What are the guidelines for using Extracorporeal Membrane Oxygenation (ECMO) in beginners?

ECMO for Beginners: Essential Guidelines for Program Organization and Implementation

If you are establishing or learning about ECMO, you must understand that this therapy should only be performed at high-volume tertiary centers (>20 cases/year) with dedicated multidisciplinary teams, 24/7 availability, and comprehensive infrastructure—attempting ECMO without these resources significantly compromises patient outcomes. 1, 2

Institutional Requirements Before Starting ECMO

Minimum Volume and Experience Standards

• Centers must perform at least 20-25 ECMO cases annually to achieve acceptable outcomes, with higher-volume centers demonstrating significantly better survival rates 1, 2
• The learning curve requires a minimum of 20 cases to establish basic competence 2
• New ECMO centers should not be established in regions already well-served by existing high-volume programs 1
• ECMO programs for cardiac and respiratory failure should ideally be co-located in the same institution to share expertise, though not necessarily in the same ICU 1

Staffing Requirements

• Nurse-to-patient ratio must be at least 1:1 to 1:2 (one nurse for up to two ECMO patients maximum) 1
• A physician ECMO program director must oversee all operations, including training, equipment maintenance, and quality improvement 1
• An ECMO coordinator (nurse, respiratory therapist, or perfusionist) should assist with training, staffing, quality improvement, and data registry submission 1
• The ECMO team must be self-sufficient and trained to prime and set up circuits independently 1
• All staff must meet subspecialty training requirements set by their governing national or regional boards 1

Physical Infrastructure and Equipment

A wet-primed ECMO circuit must be available for immediate use 24/7, as circuit changes must occur in under 15 minutes during emergencies 1

Essential equipment includes: 1

• Backup components for all circuit parts
• Uninterrupted Power System (UPS) supporting all equipment for at least 45 minutes
• Doppler and cardiac echocardiography machines
• Fiberoptic bronchoscopes
• Mobile ECMO cart with portable monitoring
• Emergency transport backpack with clamps and drugs
• Surgical instrument sets for cannula revision or bleeding exploration
• Adequate lighting for surgical interventions

Support Services

24-hour emergency access (≤30 minutes) to cardiovascular/thoracic surgery and abdominal surgery is mandatory 1

Mobile ECMO Teams and Transfer Networks

• Each ECMO network should create mobile retrieval teams available 24/7 with experienced personnel trained in critical care transport, cannula insertion, and circuit management 1
• The team should include a mix of physicians, transport specialists, nurses, perfusionists, or ECMO specialists 1
• A clinician trained in echocardiography should accompany transfers when needed, with portable ultrasound equipment available 1
• Hospitals without ECMO capability must establish relationships with ECMO-capable institutions for timely patient transfer 1, 2
• Successful transportation has been documented for short and long distances by ambulance, helicopter, and airplane 1

Clinical Indications: When to Consider ECMO

For Severe Respiratory Failure (VV-ECMO)

VV-ECMO should be considered only after all conventional therapies have failed, specifically: 1, 2

• PaO₂/FiO₂ < 80 mmHg for ≥3 hours despite optimal ventilation 2
• PaO₂/FiO₂ < 100 for ≥6 hours despite optimization 2
• Plateau pressure > 28 cmH₂O for ≥6 hours despite lung-protective ventilation 2
• Evidence of right ventricular overload with pulmonary artery systolic pressure > 40 mmHg and acute cor pulmonale on echocardiography 2

Before initiating ECMO, you must optimize these interventions first: 1, 2

• Lung-protective ventilation (tidal volumes 4-8 mL/kg, plateau pressure <30 cmH₂O)
• Prone positioning for >12 hours daily
• Neuromuscular blockade
• Higher PEEP strategies
• Inhaled nitric oxide or prostacyclin (though these lack mortality benefit)

For Cardiogenic Shock (VA-ECMO)

VA-ECMO is indicated for: 2

• Severe cardiogenic shock with very low cardiac output and reduced LV ejection fraction confirmed by echocardiography
• Requirement for significant inotropic support and/or norepinephrine >0.5 µg/kg/min

Timing Considerations

• VV-ECMO should be initiated within 7 days of respiratory failure onset for optimal outcomes 2
• Prolonged mechanical ventilation (>9.6 days) before ECMO is associated with worse outcomes 2
• Early consideration is recommended before irreversible end-organ damage occurs 2

Quality Assurance and Program Evaluation

• All ECMO centers must submit data to large national or international databases (such as the ELSO registry) to cross-analyze results 1
• The multidisciplinary ECMO team must have quality assurance review procedures for annual internal program evaluation 1
• Formal meetings should be held routinely to analyze activity and review equipment needs, with accessible minutes 1
• Regional and national accreditation organizations should evaluate ECMO programs regularly 1
• Centers with poorer than expected results should engage in extensive practice evaluation and improvement strategies 1
• Regular network meetings should include referral centers and non-ECMO performing centers to discuss activity and review cases 1

Evidence Limitations and Current Recommendations

The American Thoracic Society states that additional evidence is necessary to make a definitive recommendation for or against ECMO in severe ARDS, though it may be considered as salvage therapy 1

The evidence base shows: 1

• Insufficient evidence to support general ECMO use for respiratory failure
• The CESAR trial (2009) showed a trend toward mortality benefit (37% vs 50%, p=0.07) but had significant limitations including incomplete intervention application and confounding by transfer to high-volume centers
• Older RCTs (Morris 1994, Zapol 1979) showed no mortality benefit
• Outcomes may differ significantly by ECMO center experience level, with more experienced teams achieving better results

Critical Complications to Anticipate

Bleeding complications are common and associated with high mortality rates, particularly intracranial hemorrhage 1, 2

Key complications include: 1, 2, 3

• Intracranial bleeding (89% in premature infants, 15% in full-term infants in neonatal series)
• Acquired von Willebrand syndrome (AVWS) develops in almost all ECMO patients within hours of device implantation
• Recent data shows 42% of VV-ECMO patients experience thrombotic events, 37% experience bleeding events, and 21% experience both
• Neurological complications requiring specialist consultation, neuroimaging (preferably MRI), and tailored examinations
• Renal injury, concomitant infections, and technical/mechanical problems

Neurological Monitoring

Standardized neurological monitoring and neurological expertise are recommended for all ECMO patients 1

• All patients should have their modified Rankin Scale assessed at discharge and during each follow-up 1
• In patients with neurological complications, clinical examination by a neurological specialist and neuroimaging (preferably MRI) are recommended 1
• Multidisciplinary care maximizes chances of favorable long-term outcomes and good quality of life 1

Bottom Line for Beginners

ECMO is a complex, high-risk, and costly modality that should be used judiciously only at experienced, high-volume centers with comprehensive infrastructure and multidisciplinary expertise. 2 If you are at a hospital without an ECMO program, establish institutional guidelines to identify ECMO-eligible patients early and develop relationships with ECMO-capable institutions for safe inter-hospital transport 1. The therapy should be reserved for patients with potentially reversible cardiorespiratory failure when conventional therapies have failed, with careful attention to patient selection factors including young age, fewer comorbidities, and potentially reversible etiology 2.