Want to learn how to implement these mobilization strategies in your ECMO program? Join us January 20-21, 2026 for our hands-on ECMO Collaborative Care and Mobilization Simulation Course in Murfreesboro, TN. Register here.
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For decades, patients on ECMO faced a predictable fate: deeply sedated, paralyzed, intubated, and bed-bound. These were patients in profound cardiogenic shock or severe respiratory failure—conditions where ECMO offered the only chance at survival. Keeping them still and “comfortable” was the priority and reflected conventional ICU wisdom at the time, which held that high doses of sedation, analgesia, and paralytics decreased oxygen demand and facilitated ventilator synchrony.
This approach was nearly universal. A 2016 survey of ELSO-registered ECMO centers revealed just how entrenched this practice was—59% of centers sedated patients to a RASS of -4 or -5 (deeply unconscious), and only 22% ever got patients walking on ECMO.
But evidence began mounting that the cost of this approach was steeper than anyone realized. Deep sedation and paralytics meant immobility, and immobility meant worse survival, poorer discharge outcomes, and devastating long-term functional decline.
The pivotal moment came with a COVID-19 study comparing mobilized and non-mobilized ECMO patients. The results were stark, showing that mobilized patients had a 73.1% survival rate compared to just 43.8% for those who remained immobile—a nearly 30-percentage-point absolute difference in survival.
As a result, mobilization became the new priority. Awake ECMO, once considered radical, is now becoming standard practice at leading centers. But a critical question remained: how do you safely bridge the gap between a deeply sedated patient lying flat and a patient walking the ICU while connected to life support?
The answer is verticalization therapy.
The Missing Bridge
The challenge that stopped most ECMO programs from mobilizing patients was straightforward: it’s difficult to take someone who’s been lying flat and sedated for days and suddenly stand them up. For many, the physiological stress can be overwhelming, strength is limited, and the safety risks feel prohibitive. Intermediate steps are needed.
Verticalization therapy provides those steps. Using specialized beds like the Kreg Catalyst®, patients can be gradually tilted from lying flat to increasingly upright positions—from 15 degrees to eventually 75 degrees or more—all while remaining safely secured in the bed.
The physiological benefits are substantial. When patients are tilted upright, even partially, several important changes occur. Gravitational pressure on the chest decreases, allowing for improved gas exchange—critical for ECMO patients whose cardiopulmonary function is compromised. In addition, blood flow patterns shift, encouraging venous return and reducing fluid accumulation.
The advantage of verticalization is that it can start remarkably early—within 12 to 48 hours of ECMO cannulation—and doesn’t require the patient to be awake. Even someone sedated to a moderate level (RASS -3 to -4) can benefit from verticalization sessions. The bed’s design keeps patients completely secure with no risk of reaching for tubes or falling. The ECMO specialist can easily manage the circuit. And gradually, session by session, the patient’s body adapts to upright positioning.
Programs implementing verticalization protocols typically aim for at least three sessions per day, progressing through levels based on individual tolerance. A patient might start at 30 degrees for 15 minutes, then advance to 45 degrees for 30 minutes, eventually reaching 60 degrees and then 75 degrees. At each stage, the healthcare team monitors patient response—heart rate, blood pressure, oxygen saturation, lactate—and adjusts accordingly. Progression is patient-specific, not driven by arbitrary timelines.
The Staged Approach to ECMO Mobilization
Successful ECMO programs now think about patient recovery in phases, with verticalization serving as the foundation. This framework aligns with ELSO’s 2025 guidelines, which formally recognize verticalization as the essential first step.
Throughout all stages, sedation is minimized, although patients may continue to receive dexmedetomidine or oral antianxiety and antipsychotic medications to manage agitation, anxiety, or air hunger.
Stage 0: Passive Mobility (Verticalization) begins almost immediately after cannulation—often within 12 to 48 hours or as soon as the patient can tolerate it. Even with minimal patient participation (RASS -2 to -4), their body is being prepared through progressive tilting from 15 degrees up to 75 degrees, typically three or more times daily.
Stage 1: Active Mobility in Bed progresses as patients become more alert and can actively participate in their care. Patients engage in active range of motion exercises and edge-of-bed activities. Verticalization continues with increased patient engagement and tolerance for steeper angles and longer sessions.
