ECMO IN

EMERGENCY
SETTING
Quincy Romano Rompas
 INTRODUCTION
Extracorporeal membrane oxygenation (ECMO), a life support system,
is an invaluable tool to treat adults and children with life-threatening
cardiac and pulmonary dysfunction that is refractory to the
conventional management or when cardiopulmonary resuscitation
(CPR) measures are not successful in achieving the return of
spontaneous circulation (ROSC)

ECMO is supportive therapy, not a disease-modifying treatment.

Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
 ECMO is temporary therapy used to provide cardiac
and/or respiratory support to patients whose heart
or lungs can no longer serve their function, but have
a chance of recovery.

ECMO
ECMO therapy does not restore cardiac or
respiratory functions, but replaces them during
reversible heart or lung disorders.

ECMO Therapy is designed for 3 to 10 days of

support.

Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022 Nov 28]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
 ECMO consists of a circuit where blood is drained
through a catheter from the venous vascular system,
circulated in a pump outside the body, and reinfused
into the other venous or arterial vascular system
depending on the ECMO circuit type for circulation in

ANATOMY
the body.

AND Cannulas made of plastic tubes are placed in veins or

PHYSIOLO
arteries in the groins, neck, or chest.

GY
A catheter withdraws blood from the cannula through
veins that consist of high carbon dioxide (CO2) and low
oxygen (O2) content.

Richardson ASC, Tonna JE, Nanjayya V, Nixon P, Abrams DC, Raman L, Bernard S, Finney SJ,
Grunau B, Youngquist ST, McKellar SH, Shinar Z, Bartos JA, Becker LB, Yannopoulos D,
Bˇelohlávek J, Lamhaut L, Pellegrino V. Extracorporeal Cardiopulmonary Resuscitation in Adults.
Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization.
ASAIO J. 2021
 ANATOMY AND
PHYSIOLOGY
Deoxygenated blood extracted from the venous catheter gets transferred to the oxygenator with
the help of a pump.

An oxygenator works as an artificial lung that maintains the CO2 extraction and oxygenation flow
rate. Air and oxygen flow through the hollow fibers in the oxygenator. As the blood passes through
tiny fibers, oxygen leaves the fibers and replaces carbon dioxide in the red blood cells (RBCs).

CO2 then enters the fiber and is removed in the exhaust gas. Oxygenated blood is delivered
through the catheter back to the patient.

Richardson ASC, Tonna JE, Nanjayya V, Nixon P, Abrams DC, Raman L, Bernard S, Finney SJ, Grunau B, Youngquist ST, McKellar SH, Shinar Z, Bartos JA, Becker LB, Yannopoulos D, Bˇelohlávek J, Lamhaut L, Pellegrino V. Extracorporeal
Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J. 2021
TYPES
Two basic types of ECMO VV ECMO provides
exist, VV ECMO and VA respiratory support only,
ECMO. and

OF Therefore is a choice in

ECMO VA ECMO bypasses the

heart and lungs;
patients with cardiogenic
shock or patients with
cardiac arrest with failed
therapies.

Lafç G, Budak AB, Yener AÜ, Cicek OF. Use of extracorporeal membrane oxygenation in adults. Heart Lung Circ. 2014 Jan;23(1):10-23.
Nekic, P. (2016). Extra Corporeal Oxygenation (Ecmo) Learning Package. Intensive Care: Learning Packages, February, 35.
VV ECMO
VA ECMO
 • Veno-Venous (VV) ECMO

TYPES OF • Single Venous Cannula

Extraction of blood from the vena cava or
CANNUL right atrium transferred to the ECMO
circuit, which is returned to the right
A atrium. Seldinger technique is used via a
right jugular vein to place cannula
percutaneously.
• Double Venous Cannula
One cannula for drainage is placed in the
common femoral vein, and blood infusion
through the cannula is placed in either
the right internal jugular or femoral vein.
• ECMO circuit is connected in series to the
heart and lungs.
Shah A, Dave S, Goerlich CE, Kaczorowski DJ. Hybrid and parallel
extracorporeal membrane oxygenation circuits. JTCVS Tech. 2021
Aug;8:77-85.
 • Veno-Arterial (VA) ECMO

TYPES • Peripheral Cannula: Blood drainage from

the right atrium or vena cava and infusion

OF
of blood to either femoral, axillary, or
carotid arteries.
• Central Cannula: Blood drainage from the
CANNUL right atrium or vena cava and infusion of
blood to the ascending aorta.

