Clinical Management of the Extracorporeal
Membrane Oxygenation Circuit
Warwick Butt, MBBS, FRACP, FCICM1–3; Micheal Heard, RN4; Giles J. Peek, MD, FRCS, CTh, FFICM5
Abstract: The clinical management of patients on extracorpo-
real membrane oxygenation should be standardized and follow
clear guidelines or protocols. However, due to the diversity of
cannulation strategies and the complex situations that extracor-
poreal membrane oxygenation is now used in, each extracor-
poreal membrane oxygenation program has developed its own
clinical management strategies. These vary widely across the
globe. Extracorporeal membrane oxygenation provides partial
or complete support of ventilation and oxygenation, as well as
univentricular or biventricular support of myocardial function,
either individually or in combination. High-flow extracorporeal
membrane oxygenation can also provide circulatory support in
profound vasoplegic shock. Improvements in technology and
greater understanding of disease pathophysiology, coupled to
refinements in technology, which lessen the adverse interac-
tion between the circuit and the patient, all contribute to fewer
mechanical and patient complications on extracorporeal mem-
brane oxygenation. Earlier and more appropriate use of extra-
corporeal membrane oxygenation has been associated with
improved patient outcomes. These clinical management strate-
gies are reviewed in this article, part of the Pediatric Cardiac
Intensive Care Society/Extracorporeal Life Support Organiza-
tion Joint Statement on Mechanical Circulatory Support. (Pedi-
atr Crit Care Med 2013; 14:S13–S19)
Key Words: extracorporeal life support; intensive care; mechanical
circulatory support; pediatric
1
Department of Intensive Care, Royal Childrens Hospital, Melbourne,
Australia.
2
Department of Paediatrics, University of Melbourne, Melbourne, Australia.
3
Department of Paediatrics, Critical Care and Neurosciences Theme
MCRI, Melbourne , Australia.
4
Department of Critical Care, Children’s Healthcare of Atlanta at
Egleston, GA.
5
East Midlands Congenital Heart Centre, Glenfield Hospital, Leicester, UK.
Dr. Heard has disclosed receiving honoraria from the University of Michi-
gan. The remaining authors have disclosed that they do not have any
potential conflicts of interest.
For information regarding this article, E-mail: warwick.butt@rch.org.au
Copyright © 2013 by the Society of Critical Care Medicine and the World
Federation of Pediatric Intensive and Critical Care Societies
DOI: 10.1097/PCC.0b013e318292ddc8
Pediatric Critical Care Medicine www.pccmjournal.org S13
E
xtracorporeal membrane oxygenation (ECMO) has
continuously evolved over the last 30 years, and its
applications have expanded (1). ECMO provides partial
or complete support of ventilation and oxygenation, as well as
univentricular or biventricular support of myocardial function,
either individually or in combination. High-flow ECMO can
also provide circulatory support in profound vasoplegic shock.
ECMO is now also used to facilitate other therapies such as
temperature control (rewarming from hypothermia or induc-
ing therapeutic hypothermia) or high-volume hemofiltration
in small children. ECMO has become a standard therapy for
resuscitation of acute cardiogenic shock or cardiac arrest. The
exact configuration of the ECMO circuit will depend on the
indication for ECMO, the goals of therapy, and the type of
organ support required. The duration of therapy, as well as the
likely ultimate patient outcome, will also impact on the circuit
design and the cannulation strategy. These will all affect the
clinical management of the patient and the circuit.
INDICATIONS FOR ECMO
ECMO is used in neonates, infants, and children with heart
disease, who fail to wean after cardiopulmonary bypass (CPB)
surgery; suffer cardiac arrest; have acute cardiogenic shock and
progressive deterioration of cardiac function with multiple
organ failure; or worsening low cardiac output syndrome
despite maximal treatment. The definition of maximal
treatment varies in these circumstances but includes adequate
circulating blood volume, adequate hemoglobin, and a large
amount of inotropic drugs. Echocardiography is essential
to gain an accurate diagnosis and assess the severity of the
problem. Early use of mechanical support may reverse the
progression of organ failure and lead to shorter duration of
ECMO and increased patient survival (2).
