Crit Care Nurs Q

Vol. 36, No. 1, pp. 89–100

Copyright c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Extending the Benefits of Early

Mobility to Critically Ill Patients
Undergoing Continuous Renal
Replacement Therapy
The Michigan Experience
Cheryl L. Talley, RN; Robert O. Wonnacott, ADN;
Janice K. Schuette, BSN, RN, CCRN; Jill Jamieson, RN;
Michael Heung, MD

Evidence to support improved outcomes with early ambulation is strong in medical literature. Yet,
critically ill continuous renal replacement therapy (CRRT) patients remain tethered to their beds
by devices delivering supportive therapy. The University of Michigan Adult CRRT Committee iden-
tified this deficiency and sought to change it. There was no guidance in the literature to support
mobilizing this population; therefore, we reviewed literature from devices with similar technolog-
ical profiles. Revision of our institutional mobility protocol for the CRRT population included a
simple safety acronym, ASK. The acronym addresses appropriate candidacy; secured, appropriate
access; and potential device and patient complications as a memorable aid to help nursing staff
determine whether their CRRT patients are candidates for early mobility. After implementing our
CRRT mobility standard, a preliminary study of 109 CRRT patients and a review of incident reports
related to CRRT demonstrated no significant adverse patient events or falls and no access compli-
cations related to mobility. This deliberate intervention allows CRRT patients to safely engage in
mobility activities to improve this population’s outcomes. A simple mobility protocol and safety
acronym partnered with strong clinical leadership has permitted the University of Michigan to
add CRRT patients to the body of early mobility literature. Key words: ambulation, continuous
renal replacement therapy, extracorporeal devices, mechanical circulatory support, mobility

A CUTE kidney injury requiring renal re-

Author Affiliations: Departments of Nursing
(Messrs Talley, Schuette, and Jamieson and Mr
Wonnacott) and Medicine (Dr Heung), University of
Michigan Health System, Ann Arbor, Michigan.
The authors thank Sharon Dickinson for her guidance
and thoughtful review of the manuscript. They also
thank the other members of the University of Michigan
Health System CRRT Committee, in particular, Theresa
Mottes, for her efforts in data collection and quality
monitoring.
None of the authors has any relevant financial or fund-
ing disclosures to report.
Correspondence: Cheryl L. Talley, RN, Department of
Nursing, 1500 E. Medical Center Dr, C-127 MIB, SPC
5804, Ann Arbor, MI 48109 (ctal@med.umich.edu).
DOI: 10.1097/CNQ.0b013e3182753387
placement therapy is a frequent compli-
cation among critically ill patients, occurring
in up to 5% of patients admitted to an intensive
care setting.1 These patients face a mortality
of up to 50% to 60%, and survivors carry a high
degree of morbidity.2 As such, there exists a
significant opportunity to improve care in this
population.
Among critically ill patients with renal
failure, continuous renal replacement ther-
apy (CRRT) has emerged as the standard of
care. Compared with intermittent hemodialy-
sis, CRRT offers the advantages of increased
hemodynamic stability, greater solute control,
and superior fluid balance management.3,4
However, as a continuous treatment, CRRT