A • In case of emergency or cardiogenic

shock, femoral access is preferred. To
decrease the ischemia to ipsilateral lower
extremity, insertion of cannula distal to
the femoral artery or posterior tibial
artery to perfuse distal extremity or for
retrograde flow to the extremity.
• In addition to respiratory support, VA
ECMO provides hemodynamic support as
well. ECMO circuit is connected in parallel
Shah A, Dave S, Goerlich CE, Kaczorowski DJ. Hybrid and parallel
to the heart and lungs.
extracorporeal membrane oxygenation circuits. JTCVS Tech. 2021
Aug;8:77-85.
 1. Age <70 years
2. Cardiopulmonary arrest to first CPR <5 minutes
3. Witnessed arrest
4. Ventricular fibrillation (VF) or paroxysmal
ventricular tachycardia (pVT) or pulseless
electrical activity (PEA) as initial cardiac rhythm

INDICATI 5. Recurrent VF or intermittent ROSC

ON 6. Absence of comorbidities like end-stage heart

failure/chronic obstructive pulmonary
disease/liver failure/end-stage renal failure or
terminal irreversible illness
7. No known aortic valve incompetence
ECMO use has been extended to more prolonged use in
intensive care units. Extracorporeal cardiopulmonary
resuscitation: As a part of CPR in cardiac arrest, ECMO
is started in several specialized centers.
Richardson ASC, Tonna JE, Nanjayya V, Nixon P, Abrams DC, Raman L, Bernard S, Finney SJ, Grunau B, Youngquist
ST, McKellar SH, Shinar Z, Bartos JA, Becker LB, Yannopoulos D, Bˇelohlávek J, Lamhaut L, Pellegrino V.
Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the
Extracorporeal Life Support Organization. ASAIO J. 2021 Mar 01;67(3):221-228.
 INDICATIONS FOR VA ECMO
• VA ECMO is used to provide both respiratory and cardiac support.
• Cardiac conditions with low cardiac output (cardiac index < 2L/min/m) and hypotension (systolic blood pressure <90
mmHg) despite inotropic and intra-aortic balloon pump support.
• Cardiogenic shock secondary to either acute coronary syndrome, refractory cardiac arrhythmia, sepsis leading to cardiac
depression, myocarditis, pulmonary embolism, drug toxicity, cardiac trauma, anaphylaxis, acute decompensated heart
failure, septic shock; where cardiac activity is compromised and unable to pump out the adequate blood to meet the
body’s demand.
• Periprocedural for high-risk cardiac interventions
• Postoperative heart failure: Inability to wean from cardiopulmonary bypass after cardiac surgery; ECMO is very useful
post-operatively to provide rest for the heart and helps in recovery after the surgery.
• Post heart transplant: after heart or lung-heart transplantation in cases of primary graft failure
• Bridge to long-term VAD support or bridge to heart/lung transplant.

Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008;17 Suppl 4:S41-7.
 INDICATIONS FOR VV
ECMO
• VV ECMO is used for respiratory support in those who do not respond to mechanical ventilation or any acute
potentially reversible respiratory failure.
• Acute respiratory distress syndrome secondary to either severe bacterial or viral pneumonia, including COVID-19 or
aspiration pneumonitis. ECMO bypasses the compromised activity of the lungs and maintains oxygenation and
ventilation with the removal of CO2.
• Covid-19 Severe Respiratory Failure: ARDS due to SARS-CoV-2 infection when prolonged mechanical ventilatory
support fails. In some cases, when ventilation fails, ECMO support (venovenous ECMO) has been initiated.
• Extracorporeal assistance to support lung in cases of airway obstruction, pulmonary contusion (barotrauma), smoke
inhalation, drowning, air leak syndrome, hypercapnia, or hypoxic respiratory failure
• Status asthmaticus
• Massive hemoptysis or pulmonary hemorrhage
• Bridge to lung transplant
• Support for lung resections in unstable patients.

