The Early Mobilization of Patients on Extracorporeal Membrane Oxygenation: A Systematic Review
and Hero Brokalaki 1
Round 1
Reviewer 1 Report
The authors provide a solid systemic review on an very interesting and controversely discussed topic. The review is well written and aceptable from its length.
I would suggest to focus more on the limitations of the different mentioned studies regarding the study design to provide your reader a more detailed insight in "what to expect" from each study. The authors should highlight the question, if the study design was appropriate to answer the mentined questions.
Author Response
Reviewer 1
Comment 1: The authors provide a solid systemic review on an very interesting and controversely discussed topic. The review is well written and aceptable from its length.
Response: Thank you a lot for your comment.
Comment 2: I would suggest to focus more on the limitations of the different mentioned studies regarding the study design to provide your reader a more detailed insight in "what to expect" from each study. The authors should highlight the question, if the study design was appropriate to answer the mentined questions.
Response: We added two paragraphs at the end of the discussion section, where we discuss the limitations of the studies. The paragraphs are the following: It is important to refer to some limitations of the included studies. First of all, none of the studies enrolled both patients on VV ECMO and VA ECMO compared the results between these groups [15,17]. Therefore, they did not provide information regarding possible complications or appropriate vascular access. Also, half of the studies included patients with different health conditions such as ARDS, after lung transplantation, acute heart failure, chronic obstructive pulmonary disease, pulmonary hypertension, and cardiac arrest [13, 15 17-18]. However, none of these studies examined the findings within the groups in order to test the safety and the contribution of ECMO in each patient group. Finally, all studies are characterized by a lack of reproducibility since they did not provide much information regarding rehabilitation or mobilization program. More specific, most of them referred to the type of exercise like bed-level active-assisted range of motion, sitting in bed, and sitting at the edge of the bed in one patient, however they did not mentioned the duration and the frequency of each exercise.
Reviewer 2 Report
Dear authors,
Thank you for the contribution. A systematic review of early mobilisation for patients on ECMO is important, especially given that the area is under-explored, with only a few trials published.
However, I have some points that I wish to clarify or looking forward to your elaboration on.
Major revision:
1. Introduction:
It will enrich the readers’ knowledge or provide readers unfamiliar with ECMO with a brief paragraph about what ECMO is and the purpose/function it serves. Also, please provide some term definitions, such as the sweep gas and blood flow rates—similarly, the possible route of ECMO, e.g., Venovenous ECMO.
2. Diagram 1 is out of alignment, and the left-hand (grey boxes) are out of the frame of the paper size.
3. There is an extended results section to present the research from the systematic review. I suggest the authors could also summarise the findings via a table; that will make the organisation of the information more concise and make it easy for the readers to make quick references from point to point.
4. Page 4, the paragraph from lines 251 to 256, over the point regarding the linear regression analysis with a strong correlation of physiotherapy. Maybe more can be elaborated? While there is R2 values reported, I am confused with the results and the point that are trying to be presented. Hopefully, more explanation would help.
5. Discussion: Lines 297 to 304, please explain how Hayes et al.’s finding is related to reference number 17 Bonizzoli et al. (2019)’s study.
Minor revision:
The authors may want to proofread the manuscript and check on some grammatical errors; multiple such issues are spotted. E.g.
Line 70: length of stay instead of long of stay?
Line 147: maybe a missing comma after 62 sessions took place and half of them.
Lines 266-267: Also, it was reduced the dosage of noradrenaline. Should it be: “also, it reduced the dosage of …”
Please insert the year of publication after citing the authors, such as Bonizzoli et al. (2019), instead of just leaving it as Bonizzoli et al.
The in-line reference numbers are messed up after reference [14], and I cannot find the information citing reference 14. Please confirm if all the references are done accurately.
After the requested revisions, I appreciate that the article will be interesting for a broad readership of the journal.
Author Response
Reviewer 2
Comment 1: Thank you for the contribution. A systematic review of early mobilisation for patients on ECMO is important, especially given that the area is under-explored, with only a few trials published. However, I have some points that I wish to clarify or looking forward to your elaboration on.
Response: Thank you a lot for your comment.
Comment 2: Introduction: It will enrich the readers’ knowledge or provide readers unfamiliar with ECMO with a brief paragraph about what ECMO is and the purpose/function it serves. Also, please provide some term definitions, such as the sweep gas and blood flow rates—similarly, the possible route of ECMO, e.g., Venovenous ECMO.