89

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
90 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2013
has traditionally required patient immobiliza-
tion that may be prolonged for several days
and contribute to progressive deconditioning.
In recognition of the benefits of early mo-
bilization in critically ill patients, our institu-
tion recently adapted an early mobility pro-
tocol for patients undergoing CRRT. In this
review, we will describe our experience with
this protocol, including appropriate patient
selection, technical considerations, and safety
concerns.
HISTORICAL PERSPECTIVE
Patients receiving CRRT are typically hemo-
dynamically unstable. They have multiple
lines and infusions and complex clinical care
requirements, and many are supported by me-
chanical ventilation. This high-acuity profile
in combination with CRRT therapy helped es-
tablish the mindset that the CRRT patient is
a bed rest patient and not eligible for mobil-
ity. In the infancy of CRRT, continuous arteri-
ovenous hemofiltration therapy was depen-
dent on the patient’s own blood pressure.
Therapy was driven by mean arterial pres-
sure, with ultrafiltration rates determined by
the position of the patient’s bed relative to
the effluent drainage bag.5 Continuous arteri-
ovenous hemofiltration patients also required
cannulation of a femoral artery and vein with
large bore, rigid catheters. Moving these early
CRRT patients frequently resulted in changes
in hemodynamic status that interfered with
the delivery of therapy, and the presence of
the rigid catheters further complicated mov-
ing and repositioning because of the risk of
catheter dislodgement or disconnection and
distal thrombus formation.5,6 With technolog-
ical advancements, the safety of CRRT deliv-
ery has improved dramatically. Today’s de-
vices propel blood via a highly calibrated sin-
gle peristaltic pump and venovenous access is
established through single, large bore double-
lumen catheters (Table 1).6 As a result, CRRT
has emerged as the standard of care for man-
agement of critically ill patients with renal
failure.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
In the University of Michigan Health Sys-
tem, CRRT is performed on more than 300
adult patients annually, representing approxi-
mately 2500 CRRT patient-days each year. Af-
ter developing and applying an early mobility
protocol for our general intensive care unit
(ICU) population, we explored extending this
protocol to the CRRT patient population.
REVIEW OF THE LITERATURE
Early studies demonstrated the safety
and feasibility of mobility protocols in
the mechanically ventilated and critically
ill population.7,8 Subsequently, clinical tri-
als have established the benefits of early
mobility, including shorter hospital length
of stay, fewer mechanical ventilation days,
shorter duration of delirium, and quicker re-
turn to functional status.9,10 More recently,
the application of early mobility protocols to
more specialized patient populations, includ-
ing those undergoing extracorporeal thera-
pies, has been described.
Extracorporeal membrane oxygenation
(ECMO) has been used in the support of
critically ill patients with cardiopulmonary
failure for several decades. Advances in ex-
tracorporeal circuit and cannula technology
have made ECMO therapy safer and allowed
for support of patients on ECMO for ex-
tended time periods.11 These improvements
have also simplified patient positioning, mak-
ing mobility a feasible proposition. During
extended ECMO runs, hemodynamically sta-
ble patients are able to dangle at bedside
or get out of bed and sit in chairs. In
skilled ECMO centers, there have been reports
of patients ambulating while on supportive
therapy.11,12
Like ECMO, left ventricular assist devices
(LVADs) represent an extracorporeal treat-
ment modality that relies on a pump for
blood flow. Unlike ECMO or CRRT, cannu-
lation for these devices is more complex, typ-
ically involving a ventricle of the heart and the
pulmonary artery.13 Patients requiring LVAD
 Extending the Benefits of Early Mobility 91

Table 1. Comparison of early versus current continuous renal replacement therapy

Early Technology (pre-1990s) Current Technology

Access Arterio-venous Veno-venous

Catheter type Large-bore rigid catheters in both an Dual-lumen flexible catheter in a central
artery and a vein vein
Blood flow Determined by patient’s mean arterial Prescribed and regulated by a peristaltic
pressure and gravity roller pump

support as a bridge to transplant can be
severely deconditioned prior to implantation
and frequently return to the ICU postoper-
atively on mechanical ventilation.14 In addi-
tion, LVAD therapy is sometimes offered as
palliative “destination therapy” for noncardiac
transplant candidates.15 In both cases, reha-
bilitation is a primary focus, either to opti-
mize outcomes postcardiac transplant or to
improve quality of life in destination ther-
apy patients. Once implanted, the mechani-
cal cardiac support of the LVAD creates an
opportunity for early mobilization of these
patients. Implementing early mobilization in
this population has proven to be safe, im-
proves the patient’s functional mobility, and
shortens the initial and posttransplant ICU
stay.15
A comprehensive review of the literature
revealed no published articles describing ex-
perience with early mobility in CRRT patients
and only one published abstract. This abstract
described early mobilization of 2 CRRT pa-
tients waiting for liver transplant and reported
this as a “feasible” practice.16 Conversely, sev-
eral articles have been published describing
exercise or mobility regimens for patients
with end-stage renal disease receiving inter-
mittent hemodialysis. Participation in exer-
cise programs, including intradialytic exercise
regimens, appears to be safe and in some stud-
ies it was associated with an improvement in
cardiorespiratory and functional capacity of
patients with end-stage renal disease.17,18 Re-
cently, Gura et al19 described a small trial of
a wearable hemofilter that delivered continu-
ous ambulatory ultrafiltration to patients with
congestive heart failure. The device was ini-
tiated in a supine position, but once it was
running, participants were encouraged to par-
ticipate in normal activities of daily living
and demonstrated no signs or symptoms of
complications.19
In summary, our review of the literature
showed a lack of published data specifically
in CRRT patients but available data support-
ing the safety of mobility protocols in other
forms of extracorporeal therapies. We, there-
fore, decided to move forward with exploring
the applicability of early mobility in the CRRT
patient population.
CONSIDERATIONS FOR MOVING
FORWARD
In our institution, CRRT is a multidisci-
plinary and cooperative venture between
the nephrology and the critical care ser-
vices. Oversight of the CRRT program—
including policy making, education, and qual-
ity assurance—is performed through a CRRT
Committee comprising the Acute Dialysis
Program medical director, the dialysis nurse
manager, ICU nurse managers, a critical care
clinical nurse specialist, and staff nurse repre-
sentatives from each of the 5 ICUs that pro-
vide CRRT care. Three of these ICUs were
already in different stages of implementing
early mobility protocols for their general ICU
populations. Representatives approached the
CRRT Committee and asked us to consider
developing mobility inclusion criteria specif-
ically for the population undergoing CRRT.
Following the literature review previously dis-
cussed, the CRRT Committee concluded that
virtually all CRRT patients may be candidates

