Need for Early Mobilization in Pediatric Patients in Extracorporeal Membrane Oxygenation

INTRODUCTION

Early mobilization during extracorporeal membrane oxygenation (ECMO) in pediatric patients enhances functional recovery, reduces long-term disability, and supports psychosocial well-being. When delivered through structured protocols, coordinated teamwork, and rigorous safety measures, mobilization can be performed safely without increasing complication risk.^[1]

Patients considered for mobilization must demonstrate hemodynamic stability with minimal or no vasoactive support, adequate oxygenation, secure cannulation, and neurological readiness (e.g., Richmond Agitation Sedation Scale ≥–1). Contraindications include recent cannula placement within 48 h, raised intracranial pressure, uncontrolled seizures, or unstable respiratory parameters. Careful multidisciplinary assessment ensures that only suitable patients proceed.^[2]

MULTIDISCIPLINARY APPROACH

Mobilization of patients on ECMO is a highly specialized process requiring close collaboration between intensivists, ECMO specialists, perfusionists, nurses, physiotherapists, respiratory therapists, and safety observers.^[3] Education and training underpin safe and effective practice, ensuring staff understand ECMO physiology, equipment, complications, and risk assessment. Development of a site-specific protocol is essential, outlining patient selection, staffing requirements, cannula securement procedures, and emergency algorithms. Pre-mobilization hurdles should confirm suitability, allocate roles, and review contingency plans.^[4,5] Family engagement provides additional comfort, reassurance, and communication support, while rehabilitation goals focus on reducing morbidity and shortening hospital stays.

EQUIPMENT FOR EARLY REHABILITATION AND MOBILIZATION

The extent of mobilization and the type of exercises to be undertaken are determined after careful clinical assessment. Before beginning, proper patient preparation is crucial. The primary concern during mobilization is patient safety, which requires the multidisciplinary ECMO team to pay close attention to intravenous lines, ECMO cannulas, and the various monitoring devices in place. Throughout the process, oxygenation and hemodynamic stability must be maintained.

To permit safe mobilization, sufficient slack in the ECMO tubing is ensured, preventing undue traction on the circuit. A designated team member – commonly a perfusionist or ECMO-trained nurse – remains responsible for close-circuit supervision. Adjustments to sweep gas flow, ECMO blood flow, or supplemental oxygen may be made as needed. Should any signs of hemodynamic or respiratory compromise appear, therapy is immediately paused. Evidence suggests that when gradual, goal-directed mobilization is carried out under the supervision of a trained multidisciplinary team, it is both safe and beneficial, with positive impacts on recovery. Therefore, mobility and exercise should form an integral part of daily intensive care unit care for ECMO patients.

ECMO CANNULATION AND REHABILITATION

Special care is given to the stability and integrity of cannulas and tubing during rehabilitation. In some cases, thermoplastic splints or similar stabilizing devices may be used to secure cannulas and minimize displacement during activity. The ECMO circuit – comprising the centrifugal pump, polymethylpentene oxygenator, and console – is mounted on a mobile cart that can be moved alongside the patient during ambulation. During physiotherapy sessions, gas exchange support (through sweep gas flow, blood flow, and supplemental oxygen) may be temporarily increased at the clinician’s discretion. Continuous monitoring of respiratory and cardiovascular status, including pulse oximetry, is essential throughout mobilization [Tables 1 and 2].^[5]

GENERAL SAFETY CONSIDERATIONS

Always ensure redundant securement: At least two points of fixation (site + loop or loop + garment). Daily checks for tension, migration, skin integrity, and circuit safety are routinely done. It is important to clearly define mobilization limits by cannula site as neck cannulas: Allow sitting, walking with support; secure femoral cannulas safely (as latter may restrict full ambulation) may restrict full ambulation. Although subclavian cannulation carries a potential for early and high mobility due to its harnessing property, it is preferred, but with it, ECMO flows are less.

GENERAL SAFETY CONSIDERATIONS

Monitoring includes continuous mean arterial pressure, heart rate, SpO₂, ECMO flow, and sweep gas tracking. Maintain vigilance for desaturation, arrhythmia, cannula displacement, or circuit alarms.

Emergency readiness includes the immediate availability of clamps, airway equipment, and a predefined response plan, which are safety measures documented.^[6]

CANNULA-SPECIFIC CONSIDERATIONS

Jugular allows higher mobility, including supported walking. Femoral includes generally, limiting activity to standing transfers. Subclavian supports broader mobilization with secure harnessing. Securement methods vary by age group – infants require gentle, padded supports; adolescents may use adult-style fixation systems.

REHABILITATION TOOLS

All staff involved must undergo simulation-based and supervised training, covering ECMO physiology, mobilization risk assessment, emergency response, and role delineation. Competency requires proficiency in safe handling, troubleshooting, and adherence to defined safety limits.

TRAINING AND COMPETENCY

Staff must complete simulation-based and mentored training covering ECMO physiology, mobilization risk assessment, emergency management, and role allocation. Competency includes safe handling, troubleshooting during mobilization, and adherence to protocolized limits.^[7]

CONCLUSION

Early mobilization in pediatric ECMO is both feasible and beneficial when implemented through evidence-based protocols, adapted to cannula type and patient age, and supported by training and family engagement. Integration of AI and emerging technologies provides additional opportunities to improve safety, optimize outcomes, and deliver standardized care across centers.