SUBSCRIBE TO THE PODCAST

As ECMO programs have grown in demand and popularity during COVID19, what have we learned about the safety, feasibility, and benefit of early mobility? Why is there such a significant disparity in mobility practices between ECMO teams? Dr. Julian Macedo shares with us his expertise and insights into early mobilization during ECMO.

Episode Transcription

Kali Dayton 0:20
For anyone that has listened to this podcast, it is clear that mobility practices vary drastically between hospitals and even ICU teams. Usually, a lack of mobilization during mechanical ventilation is rooted in what is quote, normal, or perceived to be convenient, rather than what is possible and best. This is also happening with patients on extra corporeal Membrane Oxygenation or ECMO.

When I’ve posted videos and pictures of intubated patients walking on mechanical ventilation, some commentators have said quote, “yeah, well, they’re not on ECMO”, unquote. Revealing the cultural belief that all patients on ECMO must remain on bedrest and often under sedation and immobilized.

During COVID, the demand for ECMO boomed and ECMO programs grew. The increase in popularity of ECMO has exposed significant disparities between teams. While often treating the same kind of COVID patients with the same diagnoses, the same mechanical ventilation and ECMO, we have seen that many teams have locked patients into delirium under numerous sedatives, including high dose benzodiazepines, and opioids and prolonged immobility, lasts in weeks to even months, while other teams have those similar or same patients awake and walking. Are we stopping to ask if our treatments are best, or just what is familiar?

Check out the blog at www dot Dayton ICU consulting.com under the resources tab, and in this episode, to access the citations to research that demonstrate the safety feasibility and undeniable benefits of early mobility during ECMO. And this episode, Dr. Julian Macedo joins us to share his expertise in early mobilization during ECMO. Dr. Macedo thank you so much for coming on the podcast. Do you mind introducing yourself to our listeners?

Dr. Julian Macedo 2:47
Good morning, Katie. It’s really good to be here. Well, first, my introduction. My name is Dr. Julian Seto. I am a board certified physician in emergency medicine neurocritical care and anesthesia critical care beyond my interest in just early mobility of cardiovascular ICU patients, and who require device support like ECMO. I also have interest in neurologic emergencies in the ICU resuscitation, and medical education. I am currently a attending physician at the TriHealth hospital system here in Cincinnati. We’re the largest hospital system in the area, I provide services in our 35 bed, cardiovascular ICU. Within our cardiovascular ICU, we have our heart firm as well as we house our device patients. And these patients include balloon pumps, an array of impellers, as well as VV and VA ECMO. And recently, we have a blossoming durable LVAD program that’s been initiated.

Kali Dayton 3:57
And you’re coming from a previous cvicu that has a really strong culture in mobility, I would probably even consider it and awaken walking cvicu Tell us a little bit about what that culture was like and what it was like to work in that kind of atmosphere.

Dr. Julian Macedo 4:13
So it’s really, really amazing and impressive to be around such a robust physical therapy program. I would say the one thing that jumps out at me when I think about my experience at my most recent Hospital, which was the University of Utah, just how aggressive the mobility program was there and aggressive is not to imply that it was a labor of work. It was actually impressive and aggressive in the sense that there’s such a flow to how the therapists and the team was able to care and provide mobility to some of these really complex device patients. Patients like the patients we’re here to talk about today, which are ECMO patients are your mobile device and cardiovascular device patients.

Kali Dayton 5:04
And when I post pictures online of patients walking on mechanical ventilation, a lot of times the argument that people will put in their comments as “well, they’re not an ECMO, so they’re not that sick.” And so I’m excited to dive into that, because in the CDC that you’re coming from, they have a variety of devices, severe high acuity patients, yet the mobility continues.

So how does this apply to ECMO? How do you navigate sedation to start off with because you obviously can’t mobilize patients that are sedated and in some ICOs, any patient on ECMO is going to be deeply sedated the entire time. So how did that team navigate sedation? How do you determine when it is and is not necessary?

Dr. Julian Macedo 5:51
So sedation is one of those topics that probably has multiple book chapters committed to it in terms of ECMO and, and some of the nuances. But I think when I step back and look at this in terms of broad strokes, that when it comes to sedation and ECMO, and this probably shouldn’t be the case across the board, when we’re talking about critical care is that we always try to minimize the amount of sedation required, we let the patient be the guide on on the amount of sedation that’s required, or whether sedation is even required at all.

