Skip to main content
NCBI home page
BJA Education logoLink to BJA Education
. 2024 Feb 1;24(4):138–144. doi: 10.1016/j.bjae.2024.01.001

Veno-venous extracorporeal membrane oxygenation in severe acute respiratory failure

J Offer 1, C Sampson 1,∗, M Charlton 1
PMCID: PMC10928311  PMID: 38481419

Learning Objectives.

By reading this article, you should be able to:

  • •

    List the indications and contraindications for VV-ECMO.

  • •

    Recognise the factors that influence outcome with VV-ECMO.

  • •

    Discuss when VV-ECMO support is appropriate.

  • •

    Describe common requirements for VV-ECMO cannulation.

  • •

    Detail potential complications associated with cannulation.

Key points.

  • •

    VV-ECMO is used to support patients with potentially reversible severe acute respiratory failure refractory to maximal conventional critical care management.

  • •

    VV-ECMO supports gas exchange, enabling lung protective ventilation and reduction in the fraction of inspired oxygen (Fio2).

  • •

    Patients may be commenced on mobile ECMO support in referring hospitals before transfer to specialist centres.

  • •

    Outcomes are best when patients requiring VV-ECMO are managed in high-volume ECMO centres.

  • •

    Invasive ventilation for >7 days before ECMO, immunosuppression, older age and extrapulmonary organ failure are associated with increased mortality in patients on VV-ECMO.

Extracorporeal membrane oxygenation (ECMO) is an established option in the management of severe acute respiratory failure. It supports blood oxygenation and carbon dioxide (CO2) removal. In 1972 Dr J.D. Hill reported the first adult survivor of ECMO for a patient with post-traumatic acute respiratory distress syndrome (ARDS) in intensive care.1,2 Developed as part of cardiopulmonary bypass machines, improvements in technology have enabled its use beyond the operating theatre.

This review is primarily written for the non-ECMO specialist and focuses on veno-venous ECMO (VV-ECMO) in severe acute respiratory failure. We present an overview of fundamental principles, evidence for VV-ECMO in respiratory failure, indications for referral, different service structures, suitability for VV-ECMO and variables associated with outcomes in patients supported with VV-ECMO. Thereafter, practical details are discussed, including cannulation, initiation and early complications.

Overview of ECMO principles

Main types of ECMO support

Extracorporeal membrane oxygenation machines (Fig. 1) use an extracorporeal pump to generate a negative pressure gradient, causing blood to flow out of the body through an ECMO cannula and into a extracorporeal circuit.1 Blood is then propelled through an oxygenator (membrane lung) where oxygen diffuses in and CO2 out down a concentration gradient (akin to gas exchange at the alveolar capillary membrane).1 In VV-ECMO, blood is drained from and returned to the central venous circulation providing extracorporeal respiratory support. For veno-arterial ECMO (VA-ECMO) the return is into the arterial system, commonly via the femoral artery.2 In addition to supporting gas exchange, the continuous return of blood into the arterial system produces a non-pulsatile systemic pressure and therefore provides mechanical circulatory support. Veno-arterial extracorporeal membrane oxygenation in adults is used for patients requiring cardiac and respiratory or isolated cardiac support.

Fig 1.

Fig 1

Open in a new tab

VV-ECMO components. Patient's venous system, usually superior vena cava, inferior vena cava, or both. Drainage cannula and return cannula can either be separate cannulae (single-lumen ECMO cannulae) or part of single cannula with two separate lumens (dual-lumen ECMO cannulae).

Physiology of VV-ECMO

Oxygenated blood is returned from the VV-ECMO circuit to the patient. Blood flow during VV-ECMO is therefore a key factor in determining oxygen delivery to the patient. Overall oxygenation is determined by blood returned from the ECMO machine and the patient's blood flow that bypasses the ECMO machine.1,2 The former is oxygenated in the ECMO circuit whereas the latter receives some oxygenation from the diseased lungs. Extracorporeal membrane oxygenation blood flow achievable is usually between 3.5 and 6 L min−1 depending on both the circuit pump revolutions per minute (RPM) and size of the cannula.1, 2, 3 A patient's cardiac output will determine the volume of blood that bypasses the ECMO machine and therefore it is the ratio of ECMO blood flow to cardiac output that determines oxygenation.

The sweep gas flow supplies the oxygenator. Titration of sweep gas flow is performed to facilitate CO2 clearance. Carbon dioxide diffuses out across the oxygenator membrane along a concentration gradient.2 Increasing the sweep gas flow rate enables greater CO2 clearance within the oxygenator by increasing the CO2 concentration gradient.3,4 For adults, typically 100% oxygen is used at flow rates of 1–10 L min−1. Increasing the sweep gas flow rate does not improve oxygenation as blood leaving the oxygenator is fully saturated with sweep gas flows of <1 L min−1, owing to the efficiency of the oxygenator.

