key: cord-0945432-lgu9xsdq
authors: Mark, Alex; Crumley, Jennifer P; Rudolph, Kristina L; Doerschug, Kevin; Krupp, Anna
title: Maintaining Mobility in a Patient Who Is Pregnant and Has COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Case Report
date: 2020-10-17
journal: Phys Ther
DOI: 10.1093/ptj/pzaa189
sha: 5c75a05b4b41a42f5c63297a2c8373754c116c9d
doc_id: 945432
cord_uid: lgu9xsdq

OBJECTIVE: Mobilization while receiving life support interventions, including mechanical ventilation and extracorporeal membrane oxygenation (ECMO), is a recommended intensive care unit (ICU) intervention to maintain physical function. The purpose of this case report is to describe a novel approach to implementing early mobility interventions for a patient who was pregnant and receiving ECMO while continuing necessary infectious disease precautions because of diagnosed coronavirus disease-19 (COVID-19). METHODS (CASE DESCRIPTION): A 27-year old woman who was pregnant was admitted to the ICU with COVID-19 and rapidly developed acute respiratory failure requiring 9 days of ECMO support. After a physical therapist consultation, the patient was standing at the bedside by hospital day 5 and ambulating by hospital day 9. RESULTS: The patient safely participated in physical therapy during ICU admission and was discharged to home with outpatient physical therapy follow-up after 14 days of hospitalization. CONCLUSION: Early mobility is feasible during ECMO with COVID-19, and active participation in physical therapy, including in-room ambulation, may facilitate discharge to home. Innovative strategies to facilitate routine activity in a patient who is critically ill with COVID-19 require an established and highly trained team with a focus on maintaining function. IMPACT: Early mobility while intubated, on ECMO, and infected with COVID-19 is feasible while adhering to infectious disease precautions when it is performed by an experienced interdisciplinary team.

U N C O R R E C T E D M A N U S C R I P T U N C O R R E C T E D M A N U S C R I P T 3

The coronavirus disease-2019 (COVID- 19) pandemic has overwhelmed intensive care units (ICUs) around the world and disrupted normal processes for how some evidence-based interventions are delivered to adults who are critically ill with suspected or confirmed COVID- 19 . International guidelines report early mobility as safe and feasible in the ICU setting to reduce ICU-acquired weakness, reduce delirium, improve functional recovery, and reduce ICU and hospital lengths of stay. 1, 2 Early mobility is a complex intervention, requiring thorough patient assessment and interdisciplinary teamwork to effectively implement the highest level of patient mobilization possible each day while maintaining patient and staff safety. A patient who is critically ill with highly contagious COVID-19 requires advanced assessment and an experienced team to maintain patient and staff safety when considering early mobility interventions.

COVID-19 mainly affects the respiratory system and can lead to acute respiratory distress syndrome (ARDS). ARDS is the result of an inflammatory response, causing diffuse alveolar damage and increased pulmonary vascular permeability, resulting in hypoxemia. 3 Most patients with ARDS from COVID-19 require mechanical ventilation, using low volume and low pressure to maintain oxygenation. 4 During mechanical ventilation, patients may require analgesics and sedatives to maintain comfort, and chemical paralysis may be added to maintain compliance with the ventilator. 3 If adequate oxygenation is not achieved with maximal ventilator settings, rescue therapy, such as extracorporeal membrane oxygenation (ECMO), may be initiated. 3 

interventions in the ICU, therapists with ICU skills should be involved in complex decisionmaking. 13 For patients requiring organ support, preventing tubing disconnections, a risk with out-of-bed activity, is of utmost importance. Ventilator tubing disconnections may cause alveolar decruitment and staff exposure to the virus.

The purpose of this case report is to describe the treatment of a patient who was pregnant, had COVID-19, and rapidly developed ARDS requiring ECMO. We outline the interdisciplinary assessment, treatment, and staffing strategies implemented to safely deliver early mobility interventions and successfully maintain physical function status until hospital discharge.

