Get ready for ECMO

Get ready for ECMO
Photo by Ian Taylor / Unsplash

If you work in a district general hospital then chances are at some point you'll be involved in an ECMO retrieval.

This exciting and unusual procedure can feel stressful and chaotic initially, but if you're aware of the steps and what is expected of you as the on-site anaesthetist, it can make your life a lot easier.

Here's our list of top tips on what to do and what to expect on the day.

Making the referral to ECMO

What does the ECMO team do?

  • Veno-venous ECMO for acute severe respiratory failure
  • Veno-arterial ECMO for acute severe cardiac failure*

*plus some other cool stuff like ventricular assist devices

  • Really great advice on ITU management of patients with acute cardiac or respiratory failure, even if your patient isn't a candidate for retrieval.

Should I refer for VV ECMO?

If your patient has a reversible life-threatening respiratory failure that would benefit from giving the lungs a complete rest, then maybe, if:

  • They have decent enough cardiac function
  • They're hypercapnoeic with a pH <7.2
  • They have a Murray score of 3 or more

If your patient is satisfying the above criteria, and none of the following are present:

  • Severe heart failure or cardiogenic shock not managed with medical therapy
  • Severe chronic pulmonary hypertension
  • Ongoing cardiac arrest

...Then give them a call.

They might say that VV-ECMO isn't indicated in the case of:

  • More than 7 days of ventilation with plateau pressures over 30cmH2O and FiO2 80%
  • Severe immunosuppression
  • More than 30 min of CPR with no documented neurological recovery
  • BMI less than 18

But it's still worth a call, if only for advice.

Should I refer for VA ECMO?

If your patient has severe but potentially reversible, refractory cardiogenic shock, where ECMO would be a bridge to a more definitive treatment, then potentially, if:

  • They need to have no absolute contraindications to a heart transplant
  • Lacte is >3 between 1 and 12 hours after starting inotropes
  • Persistent cardiac index <2.2
  • End organ dysfunction due to cardiogenic shock
  • LVEF <30% or aortic velocity time integral <8-12 cm/sec

Absolute contraindications to VA-ECMO

  • Any contraindication to heart transplant
  • Aortic dissection or peripheral arterial disease that means cannulation not possible
  • Uncontrolled major haemorrhage
  • Known CVA within 6 month
  • More than 30 mins of CPR at time of cannulation

When definitely not for ECMO

  • Chronic medical condition with a life expectancy of less than 12 months
  • Progressive heart or lung disease not suitable for transplant
  • Chronic severe pulmonary hypertension
  • Advanced cancer
  • Graft vs Host disease
  • Unwitnessed cardiac arrest
  • Bone marrow transplant if within last 9 months

A game of logistics

The complexity of an ECMO retrieval lies in the logistics, the organising people, space and equipment.

Investigations they'll want for the referral

  • FBC
  • Electrolytes and creatinine
  • LFT
  • Lactate (ABG)
  • CRP
  • Clotting
  • Fibrinogen
  • CXR
  • ECG
  • Echo if possible
  • Relevant microbiology results

Things you're going to need when they get here

  • A theatre with anaesthetist and scrub nurse - you're going to need to coordinate with CEPOD to avoid pausing CEPOD unnecessarily
  • A half-decent ultrasound machine
  • 2 large and 1 small empty surgical trolleys
  • A radiolucent table - usually with the head at the foot end of the table with it fully traversed to the feet so that you can X-ray all the way from groin up to chest
  • A friendly radiographer with a C-arm - they'll also need special IV contrast
  • Lots of lead gowns and thyroid shields
  • Four units crossmatched blood
  • Platelets if less than 100
  • FFP if INR or APPTr is more than 1.5
  • Good bilateral IV access or central lines (avoid the groin where possible, but don't remove lines that are already in - the ECMO team occasionally rewire them)
  • Radial arterial line


  • The ECMO team should have had a decent handover from whoever made the referral from ITU, but if you're the CEPOD anaesthetist helping out, it's a good idea to clarify the patient's history in your own mind, so that you can answer questions during the procedure
  • The patient is probably already intubated on ITU, and therefore this whole procedure is probably being done via a consent form 4
  • It is imperative that the family or next of kin are aware of the plan and what's going on
  • The ECMO team will consent the patient's family where possible and appropriate, but it certainly shouldn't be the first time that they're hearing about it
  • If you can have the family ready in the relatives' room when the ECMO team arrive, this will speed things along remarkably

For the ECMO team's journey

  • Have a fresh bag of Hartmann's or Plasmalyte or equivalent on a blood giving set ready to go
  • Noradrenaline, propofol, fentanyl, rocuronium and any other active infusions should be made up and ready to go
  • Make sure all the relevant notes and images have been sent to the receiving hospital
  • An offer of food and drink before they set off always goes down well, even if it's just tea and NHS issue bourbons!

Our top tips on the day

  • The patient is going to be really unwell - it's why they're going onto ECMO in the first place
  • The patient may be proned, making the logistics of positioning somewhat more complex - discuss this in detail with the ECMO team before hand
  • You want to flip them at the very last minute
  • Expect them to desaturate and be very cardiovascularly unstable
  • If they're already on pressors, then have more ready, and you may end up giving boluses of adrenaline (10mcg per ml) just to buy time while they get the cannulae in
  • Antibiotics - Your patient is probably already on domestos antibiotics if they're headed for ECMO, but either way, the EMCO team will usually ask for some spicy antimicrobials like linezolid and clindamycin, so just check what they want beforehand

Chill out

In general the ECMO teams are extremely helpful, approachable and will happily give advice even if your patient isn't a candidate, so don't be afraid to call them (assuming you have read the above already).