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
92 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2013

for some form of early mobility and unani-
mously endorsed proceeding with develop-
ment of a CRRT mobility protocol.
We highlight this important initial step in
the process because we believe that early
acceptance and buy-in from all stakeholders
was crucial to ensuring the eventual success
of implementing such a significant change in
our approach to the activity status of CRRT
patients.
DEFINING EARLY MOBILITY
To try and limit deconditioning from bed
rest, early mobility was defined as assess-
ing patients for mobility therapy within 48
hours of starting CRRT. The components of
the CRRT mobility protocol were based on
the general mobility protocol and progress
through different phases of activity (Table 2).
At baseline, all patients undergo passive repo-
sitioning on a regular basis, primarily to limit
pressure sore development. The first part of
the mobility protocol, Phase 0, builds on this
with the introduction of passive and/or ac-
tive range of motion (ROM) exercises. Phase 1
involves additional patient participation from
dangling of the lower extremities off the side
of the bed to having the patient move out of
bed and to a chair using a transfer device such
as a sling or lift. Phase 2 represents the highest
level of mobility in the protocol and includes
active ROM with weight-bearing activities that
may include ambulating with assistance. Each
patient is assessed first for suitability to enter
the protocol and then advancement through
the protocol is based on the patient’s ability
to participate safely and effectively.
APPROPRIATENESS—PATIENT
SELECTION
Modeling the institutional mobility proto-
col, CRRT patients were considered suitable
early mobility candidates when they exhib-
ited improved hemodynamic stability but still
required CRRT to optimize fluid balance or
solute control. Frequently, our CRRT patients
are on low-dose catecholamine infusions for
hemodynamic support during therapy, but
the Committee decided that this did not need
to be a precluding factor for this population.
Figure 1 summarizes the hemodynamic and
infusion criteria.
A second important consideration in patient
selection was the type of vascular access be-
ing used. The committee identified femoral
dialysis catheters, arteriovenous fistula, and
arteriovenous graft access as initial exclusion
criteria for CRRT patients due to concerns
about the ability to maintain stability of these
vascular accesses during transfer or ambula-
tion. In addition, a history of frequent CRRT
flow alarms was considered a barrier to early
mobility therapy due to the constant need to
address the CRRT machine. Table 3 provides a
summary of these early contraindications and
their rationales.
As we gained familiarity with perform-
ing early mobility on CRRT patients, we
discovered that we could eliminate the ab-
solute exclusion criteria of femoral access.

Table 2. University of Michigan early mobility protocol

Phase Baseline Phase 0 Phase 1 Phase 2

Example of Passive Passive and active • Extremity • Standing at the

activity level repositioning range of motion dangling side of the bed
exercises • Passive • Ambulating with
transfer to assistance
chair or bed
in chair
position

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Extending the Benefits of Early Mobility 93

Figure 1. Hemodynamic and infusion inclusion criteria for continuous renal replacement therapy patient’s
participation in early mobility protocol.

Advances in technology have resulted in ulate a “culture shift,” we subsequently re-

catheters that are less rigid and less resistant,
and this allows us to deliver prescribed CRRT
flow rates while patients are out of bed or am-
bulating with clinicians.20 Therefore, at this
time, the only absolute access-related mobil-
ity exclusion criterion in our institution is the
presence of an A-V fistula or graft accessed
with large bore needles. Of note, we are con-
tinuing to explore the possibility of lifting mo-
bility restrictions on these patients as well.
There are progressive phases to the mobility
protocol that include passive and active ROM.
At a minimum, CRRT patients with A-V fistulas
or grafts should be considered for early mo-
bility at these levels, limiting movement, re-
sistance, and weight bearing in the accessed
extremity.
SHIFTING EXPECTATIONS
Initially, all CRRT patients had an activity
order specifying bed rest, and this order was
discontinued if the patient was deemed appro-
priate for the mobility protocol. To help stim-
moved patient activity orders from the CRRT
order sets, and the primary medical team and
ICU nursing staff generate patient activity or-
ders after making the early mobility and phase
determination. With this transfer of activity
ownership, the activity order was no longer
defaulted and clinicians were encouraged to
ask themselves, “Is my CRRT patient ready
for early mobility?” To further facilitate in-
corporation of the mobility criteria for CRRT
patients, the committee adopted the simple
safety check acronym, ASK (Figure 2):
r A—assessment and appropriateness of the
CRRT candidate is the first step to iden-
tifying early mobility patients. Once iden-
tified, we wanted the nurse to start
thinking about vascular access and the
circuit.
r S—for secured site. Reminding nurses to
check not only that the vascular access de-
vice is secure but to inspect the lines and
circuit connections to ensure that they are
tight.