Despite return of blood into the venous circulation, VV-ECMO can improve haemodynamic stability, particularly in cases of right ventricular dysfunction. Improved arterial oxygenation and CO2 along with reduction in ventilator pressure may reduce pulmonary vascular resistance and right ventricular afterload.2,4 Left ventricular dysfunction can be mitigated with improved systemic oxygen delivery.4

Rationale for VV-ECMO in respiratory failure

For patients with respiratory failure, VV-ECMO can provide correction of critical hypoxaemia and/or respriatory acidaemia, and facilitate a reduction in potentially harmful mechanical ventilation.4,5 During VV-ECMO, gas exchange is not solely dependent on the ventilator and native lung function, thus it allows for a decrease in ventilator pressures/volume to reduce ventilator-induced lung injury (e.g. driving pressure <15 cmH2O, plateau pressure <25 cmH2O, ventilatory frequency 4–15 bpm).4,6 In cases of extensive consolidation and poor lung compliance, pressure reduction may result in extremely low tidal volumes (e.g. Vt <100 ml). The addition of ECMO support enables acceptable gas exchange during this period of critical respiratory failure, thereby allowing time for the underlying lung injury to heal.

Evidence for ECMO in the management of severe acute respiratory distress syndrome (ARDS)

There are two randomised controlled trials evaluating the efficacy of ECMO in patients with ARDS: Conventional ventilation or ECMO for Severe Adult Respiratory failure (CESAR) and ECMO to rescue Lung Injury in severe ARDS (EOLIA). The CESAR trial evaluated 180 patients, randomised 1:1, to either transfer and consideration of ECMO (delivered at a single centre) or a control group that continued with conventional mechanical ventilation. Inclusion criteria were age 18–65 yrs old, severe but potentially reversible respiratory failure (reversibility decided clinically by an ECMO consultant) and any one of;

  • (i)

    Murray score ≥3 (calculated from four variables; ratio of partial pressure of oxygen in arterial blood to the fraction of inspired oxgen (Pao2/Fio2), level of positive end-expiratory pressure (PEEP), chest X-ray opacification, lung compliance

  • (ii)

    Uncompensated hypercapnia with pH <7.2 despite optimal conventional treatment

The primary outcome of ‘freedom from death or major disability at 6 months’ was 63% in the ECMO group and 47% in the control group. The relative risk (RR) (95% confidence interval [CI]) was 0.69, [0.05–0.97], P=0.03.7 However, 24% of the ECMO group did not require ECMO and only 70% of the control group received lung protective ventilation whereas 93% of the ECMO group received protective lung ventilation. Prone positioning, which is associated with reduced mortality in ARDS, was only used in 42% of patients in the control group and 37% in the ECMO group.7,8 The CESAR trial may therefore demonstrate the importance of lung protective ventilation and specialist input rather than benefits of ECMO per se.9

The EOLIA trial was an international multicentre randomised controlled trial with 249 patients randomised to VV-ECMO vs conventional management. Inclusion criteria included ARDS, age >18 yrs old, <7 days invasive ventilation and any one of the criteria below despite optimisation of ventilator settings defined as Fio2 >80%, PEEP ≥10 cmH2O, Vt 6 ml kg−1 predicted body weight:

  • (i)

    Pao2/Fio2 <6.67 kPa for >3 h

  • (ii)

    Pao2/Fio2 <10.6 kPa for >6 h

  • (iii)

    pH <7.25 with Paco2 >8 kPa for 6 h (despite maximum ventilatory frequency of 35 with plateau pressure ≤32 cmH2O).

Physicians were encouraged to use neuromuscular blocking agents and prone positioning before randomisation. A total of 98% of the intervention group received ECMO and a lung protective protocol was used for mechanical ventilation in the control group. A total of 90% of the control group underwent prone positioning and 66% in the ECMO group. The trial was stopped early at 75% recruitment as the predefined 20% decrease in mortality was deemed to be unachievable. There was no significant difference in mortality between ECMO and conventional ventilation.10 However, the trial suggests the potential for ECMO to be used as a rescue measure in patients in whom conventional management failed (defined as inability to achieve arterial oxygen saturation >80% for >6 h, despite adjuvant therapies including recruitment manoeuvres, inhaled nitric oxide, inhaled prostacyclin and prone positioning) in the absence of irreversible multiorgan failure. Twenty-eight percent of patients met these criteria and were crossed over from the control to the ECMO group. Forty-three percent of these patients crossed over to ECMO were still alive at day 60.