GOALS OF SUPPORT ONCE ECMO
IS ESTABLISHED
These may include one or all of the following.
Provision of Adequate Blood Flow for Cellular Metabolic
Needs in Patients With Inadequate Cardiac Output
This will vary from 100 to 150 mL/kg/min but occasionally may
be higher. Evidence of adequate perfusion may be obtained by
Butt et al
assessment of clinical signs (e.g., capillary refill time, urine
output) and measurement of mixed venous oxygen saturation,
preoxygenator Sao2 or arterial lactate.
Provision of Adequate Oxygenation and Carbon
Dioxide Clearance in Pulmonary Dysfunction to
Ensure Adequate Cellular Respiration
Adequate oxygenation, assuming appropriate blood flow and
sufficient hematocrit, will be Sao2 greater than or equal to 75%.
This depends on the exact patient diagnosis and circuit con-
figuration and must be monitored with arterial blood gases
and lactate. The desired Paco2 and arterial pH is easily obtained
with modern oxygenators and gas flows; these are readily
monitored.
The Prevention of Complications From Other
Therapies
These include lung damage from ventilation-induced lung
injury; the negative circulatory effects of ventilation and
high intrathoracic pressures; and the increase in myocardial
work and end-organ injury that may be seen from high-dose
inotropes and vasoconstrictors.
ECMO is also used for the facilitation of other therapies,
such as support before or after complex airway interven-
tions; during complex cardiac catheter interventions; tem-
perature control; removal of solute, drugs or toxins from
the blood; or maintenance of organ perfusion in donors for
transplantation.
PRINCIPLES OF CIRCUIT DESIGN THAT
IMPACT CLINICAL MANAGEMENT
There are many factors that dictate institutional preferences in
specific circuit configurations and usually represent a balance
of clinical factors, the experience of the cannulating physician,
and other treatments available. These differences impact on
the clinical management of ECMO so that many different sys-
tems of care can be successfully used. Each has advantages and
disadvantages. Some of the variations include the following:
Target blood flows: If these are very high, larger cannu-
las (venous or arterial) or a second drainage cannula may be
required.
Presence or absence of a circuit bridge: Bridges facilitate
slow weaning and circuit changes, especially in prolonged
ECMO. However, the presence of the bridge itself may lead to
stasis of blood flow and turbulence, thus increasing the risk of
hemolysis or thromboembolism.
Number of circuit access points: These increase the risk
of hemolysis but also increase the capacity to monitor vari-
ous pressures, blood flow, and oxygen saturation, and provide
access for other therapies such as hemofiltration.
Circuit tubing: The tubing and oxygenator should have the
lowest inflammatory signature to minimize the interaction
with blood. There are many products available, but not all are
distributed worldwide.
The size of oxygenator in relation to the patient: The smaller
the oxygenator, the less its capacity for gas exchange. However,
S14 www.pccmjournal.org June 2013 • Volume 14 • Number 5 (Suppl.)
smaller oxygenators also have fewer low-flow zones and thus
less stasis, clots, and potential for hemolysis.
Type of pump: Roller pumps require a bladder and a more
complicated ECMO circuit and have the potential for tubing
rupture. Centrifugal pumps have greater potential for inad-
equate venous drainage and are afterload sensitive.
Cannulation
Cannulation can be central or peripheral and is performed by
cutdown or percutaneously. Central (transthoracic) ECMO
generally requires a cardiac surgeon to perform a sternot-
omy. This is easily done when cannulation occurs following
CPB. The major disadvantage of a sternotomy for ECMO is
increased risk of infection and bleeding. The bleeding can usu-
ally be managed with meticulous hemostasis and if needed,
repeat clot removal. The major advantage of sternotomy is easy
insertion of large cannulas with adequate blood flow and arte-
rial inflow to the ascending aorta. However, in many ECMO
programs, general surgeons primarily perform cannulation,
and these physicians may not be as familiar as cardiothoracic
surgeons with central cannulation. In this case, cannulation via
the neck or groin is more common.
