Types of Extracorporeal Life Support (ECLS)

Indications

General Comments

• Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO) (Similar to Extracorporeal CO2 Removal, ECCO2R) Provides Only Respiratory Support: VV-ECMO is dependent on the patient’s intrinsic cardiac output

Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome)

Clinical Efficacy

• Early JAMA ECMO Trial (JAMA, 1979) [MEDLINE]
  • ECMO Had No Mortality Benefit
• ECCO2R Trial (Am J Respir Crit Care Med, 1994) [MEDLINE]
  • ECCO2R Had No Mortality Benefit
• ANZ ECMO Influenza Trial (JAMA, 2009) [MEDLINE]
  • ECMO Had No Mortality Benefit in Treatment of ARDS Associated with Influenza
• CESAR Trial of ECMO in the UK (Lancet, 2009) [MEDLINE]
  • ECMO Decreased Mortality Rate/Severe Disability at 6 Months
  • However, the Study was Flawed by Not Defining the Usual Care Group and ECMO Patients Were Concentrated in One Center in the Trial
• Systematic Review and Meta-Analysis of ECMO in Adult Patients with ARDS (J Crit Care, 2013) [MEDLINE]
  • ECMO Had an Unclear Hospital Mortality Benefit: further studies were recommended
• Cochrane Review of VV-ECMO and VA-ECMO in Critically Ill Adults (Cochrane Database Syst Rev, 2015) [MEDLINE]
  • ECMO Had No 6-Month (or Prior to 6 Month) All-Cause Mortality Benefit: low-moderate quality of evidence from trials
• Study of the Long-Term Survival and Quality of Life Following ECMO (Eur J Cardiothorac Surg, 2017) [MEDLINE]
  • Survival to Discharge was Higher in the Non-ECMO Group, as Compared to the ECMO Group: however, this difference was not statistically significant after propensity score matching
  • One Year Survival was 67% in the Non-ECMO Group vs 60% in the ECMO Group
  • Two Year Survival was 50% in the Non-ECMO Group vs 45% in the ECMO Group
• Single-Center Swedish Retrospective Study of Outcomes After ECMO for ARDS Associated with Sepsis (Crit Care Med, 2017) [MEDLINE]
  • Approximately 64% of ECMO Patients Survived to Discharge
  • High Mortality Rate Within the First Few Months After Discharge
• Systematic Review and Meta-Analysis of Mortality and Complications with the Use of Venovenous ECMO in ARDS (Ann Intensive Care, 2017) [MEDLINE]
  • Mortality Rate at Hospital Discharge was 37.7%
  • Factors Associated with Increased Hospital Mortality
    • Age
    • Year of Study
    • Mechanical Ventilation and Prone Positioning Days Prior to ECMO
• Systematic Review of Venovenous ECMO for ARDS (J Crit Care, 2017) [MEDLINE]: n = 27 studies
  • Mortality Benefit of ECMO is Unclear
• French EOLIA Trial of VV-ECMO in Severe ARDS (NEJM, 2018) [MEDLINE]
  • Clinical Triggers for Randomization
    • pO2/FiO2 Ratio <50 mm Hg for >3 hrs
    • pO2/FiO2 Ratio <80 mm Hg for >6 hrs
    • Arterial Blood pH <7.25 with pCO2 ≥60 mm Hg for >6 hrs
  • VV-ECMO Did Not Improve the 60-Day Mortality in Severe ARDS, as Compared to Conventional Ventilator Management (with VV-ECMO as Rescue Therapy) (Relative Risk 0.76; 95% Confidence Interval 0.55 to 1.04; P = 0.09)
  • Crossover to ECMO Occurred a Mean (± SD) of 6.5 ± 9.7 Days After Randomization in 28% of Patients in the Control Group, with 57% of These Patients Dying
  • VV-ECMO Group Had Higher Rate Bleeding Events and Severe Thrombocytopenia, But Lower Rate of Ischemic Cerebrovascular Accidents