I think it’s a strong misconception that patients on ECMO need sedation, I think I would be backed up by multiple colleagues of my own. If I if I were to state that it’s only necessary to the extent that would be for other indications. So I’ll give the example of safety of the devices which support the patient that may be ECMO, or maybe the ventilator, or sedation is oftentimes required for facilitation of nursing care, or if the patient’s still on the ventilator, perhaps some sedation is required for good synchrony. But if I can bottom line it, sedation is not required unless there’s a outstanding indication. And in fact, patients can often be managed with little to no sedation at all.

Kali Dayton 7:19
Which I appreciate so much, we’ve said patients to the ICU that had needed ECMO. And we had them awake and walking up until the point that they couldn’t oxygen with movement. And then oftentimes, they were cannulated in our ICU and then sent to your Ico or your previous ICO. And there once they were on ECMO and could oxygenate, they were awakened, walking again. And so I really appreciate that that was the case, a new ICU popped up that was certainly an ECMO program that did not have that focus. And we felt very conflicted about setting them there, because we knew the outcomes would be so different, which we’ll get into. But what are the thresholds for early mobility with with your ECMO patients? So if the majority of them can be awake and off of sedation, and they’re navigating their own needs? How then do you know if they’re safe to mobilize?

Dr. Julian Macedo 8:14
So also a very good question, Kali. I think it can be intimidating, when you have patients requiring so much device support knowing when it’s safe, when you see so much support provided to the patient by various means including ECMO can can make you a little apprehensive. So when it comes to thresholds, there are probably some absolutes with respect to advanced mobility. So some extremes of circumstance where it may not be a good idea, or those patients in whom there’s hemodynamic instability, bleeding, or perhaps the patient has sustained the saturation events, those patients probably don’t meet requirements for early mobility.

What I would say though, is that we try not to put hard, fast rules when it comes to limiting mobility. I think it’s important to evaluate patients in terms of their mobility, readiness in terms of stability, as well as trajectory. And so what I mean by that is that oftentimes, we’ll come across patients who have blood pressures that are marginal, but perhaps for a period of 24 hours or more their trajectory has been improving. What I would encourage folks to consider is that we take a look at these patients case by case and if it’s deemed so by the team that we consider advancing these patients in terms of their mobility. And what I think you’ll find is that when you start looking at these patients case by case you give him the benefit of the therapy that we know benefits him in a number of ways. And then you can start pushing in avoid, avoid placing limits on the amount of mobilities patients can achieve is

Kali Dayton 10:08
I absolutely agree with that approach. I think when I discuss and consult with a lot of ICU teams, they want really clear, hard thresholds, which I think we can do parameters. We can do algorithms, things like that. And yet, when it comes down to it, we cannot optimize care if we don’t customize it, every patient is different, every patient is going to tolerate certain blood pressures and heart rates different than others. And so how do you know what they can tolerate? How do you know what’s best for them until you try?

Dr. Julian Macedo 10:38
I want to make one more point Kali, which I think it’s important to hit on, which is not to set timelines or not to set deadlines. In terms of evaluating for readiness. I think it’s important to do, if not, day by day, and maybe even hour by hour assessments of readiness. And what I think you can achieve in doing so is the serial assessments that allow you to assess readiness, rather than I think, when you start placing timelines and deadlines on folks, you can delay and put off an opportunity to begin mobilizing a patient. And that’s not necessarily what’s best for the patient, in many cases,

Kali Dayton 11:26
Absolutely. Even in an MSICU, I see with patients on mechanical ventilation or just in critical crisis, that their status can change within hours. And they can be mobilized in the afternoon versus they their appropriateness in the morning. So it all depends on what they’re doing in that moment. And so who is doing these assessments?

Dr. Julian Macedo 11:51
Yeah, so this probably is a segue into a bigger concept, which is, I think it’s important to have a multidisciplinary approach. It probably starts with the bedside RN who spends moment to moment with the patient. But I think it’s also incumbent upon respiratory therapists, the physical therapist, occupational therapist, as well as myself, who may not spend as much time as I would like at the bedside compared to the RN, for example. But bringing it to the attention of the team that my impression is that the patient is physiotherapy ready, and that we should start moving in that particular direction.