Table 3. Initial mobility protocol exclusion criteria with rationale for CRRT patients

CRRT Contraindications Rationale

Femoral access
A-V fistula/grafts
Frequent CRRT flow alarms
Catheter may kink or bend, not allowing blood flow causing a loss of
patency and decrease treatment time
Catheter disconnection
Risk of dislodgement
Ambulation increases the risk of catheter fracture and migration
Ambulation increases the risk of needle loss or access damage
Decreasing the CRRT treatment time

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
94 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2013
Figure 2. ASK acronym for determining continuous renal replacement therapy patient’s eligibility for
early mobility protocol.
r K—for kinks and pressure. Prior to getting
CRRT patients out of bed, nurses need to
be prepared for some of the alarms and flow
issues that may be triggered by the patient’s
activity. This final element is designed to
move bedside nurses’ thinking beyond the
action of the moment into the anticipatory
realm of “what if?” so that they are prepared
for potential troubleshooting.
TECHNICAL AND SAFETY
CONSIDERATIONS: SECURED SITE
Line disconnections and subsequent exsan-
guination or air embolus are major safety con-
cerns when preparing to mobilize a CRRT pa-
tient. One important intervention to help mit-
igate this risk is to ensure tight connections
within the circuitry. CRRT nurses are taught
to check connections frequently throughout
their shift and prior to any mobility activities.
One lesson learned prior to early mobility was
that the use of tape over a connection created
a false sense of security. Early on, nurses were
not regularly assessing the obscured connec-
tions, and there were a few reported inci-
dences of disconnection despite the presence
of tape. Therefore, using tape over CRRT line
connections was eliminated from institutional
practice.
An important consideration in the manage-
ment of CRRT is the maintenance of circuit
patency, and recently citrate anticoagulation
has emerged as a preferred option to achieve
optimal circuit life.21 Regional citrate antico-
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
agulation protocols require a calcium infusion
to replenish patient calcium stores, and our
institutional protocol historically used a stop-
cock on the distal end of the return line for
this purpose. To date, the only serious CRRT
mobility-related adverse event in our institu-
tion occurred when this stopcock connection
failed during a patient transfer. In response to
this event, we designed an extension line with
a T-junction pigtail that enabled us to elimi-
nate the use of stopcocks (Figure 3), and no
further disconnections have been observed.
During early mobility, access and return
lines should be secured to the patient with
a tension loop (Figure 4). The tension loop
should be secured with line clamps and po-
sitioned to support the weight of the lines
without adding extra weight to the sutured
catheter. A tension loop is coiled tubing at-
tached to the patient’s gown in such a way
that it takes the brunt of a tug or pull, elim-
inating strain on the line at the point of in-
sertion. In addition, while mobility is being
performed, the device and lines should be
positioned in such a way as to create ade-
quate room for the planned activities but not
in a place where they become a tripping haz-
ard for the patient or the health care workers
(Figure 5A and B).
TROUBLESHOOTING: KINKS AND
PRESSURES
With the stage set, the principal partici-
pants need a supporting cast to move forward
 Extending the Benefits of Early Mobility 95

Figure 3. Extension or bloodline tubing with T-junction pigtail. (Printed with permission from Molded
Products: UM-872-36—Molded Products Inc, Harlan, Iowa).

with the actual mobilization of the patient.
Whether using a lift or ambulating the pa-
tient, we use a minimum 2 to 4 staff members
Figure 4. Tension loop used to secure continuous
renal replacement therapy lines.
to transfer a CRRT patient from bed to chair.
Ideally, the team will consist of the bedside
nurse and a physical therapist to support the
patient during transfer, and a second nurse as-
sists with the CRRT lines and circuit. When
necessary, a respiratory therapist is present
to oversee the patient’s airway and ventilator.
It is important for the participants to review
and visually rehearse the move together be-
fore initiating the activity. While discussing
the move, any person on the team may inter-
ject if they perceive a potential hazard. This
ensures that the transfer is well thought out
prior to initiation, minimizing potential injury
to patient or staff. In addition, during the ac-
tivity every person engaged in the move, in-
cluding the patient, has a voice. If one per-
son encounters a barrier moving forward, he
or she may stop the transfer until the prob-
lem is corrected to everyone’s satisfaction.
Forethought, teamwork, and good communi-
cation all contribute to a safe and successful
early mobility event.
During mobility, it is possible for the ac-
cess catheter to become kinked, which will
impede flow and potentially stop the flow
of blood through the circuit. Correct sutur-
ing and securement minimizes kinking. Ten-
sion loops minimize tugging and pulling that