Criteria to Start Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO)

• French REVA (Reseau Europeen De Recherche En Ventilation Artificielle) Criteria (2009)
  • pO2/FiO2 Ratio <50 Despite High PEEP (10-20 cm H2O) and High FiO2 (>80%)
  • Plateau Pressure At Least 35 cm H2O Despite Decrease in Tidal Volume to 4 mL/kg
• NEJM, 2011 Review of ECMO in ARDS Criteria [MEDLINE]
  • Severe Hypoxemia: pO2/FiO2 Ratio <80 Despite High PEEP (15–20 cm of H2O) for at Least 6 hrs in Patient with Potentially Reversible Respiratory Failure
  • Uncompensated Hypercapnia with Acidemia (pH <7.15) Despite the Optimized Ventilator Management
  • Excessively High Plateau Pressure (>35–45 cm of H2O, According to the Patient’s Body Size) Despite Optimized Ventilator Management
• Extracorporeal Life Support Organization (ELSO) Criteria (Extracorporeal Life Support Organization (ELSO) Guidelines for Adult Respiratory Failure v1.3, 2013) [LINK]
  • pO2/FiO2 Ratio <150: ECMO should be considered
  • pO2/FiO2 Ratio <80: ECMO should be utilized
  • pCO2 >80 m Hg or Plateau Pressure >30 cm H2O: ECMO should be utilized

Contraindications

Absolute

• Contraindication to Anticoagulation: although in patients with severe bleeding, anticoagulation can be held for limited periods of time

Relative (NEJM, 2011) [MEDLINE]

• Any Condition or Organ Dysfunction that Would Limit the Likelihood of Overall Benefit from ECMO, Such as Severe, Irreversible Brain Injury or Untreatable Metastatic Cancer
• High FiO2 Requirement >80% for >7 Days
• High-Pressure Ventilation (Plateau Pressure >30 cm of H2O) for >7 Days
• Limited Vascular Access

Physiology

Blood Flow Rate During VV-ECMO

• Determinants of VV-ECMO Blood Flow Rate
  • Resistance to Flow in the Drainage Cannula
    • Maximal Flow for Commonly Used Venous Cannulas (at 100 cm H2O Suction): approximately 4-5 L/min
  • Suction Produced by the Pump or Siphon
  • Geometry of the Cannulated Vessel (Usually the Inferior Vena Cava or Right Atrium)

Oxygenation During VV-ECMO

• Determinants of Oxygen Supply from the VV-ECMO Membrane
  • VV-ECMO Blood Flow Rate
  • Hemoglobin
  • Difference Between the Outlet Minus Inlet Oxygen Content
    • Because the Outlet Blood is Typically 100% Saturated and PO2 is >500 mm Hg, the Dissolved Oxygen Can Be as Much as 10% of the Oxygen Content
• Major Determinants of Oxygenation During VV-ECMO
  • VV-ECMO Blood Flow Rate
    • Small Study of the Determinants of Oxygenation and CO2 Removal During VV-ECMO (Int Care Med, 2013) [MEDLINE]
      • Arterial Oxygenation was Determined by VV-ECMO Blood Flow Rate and ECMO FIO2
      • ECMO Blood Flow was the Main Determinant of Arterial Oxygenation
      • CO2 Elimination Depended on the Sweep Gas Flow Rate Through the Oxygenator
      • ECMO Blood Flow/Cardiac Output Ratio >60% was Associated with Adequate Blood Oxygenation
      • Packed Red Blood Cell Transfusion Increased O2 Delivery, Allowing Lower ECMO Flows to Reach an Adequate SaO2
  • VV-ECMO FIO2
    • Small Study of the Determinants of Oxygenation and CO2 Removal During VV-ECMO (Int Care Med, 2013) [MEDLINE]
      • Arterial Oxygenation was Determined by VV-ECMO Blood Flow Rate and ECMO FIO2
      • ECMO Blood Flow was the Main Determinant of Arterial Oxygenation
      • CO2 Elimination Depended on the Sweep Gas Flow Rate Through the Oxygenator
      • ECMO Blood Flow/Cardiac Output Ratio >60% was Associated with Adequate Blood Oxygenation
      • Packed Red Blood Cell Transfusion Increased O2 Delivery, Allowing Lower ECMO Flows to Reach an Adequate SaO2