A subsequent Bayesian analysis of the EOLIA trial has provided some evidence for a high posterior probability (88–99%) of mortality benefit (RR <1). An absolute risk reduction of ≥2% was shown with a posterior probability between 78% and 98%.11 In addition, recent meta-analyses combining data from these trials show that there seems to be a reduction in mortality at 60 days (RR 0.73, 95% CI 0.58–0.92; P=0.008) and 90 days (RR 0.75, 95% CI 0.6–0.94; P=0.013) in patients with severe ARDS treated with ECMO.12,13

Service structure and referral process

The Extracorporeal Life Support Organisation (ELSO) reports an increasing trend in the number of patients supported on VV-ECMO worldwide.4,5 The structure and configuration of ECMO services varies between countries. Extracorporeal membrane oxygenation is delivered in either a small number of high-volume centres (e.g. the UK model) or a larger number of small-volume centres. There is evidence to suggest a mortality benefit if ECMO is delivered in specialised centres with a high case load.14, 15, 16 In the UK, the ECMO network consists of seven centres, each covering a defined geographical area. Each centre provides a 24 hour service for advice and referral and has a dedicated transport team to retrieve patients from their catchment area. The centres work collaboratively to ensure equity of access and to meet peaks in demand.

The ECMO referral process varies depending on the service structure and may be in person, via telephone, or via an online pathway. During the COVID-19 pandemic, the NHS England national ECMO service started using the online referral system ‘referapatient’. Such a system allowed ease of access, prompting of important referral information, record keeping and documentation of responses that could be viewed by both the referring and ECMO teams. Completing a detailed ECMO referral often takes time and can be challenging whilst looking after an acutely unwell patient, but the information provided is essential for establishing the indication for ECMO and assessing suitability and timing of ECMO support.

Indications and contraindications

Veno-venous extracorporeal membrane oxygenation is used to support patients with potentially reversible lung pathology in severe acute respiratory failure refractory to conventional management.4 Table 1 displays current indications according to ELSO consensus guidelines based on recent data and ECMO trials including EOLIA and CESAR. Indication for ECMO in ARDS and refractory hypoxemic respiratory failure is quantified by Pao2/Fio2 ratio. pH is used for hypercapnic respiratory failure. NHS England and Scotland consensus referral criteria are also displayed in Table 1, demonstrating that ECMO support is considered at different degrees of severity of respiratory failure depending on the provider.17 Referral rather than acceptance criteria are listed and it is important to emphasise that thresholds for ECMO initiation can vary depending on clinical case, respiratory failure trajectory and local practice. For example, in a patient with a Pao2/Fio2 ratio of 9 kPa, advice may be given to continue with optimised conventional treatment with active follow-up and a plan to proceed to ECMO in the event of failure to improve or further deterioration. Veno-venous extracorporeal membrane oxygenation can also be used in patients with chronic pathology where appropriate such as a bridge to lung transplant.4

Table 1.

Indications and referral criteria for veno-venous ECMO. Fio2, fraction of inspired oxygen; Pao2/Fio2, ratio of arterial partial pressure of oxygen to fractional inspired oxygen.

ELSO (Extracorporeal Life Support Organisation) Indications for adult VV-ECMO:
  • (i)

    Hypoxaemic respiratory failure (Pao2/Fio2 <10.7 kPa), after optimal medical management, including, in the absence of contraindications, a trial of prone positioning

  • (ii)

    Hypercapnic respiratory failure (pH <7.25), despite optimal conventional mechanical ventilation (ventilatory frequency 35 bpm and plateau pressure ≤30 cmH2O)

  • (iii)

    Ventilatory support as a bridge to lung transplantation or primary graft dysfunction after lung transplant
NHS England and Scotland ECMO Service Consensus criteria for referral for ECMO:
  • (i)

    Potentially reversible severe respiratory failure (e.g. Pao2/Fio2 <6.7 kPa for ≥3 h or Pao2/Fio2 <10 kPa for ≥6 h)

  • (ii)

    Murray lung injury score ≥3 (calculated by four variables; P/F ratio, PEEP, chest X-ray opacification, lung compliance)

  • (iii)

    Uncompensated hypercapnia with pH <7.2 despite ventilatory frequency >35 bpm or because of life threatening airway disease (e.g. asthma or airway trauma, air leak)

Criteria for considering ECMO:
  • (i)

    Failed trial of ventilation in the prone position for ≥6 h (unless contraindicated)

  • (ii)

    Failed optimal respiratory management with lung protective ventilation after discussion with national ECMO centre
Open in a new tab

