Early Rehabilitation During Extracorporeal Membrane

Oxygenation to Prevent ICU-Acquired Weakness: Systematic

Review

Lili Sofia

, Raufina Riandhani Mulyoto

, Hui-Chen Hsieh

and Lee Huan-Fang

3,* b

Hasan Sadikin Public Hospital, Bandung, West Java, Indonesia

Physical Therapy Department, Medical College, National Cheng Kung University, Tainan, Taiwan

Nursing Department, Medical College, National Cheng Kung University, Tainan, Taiwan

Keywords: Intensive Care Unit Acquired Weakness, ICU-AW, Muscle Weakness, Early Mobilization, Ambulation,

Extracorporeal Membrane Oxygenation.

Abstract: Extracorporeal membrane oxygenation (ECMO) patients often experience significant muscle weakness and

physical impairments during their stay in the critical care unit. This systematic review aims to explore early

mobilization to prevent ICU-AW in ECMO survivors. A systematic search of five electronic databases for

English language articles reporting on randomized controlled trials or quasi-experimental studies was

conducted. Two reviews independently screened selected articles and reported results following the PRISMA

guidelines. Of the 168 articles screened, 21 studies were identified for eligible criteria, while two articles were

randomized control trials. The finding shows there is no significant data compared to a control group, the

patients in the early rehabilitation have the highest level of mobility in the intervention group. Another finding

result is the study described that cardiopulmonary rehabilitation was a proven effective method to improve

respiratory and cardiovascular diseases. However, the efficiency of weaning ECMO treatment has not been

well verified. This method must be conducted in routine clinical practice, even encounters some barriers to

applying it.

1 INTRODUCTION

Intensive care units (ICU) treated 13 to 20 million

people annually (Haji et al., 2021). The most common

complication during an ICU stay is intensive care

unit-acquired weakness (ICU-AW) (Witteveen et al.,

2020). ICU-AW incidence is 50% of patients (van

Wagenberg et al., 2020). Increase up to 67% in

critically disease patients with severe cases (Piva et

al., 2019). ICU-acquired weakness defines limb

symmetry weakness due to neuromuscular, muscle

weakness, and skeletal muscle dysfunction in

critically conditioned patients (Vanhorebeek et al.,

2020; Wang et al., 2018). Many symptoms include

43% of patients having decreased muscle strength

(Chen et al., 2021). 40% of patients suffered muscle

mass in the 1st week in ICU (Fan et al., 2014). The

effects of ICU-AW are prolonged ventilator

https://orcid.org/0009-0006-2105-689X

https://orcid.org/0000-0002-1276-4409

(Knudson et al., 2019), physical disability and need

rehabilitation (Schweickert et al., 2009), weakness

including tetraplegia, reduction or loss of tendon

reflex (Fan et al., 2014; Rahiminezhad et al., 2022),

increase mortality rate and decrease quality of life

(Chen et al., 2016; Christos Kourek et al., 2022).

Common causes (of ICU-AW) are metabolic

problems, long-term ventilation, and drug use;

glucocorticoids, steroids, and

neuromuscular

blocking drugs (Lin et al., 2022).

ECMO patients frequently use the ventilator and

have sedative drugs and neuromuscular blocking

agents (Abrams et al., 2014; Singh & Hote, 2021).

ECMO plays a significant in ICU-acquired weakness,

with a prevalence of 80% of ECMO patients (Chen et

al., 2021; Kurniawati et al., 2021). ECMO is very

often present (ICU-AW) (Christos Kourek et al.,

2022).

Extracorporeal membrane oxygenation (ECMO)

Soﬁa, L., Mulyoto, R. R., Hsieh, H.-C. and Huan-Fang, L.

Early Rehabilitation During Extracorporeal Membrane Oxygenation to Prevent ICU-Acquired Weakness: Systematic Review.

DOI: 10.5220/0013663200003873

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Medical Science and Health (ICOMESH 2023), pages 62-68

ISBN: 978-989-758-740-5

is an advanced method and standard gold treatment

for critical patients (Chen et al., 2022). This lifesaving

technology of heart/ lung or combining both for

critically ill patient lifesaving in the critical disease

patients who failed conventional treatment (Haji et

al., 2021; White A Fau - Fan & Fan, 2016). The

ECMO principal for respiratory support is

venovenous (VV), for cardiovascular or combined

cardio-respiratory support placed on veno-arterial

support (Chen et al., 2022; Singh & Hote, 2021);

even though ECMO is a high standard in the critical

patient, there are some complication during ECMO

treatment (Christos Kourek et al., 2022; van Dyk,

2018)

Complications receiving ECMO, such as

neurologic complications, infection, metabolic

problems, and vascular issues (Berger et al., 2022;

Bonicolini et al., 2019), influence physical weakness

and impairment (Fan et al., 2014). ECMO patients

often experience significant muscle weakness and

physical impairments during their stay in the ICU

(Mayer et al., 2022). One of the significant issues in

ECMO during critical illness is physical impairment

and ICU-AW (Kurniawati et al., 2021; Wang et al.,

2020). Early mobilization effectively prevents ICU-

AW (Lacomis, 2022; Luo et al., 2021). Individuals'

early mobilization during their stay in the ICU is an

important indicator for predicting patient outcomes

and discharge from the ICU (Lee et al., 2021) because

it can improve mobility for the patient during their

recovery phase (Linke et al., 2020; Patel et al., 2018).