Kali Dayton 12:38
And there’s the culture within that team where they’re, they’re going to jump on board with you, or they’re going to have the same desires. And so you know, when they give their input, or feedback, it’s not out of a place of fear, but out of true assessment, because they’ve walked patients, they they’re comfortable with that process. And so they have concerns. Are you able to trust their concerns or recognize that those are valid?

Dr. Julian Macedo 13:04
Yeah, so I strongly support them, you bring up this term culture, which is you have to build that culture of support for for early mobility and for folks to speak up with respect to its time now, I would also reiterate, sometimes it’s equally important to know that it’s not time, but speaking up to know that it is time, and that, that everyone within our multidisciplinary team feels empowered to speak up and contribute to the assessment of therapy readiness for individual patients. Culture is very important.

Kali Dayton 13:41
Absolutely, we hit on that a lot throughout this podcast because it does take a team, especially when you have multiple devices and some tenuous acuities within your patients. And with ECMO patients, often they’re coming to you after being deeply sedated and mobilized. They’re not usually coming from awake and walking ICUs. How does that impact the complexity of initiating early mobility?

Dr. Julian Macedo 14:08
So it can be particularly challenging. And, you know, our recent experience with COVID is a good example of patients who become deconditioned have been on the ventilator for an amount of time have oftentimes been on ECMO for weeks, undergone serial periods of paralysis and sustained analgosedation. And this is a really big deal. This is a hard process to bounce back from.

And so I think it’s important to step back into the fundamentals and take a look at what patients can tolerate when they’re in these particularly severe ill predicaments. So fundamental physical therapy, things like range of motion. I think it’s an important starting point may not be ideal, but it provides at least some degree of therapy for for that particular patient. With respect to our recent experience with COVID It’s it’s been a real challenge because these patients, like I mentioned oftentimes require sustained periods of time of sedation and recurrent paralysis. And unfortunately, we don’t have a magic bullet.

For a lot of these really challenging sedation cases, we have looked at various cocktails of medication, various sedatives, and an algo sedation. And there’s no magic bullet. Now, there are various things that you can do to facilitate mobility with respect to trying to get patients awake and alert, and away from that situation where they’ve been on the ventilator for sustained periods of time. So we want to make sure we’re doing our, our daily awakening trial, I think where we can get a little bit in a rut, when we talk about these really challenging cases, it’s feeling like yesterday was a bad day. So today is going to be a bad day as well. And you get into this mentality of, “okay, we’re not going anywhere.” And it’s kind of cyclical that that that that rut develops.

So I encourage everyone on our team to recall that, oftentimes, a tincture of time is what’s required. And yesterday was yesterday, and today is today, and that we should keep forging forward. And it’s actually been my experience, actually, through through the pandemic in particular, that if you’re willing to remain patient, if you’re willing to remain resilient. Oftentimes, in particular, in the COVID population, what we saw is that there is a almost like a light switch that occurs with a number of these patients, even though supported on ECMO, and maybe, especially those supported on ECMO, where their cognition improves. And shortly thereafter, what you see is a rapid improvement in their ability to tolerate physiotherapy, and a sustained and maintain level of clinical improvement. It’s quite impressive.

Kali Dayton 17:00
I’m suspecting that a lot of that has to do with how your team approaches awakening trials, because a lot of teams just culturally, and it’s understandable. When you turn on that sedation and you have delirium that’s developed under sedation, they’re going to be agitated and thrashing, if they’re strong enough to thrash right. And yet, your team probably works through that when you talk about resilience and patience. Sounds like maybe your nurses aren’t afraid of movement, and allow them to work through that safely and then involve physical therapy and occupational therapy. I would imagine that your delirium rates are significant after patients have been sedated and immobilized. How does your team approach delirium?

Dr. Julian Macedo 17:45
Yeah, so So delirium, it can be really a challenging issue, particularly when it comes to ECMO. Because we worry about safety, obviously, I would say that a large part of this comes from the experience and the willingness to try. I wish I could sit and tell you when enough is enough for a patient who is agitated but in large part, it does come from being at the bedside and having an appreciation for “Okay, they’re a little bit agitated. And perhaps they have an increased RASS scale. But it’s not causing issues with their vent synchrony hemodynamically, they’re still doing well. And if I give this a period of time, perhaps we’ll see some improvement.”