ELSO maintains that the only absolute contraindication for VV-ECMO is an irreversible diagnosis without a plan for decannulation from ECMO support.4 NHS England and Scotland consensus exclusion criteria include refractory or established multiorgan failure, evidence of severe neurological injury or prolonged cardiac arrest (>15 min).17

Assessing suitability for VV-ECMO support

Identification of an indication for VV-ECMO support should prompt referral. Extracorporeal membrane oxygenation support may be lifesaving but carries a number of significant risks. Thus each referral must be individually assessed with these in mind. Indeed, multiple members of the ECMO team may be involved in deciding whether escalation to ECMO is likely to improve the chances of recovery. Common examples of factors taken into consideration when assessing suitability are listed below.

Age

Increasing age has been shown to correlate with increasing mortality in patients on VV-ECMO.14,18 The CESAR trial excluded patients aged >65 yrs whereas the EOLIA trial did not specify an upper age limit. A 2014 review of the ELSO registry of ECMO offered in elderly patients (age >65 yrs) for respiratory failure found a reduced survival to hospital discharge (41% in elderly patients vs 55% in all adults).19 The ELSO guidelines note the increased mortality seen in older patients but highlight that there is no established threshold.4 Age should always be considered in conjunction with other factors such as baseline comorbidities, degree of clinical frailty and physiological reserve.

Weight

Similar to many studies in other aspects of critical care, the obesity paradox can be found in the ECMO literature. Several studies have found a mortality benefit in patients with moderate obesity (BMI >30 kg m−2).14,20, 21, 22

In patients with severe obesity, cannulation and oxygenation can be challenging. Depending on the size of the ECMO cannula, there can be a mismatch in ECMO blood flow in relation to native cardiac output.21,22 There may also be difficulties in transfer, delivery of nursing care and feasibility of imaging.

Immunosuppression

Immunosuppressed patients needing VV-ECMO support have a greater mortality than equivalent immunocompetent patients.20 The ELSO guidelines list immunosuppression as a relative contraindication.4 Details of a patient's immunosuppression are important to enable careful case selection and identification of patients who may still benefit. A retrospective international multicentre study of immunocompromised patients supported with ECMO for severe ARDS identified patients with immunodeficiency after solid organ transplant, long-term or high-dose corticosteroids and immunosuppressant therapy within 6 months as having comparatively better 6-month mortality than patients with acquired immune deficiency syndrome (AIDS), solid tumours and haematological malignancy.23 A shorter time period between immunosuppression diagnosis and admission to intensive care (<30 days) was associated with a lower 6-month mortality.23

Ventilation before ECMO

Detailed information regarding ventilation is useful when referring a patient. It allows assessment of pulmonary mechanics, understanding of disease progression and scope for further optimisation of ventilation. Ventilator-induced lung injury in pursuit of acceptable gas exchange can itself form part of the indication to commence VV-ECMO (Table 1).4

Prolonged duration of mechanical ventilation before ECMO has been shown to be a predictor of 6-month mortality.20 ELSO guidelines list ventilation beyond 7 days as a relative contraindication as there is a reduction in survival for VV-ECMO initiated after this period.4,5,18,20 Long duration of mechanical ventilation may lead to further lung injury and reduced reversibility.5,24 However, delayed escalation to VV-ECMO may still be appropriate in favourable cases (e.g. a patient initially needing invasive ventilation because of extrapulmonary pathology who develops a potentially reversible condition such as ventilator-associated pneumonia). In patients with COVID-19, the relationship between duration of mechanical ventilation before ECMO and survival is uncertain as retrospective evidence shows conflicting results.25,26

In addition to duration of mechanical ventilation before ECMO, higher peak ventilatory pressure (≥42 cmH2O), high Paco2 (≥10 kPa) and plateau pressure >30 cmH20 have been identified as risk factors for in-hospital mortality. Neuromuscular blockade and prone positioning before ECMO have been demonstrated to be associated with improved survival.18,27 The severity of hypoxaemia before ECMO cannulation has not been demonstrated to influence mortality on ECMO.20

Aetiology of respiratory failure

ELSO report an overall 60% survival rate for adults requiring VV-ECMO in severe acute respiratory failure.28 The aetiology of respiratory failure is an important determinant of prognosis: asthma, H1N1 pneumonitis, aspiration pneumonia and bacterial pneumonia are examples of favourable aetiologies.5,13,18 Asthma carries an especially good prognosis with reported UK survival to discharge from ICU of 95%.5, 13, 18 In contrast, invasive aspergillosis, extrapulmonary ARDS (e.g. pancreatitis/non-pulmonary infections) and respiratory failure after stem cell transplant have worse outcomes.29, 30, 31