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
96 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2013

Figure 5. (a) Phase 2 patient ambulating while receiving continuous renal replacement therapy. (b) Phase
2 patient out of bed to chair while receiving continuous renal replacement therapy.

can kink or even dislodge the catheters, and
other techniques may be employed to anchor
lines to the patient minimizing the risk of ac-
cess loss. For example, with internal jugular
catheters, when the head is upright, the lines
can easily fold over on themselves causing a
kink. Consider securing the line parallel to the
patient’s neck with some type of headband-
like anchor to prevent the line from flipping
over on itself. Or, if mobility is anticipated
before the line is inserted, consider using a
curved dialysis catheter to help combat this
issue. While not an absolute fix, the curved,
downward direction of the catheter ports can
help minimize kinking when the patient is
upright and moving. Femoral and subclavian
lines can be made more secure by reinforcing
or extending the surface area of the hemodial-
ysis catheter dressing.
Blood flow through the circuit is another
potential obstacle to mobility. Regardless
of catheter location, patient mobility may
change the fluid dynamics within the CRRT
circuit. Extremely high or extremely low cir-
cuit pressures will stop the peristaltic pump
and therefore blood flow; prolonged stasis can
result in clotting and loss of the circuit with
associated blood loss of the patient. It is im-
portant that the person monitoring the lines
and device during the mobility episode un-
derstand the dynamics of the CRRT circuit
so that he or she is able to efficiently trou-
bleshoot any triggered pressure alarms. For
example, high access or return line pressures
are likely to be kinks or obstructions. Simple
to troubleshoot, one can start at the patient
and work backward toward the circuit until
the obstruction is discovered and removed.
Gradual or insidious elevations in pressure
may be a result of the patient’s position or
level of exertion during the activity. These 2
entities can be thought of as resistance or af-
terload in relation to the CRRT circuit. After
kinking or obstruction is ruled out, consider
decreasing the circuit blood flow rate. Typi-
cally, this will decrease the resistance imped-
ing blood flow, which in turn improves circuit
pressures. One of our mobility strategies for
globally increased CRRT circuit pressures is
to decrease the blood flow rate by 25% during
the mobility activity.
Precipitous drops in CRRT circuit pressures
can be the result of disconnection, dislodge-
ment, or loss of the patient’s vascular access.
Should any of these occur during the mobil-
ity session, preventing air embolism is the