And that that is that takes a certain amount of experience if you’re a RN, or a physician to get a feel, if you will, for whether the patient is safe to continue all sedation, or whether sedation put back into position is the the optimal choice there. But first and foremost, you have to be of the culture that you’re willing to try and that you wake the patient up and give them a chance to be awake.

Kali Dayton 18:59
That sounds like that team definitely has that expertise. And how do you see mobility helping you with delirium or that agitation?

Dr. Julian Macedo 19:07
Yeah, so I think you can look at that from a couple of standpoints. I think from the patient standpoint, it can be quite impressive that when you start waking patients up, their level of cognition improves. And I don’t think this is just me speaking, I think the evidence would support that as well, that there’s a growing body of evidence that supports that. Patients who receive less sedatives and spend more time awake during the day to perhaps get some sleep at night, the third level of delirium is going to do better. And so seeing that in action, and seeing those patients improved by minimizing their sedation, minimizing their Helen doozy and the time they spend sedated during the day, that’s gonna make the clinical team happy and I think that’s also going to serve the patient well.

Kali Dayton 19:54
And then once they start being mobilized, how do they tolerate it? I think the fear even just with mechanical and insulin lesion that this is going to be torture for the patient and terrible. And then you add in this huge catheter, how does the patient tolerate it? And especially, do they remain hemodynamically, stable, oxygenated? How is that usually tolerated by the patient and during the actual process of mobility?

Dr. Julian Macedo 20:19
So I’m smirking a little bit, because I think this is something that comes up quite a bit in terms of the fear of mobilizing this patient of mobilizing ECMO patients in particular, although this can also be translated to device patients in general. I think you can look at this a couple of ways. I think there’s the patient perspectives. And I think there’s the provider perspective, and I’ll start with the patient perspectives.

I think when it comes to the patient perspective, patients don’t want to be in bed all day. And I think this has actually been shown in literature that patients actually have increased satisfaction on ECMO when they’re mobilized. So even from the patient experience, it’s best from a patient satisfaction standpoint, to actually get them up and mobile, you know, I can speak for myself that being sedentary in one place all day, it’s probably not how I want to spend the day, you can imagine the effect that would have on the patient, if they were restrained and confined to a bed for the extent of a day or weeks, even then that would be really, really challenging.

The staff perspective, I think, is an interesting one, because it’s been my experience that in general, staff are much more worried at the idea of mobilizing these patients than they are the actual mobilization of the patient. And so once you actually get these patients mobile, I think what you’ll find is that there’s a comfort and a certain satisfaction and a feeling of a job well done. Once you go get a mobile actually, when I reflect back to the first time I saw a live ads patients mobilizing in the ICU as a fellow, it wasn’t the fear of seeing that patient up mobilizing the ICU that overcame, and he was actually the on inspiration of seeing the patient mobilize around the ICU. And I think if you were to take a poll of providers, whether it be nurses, physicians, therapists, it’s that all of seeing the patient mobilize around the ICU that actually overtakes us and not necessarily the fear of the mobilizing.

Kali Dayton 22:34
Yeah, I’ve absolutely seen that in action, the idea is terrifying. But when the new nurse comes to an “Awake and Walking in ICU”, they hear what we do, they get terrified. But when they see it in action, and even the team rallies around, other experts are coming in and doing it, it flows. It’s natural. Then the excitement kicks in. And that’s how you really change a culture

Dr. Julian Macedo 22:58
It’s it’s kind of interesting to have had the privilege of seeing one ICU in which I trained actually go through this particular process of mobilizing some of these advanced heart failure patients with devices. And it’s funny seeing that feeling of the staff go from we are wide eyed, and we’re concerned about mobilizing this patient because the number of support devices, they have to, oh, we’re just mobilizing another ECMO patient. And when you you get to that end, that’s, that’s, that’s a real professional satisfier in terms of, okay, we’re just mobilizing another ECMO patient. I think that’s where providers want to be to that point where they feel like, yes, it’s just another ECMO patient. And it’s a routine thing to mobilize them.

