22-05-2025
Unsedated patients on life support have lower risk of heart complications, muscle shrinkage: NUH
A patient in intensive care is undergoing awake Ecmo, where she is kept awake and breathing on her own, without the need for total sedation. PHOTO: NUHS
SINGAPORE – Critically ill patients in intensive care will now have the option of staying awake and breathing on their own while on life support, without the need for total sedation.
This will also give them a chance to interact with the healthcare team, reduce the chances of muscle shrinkage and for early rehabilitation.
Patients are often placed in a medically induced coma when undergoing extracorporeal membrane oxygenation (Ecmo), a treatment for those with life-threatening heart and lung failure that keeps the blood pumping and oxygenated outside the body.
An alternative treatment, called awake Ecmo, has been performed successfully on three patients at the National University Hospital since 2023.
'These patients are equally sick, but they are strong enough to get the Ecmo process started while they are conscious,' said Adjunct Associate Professor K.R. Ramanathan, a senior consultant in the Cardiothoracic ICU at the National University Heart Centre, Singapore (NUHCS).
'Most of them are young and they have a single organ failure, such as the heart or lungs.'
On the advancements made in managing patients on Ecmo, he said: 'Now we have come to a stage where we do not use sedation at a ll. This helps the patients and caregivers in a big way.'
When the patients know what is happening, they are able to communicate better with the medical staff for more favourable outcomes.
He added: 'They are able to partake in the rehabilitation process within a few days. It enhances their recovery, and they leave the ICU much earlier.'
Avoiding sedation while Ecmo is being initiated also reduces the risk of the patient's heart stopping, he said.
However, not all patients are suitable for awake Ecmo. Doctors have to assess the severity of the illness, as well as the patient's ability to maintain a clear airway and tolerate life support while conscious, Prof Ramanathan said.
One of the three patients who underwent awake Ecmo was nursing student Gwendolyn Lye, after she developed a high fever and shortness of breath in late January 2024.
'I felt something was truly wrong when I started to feel short of breath, not being able to lie flat to sleep and even sitting up, I would wake up gasping for air. My fever was also not improving despite taking medication,' she said.
She was referred to National University Hospital (NUH) on Jan 30 after blood tests showed that she was infected by enterovirus, which is a common virus that usually causes cold-like symptoms, but 'it had somehow managed to get into my bloodstream and got to my heart'. This caused myocarditis, or inflammation of the heart muscle, which led to fluid build-up in her lungs.
'Prior to being placed on awake Ecmo, I only remember feeling super unwell, constantly vomiting and being unable to eat,' Ms Lye said.
Her heart was too weak for her to be anaesthetised for traditional Ecmo.
'I was mainly concerned about how much pain I was going to feel,' she said. 'But in the end, I felt completely comfortable and having been able to be awake to see the preparation process – it was interesting.'
Nurses and physiotherapists on her care team also initiated gentle exercise sessions, such as stretching and mobility drills, to prevent rapid loss of muscle mass.
'I am thankful that the medical team decided on awake Ecmo as I knew how intubation could possibly lead to a longer recovery process instead,' added Ms Lye.
She recovered enough to stop Ecmo on Feb 4 and was discharged on Feb 15, and has returned to doing everything that she used to before hospitalisation, such as hiking and going for clinical attachments for nursing.
Prof Ramanathan said that for patients who require sedation during Ecmo treatment, the team aims to wake them after 14 to 21 days to begin rehabilitation and prevent muscle wastage.
Thirty-year-old Nathan Tan checked himself into the emergency department in March 2023 after he felt pain in his back and was taking shallow breaths.
Despite losing his fingers, toes and his left leg below the knee after a bout of pneumonia in 2023, Mr Nathan Tan, 30, has learnt to dance again after undergoing rehabilitation.
PHOTO: LIANHE ZAOBAO
He was diagnosed with pneumonia. 'That was when everything went downhill,' he said .
Mr Tan remained sedated while on Ecmo for 38 days, but was awakened for rehabilitation as his care team did not want the young man's muscles to atrophy.
Unfortunately, in his third month in hospital, the virus that caused his pneumonia entered his bloodstream, causing sepsis. He ended up requiring amputation of his fingers and toes and his left leg below the knee, as they had turned gangrenous.
Despite that, Mr Tan continues to live his dream of being a dancer, citing non-traditional dance companies in the US that feature dancers with disabilities, as a source of inspiration.
'My physiotherapists got creative and worked in dance moves for my therapy, helping me to continue to feel that I am worthy. I regained my confidence and I even went to the Lady Gaga concert on May 21 and danced my heart out,' he said.
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