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Extending the Benefits of Early Mobility
primary intervention of the clinician monitor-
ing the patient and the access. In the case
of sudden disconnection, staff should clamp
the open lumen of the catheter, stop the
mobility session, and assess the patient for
signs and symptoms of an air embolus (Figure
6).22 Catheter dislodgement should be han-
dled in a similar manner. When migration of
the catheter is noticed, clinicians should man-
ually secure the access, stop the mobility ses-
sion, and position the patient if possible in
such a way to minimize further movement of
the catheter and or protect the patient from
air embolism. Finally, if loss of access occurs,
staff should immediately compress the site,
stop the mobility session, and position the
patient in such a way to prevent the devel-
opment of air embolus. For example, if the
patient is ambulating, he or she should be
gradually lowered into a wheelchair or low-
ered to a supine position on the floor, with
legs and feet elevated. If the patient is upright
in a chair, he or she should be placed in a
recumbent position, with legs and feet ele-
vated. In all of the aforementioned scenarios,
the medical team should be notified and pa-
tient safety report or incident report should
be completed.
BEYOND ASK
Several additional technical and environ-
mental concerns need to be considered be-
Figure 6. Signs and symptoms of an air embolism.
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
97
fore implementing early mobility: scale ver-
sus volumetric CRRT devices, power supply,
length of CRRT circuit tubing, and other sup-
portive technologies that may be in use at
the point of care. Each of these elements has
the potential to impact successful implemen-
tation of early mobility.
Available CRRT machines currently use ei-
ther scale-based or volumetric technology to
measure fluid balances. Scale-based devices
rely on finely calibrated scales to regulate fluid
volumes, and these machines are not easily
moved while operating. During mobility ses-
sions, bags may swing, and circuit lines may
interfere with scale weights activating scale
alarms. Even subtle changes in scale weights
that are not consistent with programmed fluid
rates trigger alarms that stop blood flow and
therapy. Clinicians should consider using a
feature to suspend scale alarms when the
machine is being moved to prevent disabling
the machine while it is in motion. Conversely,
CRRT systems that rely on volumetric fluid
management may be more accommodating
to continuous movements such as ambula-
tion. Theoretically, these systems may even
deliver prescribed therapy while the patient
is walking without alarm interruptions. How-
ever, not all CRRT devices have an uninter-
rupted power source or battery backup. Ma-
chines that have uninterrupted power source
technology can be unplugged from the wall
and transported alongside the patient during
the ambulatory phase of an early mobility pro-
tocol. Power supply is a limiting factor, and
without uninterrupted power source technol-
ogy, devices are tethered to outlets and pa-
tient mobility while remaining on CRRT is re-
stricted to the room or bedside.
The length of the CRRT tubing is another
consideration. There must be enough length
and slack in the tubing to allow for patient
and device movement without pulling on the
catheter. For this reason, we use extension
tubing that gives nursing an extra 36-in line to
manipulate the device when mobilizing the
patient. To support the additional weight of
the lines, it is even more important that the
tubing be attached to the patient’s gown with
98 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2013
line clamps and tension loops to establish a
cushion between the patient and the device.
When the presence of multiple, supportive
medical devices limit the patient’s ability to
get out of bed, staff may employ other strate-
gies to increase mobility. In our institution,
we may use either ceiling or portable lifts to
suspend the patient above the environment
while the bed is exchanged for a chair. If this
is not possible, we are able to position our
patients in full chair position with feet on the
floor without completely exiting the bed. In
situations such as this occupational and physi-
cal therapists may, and should be consulted to
evaluate the patient for adjunctive equipment
that can be used while the patient is in bed.
In our facility, we use portable bicycle ped-
als and elastic bands and tubing to provide
resistance and ROM.
Finally, an important consideration to
weigh against the risks described previously
is whether it may be simpler to temporarily
disconnect the patient from the CRRT device
and suspend treatment for the duration of
the planned mobility activity. For several rea-
sons, the CRRT Committee in our institution
favored pursuing mobility concomitant with
CRRT delivery. First, interruptions in CRRT
have a significant impact on the total dialy-
sis dose delivered, which may in turn have
an impact on clinical outcomes.23,24 Second,
recirculation of a filter circuit can be associ-
ated with a drop in circuit performance due to
clotting, with resultant increased costs. Third,
disconnection and reconnection procedures
add nursing workload to an already busy ICU
environment. Finally, the increased manipula-
tion of the vascular access (most frequently
a catheter) can result in an increased risk for
line infection.
THE MICHIGAN EXPERIENCE:
OUTCOMES
We have now had approximately 10 months
of experience with applying the mobility pro-
tocol to CRRT patients. We recently per-
formed an analysis of our experience dur-