Stage 2: Static Standing involves transferring patients out of bed for sit-to-stand exercises. This stage focuses on weight-bearing and balance while stationary, building the foundational strength needed for dynamic movement.
Stage 3: Dynamic Standing advances to weight-shifting exercises and movement while standing. Patients work on pivoting, turning, and maintaining balance during position changes—essential skills for safe ambulation.
Stage 4: Active Ambulation represents the most advanced stage of mobility. Patients progress through gait training, starting with short distances and advancing to walking laps around the unit. The ECMO specialist is present for every mobility activity, managing the circuit and ensuring the cannulas stay secure. This is also when patients often transition to eating real food instead of tube feeds—a seemingly small change that has enormous psychological benefit.
Throughout all stages, progression is patient-specific and based on individual tolerance rather than arbitrary timelines. The healthcare team monitors vital signs, ECMO flows, and patient comfort at each level, advancing when ready and providing additional support when needed.
Making It Real: Implementation Challenges
None of this happens automatically. Changing decades of ingrained practice patterns requires sustained effort, visible leadership, and patience. Healthcare teams—especially nurses who spend the most time at the bedside—need to see that this new approach actually works before they’ll fully embrace it.
Early attempts are often met with anxiety. Watching a patient on ECMO struggle with air hunger as sedation is weaned is uncomfortable. Seeing them work hard during a verticalization session triggers protective instincts to intervene. The first time a patient stands up while connected to ECMO, everyone in the room is holding their breath.
But when that patient walks for the first time, when they eat a meal with their family, when they leave the ICU under their own power—that’s when belief shifts. One patient at a time, one nurse’s mind at a time, the culture changes.
Staffing models need to evolve too. Some programs found innovative solutions during COVID-19 that stuck around. Instead of requiring only specially trained ECMO nurses at the bedside, they trained all their ICU nurses to care for ECMO patients while having dedicated ECMO specialists manage the circuit itself. This meant more staff could care for ECMO patients safely, making mobility programs more feasible even when patient volumes surged.
The key is having clear protocols. Epic-integrated order sets that specify when to order a verticalization bed, how to progress through the levels, when to involve physical therapy, when it’s safe to discontinue. Documentation systems that track tolerance and outcomes. Safety checklists that ensure nothing is forgotten when moving a patient who’s tethered to complex life support.
Verticalization is Vital
ECMO use has surged worldwide over the past decade and continues to grow as the technology improves and more conditions prove responsive to treatment. Yet ECMO remains significantly underutilized, with many patients who could potentially benefit never receiving it. The gaps exist partly because institutions perceive ECMO as too complex, too risky, or too resource-intensive.
Verticalization therapy and evidence-based mobility protocols help build the confidence needed to overcome these barriers. They provide a clear, systematic pathway from cannulation to recovery. They improve outcomes dramatically—often in patients who would have zero chance of survival without ECMO. They also create visible success stories that demonstrate what’s possible, and that visible success is what ultimately changes minds and expands access.
The bridge is there. We just need more hospitals and clinicians willing to help patients cross it.
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Ready to safely mobilize your ECMO patients? Join us in January for hands-on training.
ECMO Advantage, powered by Integration Health, is offering a comprehensive 2-day course designed for healthcare professionals who want to master ECMO mobilization protocols.
ECMO Collaborative Care and Mobilization Simulation Course (Adult)
January 20-21, 2026 | Murfreesboro, TN
This intensive course combines didactic learning with high-fidelity simulation at the state-of-the-art ExtraCorporeal Education Center (EC2). Led by experienced ECMO and physical therapy faculty, you’ll gain hands-on experience with:
- Verticalization protocols and progression strategies
- Safety assessments and complication management
- Team coordination during ECMO mobility
- Practical simulation with ECMO circuits and cannulation approaches
The course covers both VA and VV ECMO modalities and is limited to a small cohort to ensure maximum hands-on practice time with expert faculty.
Who should attend: Physical therapists, occupational therapists, and other healthcare professionals who care for and assist with mobilization of patients requiring ECMO support.
Want a preview? Watch highlights from our webinar with Kathie Posa-Kearney in our “We’re on ECMO” video series. Watch here.