Percutaneous cannulation is always peripheral. The major
disadvantage of neck cannulation is the potential for emboli into
the brain and interference with cerebral blood flow, especially in
older children. The major disadvantage of femoral vessel can-
nulation is the need for smaller catheters and the potential for
peripheral limb ischemia or venous obstruction. The major
advantage of percutaneous cannulation is decreased bleed-
ing around the insertion site. The major disadvantage is in the
technical insertion and advancement of the cannulas, which are
often smaller and also harder to insert than directly under vision.
It is important at the beginning of the ECMO run to have
a clear view of the likely length of support required and ulti-
mate destination; this may be bridge to transplant or recovery.
This clearly affects cannulation strategies. For example, a child
with decompensated cardiomyopathy may have peripheral
cannulation to avoid sternotomy or central cannulation, which
can complicate cardiac transplantation later if it is required.
Similarly, a patient with severe acute respiratory distress syn-
drome (ARDS) may need 3–6 weeks of support, and thus,
peripheral venovenous access should be used to facilitate wake-
fulness and movement. After cardiac surgery, central ECMO is
often used but mediastinitis is increasingly likely if more than
5–7 days of central support is required.
Some key principles in planning cannulation include the
following.
Venoarterial Is the Standard for Cardiac ECMO. Venoarterial
(VA) ECMO provides direct circulatory support. Therefore, if
the principal indication for ECMO is for mechanical circula-
tory support rather than refractory hypoxia or hypercapnia,
then VA is the default cannulation strategy. Occasionally, in very
experienced centers and in very specific situations (see below),
venovenous (VV) ECMO can be used to improve circulatory
function, but this should not be regarded as a conventional
strategy.

Ensure Sufficient Venous Drainage. Poiseuille’s law states that
flow is directly proportional to the pressure gradient multi-
plied by the fourth power of the radius divided by the length
of the tube, so a short fat cannula is best for venous drainage.
However, although this is true in principle, it may not be true
when the cannula is in a small vein, which collapses around
it because of the suction of a centrifugal pump. In this situ-
ation, better drainage may occur with a slightly smaller can-
nula, approximately two thirds of the diameter of the vein. If
sufficient venous drainage can be achieved with percutaneous
extrathoracic cannulation, then this should be considered.
The right jugular vein is usually the first choice as this affords
the shortest route to the right atrium. If there is insufficient
drainage, then an additional venous cannula can be inserted.
Children who have started walking (i.e., toddlers) can have a
catheter placed in the femoral vein and advanced into the right
atrium. In smaller patients, it may be necessary to use a cepha-
lad venous cannula or direct right atrial cannula.
Venous drainage can also be improved by increasing the
revolution speed on a centrifugal pump or the height of the
venous siphon on a roller pump, but this will come at the price
of increased risk of hemolysis and possible flow interruption
due to cannula obstruction. Although this may be countered
by the introduction of a venous-line compliance chamber (e.g.,
Better Bladder) and venous-line pressure monitoring, it none-
theless creates a potential for air entrainment.
Return the Oxygenated Blood to the Patient. In cardiac ECMO,
VA support will be almost always be chosen because it provides
direct circulatory support and gas exchange. The options for
arterial inflow are often dictated by the site of venous drain-
age. For example, when using transthoracic ECMO, the arte-
rial inflow cannula is best placed in the aorta. It is usually
safer to choose a straight ECMO arterial cannula rather than
a bypass cannula, as the latter usually only has a few millime-
ters of cannula inside the aorta. If a straight ECMO cannula
is used, it can be inserted more deeply into the aorta, and the
cannula tip can be advanced around the arch and placed away
from any aortic suture lines, making its position more secure.
In many respects, the ideal transthoracic cannulation is via a
graft anastomosed end to side on the innominate artery. This
allows the cannula to be introduced without ligating a vessel
and makes decannulation (and recannulation) easy as the graft
is simply folded over, secured with a ligation clip, and over-
sewn. It is important to cut the graft short enough that it does
not protrude from the chest, as sterility must be maintained. It
is also wise to apply fibrin glue to the suture line before releas-
ing the clamps to prevent suture line bleeding via the needle
holes. To determine which size of cannula to use, multiply the
diameter of the graft in millimeters by 3.142 to get the French
gauge (catheter circumference in millimeters). The side-graft
technique is also useful for peripheral cannulation when try-
ing to avoid arterial ligation, such as when using the axillary
or femoral arteries for access. It may also be useful when using
the carotid artery in patients after reverse subclavian flaps for
aortic arch reconstruction, who only have three cerebral arter-
ies instead of four.
