Construction And Application Of Early Rehabilitation Program For Patients With Venovenous Extracorporeal Membrane Oxygenation

ObjectiveTo summarize the best evidence on early rehabilitation of VV-ECMO patients,construct the early rehab.ilitation program for VV-ECMO patients on the basis of the best evidence combined with Delphi expert letter consultation method,and apply the constructed program to clinical practice to verify the effect,in order to provide theoretical reference for the standard development of early rehabilitation for VV-ECMO patients.Methods1.Based on the theoretical framework of evidence-based nursing,the guidelines,systematic evaluation,expert consensus,evidence summary and related original studies related to early rehabilitation of VV-ECMO patients at home and abroad were systematically searched,and the quality evaluation and evidence summary of the included literature were conducted.2.On the basis of summarizing the best evidence of early rehabilitation of VV-ECMO patients and combining the group discussion method,the early rehabilitation plan of VV-ECMO patients was initially constructed,and then the final plan was formed through two rounds of Delphi method expert consultation.3.A total of 60 patients with VV-ECMO who were hospitalized in the Department of Critical Care in a Grade A general hospital in Qingdao from January 2021 to December2022 were selected as the research objects by convenient sampling method.Using the historical control study design,30 patients with VV-ECMO admitted from January 2021to December 2021 were selected as the control group,and 30 patients with VV-ECMO admitted from January 2022 to December 2022 were selected as the intervention group.The control group was given routine ICU early rehabilitation nursing measures,and the intervention group was given evidence-based early rehabilitation program based on routine nursing.Duration of ICU stay,mechanical ventilation time,duration of ECMO treatment,MRC score,IMS score,incidence of ICU acquired asthenia,incidence of adverse events,and ultrasound parameters of respiratory and skeletal muscles at day 1,4,7,10,and 14 after VV-ECMO treatment were compared between the two groups.Results1.A total of 2 guidelines,2 expert consensuses,2 systematic reviews and 8 original studies were included.The evidence was summarized from 9 aspects including the necessity of early rehabilitation,rehabilitation initiation time,rehabilitation location,pre-rehabilitation preparation,pre-rehabilitation assessment,rehabilitation method,rehabilitation frequency and duration,rehabilitation process monitoring and effect evaluation,and finally 24 pieces of the best evidence were summarized.2.The recovery rates of the two rounds of expert letter questionnaires for the preliminary construction of the early rehabilitation program of VV-ECMO were both100%,the expert authority coefficients were 0.840,the coefficients of variation of each item in the two rounds of expert letter inquiries were 0.000 to 0.353 and 0.000 to 0.237and the Kendall’s coefficients of concordance were 0.137(X~2=164.538,P<0.001)and0.125(X~2=147.066,P<0.001).An early rehabilitation program for patients with venovenous extracorporeal membrane oxygenation including 4 first-level indicators,16second-level indicators,and 45 third-level indicators was finally formed.3.There was no significant difference in general data and baseline data between the intervention group with VV-ECMO early rehabilitation program and the control group with routine rehabilitation nursing measures(P>0.05).The change rate of diaphragm excursion(DE)of intervention group was not decreased or had no statistical significance at the 4th,7th,10th and 14th days after VV-ECMO treatment(P>0.05).The change rate of diaphragm thickening fraction(DTF)in intervention group did not decrease on day 4after VV-ECMO treatment,but significantly decreased on day 7,10 and 14(P<0.05).The change rate of intercostal muscle thickening fraction(ICMTF)was significantly decreased at day 4,7,10 and 14 after VV-ECMO treatment(P<0.05).The thickness of rectus femoris(RF)and vastus intermedius(VI)in intervention group had no statistical significance at day 4 after VV-ECMO treatment(P>0.05),but significantly decreased at day 7,10 and 14(P<0.05).The rectus femoris muscle cross-sectional area(RF-CSA)of intervention group was significantly decreased at the 4th,7th,10th and 14th days after VV-ECMO treatment(P<0.05).The duration of ICU stay,mechanical ventilation and ECMO treatment in intervention group were significantly shorter than those in control group(P<0.05).MRC score and IMS score of intervention group were significantly higher than those of control group(P<0.05).The incidence of ICU-AW in experimental group was 20.00%,which was significantly lower than that in control group(46.67%)(P<0.05).There was no significant difference in the incidence of adverse events between experimental group and control group(P>0.05).ConclusionBased on evidence-based theory and Delphi method,this study constructed an early rehabilitation program for VV-ECMO patients,including four aspects:preparation stage,implementation stage,rehabilitation process monitoring and emergency treatment stage,evaluation and feedback stage,covering the whole process of early rehabilitation for VV-ECMO patients,which is scientific and feasible to a certain extent.It provides clinical practice guidance for early recovery of VV-ECMO patients.Its clinical application can effectively improve muscle atrophy and mobility disorders in VV-ECMO patients,reduce the incidence of ICU-AW,shorten the duration of ECMO and mechanical ventilation therapy and ICU stay.