Response: We added that following paragraph: The ECMO machine is connected to a patient via plastic tubes called a cannula. The tubes are placed in large veins and arteries in the legs, neck, or chest. The ECMO machine pumps blood from the patient’s body to an oxygenator that adds oxygen to it and removes carbon dioxide. The ECMO machine then sends the blood back to the patient through a pump with the same force as the heart, replacing its function. Membrane surface area and blood flow determines maximal oxygen delivery. The capacity of oxygen exchange is referred as a rated flow which is the volume of desaturated blood (SO2 75%) that the membrane can return to an SO2 of 95% per minute (L/min). Also, sweep gas is either 100% oxygen or carbogen (95% O2 and 5% CO2) which is a gas flow in liters/minute via the membrane oxygenator. Sweep gas flow rates are equal to blood flow. An increase of sweep gas flow increases CO2 elimination. Two types of ECMO are commonly used. The venoarterial (VA) ECMO is connected to both a vein and an artery and the venovenous (VV) ECMO which connected to one or more veins.
Comment 3: Diagram 1 is out of alignment, and the left-hand (grey boxes) are out of the frame of the paper size.
Response: We adjusted the size of the diagram.
Comment 4: There is an extended results section to present the research from the systematic review. I suggest the authors could also summarise the findings via a table; that will make the organisation of the information more concise and make it easy for the readers to make quick references from point to point.
Response: We added the Table 2 in which presented the main findings of the studies.
Comment 5: Page 4, the paragraph from lines 251 to 256, over the point regarding the linear regression analysis with a strong correlation of physiotherapy. Maybe more can be elaborated? While there is R2 values reported, I am confused with the results and the point that are trying to be presented. Hopefully, more explanation would help.
Response: We rephrased the sentence as: At linear regression analysis, time from ECMO start to first physiotherapy session was associated with length of stay (r2=0.48, P<0.001).
Comment 6: Discussion: Lines 297 to 304, please explain how Hayes et al.’s finding is related to reference number 17 Bonizzoli et al. (2019)’s study.
Response: We accidentally added the number 17. We correct it to number 16.
Minor revision:
The authors may want to proofread the manuscript and check on some grammatical errors; multiple such issues are spotted. E.g.
Comment 1: Line 70: length of stay instead of long of stay?
Response: We rephrase it as length of stay.
Comment 2: Line 147: maybe a missing comma after 62 sessions took place and half of them.
Response: We rephrased the sentence as A total of 62 sessions took place, half of them were conducted via a passive range of motion.
Comment 3: Lines 266-267: Also, it was reduced the dosage of noradrenaline. Should it be: “also, it reduced the dosage of …”
Response: We rephrased the sentence as mentioned.
Comment 4: please insert the year of publication after citing the authors, such as Bonizzoli et al. (2019), instead of just leaving it as Bonizzoli et al.
Response: We inserted the year of publication after each citing author.
Comment 5: The in-line reference numbers are messed up after reference [14], and I cannot find the information citing reference 14. Please confirm if all the references are done accurately.
Response: We revised and posted all the references accurately.
Reviewer 3 Report
The paper deals with a very important topic concerning the rehabilitation care of patients requiring the use of ECMO. The success of a given medical procedure is not the mere fact of patient survival, but the quality of life that can be achieved after discharge from the hospital. Early rehabilitation after ECMO is very important. In this paper, there is no grouping of patients due to the indications for the use of ECMO therapy. Patients after transplantation are a different group than those with ARDS. A table grouping results according to indications for ECMO and applied rehabilitation would be useful. Were there other indications for ECMO therapy apart from transplantation and ARDS? The discussion should take into account the difficulties and challenges related to the limitation of mobility in patients after ECMO therapy and the differences between patients due to their initial condition.
Author Response
Reviewer 3
The paper deals with a very important topic concerning the rehabilitation care of patients requiring the use of ECMO. The success of a given medical procedure is not the mere fact of patient survival, but the quality of life that can be achieved after discharge from the hospital. Early rehabilitation after ECMO is very important. In this paper, there is no grouping of patients due to the indications for the use of ECMO therapy. Patients after transplantation are a different group than those with ARDS. A table grouping results according to indications for ECMO and applied rehabilitation would be useful. Were there other indications for ECMO therapy apart from transplantation and ARDS? The discussion should take into account the difficulties and challenges related to the limitation of mobility in patients after ECMO therapy and the differences between patients due to their initial condition.
Response: Dear Reviewer, thank you a lot for your kind comments. We added the Table 2 in which presented the main findings of the studies. In this Table, we presented the results according the indication for ECMO therapy. The majority of studies used the ECMO in patients with ARDS and/or as a bridge either before or after transplantation, whereas only one study enrolled patients with different health conditions. It is important to mention that none of the studies compared the results within different indication for ECMO. Finally, we added two paragraphs in the end of discussion section where we discusses the main limitations of each study.
Round 2
Reviewer 2 Report
Dear Authors,
Thank you very much for the revision.
I have no further comments.
All the best,