In addition to diagnosis, the associated risks of ECMO should be considered. For example, significant bleeding and ongoing severe respiratory failure in the multiply injured polytrauma patient. Approximately 10–19% of patients receiving VV-ECMO are reported to have a significant bleeding complication.5,12 Although ECMO circuits can be safely managed without continuous systemic anticoagulation for a period of time extending to several days, systemic anticoagulation is required at cannulation. Even in the absence of anticoagulation, the ECMO circuit itself impairs coagulation, platelet function and von Willebrand factor activity which needs to be considered when assessing bleeding risk.3,32

Cardiac arrest before starting ECMO is a prognostic concern, though not necessarily an absolute contraindication for escalation.17,18 Duration, cause and any neurological assessment since the arrest will form part of the decision-making process.

VV-ECMO scoring systems

There are multiple ECMO survival scoring models. For example:

  • (i)

    Respiratory Extracorporeal membrane oxygenation Survival score (RESP)

  • (ii)

    PREdiction of Survival on ECMO Therapy score (PRESET)

  • (iii)

    PRedicting dEath for SEvere ARDS on VV-ECMO (PRESERVE).

These scoring systems are generally derived from ECMO datasets, and therefore function best in predicting mortality of patients once initiated on VV-ECMO.27 They can be considered before initiation of ECMO, but they do not primarily function to determine who should or should not be established on ECMO. The scores are also variable as to sample sizes and number of centres from which they were formed.

The PRESET score consists of mean arterial pressure, pH, lactate, platelet level at ECMO initiation and hospital days before ECMO. These components contribute to a total score between 0 and 15. Three classes are identified depending on the score, Class I (0–5), Class II (6–9) and Class III (10–15), with corresponding ICU mortalities of 26%, 68% and 93%, respectively.24 The PRESET score consists of extrapulmonary variables and thus highlights the poorer prognosis in patients with extrapulmonary organ failure in the context of severe respiratory failure, irrespective of the underlying aetiology.13,24,33, 34, 35

Patient retrieval and VV-ECMO initiation

Retrieval

The ECMO team may cannulate the patient at the referral hospital, commencing on mobile ECMO before transfer via road, sea or air.16 Alternatively, the patient may be moved conventionally including in the prone position with cannulation performed at an ECMO centre.4 Inhaled nitric oxide, although not shown to improve mortality in ARDS, can improve oxygenation and may be used as an adjuvant to facilitate safe transfer.36 Where there is the option, the decision whether to commence on mobile ECMO or transfer conventionally is determined by the patient's clinical condition. The CESAR trial provides evidence to support transferring patients with severe acute respiratory failure to an ECMO centre even if they did not ultimately require VV-ECMO.7

VV-ECMO cannulation

Cannulation can take place in the operating theatre, at the bedside in the ICU or in other areas (e.g. angiography suite, cardiac catheter laboratory).3 There will be variation in approach, but an understanding of common requirements and the process will help in preparation before the ECMO team's arrival and during cannulation. Extracorporeal membrane oxygenation centres may provide checklists that can be viewed before the team's arrival (see Supplementary material for example). Cannulation requires a multidisciplinary team, combining referral hospital and ECMO personnel. A team briefing before cannulation enables roles to be clarified and optimal cannulating conditions.

The primary operator from the ECMO team will perform cannulation, using a percutaneous Seldinger technique or open approach. The former is more common with VV-ECMO.2,3,37 During percutaneous cannulation, fluoroscopy or transoesophageal/transthoracic echocardiography (TOE/TTE) are commonly used to ensure correct placement of the guidewire and cannula2, 3, 4,37 If fluoroscopy is used then the patient must be positioned on the procedure table to ensure scanning is possible from neck to groin. A scrub nurse or assistant is required to help position the dilators and the cannula.3 Simple procedure packs from the referral hospital are usually sufficient as specialised equipment (e.g. ECMO circuit components, ECMO cannulae and insertion sets) is brought by the team. The ECMO nurse specialist or perfusionist will manage the ECMO machine, which needs to be positioned near the patient to enable connection to the cannula.

An anaesthetist/intensivist is required to manage the patient during cannulation. Preparing anticipatory drugs and ensuring sufficient venous access is essential before starting. A bolus of anticoagulation, usually heparin (50–100 units per kilogram) is required during cannulation to reduce the extracorporeal circuit initiating clot.2,3,9,38 The timing and dose are directed by the primary operator. Fluids or blood transfusion and vasopressor and inotropic drugs may be required.