Richardson ASC, Tonna JE, Nanjayya V, Nixon P, Abrams DC, Raman L, Bernard S, Finney SJ, Grunau B, Youngquist ST, McKellar SH, Shinar Z, Bartos JA, Becker LB, Yannopoulos D, Bˇelohlávek J, Lamhaut L, Pellegrino V. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus
Statement From the Extracorporeal Life Support Organization. ASAIO J. 2021 Mar 01;67(3):221-228.
Liu JY, Merkow RP, Cohen ME, Bilimoria K, Ko CY, Sweeney JF, Sharma J. Association of Weekend Effect With Recovery After Surgery. JAMA Surg. 2020 Oct 01;155(10):988-990.Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation) support in critically
ill adult patients. Heart Lung Circ. 2008;17 Suppl 4:S41-7.
 CONTRAINDICATIO
NS

Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan
Makdisi G, Wang IW. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis. 2015 Jul;7(7):E166-76.
 VENO-VENOUS ECMO
FOR SEVERE ACUTE RESPIRATORY FAILURE

Mosier, J.M., Kelsey, M., Raz, Y. et al. Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions.  Crit Care 19, 431 (2015).
VENO-VENOUS ECMO
FOR SEVERE ACUTE RESPIRATORY FAILURE
With Cardiogenic Cardiogenic
Hypercapnia With Hypoxemia Hypoxemia
Shock Shock

Without Hypoxemia
Without Shock or Heart failure Heart Isolated RV
with Distributive due to failure failure
Shock hypoxemia (pulmonary
hypertension
Low flow veno-
venous ECMO

Minimally invasive Venoo-venous Veno-arterial ECMO or PA to LA pumpless

ECCO2R ECMO Veno-veno-arterial ECMO device

Artero-venous
Mosier, J.M., Kelsey, M., Raz, Y. et al. Extracorporeal membrane oxygenation (ECMO) for critically ill
pumpless ECCO2R adults in the emergency department: history, current applications, and future directions. Crit Care 19,
 VA ECMO FOR SHOCK

Maya Guglin, Mark J. Zucker, Vanessa M. Bazan, Biykem Bozkurt, Aly El Banayosy, Jerry D. Estep et al. 2019. Journal of the American College of Cardiology.73 (6): 698-716.
 VENO-ARTERIAL ECPR
FOR CARDIAC ARREST

Kendirli, Tanil & Özcan, Serhan & Havan, Merve & Baran, Cagdas & Cakici, Mehmet & Arıcı, Burcu & Can, Özlem Selvi & Eyileten, Zeynep & UÇar, Tayfun & Tutar, Ercan & Akar, Ahmet Rüçhan. (2020). Pediatric extracorporeal
cardiopulmonary resuscitation: single-center study. Turkish journal of medical sciences. 51. 10.3906/sag-2002-10.
ECPR
ECPR can be defined as the rapid initiation of VA-ECMO during CPR in
patients who experience a sudden and unexpected pulseless condition
secondary to cessation of cardiac mechanical activity

ECPR is an emergency procedure. Well-defined criteria to help in

selection of ideal patients for ECPR are mandatory to save the deserving
cardiac arrest patients and to differentiate from the patients on whom
the ECPR’s outcome is unacceptably low.
 ECPR PROCEDURE
• ECPR cannulation should ensure complete mechanical support to provide adequate circulation and
gas exchange.
• The choice between percutaneous or surgical approach to the femoral vessels mostly depends on the
skill and preference of the clinician.
• Cannulation is usually done in the femoral vessels, because of easy accessibility with ongoing CPR.
Alternative approaches include jugulo-femoral, femoro-subclavian or jugulo-subclavian routes.
• Pre-primed circuits help to reduce the down time in ECPR.
• Echocardiography offers advantage of cardiac function assessment.
• Other mechanical devices are also used along with VA-ECMO. The most commonly used device is the
intra-aortic balloon pump (IABP), Impella or TandemHeart to decompress the left ventricle which also
helps in cardiac recovery.
• During ECPR, the following parameters guide us to assess the adequacy of the CPR.
• Appropriate transport facility should be available to transfer the patients connected to ECMO during
ECPR to the intensive care unit (ICU), especially those who had out-of hospital cardiac arrest (OHCA).
 PREPARATION
The preparation consists of the following steps:
1.Insert the cannula.
2.Connect to the circuit (removal of all air from the circuit).
3.Check for gases.
4.Make sure that there are no air bubbles in the circuit, membrane, or connections.
5.Connect sweep gas flow to the oxygenator and start at 3-4 L/min (titrate to CO2 on ABG)
6.Increase rotations per minute (RPM) to generate adequate positive pressure in the return
limb of the circuit.
7.Clamps on the circuit are removed and ensure the antegrade blood flow of ECMO.
8.Increase RPM to achieve 3 to 4 L/min ECMO blood flow.
9.Mechanical chest compressions are discontinued if in cardiac arrest.

Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
TECHNIQUES FOR ECMO
CANNULATION
1) cut down
2) Seldinger technique
3) Combination of cut down
exposure and Seldinger
cannulation
4) Direct cannulation of the
right atrium and aorta via
thoracotomy
TECHNIQUE

Traditional Hybrid Parallel

ECMO ECMO ECMO
Circuits Circuits circuits
 1. Veno-Venous (VV) ECMO
Cannula Configurations
• Femoro-atrial: Femoral vein for drainage cannula
with the tip advanced to the diaphragm and return
cannula in the right internal jugular vein with the
tip at the superior vena cava-right atrium junction.
TRADITION Rich et al. performed a comparison between atrio-
femoral and femoro-atrial flow for VV ECMO
AL ECMO suggested femoro-atrial cannulation had less
recirculation and improved flow.
CIRCUITS • Femoro-femoral: Drainage cannula in the femoral
vein that is advanced to the distal inferior vena
cava and returns cannula into the contralateral
femoral vein that is advanced to the right atrium.
• Double-lumen drainage and return cannula, which
is placed in the jugular vein with the tip advanced
to inferior vena cava.

Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022

Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-.
 2. Peripheral Veno-Arterial (VA) ECMO

• The drainage cannula can be placed ipsilateral or

contralateral to the femoral vein, and the return
cannula can be placed into the femoral artery.
• The arterial and venous cannula should be put in the
TRADITION different groins, insertion of the arterial cannula
should be on an end to side graft, and insertion of the

AL ECMO only tip of the arterial cannula is advised to prevent

distal limb ischemia.

CIRCUITS • If the Seldinger technique is used, peripheral VA ECMO

is discouraged in cases of peripheral vascular disease.
• Monitoring for compartment syndrome is required.
• In cases of left ventricular dysfunction or poor
ventricular contractility or non ejecting left ventricle or
atrium leads to distention of the left ventricle. In such
a scenario switching over to central VA ECMO is
advised.

Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022

Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-.
 3. Central Veno-Arterial (VA) ECMO

• In case of LV dysfunction
TRADITION addition of the LV vent to the
ECMO circuit is recommended.
AL ECMO • The arterial and venous cannula
CIRCUITS should be inserted in a separate
incision to help with the
temporary closure of the chest,
and that helps in the early
ambulation of the patient.

Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022

Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-.
 HYBRID ECMO
CIRCUITS
1. V-AV ECMO 2. VV-A ECMO
• Venous drainage through a venous cannula and • It requires two or more drainage cannulas.
return cannula to both arterial and venous Additional venous drainage cannula
circulation inserted to the right internal jugular vein in
• In VV ECMO patients, the addition of arterial case of the existing femoral venous cannula
cannula through either femoral or axillary artery. or contralateral femoral vein can also be
In VA ECMO, additions of venous return cannula used. The left subclavian vein is another
through either right internal jugular vein or alternative.
femoral veins. • This technique is useful to patients with
• The additional cannula is connected to the ongoing end-organ malperfusion.
existing ECMO circuit with a Y-connector. • Stohr et al. mentioned improved outcomes
• This technique can be used in harlequin in ARDS patients with V-AV ECMO compared
syndrome or to treat profound upper body to isolated VV or VA ECMO. Mortality
hypoxia. mentioned in various literature ranges from
Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022 Nov 28]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 27 to 61%.
 In the case of VV ECMO for respiratory failure, when the
inability to capture an adequate fraction of cardiac output
that results in refractory hypoxia, additional drainage and
return cannula connected to a separate circuit provides

PARALL additional oxygenation.

With VA ECMO, when flows are insufficient to provide

EL adequate end-organ perfusion, an additional VA ECMO

circuit provides additional systemic flow.

ECMO In case of cardiac and respiratory failure, in addition to

traditional VA and VV ECMO circuits, parallel circuits serve

CIRCUIT as an alternative to V-AV ECMO.