Kali Dayton 23:50
And coming into a new environment. You’re bringing all this expertise and this culture and this almost expectation to have this practice. What are some of the barriers that you face in helping the team elevate their practices?

Dr. Julian Macedo 24:06
Yeah, so there’s been a number of barriers, I think, you have to do a survey of your individual ICU and get an idea of, of what barriers exist. There’s a number of misconceptions when it comes to mobilizing device patients, I think some of the misconceptions that come to mind are, “it’s uncomfortable for the patient. They’re, they’re too sick. I don’t want to make them more hard because they’re too sick. We don’t have enough staff members or takes too much time.”

And then I think we’ve mentioned sedation a couple of times. And that’s something that comes up pretty commonly with respect to the physical therapy staff in terms of mobilizing this these patients. But truth remains is that there are avenues for addressing a lot of these misconceptions a lot We can begin with simple education. When it comes to these individual challenges and educating the staff on on what’s able to be done. I think a lot of institutions tackle this from a quality improvement standpoint, where, you know, individual surveys are done with respect to what the barriers are. And there may be certain barriers that are unique to individual institutions. But experience tells us and a lot of literature tells us that it can be done safely and effectively and with good outcome.

Kali Dayton 25:35
Yeah, what do we know about the impact of mobility during ECMO? How does that impact patient outcomes in the short and long term?

Dr. Julian Macedo 25:44
Sure, so, first of all, the safety feasibility is one of the things that comes up and And suffice to say it can be done safely, it is feasible, I would put one small caveat on safety visibility, which is you have to have the expertise to do it. And you have to have buy in from the individual stakeholders who provide care to the patient. But it can be done safely, it is feasible. Now, with respect to short and long term outcomes. When you start polling the literature in terms of physical therapy and device patients, it’s associated with reduction and several comorbid outcomes. We’ve bantered about delirium quite a bit today.

And and we know that mobility reduces delirium that’s associated with a reduction and infection rates. Specifically, when it comes to pneumonia. If you’re a person up in C suite, and you’re interested about throughput in your particular ICU, or your facility, it can result in a reduction in the length of stay of patients, it’s associated with decreased hospital stay, as well as cost to the institution as well. And, you know, we, we want what’s best for the patient. And when you take a look at data that’s also supported that we have improved functional outcomes when early mobility is undertaken in these particular patients.

I would, you know, point, if there’s one study I can point you towards, it’s a study by wells in critical care medicine. In 2018, they actually did a retrospective review of patients who underwent early mobility and who were on ECMO, it was a pretty large study of 254 individuals, I think, we worry about harm, and there’s very, very little signal of harm and no mortality in those patients who underwent early mobility. And that’s important, but it also supported many of the things I’ve just alluded to, which is it can be done safely and effectively. There’s one population in particular that, you know, I can highlight now, which is, when we talk about mobility, femoral cannulation is one of those things that we get really concerned about with respect to versus verticalization, and motion at the at the hip joint. But within this particular study, 15% of patients who were by femorally cannulated, were actually able to stand an ambulance. And so we have folks who are really pushing the women on what can be done safely and effectively when it comes to ECMO.

Kali Dayton 28:26
Yeah, that’s even a concern with RT lines or dialysis catheters. And we’ve seen in a literature and we’ll include it in the blog, that that’s been debunked, primarily, mostly right, that we can take precautions, but we don’t have to use that as a threshold to impede mobility. I talked to an ECMO specialist, and he said that he didn’t take patients that couldn’t walk. That was a criteria for ECMO. And I don’t know how common that is.

Dr. Julian Macedo 28:56
Yeah, I’ve never heard that particular criteria. My experience is that we’ve always done case by case evaluation of who can ambulate whether their configuration for ECMO is through the groin or not. And so if it seems like it’s a situation where it can be done safely, there’s good buy in from the individual disciplines with respect to mobilizing the patient, then we want to mobilize the patient.

Kali Dayton 29:25
And when I’m sure your unit was really maxed out during the big COVID surges, and there were many patients that were possible candidates for ECMO, if it came down to a patient that had been mobilized on mechanical ventilation versus those that had not been what, how would that impact who would be selected for ECMO?