Depending on the site of cannulation, pre-existing central venous access may be used to facilitate placement of the guidewire and additional central venous access will be required for ongoing infusions. Doing this just before ECMO cannulation (i.e. in the operating theatre) minimises time for respiratory deterioration, particularly if the patient has just been turned from the prone to the supine position. In patients not in the prone position (i.e. in the supine position), additional central access and transfer of infusions should be undertaken before the ECMO team's arrival.

Complications of VV-ECMO cannulation

Potential complications (e.g. bleeding, haematoma, damage to adjacent structures, pneumothorax and arrhythmias) are similar to those encountered with other central venous access procedures. The use of longer guidewires and large cannulae also risks additional complications (e.g. tricuspid valve injury, cardiac perforation/tamponade and air embolism).4,9,39

Haemodynamic instability can be seen during initiation of VV-ECMO. Causes can be multifactorial:

  • (i)

    Vasodilatation requiring support with fluids and vasopressors can occur from a systemic inflammatory response caused by exposure to the extracorporeal circuit.4,9

  • (ii)

    Cannulation-related bleeding and hypovolaemia.

  • (iii)

    Tension pneumothorax and tamponade can be identified at the time of cannulation using fluoroscopy and echocardiography.

Complications affecting haemodynamics can affect VV-ECMO blood flow. Therefore, a reduction in VV-ECMO blood flow can be an early sign of complications. Cardiac arrest during cannulation can be a consequence of precipitous respiratory deterioration or secondary to a cannulation complication. Standard advanced life support should be commenced with particular focus on causes such as hypovolaemia (bleeding), tension pneumothorax and cardiac tamponade. With the ECMO team on site there is the option to commence extracorporeal cardiopulmonary resuscitation with VA-ECMO if appropriate. If the arrest is felt to be as a result of respiratory failure, then the ECMO team may continue with attempts at cannulation and initiation of VV-ECMO support whilst the referring team manages the cardiac arrest.

Conclusions

Veno-venous extracorporeal membrane oxygenation is an established mode of support for patients with reversible severe acute respiratory failure. Extracorporeal membrane oxygenation is a high-cost, resource-heavy intervention requiring specialist trained teams. There are significant associated risks and it is only considered for patients who are refractory to conventional management. Knowledge of the indications and factors involved in decision-making are valuable for the referring intensivist to enable proactive referral and discussion. Timing of VV-ECMO initiation and patient selection is considered on a case-by-case basis. Cannulation and mobile ECMO commencement may be performed in the referring hospital before transfer to an ECMO centre.

Declaration of interests

The authors declare that they have no conflicts of interest.

MCQs

The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education.

Biographies

James Offer BMedSci MRCP FFICM PGDip (Med Ed) is a speciality trainee in critical care in the East Midlands, currently undertaking a fellowship in adult ECMO at Glenfield Hospital, Leicester, UK. His specialist interests are in severe acute respiratory failure, adult ECMO and medical education.

Caroline Sampson BMedSci FRCA FFICM EDIC is a consultant in anaesthesia, critical care and adult ECMO and deputy director for adult ECMO at University Hospitals of Leicester NHS Trust. Her specialist interests are in severe acute respiratory failure, adult ECMO, critical care follow-up and medical education.

Matthew Charlton MD FRCA FFICM is a consultant and clinical lecturer in anaesthesia, critical care and adult ECMO at the University of Leicester and University Hospitals of Leicester NHS Trust. His specialist interests are in severe acute respiratory failure, adult ECMO, medical education and research.

Matrix codes: 1B04, 2A11, 3A11

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.bjae.2024.01.001.

Appendix A. Supplementary data

The following is/are the supplementary data to this article:

Multimedia component 1
mmc1.docx (197.6KB, docx)