S Adequate distance between drainage and return cannula

of both circuits is recommended to prevent cross
circulation. Also, the possibility of capturing the majority
of cardiac output that culminate in the reduction of blood
flow through the heart and lungs should be considered.
Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022
Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-.
 POST ECMO PLACEMENT
CARE
• Monitor ECMO circuit blood flow.
• Refractory arrhythmias should be controlled with electric cardioversion.
• Mechanical ventilation with positive end-expiratory pressure of >10 cmH2O is suggested to decrease the LV
afterload and prevent or treat pulmonary edema.
• To prevent limb ischemia in the case of VA ECMO distal perfusion cannula should be inserted on the side of
the arterial cannulation.
• Cardiac arrests should be treated with cardiac catheterization post ECMO cannulation.
• Imaging with CT brain, CT pulmonary angiography, CT abdomen/pelvis is recommended post-cardiac arrest if
etiology is unclear or falling ECMO blood flow. Early echocardiography to assess ventricular function and
valvular assessment.
• Intra-aortic balloon pump (IABP) is considered a first choice when mechanical circulatory support is
indicated.
Vyas A, Bishop MA. Extracorporeal Membrane Oxygenation In Adults. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-.
Confirmation of canula
positiion (TTE, X-ray)
Proper Placement  Prevent
Recirculation
WEANING OFF ECMO
In the case of VV, ECMO assessment of native respiratory function is performed by altering the gas
flow through the ECMO circuit 5 to 65 %.

Weaning is considered when the gas exchange can be maintained with low FiO2 (<30%); <2 L/MIN
fresh gas flow rates into the circuit at the respiratory rate of <25 breaths/minute and <15 cm H2O of
PEEP.

In the case of VA ECMO, once the etiology of cardiac arrest is addressed and native cardiac function
is returned, weaning off ECMO can be planned.

Cardiac function assessment is performed by reducing flows in the ECMO circuit, changes to the
ventilator and oxygen flow settings, and increasing heparin dose requirement to prevent thrombosis
at low ECMO flow rates.

Inotropic weaning is usually started several hours before the weaning.

 After 1 to 2 hours of minimal support or without any support,

WEANI
There is no definite timeline for weaning and decannulation, but
typically, 3 to 4 days of ECMO support is usually seen.

NG OFF Premature decannulation may need recannulation or

hemodynamic compromise or cardiovascular collapse and death.

ECMO For patients who fail to recover myocardial function for weaning
and decannulation and are neurologically intact, mechanical
support through the ventricular assisted device (VAD) or heart
transplantation should be considered.

For some patients who cannot be weaned and are not candidates
for VAD or heart transplantation, terminal decannulation and
palliative care should be considered. Discussion of organ donation
in case of brain death is also advised.
 How To Wean VV-ECMO
ECMO Weaning Test

ECMO-Deoxy-Challenge-Test

Failed Passed

Continue ECMO
ECMO-CO2-Challenge-
Test

Failed Passed

Continue ECMO ECMO-off

12-24 Hr

Decannulate
HOW TO
WEAN VA
ECMO
 Desaturation  recirculation, inlet
problem, increase ventilatory support,
sedation and muscle relaxant

Bleeding
COMPLICATI
ON
Thrombotic

Oxygenator Problem
Sidebotham D, McGeorge A, McGuinness S, Edwards M, Willcox T, Beca J.
Extracorporeal membrane oxygenation for treating severe cardiac and
respiratory disease in adults: Part 1--overview of extracorporeal membrane
oxygenation. J Cardiothorac Vasc Anesth. 2009 Dec;23(6):886-92.
CLINICAL
SIGNIFICANCE
• ECMO is useful for treating cardiac failure in adults who cannot wean from cardiac
bypass or heart failure that cannot be treated with a ventricular assist device.
• Patients with a cardiac index of <2 L/min/mm^2, systolic blood pressure of <90 mmHg,
and lactic acidosis despite inotropic support and IABP should be considered for ECMO.
• ECMO resuscitation can serve as a bridge to heart transplantation or ventricular assisted
device in cases of irreversible cardiac failure.
• ECMO should be considered in case of life-threatening but potentially reversible
respiratory failure.
• The contact of blood components and the surface of the CPB circuit causes an
inflammatory response and free radical-mediated pulmonary damage.
THANK YOU