Factors Contributing to Hypoxemia During VV-ECMO (Excluding Equipment Failure)

• Mixture Between ECMO Oxygenated Blood Flow and Patient’s Native Venous Blood Flow: as described above
• Recirculation
  • Recirculation is Defined as the Fraction of Oxygenated Blood Which is Infused into the Right Atrium and Subsequently Aspirated Back into the Venous Limb of the ECMO Circuit
    • Factors Contributing to Recirculation
      • Cannula Type/Size
      • Cannula Position: catheter position can be most problematic with the use of a single (Avalon) catheter, where the inflow and outflow ports are in closer proximity than they are with a double catheter setup
      • Pump Speed
      • Blood Flow Rate
      • Direction of Extracorporeal Blood Flow
      • Intrathoracic/Intracardiac/Intra-Abdominal Pressures
• Intrapulmonary Shunt
  • This is the Main Mechanism of Hypoxemia in ARDS (Occurs Due to Alveolar Filling with Protein-Rich Fluid/Red Blood Cell/Neutrophils and Interstitial Changes)
    • Degree of Intrapulmonary Shunt is Related to Vascular Pressures, Vasoactive Medications/Substances, and Degree of Lung Inflation
    • Cardiac Output is Positively Correlated with the Degree of Intrapulmonary Shunt
• Flow Exceeding Oxygenator Performance
  • Rarely Occurs with the Current Generation of Technology

Strategies to Improve Systemic Oxygenation During VV-ECMO

• Increase Blood Oxygen Content
  • Increase ECMO Blood Flow Rate
    • In Some Cases, Increasing the Blood Flow Rate Will Not Improve Oxygenation, Due to Increased Recirculation
    • Higher Flow Rates Increase the Risk of Hemolysis (see Hemolytic Anemia): may occur when using high RPM with venous occlusion in the catheter (due to coughing, hypovolemia, catheter kinking, etc), resulting in a vacuum created in the pump head
  • Increase Hematocrit (Oxygen-Carrying Capacity)
    • The ECMO Oxygenator Functions Optimally at a Normal Hematocrit
    • ECMO Utilization is Blood Resource Intensive: due to the need for frequent PRBC transfusion related to both hemolysis/bleeding issues and the need to maintain a high hematocrit to increase oxygen delivery
    • Extracorporeal Life Support Organization (ELSO) Guidelines Recommend Maintaining a Hemoglobin of 12-14 g/dL with a Normal Hematocrit (v1.3 (2013) [LINK]: due to the fact that oxygen delivery is determined by blood flow through the artificial lung, and if anemia is present, a higher blood flow will be necessary to obtain the same level of oxygen delivery
    • While There are No Trials Examining Restrictive Transfusion Protocols in VV-ECMO, Data Suggest that Red Blood Transfusion is a Clinical Predictor of Mortality (Crit Care Med, 2005) [MEDLINE] and (Chest, 2007) [MEDLINE]
• Decrease ECMO Recirculation
  • Maximize the Distance Between the Two Cannulas
• Decrease Oxygen Consumption
  • Sedation (see Sedation)
  • Neuromuscular Blockade (see Neuromuscular Junction Antagonists)
  • Therapeutic Hypothermia (see Therapeutic Hypothermia)
    • Hypothermia Decreases the Metabolic Rate
    • Hypothermia Also Increases the Solubility of Oxygen in Blood
• Manipulation of Cardiac Output and Intrapulmonary Shunt
  • Beta Blockers (see β-Adrenergic Receptor Antagonists)
    • Esmolol Has Been Used to Decrease the Cardiac Output (in Patients with Cardiac Output >7 L/min), Improving the Ratio Between the Cardiac Output and the ECMO Blood Flow (Preventing the Need for Increases in the ECMO Blood Flow Rate): this treatment did not decrease the oxygen delivery (DO2)
      • Decreasing CO Also Decreases Intrapulmonary Shunt
  • Proning: while trials of combined proning and VV-ECMO have been performed, the efficacy of this strategy is unclear
• Switch to Venoarterial ECMO (VA-ECMO) or Hybrid Configuration
  • Utilization of VA-ECMO Allows Complete Bypass of the Native Lung: allowing a strategy to manage refractory hypoxemia occurring during VV-ECMO
    • Arterial Catheterization Needs to Be as Close to the Heart as Possible to Avoid the “Harlequin Syndrome” (Blue Head and Red Legs): this occurs due to competition between the anterograde blood flow related to native cardiac output and ECMO flow delivered via a femoral cannula, resulting in compromised perfusion of the upper body

