Disclaimer: 

This Extracorporeal Life Support Organization guideline describes early rehabilitation or mobilization of patients on extracorporeal membrane oxygenation (ECMO). The guideline describes useful and safe practices put together by an international interprofessional team with extensive experience in the field of ECMO and ECMO rehabilitation or mobilization. The guideline is not intended to define the delivery of care or substitute sound clinical judgment. The guideline is subject to regular revision as new scientific evidence becomes available.

Purpose

This guideline describes early rehabilitation or mobilization of adult patients supported with extracorporeal membrane oxygenation (ECMO). The intent is to provide the interprofessional team caring for patients receiving ECMO with best practices for early rehabilitation or mobilization based on current evidence and extensive clinical experience.

Background

Early rehabilitation or mobilization of critically ill patients is recommended by several professional societies.^1–7 This may be due to the perceived benefits of early rehabilitation or mobilization such as reduced intensive care unit (ICU)-acquired weakness (ICU-AW), enhanced cognitive and functional recovery, and improved muscle strength.^8,9 Patients on ECMO represent the sickest cohort of critically ill patients, often having near-total dependence on the ECMO circuit for survival. Literature regarding early rehabilitation or mobilization of patients with ECMO is largely retrospective and observational and, to some extent, extrapolated from general ICU literature. A recent scoping review of early rehabilitation or mobilization on ECMO, including a large cohort study, reported minor rates of complications.^10,11 Although studies have demonstrated that early rehabilitation or mobilization during ECMO is possible in high-volume centers, for most patients on ECMO, rehabilitation or mobilization remains largely an in-bed activity. A recent international cohort study reported only 22% of patients on veno-venous (VV) ECMO achieved some level of physical mobilization. Factors independently associated with receiving early rehabilitation or mobilization included cannulation for prelung transplantation, avoidance of mechanical ventilation, being at a high-volume ECMO center, and cannulation with a dual-lumen cannula.¹² Increased rehabilitation or mobilization for patients on ECMO as a bridge to lung transplantation (BTT) is a consistent finding in the literature, suggesting that some patients may be better suited than others.¹² Maintenance of functional and rehabilitative status for the patient awaiting lung transplantation is a prerequisite to surgical intervention and ambulation has been reported as an independent predictor of successful BTT.¹³ Indeed, lack of rehabilitation or mobilization for this population is considered a strong relative contraindication and may preclude transplantation altogether.¹⁴

A recent randomized controlled study of mechanically ventilated patients found no difference in the number of days alive and out of the hospital or in adverse event rate for the early mobilization group when compared to usual care.¹⁵ Patients on ECMO represent a unique patient population and balancing risks versus benefits of early rehabilitation or mobilization in this group can be challenging. Ensuring the safety of early rehabilitation or mobilization requires individualized patient assessment before each activity and is dependent upon the collaborative efforts of an interprofessional team of experienced practitioners to mitigate potentially deleterious events.^16,17

To determine best practice regarding early rehabilitation or mobilization in this group, we performed a literature search of the MEDLINE, SCOPUS, and EMBASE databases using appropriate keywords pertaining to “ECMO,” “rehabilitation,” “exercise therapy,” “ambulation,” and “muscle strength” from January 2009 through August 2024 and summarize the data for the recommendations (Table 1). We provide a framework outlining team structure, premobility assessment, challenges, and training needs for maximizing the safety of early rehabilitation or mobilization of patients during ECMO. The guidelines have been constructed with key stakeholders involved, including relevant professional groups and the target population, including an ECMO survivor.