Pediatric Critical Care Medicine www.pccmjournal.org S15
Mechanical Circulatory Support
In patients who have not had a median sternotomy or those
in whom ECMO will be required for more than a few days, it
is usually better to use peripheral cannulation. In patients who
have yet to walk, the right carotid artery is used. This is ligated
around the cannula and can be reconstructed later if the tissue
is healthy enough. In older patients who have started walking,
the femoral artery can be used. This is usually best done using
a semi-Seldinger technique (3) in children and a percutaneous
technique in adolescents. In almost all cases when the femoral
artery is cannulated, distal perfusion must be provided. This
can be anterograde via an additional cannula, or retrograde via
the posterior tibial artery (4). Delays in perfusion can lead to
major problems requiring fasciotomy or amputation.
VV ECMO
VV ECMO is occasionally a suitable approach in the cardiac
ECMO patient. The heart will often recover before the lungs
when a patient with combined circulatory and respiratory
failure is supported with central VA cannulation. In this case,
conversion to VV cannulation using a double-lumen cannula
via the right internal jugular vein can allow the chest to be
closed and preserve the carotid artery and the jugular vein if
a semi-Seldinger or percutaneous approach is used. Another
situation where VV ECMO can be useful is when a patient has
a heart with common mixing and impaired pulmonary blood
flow (e.g., a blocked Blalock-Taussig shunt). In this situation,
the heart can work adequately if the myocardium is oxygen-
ated, allowing the problem to be fully evaluated and treated.
VV ECMO can provide excellent intraoperative support of gas
exchange whilst the shunt is revised and thereby avoid CPB.
Venoarteriovenous ECMO
Venoarteriovenous (VAV) is an elegant mode of cardiorespira-
tory support as it provides excellent myocardial oxygenation
from the VV component and support of the systemic circula-
tion from the VA side. Although rarely required in children, it
is most commonly indicated in a patient who has been can-
nulated with VA ECMO via the femoral vessels when there is
minimal cardiac function and associated impairment of pul-
monary function (e.g., concurrent severe ARDS, pneumonia,
or pulmonary edema). As the right ventricle recovers, forward
blood flow through the poorly functioning lungs increases,
and deoxygenated blood is ejected from the left ventricle into
the ascending aorta, coronary arteries, right arm, and brain.
Visually, the upper body becomes cyanosed, whereas the lower
body perfused from the pump is bright red (differential cya-
nosis). It is not possible or desirable to increase the pump
flow to retrogradely perfuse the arch in order to oxygenate the
coronaries and the brain because this will mean that the heart
will be empty and not eject because of poor preload and high
afterload. This is not a scenario best suited to recovery of the
heart. One possible solution is to introduce some oxygenated
blood into the right atrium and into a peripheral artery (VAV
ECMO), and depending on the adequacy of venous drainage,
this can be done using either a single or a double lumen can-
nula in the jugular vein. A gate clamp is applied to the venous
Butt et al
return line and adjusted to give a balance of adequate upper
body oxygenation with sufficient systemic blood flow. Usually
the heart will recover before the lungs, in which case the patient
can be gradually transitioned onto VV ECMO by slowly releas-
ing the gate clamp on the venous return line and moving it to
the arterial return line, where it is tightened over a 24-hour
period. The patient is, thus, transitioned to VV ECMO, and the
artery can be decannulated and repaired.
Venting the Systemic Ventricle
Ensuring that the systemic ventricle does not become dis-
tended is very important, as this will impede recovery and will
eventually cause hemorrhagic pulmonary edema. If the heart is
ejecting with an adequate pulse pressure (e.g., >5–10 mm Hg)
on the arterial line trace, then it is unlikely to be distended.