Technique

Equipment

• Maquet Cardiohelp
  • Centrifugal Pump (Constrained Vortex Pump)
    • Centrifugal Pump Moves Blood by Creating a Pressure Differential Across the Pump Head Which Contains a Magnetically Driven Impeller Spinning at Approximately 3000 RPM
    • Centrifugal Pumps Require Lower Levels of Anticoagulation than Roller Pumps
    • Centrifugal Pumps Result in Lesser Degree of Hemolysis than Roller Pumps
    • Centrifugal Pumps Exhibit an Increased Risk of Non-Surgical (Gastrointestinal, Pulmonary, and Neurological) Bleeding, as Compared to Roller Pumps, Despite Lower Levels of Heparin Anticoagulation (ASAIO J, 2015) [MEDLINE]
  • Duration of Use: Maquet Cardiohelp may be used for up to 30 days (per manufacturer recommendation)

Vascular Access

• Requirement for Technical Support: requires continuous monitoring by technical support personnel

Avalon Catheter Placement into the Right Internal Jugular (IJ) Vein (Avalon Laboratory, Los Angeles, CA, USA)

• Required Supplies
  • Arrow Dilator Kit
  • Avalon Catheter
• Insertion and Set-Up
  • Procure Right Internal Jugular (IJ) Access
  • Insert Long Stiff Wire
  • Serial Grey Dilators
  • Insert Black Wire Sheath Over Wire
  • Serial Dilation of Tract with Blue Dilators Over Wire/Sheath (Both Remain in Place During Dilation)
  • Insert Avalon Catheter Over Wire: orient arterial port toward patient chin (this angles the arterial port toward the tricuspid valve)
  • Remove White Stylet from Avalon Catheter
  • Use Trans-Esophageal Echocardiogram (TEE) to Assure that Arterial Port is Angled Toward the Tricuspid Valve
  • After Avalon Catheter Placement, Immediately Give Heparin 10,000 units IV: to prevent Avalon catheter from clotting
  • Fill Avalon Catheter Lines with Saline: squirt into ends of catheter just to fill
  • Connect Straight Venous Port (Green Arrow in Photograph) to ECMO Machine: unoxygenated blood should be seen in this line
  • Connect the Angled Arterial Port (Red Arrow in Photograph) to ECMO Machine: oxygenated blood should be seen in this line

Anticoagulation

• Heparin Drip (see Heparin)
  • Titrate to Achieve ACT 220-260 sec
  • However, Anticoagulation May Be Held for Short Periods During EMCO (Using Heparin-Bonded Circuits)

Extracorporeal Life Support Organization (ELSO) Guidelines for Adult Respiratory Failure v1.3 (2013) [LINK]

• Titrate Heparin Drip to Maintain ACT 180-200

Management (Extracorporeal Life Support Organization (ELSO) Guidelines for Adult Respiratory Failure v1.3, 2013) [LINK]