Dr. Julian Macedo 29:47
Sure, so that it’s a particularly challenging question in in general, you think of patients who are vigorous and more well as having better reserve and less frail, and potentially yielding a better outcome, in fact, so much so that our surgical colleagues use mobility and frailty examinations as a factor on deciding whether or not to operate on cardiac surgery patients, for example. So although I can’t say that I’ve explicitly use that as a criteria, I think it would be fair for me to say that the patient who’s exhibited more vigor, less frailty, in addition to a number of other factors when it comes to ECMO, can you see, I’d probably favor the patient who had been previously ambulating exhibited good strength, good nutrition, good mobility, that that would probably be the patient who would be a better candidate for selection for ECMO if it got to that point.

Kali Dayton 30:55
Sure, absolutely. And what kind of case studies can you provide as far as the impact and the benefit of mobility during echo?

Dr. Julian Macedo 31:04
Yeah, so when I reflect back, because I’ve had the fortune or misfortune of caring for lots of COVID patients, during the past couple of years, there’s been plenty of examples where we’ve been able to provide physical therapy to ECMO patients, who were patients who had severe ARDS, and needed therapy. And I think of a couple of cases where perhaps we started with range of motion pages, range of motion exercises, and just getting the patient awake, transition them to a next level, which might include a bicycle in bed and doing a little bit of bicycle pedaling in bed. And perhaps in, you know, the preceding five to seven days, sitting at the bedside, and ambulating around the ICU.

Now, it’s not uncommon, actually, for us to have patients who have prolonged ICU stays and becoming dependent on ECMO to a point where they can get rehab and potentially be bridge to a lung transplant. So we have a couple of instances where patients are able to effectively be rehab while on ECMO and survive their two, sometimes three month ICU stay as a bridge to a lung transplant after a very severe case of ARDS. And it’s really, really a big deal. When you’re able to achieve this, you feel like you’ve really, really helped the patient out. And that’s an incredible outcome to have, after such a long and rigorous ICU stay.

Kali Dayton 32:44
Yeah. Could they have been candidates for lung transplant? Have they not been mobilized and rehabilitated?

Dr. Julian Macedo 32:49
Yeah, so our physical therapists are actually really integral in selecting and contributing to the candidacy of care planning our patients, we do need our patients when we talk about transplant to have a certain amount of strength and rehabilitation. So much so that we expect them to fail. If they don’t have good strength, we need them rehab. We need them vigorous, we need them mobile and ideally, walking the hallways, it would be nice if they were, you know, lifting 25 pound dumbbells and, you know, had some nice muscle mass, but we’ll definitely take the patient who does numerous laps around the ICU as a patient that we predict to do well with lung transplantation after ARDS.

Kali Dayton 33:35
And that just reaffirms one of the catchphrases of the podcast that early mobility is a life saving intervention. And that sounds like that’s what your team really embodies and fills and practices.

Dr. Julian Macedo 33:49
Absolutely, I think when we see patients up mobilizing, you know, if I were just to stand back and take a look at something that makes me feel like we’re really helping our patients out and makes me feel like the patient is going to do well. It’s to see them up. Mobilizing this normalization of them up moving around. That means just a very strong positive prognosticator.

Kali Dayton 34:18
And for the loan visionaries, listening to all of this wanting this, but they’re overwhelmed by the prospect of advocating or leading such a change. What advice would you give?

Dr. Julian Macedo 34:30
Yeah, so I think I would have these individuals just ask themselves, what’s stopping you? Take a look, do a do a survey and look inwardly and ask yourself, What’s stopping you? And it may be that we circle back to a couple of things that we discussed earlier. Perhaps there’s concerns regarding safety, or there’s concerns regarding sedation. And if that’s the case that you establish a educational curriculum to address this or develop a quality improvement initiative to debunk the myth and know that it can be done safely.

So I think education is going to be important in that respect, I do think you have to recognize it complications are possible, but have those contingencies in place and in educate the staff with respect to the condition contingencies when it comes to the complications. And this is always going to be with the backdrop that we know that the benefits outweigh the risks that these events are rare. I think it’s important to create allies within your organization, we all have our colleagues that we lean on, in order to move our ideas forward, particularly when it comes to things like early mobility, have your allies within the nursing realm within your group of physical therapists, which I’m sure they’re all allies.