References

  • 1.Vuylsteke A., Brodie D., Combes A., Fowles J., Peek G. Cambridge University Press; Cambridge: 2017. ECMO in the adult patient (Core critical care) [Google Scholar]
  • 2.Brogan T.V., Lequier L., Lorusso R., Maclaren G., Peek G. 5th Edn. Extracorporeal Life Support Organisation; 2017. Extracorporeal life support: the ELSO red book. [Google Scholar]
  • 3.Extracorporeal life support organization (ELSO) general guidelines for all ECLS cases August. 2017. https://www.elso.org/ecmo-resources/elso-ecmo-guidelines.aspx (ELSO Office 3001 Miller Road, Ann Arbor, MI 48103, USA) Available from: [Google Scholar]
  • 4.Tonna J.E., Abrams D., Brodie D., et al. Management of adult patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO): guideline from the Extracorporeal Life Support Organization (ELSO) ASAIO J. 2021;67:601–610. doi: 10.1097/MAT.0000000000001432. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Vaquer S., de Haro C., Peruga P., et al. Systematic review and meta-analysis of complications and mortality of veno-venous extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome. Ann Intensive Care. 2017;7:51. doi: 10.1186/s13613-017-0275-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Schmidt M., Pham T., Arcadipane A., et al. Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome. an international multicenter prospective cohort. Am J Respir Crit Care Med. 2019;200:1002–1012. doi: 10.1164/rccm.201806-1094OC. [DOI] [PubMed] [Google Scholar]
  • 7.Peek G.J., Mugford M., Tiruvoipati R., et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374:1351–1363. doi: 10.1016/S0140-6736(09)61069-2. [DOI] [PubMed] [Google Scholar]
  • 8.Guerin C., Reignier J., Richard J.C., et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–2168. doi: 10.1056/NEJMoa1214103. [DOI] [PubMed] [Google Scholar]
  • 9.Akoumianaki E., Jonkman A., Sklar M.C., et al. A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea. Ann Intensive Care. 2021;11:107. doi: 10.1186/s13613-021-00897-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Combes A., Hajage D., Capellier G., et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378:1965–1975. doi: 10.1056/NEJMoa1800385. [DOI] [PubMed] [Google Scholar]
  • 11.Goligher E.C., Tomlinson G., Hajage D., et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and posterior probability of mortality benefit in a post hoc bayesian analysis of a randomized clinical trial. JAMA. 2018;320:2251–2259. doi: 10.1001/jama.2018.14276. [DOI] [PubMed] [Google Scholar]
  • 12.Munshi L., Walkey A., Goligher E., et al. Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Lancet Respir Med. 2019;7:163–172. doi: 10.1016/S2213-2600(18)30452-1. [DOI] [PubMed] [Google Scholar]
  • 13.Combes A., Peek G.J., Hajage D., et al. ECMO for severe ARDS: systematic review and individual patient data meta-analysis. Intensive Care Med. 2020;46:2048–2057. doi: 10.1007/s00134-020-06248-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Warren A., Chiu Y.D., Villar S.S., et al. Outcomes of the NHS England National Extracorporeal Membrane Oxygenation Service for adults with respiratory failure: a multicentre observational cohort study. Br J Anaesth. 2020;125:259–266. doi: 10.1016/j.bja.2020.05.065. [DOI] [PubMed] [Google Scholar]
  • 15.Karagiannidis C., Slutsky A.S., Bein T., et al. Complete countrywide mortality in COVID patients receiving ECMO in Germany throughout the first three waves of the pandemic. Crit Care. 2021;25:413. doi: 10.1186/s13054-021-03831-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Labib A., August E., Agerstrand C., et al. Extracorporeal Life Support Organization guideline for transport and retrieval of adult and pediatric patients with ECMO support. ASAIO J. 2022;68:447–455. doi: 10.1097/MAT.0000000000001653. [DOI] [PubMed] [Google Scholar]
  • 17.Camporota L., Meadows C., Ledot S., et al. Consensus on the referral and admission of patients with severe respiratory failure to the NHS ECMO service. Lancet Respir Med. 2021;9:16–17. doi: 10.1016/S2213-2600(20)30581-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Schmidt M., Bailey M., Sheldrake J., et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med. 2014;189:1374–1382. doi: 10.1164/rccm.201311-2023OC. [DOI] [PubMed] [Google Scholar]
  • 19.Mendiratta P., Tang X., Collins R.T., 2nd, et al. Extracorporeal membrane oxygenation for respiratory failure in the elderly: a review of the Extracorporeal Life Support Organization registry. ASAIO J. 2014;60:385–390. doi: 10.1097/MAT.0000000000000090. [DOI] [PubMed] [Google Scholar]
  • 20.Schmidt M., Zogheib E., Rozé H., et al. The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive Care Med. 2013;39:1704–1713. doi: 10.1007/s00134-013-3037-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Al-Soufi S., Buscher H., Nguyen N.D., Rycus P., Nair P. Lack of association between body weight and mortality in patients on veno-venous extracorporeal membrane oxygenation. Intensive Care Med. 2013;39:1995–2002. doi: 10.1007/s00134-013-3028-3. [DOI] [PubMed] [Google Scholar]