Adjustments To Increase the Arterial pO2

• Increase ECMO Circuit Blood Flow Rate (Blue Arrow in Photograph): blood flow rate through exchanger
  • Start with 50-80 ml/dry weight/min (Approximately 3.5-5.6 L/min for a 70 kg Patient): this will achieve a DO2 of approximately 3 mL/kg/min (assuming a cardiac output of 5 L/min and hemoglobin concentration of 15 g/dL)
    • Start with the Maximum End of This Range Initially, Then Decrease to Lowest Blood Flow Rate to Maintain SaO2 >80-85% (at Resting Vent Settings)
      • Arterial pO2 Will Be 45-55 mm Hg in this Scenario: the lower limit of pO2 below which brain injury may occur during VV-ECMO is unknown (ASAIO J, 2015) [MEDLINE]
      • Note that the Compensatory Increase in Cardiac Output Which Occurs and Transfusion to Achieve a Hematocrit >40% Will Ensure Adequate Oxygen Delivery (DO2)
    • Goal DO2:VO2 Ratio >3 (Corresponds to an SvO2 Which is 25-30% Less than the SaO2)
      • Total DO2 = Patient Lung DO2 + Circuit DO2
      • Circuit DO2 = Flow x Outlet-Inlet O2 Content
      • VO2 = 3 ml/kg/min
  • The Ability to Achieve a Specific Blood Flow Rate Will Depend on the Vascular Access Characteristics, Drainage Tubing Resistance, and Pump Properties
    • Typical Pven (Venous Limb Pressure, Yellow Airway in Photograph) is Approximately -70 mm Hg (Example: -140 mm Hg Indicates an Excessively High Negative Pressure in Venous Limb of the Avalon Catheter, Which Might Prevent an Increase in the Blood Flow)
• Increase Sweep Gas FIO2 (Red Arrow in Photograph)

Adjustments To Change the Arterial pCO2

• Maintain Arterial pCO2 at 40 mm Hg by Altering the Sweep Gas Flow Rate (Green Arrow in Photograph): oxygen flow rate through exchanger (range: 1-10 L/min)
  • Increase in Sweep Gas Flow Rate Will Decrease the Arterial pCO2: functions similarly to the minute ventilation (VE) on the ventilator
  • Decrease in Sweep Gas Flow Rate Will Increase the Arterial pCO2: functions similarly to the minute ventilation (VE) on the ventilator
  • Sweep Gas Flow Rate is Usually 1:1 with the ECMO Blood Flow Rate
    • However, Sweep Gas Flow Rate Can Be Decreased to as Low as 1 L/min to Increase the Arterial pCO2
    • However, Sweep Gas Flow Rate Can Be Increased to as High as 10-15 L/min to Decrease the Arterial pCO2

Maintenance of a Near-Normal Hematocrit

• Maintain Hemoglobin 12-14 g/dL (with a Normal Hematocrit)
  • Extracorporeal Life Support Organization (ELSO) Guidelines Recommend Maintaining a Hemoglobin of 12-14 g/dL with a Normal Hematocrit (v1.3 (2013) [LINK]: due to the fact that oxygen delivery (DO2) is determined by blood flow through the artificial lung, and if anemia is present, a higher blood flow will be necessary to obtain the same level of oxygen delivery (DO2)

Ventilator Management During Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO)

• Optimal Ventilator Management During ECMO is Unknown: rationale is to use adequate tidal volume to prevent lung atelectasis and use low respiratory rate to prevent ventilator-induced lung injury
• Suggested Settings (Same as Used in the CESAR Trial): turn down vent settings gradually, while monitoring serial ABG’s
  • Pressure Control Ventilation (PCV) with RR 10, PIP 20-25 cm H2O (with Tidal Volume <4 mL/kg PBW), PEEP +10-15, and FiO2 30%

