Med. 2015;41(5):865–74.PubMedCrossRefGoogle Scholar
  23. 23.
    Patman S, Sanderson D, Blackmore M. Physiotherapy following cardiac surgery: is it necessary during the intubation period? Aust J Physiother. 2001;47(1):7–16.PubMedCrossRefGoogle Scholar
  24. 24.
    Hodgson C, Bellomo R, Berney S, et al, for the TEAM Study Investigation. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care. 2015;19:81.Google Scholar
  25. 25.
    Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013;41(6):1543–54.PubMedCrossRefGoogle Scholar
  26. 26.
    Kress JP. Clinical trials of early mobilization of critically ill patients. Crit Care Med. 2009;37:S442–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Schweickert WD, Kress JP. Implementing early mobilization interventions in mechanically ventilated patients in the ICU. Chest. 2011;140(6):1612–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Kram SL, DiBartolo MC, Hinderer K, et al. Implementation of the ABCDE bundle to improve patient outcomes in the intensive care unit in a rural community hospital. Dimens Crit Care Nurs. 2015;34(5):250–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Rehder KJ, Turner DA, Hartwig MG, et al. Active rehabilitation during extracorporeal membrane oxygenation as a bridge to lung transplantation. Respir Care. 2013;58(8):1291–8.CrossRefGoogle Scholar
  30. 30.
    Garcia JP, Iaconao A, Kon ZN, et al. Ambulatory extracorporeal membrane oxygenation: a new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg. 2010;139(6):e137–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Garcia JP, Kon ZN, Evans C, et al. Ambulatory veno-venous extracorporeal membrane oxygenation: innovation and pitfalls. J Thorac Cardiovasc Surg. 2011;142(4):755–61.PubMedCrossRefGoogle Scholar
  32. 32.
    Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012;186(8):724–31.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Shehabi Y, Chan L, Kadiman S, et al. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med. 2013;39(5):910–8.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Tanaka LM, Azevedo LC, Park M, et al. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care. 2014;18(4):R156.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201–9.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Kress JP, Pohlman AS, O’Connor MF, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–7.CrossRefGoogle Scholar
  37. 37.
    Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126–34.PubMedCrossRefGoogle Scholar
  38. 38.
    Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet (London, England). 2010;375(9713):475.CrossRefGoogle Scholar
  39. 39.
    Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle. Crit Care Med. 2014;42(5):1024.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Ko Y, Cho YH, Park YH, et al. Feasibility and safety of early physical therapy and active mobilization for patients on extracorporeal membrane oxygenation. ASAIO J. 2015;61(5):564–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Boling B, Dennis DR, Tribble TA, et al. Safety of nurse-led ambulation for patients on venovenous extracorporeal membrane oxygenation. Prog Transplant (Aliso Viejo, Calif). 2016;26(2):112–6.CrossRefGoogle Scholar
  42. 42.
    Polastri M, Loforte A, Dell'Amore A, et al. Physiotherapy for patients on awake extracorporeal membrane oxygenation: a systematic review. Physiother Res Int. 2016;21(4):203–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Hein OV, Birnbaum J, Wernecke K, et al. Prolonged intensive care unit stay in cardiac surgery: risk factors and long-term-survival. Ann Thorac Surg. 2006;81(3):880–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Schelling G, Richter M, Roozendaal B, et al. Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery. Crit Care Med. 2003;31(7):1971–80.PubMedCrossRefGoogle Scholar
  45. 45.
    Jackson DL, Proudfoot CW, Cann KF, et al. The incidence of sub-optimal sedation in the ICU: a systematic review. Crit Care. 2009;13(6):R204.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Rakesh C. Arora
    • 1
    • 2
    • 3
  • Dave Nagpal
    • 4
  • Yoan Lamarche
    • 5
  • Rohan Sanjanwala
    • 2
  • Andrea Szwajcer
    • 6
    • 7
  1. 1.Department of Surgery, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  2. 2.Cardiac Sciences ProgramSt. Boniface HospitalWinnipegCanada
  3. 3.I.H. Asper Clinical Research Institute – St. Boniface HospitalWinnipegCanada
  4. 4.Department of SurgerySchulich School of MedicineLondonCanada
  5. 5.Department of SurgeryMontreal Heart InstituteMontrealCanada
  6. 6.St. Boniface Hospital Research CentreWinnipegCanada
  7. 7.LibrariesUniversity of ManitobaWinnipegCanada

Personalised recommendations