ing the 6-month period from January to
June 2012, focusing on patients who under-
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
went CRRT for at least 48 hours. A total
of 109 patients met this criteria and were
reviewed.
Of the total cohort, 104 (95.4%) patients
underwent some degree of early mobility
within 48 hours of initiating CRRT. The ma-
jority of patients achieved Phase 0 (92/104,
88.5%), whereas 10 (9.2%) patients were able
to progress to Phase 1 and 2 patients (1.8%)
were able to ambulate while on CRRT. With
prolonged duration of CRRT beyond 48 hours,
an increasing number of patients were able to
achieve higher phases of mobility.
The majority of CRRT patients (70/104,
67.3%) were managed in surgical ICUs. Sim-
ilarly, most of the patients who were able
to progress beyond Phase 0 were in surgi-
cal ICUs (9/12, 75%), which appear to be
consistent with the overall ratio of surgical
to medicine patients. Most (78/109, 71.6%)
patients were on vasopressors. The majority
of our patients had jugular or femoral access
(91/104, 88%). and the location of CRRT vas-
cular access did not affect patient participa-
tion in the protocol. Of the patients, 62 of
104 (60%) had acute jugular access, 17 of 104
(16%) patients had femoral access, and an ad-
ditional 12 of 104 (12%) patients had tunneled
jugular access. Patients in all 3 of these access
subgroups participated in the protocol; how-
ever, patients with jugular access were more
likely to progress to an advanced phase: Phase
1 (9/74, 12%) and Phase 2 (2/7, 43%)
Overall survival of CRRT patients during the
evaluation period was 45% (49/109 patients).
Mortality appeared to trend downward with
increasing degree of mobility achieved in the
first 48 hours: mortality was 4 of 5 (80%) in
nonmobility protocol patients compared with
49 of 78 (62.3%) in Phase 0 patients and 6 of 10
(60%) in Phase 1 patients. Of the 2 Phase 2 pa-
tients, 1 (50%) survived to hospital discharge.
However, interpretation of these data is lim-
ited by the small sample size in each group
and the trend was not statistically significant
(P > .05).
As part of our quality assurance metrics,
the CRRT Committee reviews all incident
reports related to CRRT regularly, and the
institution promotes a no-fault culture for
 Extending the Benefits of Early Mobility
reporting medical errors and adverse events
to ensure a high level of event capture. As
part of the review process for the mobility
protocol, we specifically searched for poten-
tial adverse events relating to patient mobil-
ity. During the 6-month evaluation period,
there were no CRRT patient falls, dialysis ac-
cess dislodgments, or other serious adverse
events. However, during the early implemen-
tation period (before the 6-month analysis pe-
riod), there was one mobility-specific adverse
event in which a catheter and extension line
became disconnected while transferring a pa-
tient. Following a review of this event, new
equipment was designed by our CRRT Com-
mittee (as described previously) to decrease
the risk of accidental disconnections and no
further serious adverse events have been re-
ported.
DISCUSSION
CRRT offers critically ill patients with re-
nal failure treatment options and benefits that
may improve outcomes for this population.
However, its established caveat, immobility is
contradictory in today’s ICUs that are mobi-
lizing critically ill patients earlier as a means
to lessen complications from prolonged bed
rest. In our effort to create an early mobility
protocol for our critically ill CRRT patients,
we were unable to locate literature to support
mobilizing this population. As a result, we de-
cided to review the literature of other extra-
corporeal, pump-driven devices used in the
ICU. That literature indicated that successful
extracorporeal mobility programs exist and
those patients can be safely mobilized and
ambulated while connected to these complex
devices. We decided to weigh the benefits of
mobility on CRRT versus the risks of immobil-
ity and proceeded to develop a mobility pro-
tocol that is applicable to more than 90% or
our CRRT patients. Our protocol has demon-
strated that early mobility on CRRT is not only
feasible but also safe. We did experience an
adverse event in the early stages of the pro-
tocol, and we responded by adjusting equip-
ment and practice. Since that time, we have
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
99
not had any significant adverse events, falls, or
catheter dislodgments. As with any dramatic
change in ICU practice, we challenged clin-
icians at all levels to question ritual behav-
iors and partnered with our multidisciplinary
teams to change culture and deep-rooted be-
liefs. A simple safety acronym, a supportive
environment, and teamwork were instrumen-
tal in our success. Other elements that con-
tributed to the successful implementation of
this protocol were ongoing, standardized ed-
ucation by a central CRRT Committee and
strong clinical, nursing leadership passionate
about early mobility and its benefits. As a re-
sult, we are creating possibilities.
RECOMMENDATIONS
Our mobility success is directly related to
the progressive nature of our protocol. It en-
ables staff to identify appropriate early mo-
bility candidates and initiate mobility therapy
within 48 hours of beginning CRRT. Within
our small sample size of 109 patients, 95.4%
were able to participate in the mobility proto-
col at some level. Early enrollment at Phase 0
established an activity baseline for each pa-
tient that demonstrated to both staff and fam-
ily members that critically ill CRRT patients
can be moved safely. The progressive na-
ture of the protocol empowered nursing staff