Several studies showed that early mobilization

reduces weakness (Grant et al., 2018; Li et al., 2020),

so Early mobilization improves physical strength in

critically ill conditions (Wollersheim et al., 2019).

This method will reduce ICU-acquired weakness,

increase survival rate, and reduce physical disability

(Hodgson et al., 2022). Previous studies examined the

recovery phase of physical weakness in ICU

survivors (Hodgson et al., 2022; Patel et al., 2014).

Physical weakness is more prevalent than mental

impairment in ECMO patients (Abrams et al., 2014;

Kurniawati et al., 2021). However, it still limited

information on the prevalence of early mobilization

in the physical weakness of ECMO patients.

This study aims to explore early mobilization to

prevent ICU-acquired Weakness in ECMO survivors:

Systematic review.

2 METHODS

A systematic review followed the five-step systematic

review procedure according to Preferred Reporting

Items for Systematic Reviews and Meta-analyses

(PRISMA) guidelines.

2.1 Data Sources and Search Strategies

Five databases were searched including Embase,

Ovid Medline, CINAHL, Cochrane Library, and

Scopus, along with an internet search conducted in

February 2023. Databases were searched using

keywords following "Extracorporeal membrane

oxygenation," "critical care," "intensive care unit,"

"early ambulation," "mobilization," "physical

activity," "physiotherapy," "rehabilitation", "ICU-

acquired weakness." Articles were restricted to the

English language.

2.2 Study Eligible

The initial search of publications in the database for

online learning research yielded over 2000 potential

papers. After screening based on inclusion criteria: (1)

mention the rehabilitation during ECMO treatment

following the definition and scope of concepts, (2)

adult population, (3) Studies were designed in RCT or

Quasi-experimental, and (4) patients have an

intervention group that receives mobilization more

than the control group. Studies were excluded if they

were not in or available full text. The result used

JADAD Quality assessment of appraisal score is 3

which refers to a good quality trial.

2.3 Process Flow Selection of Articles

Two independent reviewers independently screened

and evaluated the abstracts and title. If the abstracts

met the criteria, the full-text articles were then

separately assessed. A matrix form was utilized to

extract information from the selected papers, such as

authors and year, design, location, method,

interventions, outcomes, and limitations.

3 RESULTS

3.1 Study Selection

The internet search generated 168 articles early

initially. Removing duplicates was performed using

Endnote 20 and also by manually reviewing the

author and title. Furthermore, 54 articles remained

after duplicates were removed. The title and abstract

were reviewed to exclude 60 articles not subject or

incomplete full text. Some articles could not reach

inclusion or exclusion criteria; 31 articles were

Early Rehabilitation During Extracorporeal Membrane Oxygenation to Prevent ICU-Acquired Weakness: Systematic Review

*Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather

than the total number across all databases/registers).

**If automation tools were used, indicate how many records were excluded by a human and how many were excluded by

automation tools.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement:

an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.

deleted at this process. The full text for the 23 articles

was then retrieved and divided among four

researchers. But in the end stage, only one article

randomized control trial for quality appraisal using an

adapted JBI checklist for RCT appraisal.

The final article was read completely with details

collected to analyze: the author and year of

publication; problem significance also purpose;

research questions and objectives; research design,

including theoretical framework and methodology;

sample population, participant number, and time

frame, data collection, analysis process/es, ethical

clearance, and considerations, and the last is the

conclusion of appraisal result of JBI checklist result.

3.2 Description of Study

The study we included was a Randomized control

trial; the First article conducted by Hayes et al. (2020)

describes how early rehabilitation among

extracorporeal membrane oxygenation patients

influences psychology. The parameter purpose of this

research is to compare the effects of early intensive

rehabilitation with standard care physiotherapy over

7 days in patients requiring ECMO. Intensive

rehabilitation includes passive and active upper

extremity and lower limb exercises. The study

outcomes showed no significant result difference

between the standard care control and intensive

rehabilitation experiment groups. Early rehabilitation

among ECMO treatment changes small respiratory

and hemodynamics among ECMO patients. Even

though there is no significant result with the control

group, the patients in the early rehabilitation have the

highest level of mobility in the intervention group.

