Stepping Forward Together: Preparing the Ground to Get Patients Mobile in the Pediatric Cardiac Intensive Care Unit on Extracorporeal Membrane Oxygenation

INTRODUCTION

Movement is a function of the human body which is widely known to be essential to health. The term “early mobilization” has various arbitrary definitions but describes the concept of helping patients to move when traditionally they would not do so. Nowhere is the challenge but the reward so great as in the pediatric cardiac intensive care unit (PCICU).

Early mobilization benefits physical and mental health and reduces intensive care unit (ICU) length of stay. It improves functional capacity by maintaining joint range of movement, preventing contractures and helps to maintain muscle strength. Complications of bed rest, such as pressure areas, deep vein thrombosis, and basal atelectasis, can be reduced. When the team is united in the goal to mobilize the patient, we question more critically the giving of sedation drugs, we strive to properly address pain and systematically screen for and treat delirium because we need a cooperative, conscious, and comfortable patient. Facilitating independence and making progress in rehab motivates the patient, family, and the whole care team.

CONSERVATIVE HISTORICAL APPROACH SO FAR

Historically, concerns about the fragility of pediatric patients and the perceived risks of mobilization led to conservative approaches, often delaying physical activity until hemodynamic stability was assured. However, accumulating evidence underscores that carefully coordinated early mobilization can be safely integrated into pediatric ICU care, fostering muscle preservation, enhancing pulmonary mechanics, and promoting neurodevelopment.

Building expertise around patient mobilization takes time and investment. Historic practice in the PCICU involved deeply sedating patients to reduce resting oxygen consumption. Poor recognition and management of delirium meant that patients awoke in a confused state, endangering lines and devices, and were sedated further which exacerbated the problem. There are now many examples of good sedation protocols and delirium screening tools and implementing these is an essential step. Nursing staff can employ a wide range of strategies for managing anxiety and distress in children, which can facilitate lower sedative use. These include play, distraction, music, child-friendly surroundings, parental presence, lack of physical restraints, reassurance, containment positioning, and therapeutic touch. Nursing staff may need to be empowered to make significant changes to culture and practice and need the support and direction of the medical and surgical staff, along with a whole team’s willingness to persist through the learning curve.

IMPLEMENTING EARLY MOBILIZATION IN NEONATAL AND PEDIATRIC EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) PATIENTS

Implementing early mobilization in neonatal and pediatric ECMO patients demands meticulous planning. Factors such as cannulation sites, anticoagulation management, hemodynamic stability, and neurodevelopmental status must be judiciously evaluated. Multidisciplinary teams – including intensivists, physical and occupational therapists, nurses, and respiratory therapists – are instrumental in devising and executing safe mobilization strategies. Techniques range from passive range-of-motion exercises to active sitting and eventual ambulation, tailored to each patient’s clinical condition and developmental stage.

ECMO AND EARLY MOBILIZATION IN THE PCICU ON ECMO IN RESOURCE-LIMITED SETTING

In a resource-limited setting, the benefits extend further. When the length of stay is shortened, more patients can be treated, and the cost of care is lower.

The mobilization of young ECMO patients is perhaps our greatest challenge in the PCICU. Edelson et al.^[1] published an extracorporeal life support organization registry analysis of 688 pediatric VA-ECMO patients and compared outcomes between mobile and non-mobile patients. Ten percent (69/688 patients) achieved some mobility and 81% of these reached a maximum mobility score equivalent to exercising while being seated in bed. When we are filled with admiration, watching videos of adult ECMO patients walking along hospital corridors, we must remember that “we can’t run before we can walk” and that good sound foundations and a strong safety framework are crucial. Edelson’s paper showed that exercising while remaining in bed is associated with greater survival or receiving a heart transplant, even after adjusting for disease severity. Successful mobilization was more likely in those that had not had a cardiac arrest before ECMO, had a longer duration on ECMO, were cannulated peripherally, and were not receiving narcotics, suggesting that these are easier patients to get moving.

PARENTAL INVOLVEMENT MATTERS

Parental involvement can be a key to the success of a mobilization program. Children look to their parents for reassurance, instruction, and permission and ideally, parents should work with staff to set goals and give children praise for the hard work that it is to exercise during critical illness. Staff need to explain to parents the benefits of mobilization, reassure them of the safety aspects, and show them what their role is. A leaflet or poster would be helpful or staff could have a structured conversation going through the important points, if literacy or language presents a communication barrier.

The role of physiotherapists is broad and includes the monitoring of tone, position, and range of movement, teaching of bedside nurses and parents about how to do passive stretching, becoming experts on safe movement, and designing a graded exercise program. Networking with other therapists is helpful to learn good practice and discuss problems and their solutions.

There will always be a concern that movement may precipitate a deterioration in a patient’s condition. It is possible to use tools to risk-stratify patients such as those described in the review article by Alaparthi et al.^[2] who have summarized objective criteria which determine whether a patient is suitable for exercise in bed or out of bed and in addition list criteria for stopping the mobilization session. These criteria include physiological observations, particular clinical conditions and therapies and symptoms.

Very few papers on the topic of early mobilization report significant or frequent adverse events. This is perhaps surprising given the variety and the regularity of adverse events we see in the pediatric intensive care unit even with patients not actively engaged in rehabilitation. A strong safety culture, a proactive approach to seeking and sorting problems with line, endotracheal tube, and device security and a checklist to go through before the session starts make unwanted events less likely. Shkurka et al.^[3] published a consensus document on early rehabilitation and mobilization of pediatric ECMO patients. The strength of this paper is the very pragmatic and practical approach to ensuring realistic goals for patients based on an acuity tool, including principles that can be extended to non-ECMO PCICU patients. They also describe best practices with respect to equipment and staff training.

Patients on ventricular assist devices (VADs) should be mobilized as much as possible. At VAD implantation, most patients are deconditioned, catabolic, poorly nourished, and have low muscle mass and functional ability. VAD allows the provision of adequate cardiac output and regaining of end-organ function, and the period on VAD should be used to rehabilitate the patient to optimize them for heart transplantation. Pediatric patients on implantable durable pumps, where hospital discharge is expected, can undergo exercise training and may participate in sports such as cycling subject to a risk assessment. Those on durable paracorporeal systems such as the Berlin Heart EXCOR can be independently mobile with the newest driving unit and with the assistance of a carer in the smallest patients.^[4] Infants can learn to crawl and walk with the support of the physiotherapy, occupational health team, and VAD specialists. Improved mobility corresponds to improved quality of life scores for both patients and families. The use of Point-of-care viscoelastic testing^[5] alongwith imbibing the habit of delayed sternal closure in those undergoing cardiac surgery, improves outcomes drastically, especially bleeding and infections.^[6]

The importance of the holistic aspects of movement, communication, and rehabilitation cannot be overemphasized. The importance of developmental care for children with cardiac disease has been given recent recognition by the American Heart Association in the publication of a Science Advisory. Children, especially those in hospitals who are deconditioned or disadvantaged by dependence on equipment, many of whom need assistance to achieve normal developmental milestones.^[7] Common sense, low-cost interventions can make a huge difference, and there are aspects of care which can be delivered by parents with appropriate guidance from professionals.

CONCLUSION

Bringing early mobilization into the culture of a PCICU is possible using a staged approach, beginning with the implementation of the necessary protocols and the training of staff and progress with rehabilitation improves outcomes and is a rewarding and beneficial experience for patients and caregivers alike.