to continue moving patients forward within
defined protocol parameters. While hemody-
namic stability and catecholamine infusions
are considerations, they are not absolute ex-
clusions. Patients with vasopressors infusing
(71.6%) were safely mobilized while on CRRT.
We also learned that line location—femoral
versus jugular—was not a barrier to early mo-
bility, and we continue to explore expanding
the protocol to patients with AV fistula and
graft access. Population-specific safety issues
and barriers to early mobility should be dis-
cussed at the unit level. Unit liaisons recog-
nized as CRRT experts played an important
role disseminating standardized education de-
veloped by the CRRT Committee. Their abil-
ity to translate and apply the protocol to their
specific populations also contributed to our
100 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2013
success. Seventy-five percent of our surgical
patients progressed to mobility phases that
include out of bed activities and ambulation.
The nursing buy-in to this culture change is
a reflection of the passion and determination
of nursing clinical leaders who believe in the
benefits of early mobility and support staff en-
gaging in new and challenging clinical prac-
REFERENCES
1. Hoste EAJ, Schurgers M. Epidemiology acute kid-
ney injury: how big is the problem. Crit Care Med.
2008;36(suppl):S146-S151.
2. Singbartl K, Kellum JA. AKI in the ICU: definition, epi-
demiology, risk stratification, and outcomes. Kidney
Int. 2012;81(9):819-825.
3. Bagshaw SM, Berthiaume LR, Delaney A, Bellomo
R. Continuous versus intermittent renal replacement
therapy for critically ill patients with acute kidney
injury: a meta-analysis. Crit Care Med. 2008;36:610-
617.
4. Bouchard J, Soroko SB, Chertow GM, et al. Fluid accu-
mulation, survival, and recovery of kidney function in
critically ill patients with acute kidney injury. Kidney
Int. 2009;76(4):422-427.
5. Dirkes S, Hodge K. Continuous renal replacement
therapy in the adult intensive care unit: history and
current trends. Crit Care Nurse. 2007;27(2):61-66,
68-72, 74-80.
6. Kaplow R, Barry R. Continuous renal replace-
ment therapies: a more gentle blood filtering tech-
nique allows for fewer complications. Am J Nurs.
2002;102(11):26-33.
7. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity
is feasible and safe in respiratory failure patients. Crit
Care Med. 2007;35(1):139-145.
8. Morris PE, Goad A, Thompson C, et al. Early intensive
care unit mobility therapy in the treatment of acute
respiratory failure. Crit Care Med. 2008;36(8):2238-
2243.
9. Schweickert WD, Pohlman MC, Pohlman AS, et al.
Early physical and occupational therapy in mechan-
ically ventilated, critically ill patients: a random-
ized controlled trial. Lancet. 2009;373(9678):1874-
1882.
10. Kress JP. Clinical trials of early mobilization of
critically ill patients. Crit Care Med. 2009;37(10
suppl):S442-S447.
11. MacLaren G, Combes A, Bartlett RH. Contemporary
extracorporeal membrane oxygenation for adult res-
piratory failure: life support in the new era. Intensive
Care Med. 2012;38(2):210-220.
12. Hayes D Jr, Kukreja J, Tobias JD, Ballard HO, Hoopes
CW. Ambulatory venovenous extracorporeal respi-
ratory support as a bridge for cystic fibrosis pa-
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
tice. Establishing simple mobility guidelines
and developing the simple safety acronym,
ASK, were essential elements that helped pro-
mote our practice and culture change. Simple,
actionable protocols are easy to remember in
a busy ICU environment and with teamwork
and clinical support they can be foundations
that transform nursing practice.
tients to emergent lung transplantation. J Cyst Fibros.
2012;11(1):40-45.
13. Sarkar K, Kini AS. Percutaneous left ventricular sup-
port devices. Cardiol Clin. 2010;28(1):169-184.
14. Perme CS, Southard RE, Joyce DL, Noon GP, Loebe
M. Early mobilization of LVAD recipients who require
prolonged mechanical ventilation. Tex Heart Inst J.
2006;33(2):130-133.
15. Slaughter MD, Meyer AL, Birks EJ. Destination therapy
with left ventricular assist devices: patient selection
and outcomes. Curr Opin Cardiol. 2011;26(3):232-
236.
16. Kramer DJ, Fitzpatrick PM, Rizzo TD, Mai MI, Gonwa
TA. Increased patient mobility during continuous re-
nal replacement therapy in liver transplant candidates
and recipients. Abstract presented at: 9th Congress of
the International Liver Transplantation Society (ILTS);
2003; Barcelona, Spain.
17. Konstantinidou E, Koukouvou G, Kouidi E, Deligian-
nis A, Tourkantonis A. Exercise training in patients
with end-stage renal disease on hemodialysis: com-
parison of three rehabilitation programs. J Rehabil
Med. 2002;34(1):40-45.
18. Parsons TL, Toffelmire EB, King-VanVlack CE. Exer-
cise training during hemodialysis improves dialysis
efficacy and physical performance. Arch Phys Med
Rehabil. 2006;87(5):680-687.
19. Gura V, Ronco C, Nalesso F, et al. A wearable hemofil-
ter for continuous ambulatory ultrafiltration. Kidney
Int. 2008;73:497-502.
20. Winkelman C. Ambulating with pulmonary artery
or femoral catheters in place. Crit Care Nurse.
2011;31:70-73.
21. KDIGO clinical practice guideline for acute kidney
injury. Kidney Int. 2012;2(suppl 1):1-138.
22. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diag-
nosis and treatment of vascular air embolism. Anes-
thesiology. 2007;106(1):164-177.
23. Clark WE, Turk JE, Kraus MA, Gao D. Dose determi-
nants in continuous renal replacement therapy. Artif
Organs. 2003;27(9):815-820.
24. Vesconi S, Cruz DN, Fumagalli R, et al. Delivered dose
of renal replacement therapy and mortality in criti-
cally ill patients with acute kidney injury. Crit Care.
2009;13(2):R57.