The patient was a 27-year-old woman who was previously healthy, pregnant at 23 weeks 6 days, and presented to an outside hospital with worsening shortness of breath, cough, nausea, and vomiting. She tested positive for COVID-19 4 days prior to her presentation. She had a witnessed tonic-clonic seizure on arrival and was endotracheally intubated following the event. The patient was transferred to our facility via airlift. She was deeply sedated and given a cisatracurium infusion (chemical paralysis). The patient was subsequently diagnosed with ARDS and aspiration pneumonia. She continued to be hypoxic despite paralysis and required maximal ventilator support. The maternal fetal medicine service was consulted, and because of the severity of respiratory failure, agreed with emergent ECMO cannulation in lieu of a trial of prone positioning. The patient was therefore referred for venovenous ECMO consideration (VV ECMO). She was cannulated with a dual-lumen Avalon cannula (Getinge, Gothenburg, Sweden)

placed in the right internal jugular vein. Cisatracurium infusion was discontinued following cannulation.

To account for increased oxygen requirements and to maintain adequate placental blood flow during pregnancy, the maternal fetal medicine service recommended specific monitoring parameters during ECMO therapy. The monitoring parameters included the following: maintenance of peripheral oxygen saturation at >95%; immediate treatment of blood pressures >160/110 mm Hg; maintenance of mean arterial pressure at >65 mm Hg; and signs and symptoms of preterm labor, such as increased pain, concern for contractions, bleeding, or leaking of fluid. Typically, a peripheral oxygen saturation of 75%-80% while a patient is receiving VV ECMO is tolerated. 14 Hemodynamic goals on VV ECMO followed the recommendations of fetal medicine. Otherwise, evidence-based ARDS management was used to optimize care of both fetus and mother, including conservative fluid management and daily sedative interruptions. We used ultra-lung protective ventilation strategies, including the maintenance of plateau pressures of ≤24 cm of H 2 O and driving pressures of ≤14 cm of H 2 O.

The fetal medicine service monitored the fetus via daily ultrasound studies.

On day 2 of VV ECMO, weaning of sedation began, initially targeting a Riker Sedation-Agitation Scale score of 3 (the patient is sedated but awakens and is able to follow simple commands). This continued over days 3 and 4 of VV ECMO. Physical therapist-delivered interventions were held during this period, as out-of-bed mobility was not expected, in part because of issues in achieving effective lung protective ventilation. In light of the strain on hospital resources, including personal protective equipment, because of the COVID-19

pandemic, it was decided by the Department of Rehabilitation Services and ICU leadership that

physical therapists would initiate direct treatment only for patients who were intubated if outof-bed mobility was thought to be feasible. This was to conserve personal protective equipment, especially our supply of respirators, as mobilization during mechanical ventilation has the potential to be an aerosol-generating procedure. 13 The physical therapy service continued to follow the patient through the electronic medical record and daily face-to-face interaction with the ECMO team (Table) .

The physical therapy service initiated direct intervention on day 5 of VV ECMO, as the patient was awake and calm on minimal sedation (Riker Sedation-Agitation Scale score of 4), mechanical ventilation parameters were stable, the ECMO flows were stable, the cannula was secure, and the patient was deemed to be ready for out-of-bed activity upon discussion by the multidisciplinary team. Physical therapy commenced with in-bed active-assisted range-ofmotion exercises, in which the patient was deemed to have suitable extremity strength (at least 3/5 on the Medical Research Council Scale for Muscle Strength) to attempt sitting at the bedside. Nonessential intravenous infusions were paused, and a heparin lock flush was applied to minimize extraneous lines. The ECMO cannula and tubing were supported using an elastic headband with hook-and-loop closures that wrapped circumferentially around the head, with the bedside ECMO specialist providing additional manual support of the device. A respiratory therapist was present to exclusively manage the endotracheal airway catheter and ventilatory tubing. Securing these 2 devices allowed the bedside nurse and physical therapist to provide adequate assistance to the patient, wherein she was mobilized to sitting at the edge of the bed and eventually standing-although requiring considerable caregiver support to achieve weight bearing on this day. Vital signs were continuously monitored and remained within goal ranges

(peripheral oxygen saturation of >95%, blood pressure of <160/110 mm Hg, mean arterial pressure of >65 mm Hg). Progression of mobility was limited by patient report of significant fatigue after standing.