  • 22.Galvagno S.M., Jr., Pelekhaty S., Cornachione C.R., et al. Does weight matter? Outcomes in adult patients on venovenous extracorporeal membrane oxygenation when stratified by obesity class. Anesth Analg. 2020;131:754–761. doi: 10.1213/ANE.0000000000004454. [DOI] [PubMed] [Google Scholar]
  • 23.Schmidt M., Schellongowski P., Patroniti N., et al. Six-month outcome of immunocompromised patients with severe acute respiratory distress syndrome rescued by extracorporeal membrane oxygenation. An international multicenter retrospective study. Am J Respir Crit Care Med. 2018;197:1297–1307. doi: 10.1164/rccm.201708-1761OC. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Hilder M., Herbstreit F., Adamzik M., et al. Comparison of mortality prediction models in acute respiratory distress syndrome undergoing extracorporeal membrane oxygenation and development of a novel prediction score: the PREdiction of Survival on ECMO Therapy-Score (PRESET-Score) Crit Care. 2017;21:301. doi: 10.1186/s13054-017-1888-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Hermann M., Laxar D., Krall C., et al. Duration of invasive mechanical ventilation prior to extracorporeal membrane oxygenation is not associated with survival in acute respiratory distress syndrome caused by coronavirus disease 2019. Ann Intensive Care. 2022;12:6. doi: 10.1186/s13613-022-00980-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Lorusso R., De Piero M.E., Mariani S., et al. In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study. Lancet Respir Med. 2023;11:151–162. doi: 10.1016/S2213-2600(22)00403-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Rozencwajg S., Pilcher D., Combes A., Schmidt M. Outcomes and survival prediction models for severe adult acute respiratory distress syndrome treated with extracorporeal membrane oxygenation. Crit Care. 2016;20:392. doi: 10.1186/s13054-016-1568-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Extracorporeal Life Support Association . April 2023. International summary.https://www.elso.org/Registry/Statistics/InternationalSummary.aspx Available from: [Google Scholar]
  • 29.Wohlfarth P., Beutel G., Lebiedz P., et al. Characteristics and outcome of patients after allogeneic hematopoietic stem cell transplantation treated with extracorporeal membrane oxygenation for acute respiratory distress syndrome. Crit Care Med. 2017;45:e500–e507. doi: 10.1097/CCM.0000000000002293. [DOI] [PubMed] [Google Scholar]
  • 30.Schmandt M., Glowka T.R., Kreyer S., et al. Secondary ARDS following acute pancreatitis: is extracorporeal membrane oxygenation feasible or futile? J Clin Med. 2021;10:1000. doi: 10.3390/jcm10051000. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Rodriguez-Goncer I., Thomas S., Foden P., et al. Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation. Eur J Clin Microbiol Infect Dis. 2018;37:1251–1257. doi: 10.1007/s10096-018-3241-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Cartwright B., Bruce H.M., Kershaw G., et al. Hemostasis, coagulation and thrombin in venoarterial and venovenous extracorporeal membrane oxygenation: the HECTIC study. Sci Rep. 2021;11:7975. doi: 10.1038/s41598-021-87026-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Montero S., Slutsky A.S., Schmidt M. The PRESET-Score: the extrapulmonary predictive survival model for extracorporeal membrane oxygenation in severe acute respiratory distress syndrome. J Thorac Dis. 2018;10:S2040–S2044. doi: 10.21037/jtd.2018.05.184. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Pappalardo F., Crivellari M. Predicting outcome of venovenous ECMO: look outside the lung. J Thorac Dis. 2018;10:1356–1360. doi: 10.21037/jtd.2018.02.78. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Pappalardo F., Pieri M., Greco T., et al. Predicting mortality risk in patients undergoing venovenous ECMO for ARDS due to influenza A (H1N1) pneumonia: the ECMOnet score. Intensive Care Med. 2013;39:275–281. doi: 10.1007/s00134-012-2747-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Germann P., Braschi A., Della Rocca G., et al. Inhaled nitric oxide therapy in adults: European expert recommendations. Intensive Care Med. 2005;31:1029–1041. doi: 10.1007/s00134-005-2675-4. [DOI] [PubMed] [Google Scholar]
  • 37.Pavlushkov E., Berman M., Valchanov K. Cannulation techniques for extracorporeal life support. Ann Transl Med. 2017;5:70. doi: 10.21037/atm.2016.11.47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.McMichael A.B.V., Ryerson L.M., Ratano D., et al. 2021 ELSO adult and pediatric anticoagulation guidelines. ASAIO J. 2022;68:303–310. doi: 10.1097/MAT.0000000000001652. [DOI] [PubMed] [Google Scholar]
  • 39.Sandhu J., Dean R.K., Landsberg D. Right atrial perforation leading to cardiac tamponade following veno-venous extracorporeal membrane oxygenation cannulation. Cureus. 2021;13 doi: 10.7759/cureus.13157. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Multimedia component 1
mmc1.docx (197.6KB, docx)

Articles from BJA Education are provided here courtesy of Elsevier

RESOURCES