I’m sure all physical therapist wants to mobilize their patients to respiratory therapy, help them, you know, build bridges with respect to mobilizing patients who still may need some respiratory support, you know, teamwork makes the dream work. And so when you have all these individuals buying in from individual disciplines, I think that’s going to lead to to the outcomes that we want in terms of early mobility. And I don’t want to excuse myself, as a physician, I think it’s important for physician leaders to be out there advocating for our early mobility of patients, because I know, I know, the positive outcomes that occur when you mobilize your patient.

Kali Dayton 36:36
And it really seems like intensivist should be some of the leaders in practicing evidence based medicine. And the evidence supports this. So if we’re practicing ABCDEF bundle, as should be the standard of care, this should be part of it. And so it takes leaders, but as well as champions within each specialty, to then light the fire and get things going. The teams that I’ve seen had the most success in transitioning this process of care are those that involve each discipline and have champions, numerous champions in each discipline. And so that can be a process of buy in, as you said, education. But it’s, it’s possible, and you’re leading some change in your current ICU, correct?

Dr. Julian Macedo 37:17
Absolutely. And so, so this is interesting, because I’ve had to reset a little bit and go go through that process of, we’re in ICU Now that does have apprehension with respect to mobilizing these patients. And so being able to bring that perspective from a different facility where mobility of some of these complex patients was the norm, translating that into my new role with a new group of individuals, and doing so in a way that provides reassurance that you can do this safely. And not only not Not, not just do it safely, but do it with positive impact. That experience I think, is going to help carry this particular team to, to that particular high square. I’d mentioned earlier, I want this to just be normal. I want mobilizing ECMO patients to feel like it’s just another day in the cardiovascular ICU and I really look forward to having that happen real soon.

Kali Dayton 38:14
Well, it’s so exciting that you’re there that you’re able to bring this expertise. I hope that even travel nurses bring in these different elements as we are more transient in our employment right now that this can be actually a good thing, hopefully, that we share our experiences. Thank you so much for sharing yours. Is there anything else you would share with the ICU community?

Dr. Julian Macedo 38:35
No, I appreciate you for having me. Kayla, I think like we’ve really hammered home today. Teamwork, and early mobility is very, very impactful for these particular patients. And I hope that we can keep pressing this message forward.

Kali Dayton 38:51
Thank you so much for helping make this the standard of care. I appreciate that so much to schedule a consultation and connect on social media, as well as find supportive resources including case studies ebook episode, transcripts and citations to research.

Transcribed by https://otter.ai

 

 

References

Abrams, et al. (2014). Early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study.Critical Care, 18(1). https://pubmed.ncbi.nlm.nih.gov/24571627/

Abrams, et al. (2022). Early mobilization during extracorporeal membrane oxygenation for cardiopulmonary failure in adults: factors associated with intensity of treatment. Annuls of American Thoracic Society, 19(1). https://pubmed.ncbi.nlm.nih.gov/34077700/

Aleef, M., & Labib, A. (2017). Early mobilization and icu rehabilitation of ecmo patients. Qatar Medical Journal, 2017(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474639/

Braune, et al. (2022) Feasibility, safety, and rescue ultilisation of active mobilization of patients on extracorporeal life support: a prospective observational study. Annals of Intensive Care, 10(161). https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-020-00776-3

Haji, J., Mehra, S., & Doraiswamy, P. (2021). Awake ecmo and mobilizing patients on ecmo. Indian Journal of Thoracic and Cardiovascular Surgery, 37. https://link.springer.com/article/10.1007/s12055-020-01075-z

Nordness, M., & Patel, M. (2019). What is the role of the abided bundle in patients on extracorporeal membrane oxygenation? Difficult Decisions in Cardiothoracic Critical Care Surgery. https://link.springer.com/chapter/10.1007/978-3-030-04146-5_17

Patrick, K., & Adams, A. (2021). Mobilization of patients receiving extracorporeal membrane oxygenation before lung transplant. Critical Care Nurse 41(4). https://aacnjournals.org/ccnonline/article-abstract/41/4/39/31508/Mobilization-of-Patients-Receiving-Extracorporeal?redirectedFrom=fulltext

 

More Resources:

****Lecture from Dr. Abrams: https://www.annalscts.com/article/view/16524/html

****https://ecmoadvantage.com/walking-and-talking-on-ecmo/

 

 

 

SUBSCRIBE TO THE PODCAST