Out-of-bed activity was held on day 6 because of concerns for preterm labor, as the patient was experiencing contractions on a tocodynamometer study. However, on days 7 and 8 of VV ECMO, the patient was again able to achieve standing at the bedside with improved duration of stance, strength of standing force, and performance of pregait exercises. Prior to the pursuit of out-of-bed activity, supine exercises were performed each day to ensure an adequate level of consciousness and appropriate responses in vital signs. On day 9 of ECMO and hospitalization, the patient began her final trial off VV ECMO support, in which the sweep gas blender was turned to zero-effectively placing her on mechanical ventilator support alone.

Upon discussion with the multidisciplinary team in morning rounds, we elected to pursue a trial of ambulation prior to her expected decannulation from VV ECMO that afternoon. This was to further test her lungs and allow for a period of bed rest following cannula removal. The ECMO cannulas were secured, the sweep gas line was connected to a portable oxygen tank with a liters-per-minute flow meter (in case of the need for reinitiation of ECMO support), and medical air and oxygen tubing were disconnected from the wall sources and secured to the ECMO cart.

Finally, the power cord was disconnected from the wall, placing the pump on battery power and making the ECMO circuit mobile. Extraneous intravenous lines were again discontinued. (Table) . She continued to report persistent lightheadedness and mild dyspnea during exercise and ambulation, despite her peripheral oxygen saturation and blood pressures remaining within goal ranges. These symptoms necessitated frequent rest periods during physical therapist sessions.

On day 14 of hospitalization the patient was discharged to home in her family's care, with the recommendation of full-time supervision and continuing rehabilitation through local outpatient physical therapy. The patient was ambulating for distances of up to approximately

10 18 m (60 ft) in her room using a walker with supervision. This was deemed suitable for her home environment. She was proficient in a home exercise program involving resistance bands.

She was weaned to room air and did not exhibit hypoxemia on exertion, though she did endorse dyspnea with prolonged exertion. The primary care team, maternal fetal medicine service, and physical and occupational therapist teams supported home-based discharge.

This case illustrates the unique approaches used to facilitate early mobility to maintain physical function in a patient who was pregnant and was diagnosed with COVID-19 requiring ECMO. Early mobility and exercise delivered by a physical therapist, including in-room ambulation, was feasible and likely facilitated discharge to home. The innovative strategies to enable routine activity in a patient who is critically ill with COVID-19 require an established and highly trained team with a focus on maintaining function.

This case report describes the efforts of experienced clinicians with an established early mobility program. 15 For ICUs planning to develop or maintain an early mobility program, there are multiple barriers to overcome. Twenty-eight distinct barriers to implementing early mobility have been identified and can be classified into patient, structural, ICU culture, and process related barriers. 16 Cultural barriers describe lack of staff buy-in, lack of knowledge about mobility, or not identifying early mobility as a priority, and strategies to overcome cultural barriers may include interdisciplinary training, sharing experiences, and champions that support practice change. 16 Generally, overcoming cultural barriers requires a significant time investment, but results in sustainable change. 17 Our ICU has been routinely ambulating patients

requiring mechanical ventilation and during ECMO for several years, and has a strong culture of mobility. As a result, the team has considerable expertise and is more adaptable to unique and challenging situations.

The timing of mobility interventions was discussed during daily interdisciplinary rounds among the medical intensivist team, registered nurse, respiratory therapist, ECMO specialist, Cohort studies have identified that ambulation while awake on ECMO can be achieved by well-experienced ECMO teams. [19] [20] [21] This case presented a unique challenge, in that clinician interaction needed to be limited in order to preserve personal protective equipment and limit exposure to highly contagious COVID-19. The ECMO, nursing, and physical therapist teams met daily, identifying which exercise interventions could be performed during routine nursing cares and which activities required the presence of rehabilitation therapy, in order to preserve respirator supply. Prior to any mobilization attempt, provider roles were clearly identified to ensure safety and efficiency, in accordance with current best practice recommendations. 22 Although 5 to 7 staff members are typically required to mobilize a patient during ECMO, our

case has demonstrated that out-of-bed mobility is feasible with a limited treatment team of 4 staff members, provided that team is highly experienced in performing early mobility interventions. Early mobility interventions are feasible during ECMO with COVID-19, and physical therapist-delivered treatments, including in-room ambulation, may facilitate discharge to home. 

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