Addition of Prone Positioning to VV-ECMO Therapy

• Clinical Efficacy
  • Systematic Review of Prone Positioning as Add-On Therapy to VV-ECMO (Respir Care. 2016) [MEDLINE]
    • Addition of Prone Positioning to VV-ECMO Had Unclear Benefit
    • Risk of Hemodynamic Instability and Catheter Dislodgment Were Low

Use of Combination Continuous Venovenous Hemodialysis (CVVHD) with Venovenous Extracorporeal Membrane Oxygenation (ECMO)

• Clinical Efficacy
  • The Pulmonary and Renal Support in Acute Respiratory Distress Syndrome Study (Crit Care Med. 2015) [MEDLINE]
    • Combination CVVHD and ECMO is Safe and Effective
    • Oxygenator Blood Flow Rate was 410 +/= 30 mL/min (Around 10% of Cardiac Output): at these low flow rates, oxygenation would be expected to be minimal (due to the low blood flow rate) and CO2 removal would be around 20-30% of total CO2 production (since sweep gas flow rate could remain at an adequate level)

Monitoring of Arterial Oxygen Saturation and pO2 During VV-ECMo

• During VV-EMCO, the Arterial Oxygen Saturation Typically Ranges from 60-90%, Depending on the Relative Amount of ECMO Blood Flow, Native Venous Blood Flow, Lung Function, and Cardiac Output
  • This Desaturated Arterial Blood Results in Normal Systemic Levels of Oxygen Delivery as Long as the Cardiac Output and Hemoglobin Concentration (i.e. Arterial Oxygen Content) are Adequate
    • This Observation May Be Confusing to ICU Staff, Since the Usual Goal of Management is to Keep the Arterial Oxygen Saturation >90%

Adverse Effects/Complications (NEJM, 2011) [MEDLINE]

• Cannula-Related Problems
  • Epidemiology: accounts for 8.4% of adverse events
• Disseminated Intravascular Coagulation (DIC) (see Disseminated Intravascular Coagulation)
  • Epidemiology: accounts for 3.7% of adverse events
• Hemolysis (see Hemolytic Anemia)
  • Epidemiology: accounts for 6.9% of adverse events
  • Physiology
    • Higher Flow Rates Increase the Risk of Hemolysis (see Hemolytic Anemia): may occur when using high RPM with venous occlusion in the catheter (due to coughing, hypovolemia, catheter kinking, etc), resulting in a vacuum created in the pump head
• Hemorrhage
  • Cannulation-Site Hemorrhage: accounts for 17.1% of adverse events
  • Gastrointestinal Hemorrhage (see Gastrointestinal Hemorrhage): accounts for 5.1% of adverse events
  • Intracranial Hemorrhage: 3.8% of adverse events
  • Surgical Site: accounts for 19.0% of adverse events
  • Pulmonary Hemorrhage (see Diffuse Alveolar Hemorrhage): accounts for 8.1% of adverse events
  • Retroperitoneal Hemorrhage (see Retroperitoneal Hemorrhage)
• Infection (Related to or Unrelated to ECMO)
  • Epidemiology: accounts for 21.3% of adverse events
• Other Mechanical Complications
  • Epidemiology: accounts for 7.9% of adverse events
• Oxygenator Failure
  • Epidemiology: accounts for 17.5% of adverse events
• Thrombocytopenia (see Thrombocytopenia)
  • Epidemiology: common
  • Physiology
    • Heparin-Induced Thrombocytopenia (HIT) (see Heparin-Induced Thrombocytopenia)
    • Platelet Consumption in ECMO Circuit: due to fibrin stranding in oxygenator
• Thrombosis
  • Thrombosis in Oxygenator
    • Epidemiology: accounts for 12.2% of adverse events
  • Thrombosis in Other Circuit
    • Epidemiology: accounts for 17.8% of adverse events

