631 Mobilization of Patient with Inhalation Burn Injury Requiring VV ECMO: A Case Study

Abstract

Introduction As extracorporeal membrane oxygenation (ECMO) becomes more popular, there is increasing evidence supporting the safety and feasibility of early physical and occupational therapy (PT, OT) and mobility with patients on ECMO. However, there is limited evidence to support mobilizing burn ECMO patients. This case discusses safety and feasibility and explains how to successfully mobilize a burn patient on ECMO. Methods The patient is a 56-year old male admitted after sustaining 16% total body surface area partial and full thickness burns to his face, neck, forearms, and hands following an explosion at work. He sustained an inhalational injury and was intubated upon admission. Progression of his inhalation injury led to respiratory failure despite maximal ventilatory support. To maintain appropriate oxygenation, he underwent placement of left femoral-left internal jugular veno-venous ECMO (VV-ECMO). The patient received PT and OT throughout his stay in the Burn ICU. After starting ECMO, the patient resumed therapy with a sitting restriction to < 45 degrees of left hip flexion. The critical care, burn, OT, PT, and cardiothoracic surgery teams discussed factors impacting his ability to participate in therapy, e.g., managing sedation to maximize wakefulness and titrating medications due to hypertension. Modifications to therapy treatments were made based on medical changes and the patient’s ability to participate. The patient was seen daily for mobilization by a PT, OT, nurse, and ECMO specialist team. Clinicians had extensive training and experience working with patients with acute mechanical circulatory support. Safety considerations were followed during all therapy sessions, including careful monitoring of ECMO flows, vitals signs, and securement of medical devices. Results While on ECMO for 11 days, the patient was engaged in daily therapy consisting of active exercise, bed mobility, transfers and standing balance activities. ECMO flows were maintained and no adverse events occurred during mobilization. From the first session on ECMO to day of discharge, the patient exhibited a 14-point increase in his Boston University Activity Measure for Post-Acute Care functional outcome score and progressed to ambulating 300 feet. Conclusions Burn patients on VV-ECMO with femoral cannulation can safely and effectively engage in therapy and early mobilization, which yield positive functional outcomes. A well-coordinated inter-disciplinary team and highly skilled staff is essential to provide safe and effective intervention. Applicability of Research to Practice Early mobilization of burn patients on ECMO is feasible and can ameliorate the effects of immobility. Burn therapists are an integral part of the inter-disciplinary team and should be trained to be skilled at providing care for patients on mechanical circulatory support.