The second article, illustrated by Zheng et al.

Identification of studies via databases and registers

Records identified from*:

Databases (n =164

)

Records removed before screening:

Duplicate records removed (n = 54)

Records marked as ineligible by

automation tools (n =0)

Records removed for other reasons

(n =0)

Records screened (n=110)

Cochrane: 5

Medline: 3

Embase: 92

CINAHL: 7

Scopus: 3

Records excluded

Cochrane: 1

Medline: 0

Embase:53

CINAHL: 4

Reports sought for retrieval

(n =50)

Cochrane: 4

Embasse:39

Medline: 3

CINAHL: 3

Sco

us:1

Reports not retrieved (n =29)

Reports assessed for

eligibility (n =21)

Reports excluded:

Reason 1 (n = Do not meet the PICO)

Reason 2 (n = Not Intervention study)

Reason 3 (n = Not in English language)

Reason 4 : (n : not full text)

Records identified from:

Websites (n = 4)

Organizations (n = 0)

Reports assessed for

eligibility

(n =1)

Reports excluded:

Reason 1 (n = Do not

meet the PICO)

Reason 2 (n = Not

Intervention stud

Studies included in review

(n = 1)

Reports of included studies

(n =0)

Identification of studies via other

Identification

Screening

Included

Reports sought for retrieval

(n =4)

Reports not

retrieved

(n = 2)

ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH

(2022b), mentions cardiopulmonary rehabilitation as

a facilitator for weaning extracorporeal membrane

oxygenation after 7-day rehabilitation. The study

purpose of this study is to compare cardiopulmonary

rehabilitation (positioning, passive range of motion,

respiratory technique, neuromuscular stimulation)

with standard care. The study described that

cardiopulmonary rehabilitation was a proven

effective method to improve cardiovascular and

respiratory function among various illnesses.

However, the efficacy of weaning ECMO treatment

has no significant data. This method must be

conducted in routine clinical practice, even

encounters some barriers to applying it.

4 DISCUSSIONS

This systematic review was formed based on several

studies regarding rehabilitation to prevent ICU

weakness (Nydahl et al., 2017; Yang et al., 2022;

Zhou et al., 2022). The result of using extracorporeal

support for the critically ill increases to prevent

further damage lungs and heart (Patel et al., 2018;

Singh & Hote, 2021). However, this lifesaving

method among ECMO patients often suffers more

risk factors of ICU-AW (Chen et al., 2021).

Developing and implementing early rehabilitation

protocol to mitigate muscle weakness during this

method (Chen et al., 2022; Linke et al., 2020). Our

systematic review study was carried out with several

participants, around 380, who underwent

rehabilitation during ECMO treatment. In general,

the two studies were not significant on changes in

oxygenation and weaning on ECMO. However, there

is an interesting finding from the two studies; it was

found that in early rehabilitation, the highest level of

patient mobility was obtained compared to the control

group.

The barrier not significant result of this method is

multiple canulation on the patient's body, which

causes limited movement. Active mobilization will

interrupt ECMO flow (Aokage et al., 2015),

influencing the body's gas exchange impairment

(Salna et al., 2020). Certified physiotherapy and

specialist equipment are available to conduct this

method (Haji et al., 2021; Lang et al., 2020). Another

obstacle is early rehabilitation cannot occur among

emergency patients and unstable conditions (Hayes et

al., 2021; Lugthart et al., 2022).

Some study describes early mobilization safety

and reliability among ECMO patients (Lugthart et al.,

2022; Rahimi et al., 2013) supported by a professional

team and integrated medical device (Abrams et al.,

2014; C. Kourek et al., 2022; Lipshutz & Gropper,

2013). However, early mobilization and physical

rehabilitation within 48-78 hours will effectively

prevent development weakness (Nydahl et al., 2017;

Yang et al., 2018). Zhou et al. (2022) mention that

early progressive rehabilitation can develop muscle

weakness. Increasing muscle strength (Hayes et al.,

2018), and daily basic motion ability enhance the

functional status and mitigate ICU-AW risk (George

et al., 2022; Labreche et al., 2021).

The general benefit of this method is reduced

healthcare utilization (Rahimi et al., 2013). Because

it will reduce the length of stay in the hospital (Haji et

al., 2021), develop quality of life (Cho et al., 2021).

Even though this method is not significant to weaning

from ECMO treatment (Zheng et al., 2022a), but

enhances the prevalence of weaning from a ventilator

(Lugthart et al., 2022).

5 CONCLUSIONS

The data of this study support that influence in early

rehabilitation is related with development outcomes.

Randomized controlled clinical trials are urgently

needed as supporting data that rehabilitation can

accommodate the healing and recovery of critical

patients on ECMO.

CONFLICT OF INTEREST

The authors have declared no conflict of interest.

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