Prognosis

• Taiwanese Study of ECMO Outcomes from 2002-2012 Associated with Coronary Artery Bypass Graft Surgery, Myocardial Infarction/Cardiogenic Shock, Trauma, and Infection/Septic Shock (Circulation, 2016) [MEDLINE]
  • Mean±SD age of the 4227-patient cohort was 57±17 years, and 72% were male
  • The overall mortalities were 59.8% and 76.5% at 1 month and 1 year
  • Survival statistics deteriorated sharply when ECMO was required for >3 days
  • Acute (30-day) survival was more favorable in the infection/septic shock (n=1076; hazard ratio, 0.61; 95% confidence interval, 0.55–0.67), coronary artery bypass graft surgery (n=1077; hazard ratio, 0.68; 95% confidence interval, 0.61–0.75), and Trauma (n=369, hazard ratio, 0.82; 95% confidence interval, 0.70–0.95) groups
  • The extended survival rapidly approached an asymptote near 20% for the infection/septic shock, myocardial infarction/cardiogenic shock (n=1705), and coronary artery bypass graft surgery groups
  • The pattern of survival for the Trauma group was somewhat better, exceeding 30% at year-end

References

General

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• Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med. 1994 Feb;149(2 Pt 1):295-305 [MEDLINE]
• Clinical predictors of and mortality in acute respiratory distress syndrome: potential role of red cell transfusion. Crit Care Med 33: 1191–1198, 2005 [MEDLINE]
• Association of RBC transfusion with mortality in patients with acute lung injury. Chest 132: 1116–1123, 2007 [MEDLINE]
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• Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients.  Heart Lung Circ  2008;17:S41–S47.  doi: 10.1016/j.hlc.2008.08.009. Epub 2008 Oct 29 [MEDLINE]
• Extracorporeal Life Support Organization (ELSO). Patient Specific Supplements to the ELSO General Guidelines, 2009. https://square.umin.ac.jp/jrcm/pdf/ecmo/ecmotext12.pdf
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• Roller and Centrifugal Pumps: A Retrospective Comparison of Bleeding Complications in Extracorporeal Membrane Oxygenation. ASAIO J. 2015 Sep-Oct;61(5):496-501. doi: 10.1097/MAT.0000000000000243 [MEDLINE]
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• Long-term survival and quality of life after extracorporeal life support: a 10-year report. Eur J Cardiothorac Surg. 2017 May 18. doi: 10.1093/ejcts/ezx100 [MEDLINE]
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• Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era: A systematic review. J Crit Care. 2017 Apr 27;41:64-71. doi: 10.1016/j.jcrc.2017.04.041 [MEDLINE]
• Fifty Years of Research in ARDS. Is Extracorporeal Circulation the Future of Acute Respiratory Distress Syndrome Management? Am J Respir Crit Care Med. 2017 May 1;195(9):1161-1170. doi: 10.1164/rccm.201701-0217CP [MEDLINE]
• Extracorporeal Life Support: The ELSO Red Book (5th Edition, 2017) [LINK]

Indications

• EOLIA Trial. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018 May 24;378(21):1965-1975. doi: 10.1056/NEJMoa1800385 [MEDLINE]
• ECMO for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018 Sep 13;379(11):1090. doi: 10.1056/NEJMc1808731 [MEDLINE]
• ECMO for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018 Sep 13;379(11):1090-1. doi: 10.1056/NEJMc1808731 [MEDLINE]
• ECMO for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018 Sep 13;379(11):1091. doi: 10.1056/NEJMc1808731 [MEDLINE]
• Learning from a Trial Stopped by a Data and Safety Monitoring Board. N Engl J Med. 2018 May 24;378(21):2031-2032. doi: 10.1056/NEJMe1805123 [MEDLINE]
• ECMO for Severe ARDS. N Engl J Med. 2018 May 24;378(21):2032-2034. doi: 10.1056/NEJMe1802676 [MEDLINE]

Prognosis

• Survival Analysis After Extracorporeal Membrane Oxygenation in Critically Ill Adults: A Nationwide Cohort Study. Circulation. 2016 Jun 14;133(24):2423-33. doi: 10.1161/CIRCULATIONAHA.115.019143 [MEDLINE]