Echocardiographic signs indicating the need for venting
include distension of the systemic ventricle and atrium, sys-
temic atrioventricular valve regurgitation, spontaneous echo
contrast, or severe pulmonary hypertension. Left atrial and
pulmonary artery pressure measurements are helpful. Blood-
stained edema fluid on endotracheal suctioning is also diag-
nostic. The left atrium can be decompressed via a septostomy
(percutaneous or surgical) by direct left atrial cannulation (via
the appendage or right superior pulmonary vein) or by cannu-
lation of the systemic ventricle via the apex. Venting is usually
achieved via the preexisting sternotomy, but in the patient with
no sternotomy, the catheter atrial septostomy is the procedure
of choice. The vent is connected to the venous drainage line
below the sampling point because the oxygenated blood in the
vent will raise the saturation of blood in the venous line, thus
making it difficult to gauge the true mixed venous oxygen satu-
ration. It is important to place a transonic flow meter on the
vent line to make sure there is continuous flow. It is usually
possible to remove the vent after a few days as the heart recov-
ers. Epicardial or transesophageal echocardiography is a use-
ful tool to assess the heart intraoperatively when removing the
vent. This is often a good opportunity to switch to extratho-
racic cannulation if ECMO is still required and close the chest.
Circuit Complications
One of the most important issues in the safe clinical manage-
ment of ECMO is the balance between anticoagulation and
thrombosis. The management strategies for anticoagulation
will, of necessity, vary according to patient diagnosis and risks.
Newborn infants, children with sepsis, and children with sys-
temic inflammatory response syndrome after cardiac surgery
are hypercoagulable, but children with septic shock and dis-
seminated intravascular coagulation (DIC) or children fol-
lowing cardiac surgery after extensive dissection and CPB are
also more likely to bleed. Individual goals are essential for each
patient and parameters such as platelet concentration, acti-
vated clotting time (ACT), and thromboelastography should
be adjusted accordingly. Some ICUs also use activated partial
thromboplastin time, prothrombin time, AntiXa, fibrino-
gen, d-dimer, or fibrinogen degradation products to provide
S16 www.pccmjournal.org June 2013 • Volume 14 • Number 5 (Suppl.)
information on how to best manage this complex situation.
This is covered in detail in another section of the statement.
Thrombosis
Clots in the ECMO circuit are the most common mechanical
complication during ECMO (5). The clotting cascade is acti-
vated during exposure to the artificial surface of the circuit,
and anticoagulation cannot completely prevent clot formation.
These clots are small in size and usually have minimal potential
to cause harm to the patient or circuit. These minor clots occur
wherever there is stasis of blood flow, such as at the dependent
side of the base of some oxygenators. This area will often have
dark clots after a few hours or days into the ECMO run. As long
as the clots do not encroach upon the blood inlet or gas outlet,
or cause pressure changes within the membrane, they can be
safely observed. Clot formation within tubing and connectors
is often very easy to see, either as dark clots or as white fibrin
strands.
Judicious use of pressure monitoring will aid in the assess-
ment and management of these clots. Anticoagulation may be
increased (e.g., increasing ACT targets or use of antiplatelet
drugs) and careful monitoring for intravascular hemolysis is
normal (e.g., plasma-free hemoglobin). Once clot formation
has been identified as causing a clinical problem, such as mod-
erate hemolysis, incipient embolism, or component failure,
then part or all of the circuit should be changed.
Air Embolism
Air in the circuit represents 4% of all complications reported
to the ELSO Registry (5). These can range from small bubbles
visualized in the venous side of the circuit to a massive air
embolus to the patient. Negative pressure occurs on the venous
drainage side of the circuit. Positive pressure occurs at the
point at which the blood starts to move forward through the
pump head and into the oxygenator and arterial return can-
nula. The appropriate placement and use of pressure modules
that servoregulate the pump and/or a bladder box are excellent
safety measures with roller pumps, which can prevent cavita-
tion and air embolism. The use of an air bubble detector that
servoregulates the pump may be considered the ultimate pre-
ventive measure. Although air embolus is a rare complication,
the use of this simple device on the tubing before the inflow
cannula can prevent any air from entering the patient.
Membrane Oxygenator Failure
Many U.S. ECMO centers continue to use silicone membrane
oxygenators and only a small percentage (6%) of them are
reported as having failed during an ECMO run (5). Polypro-
pylene and polymethylpentene oxygenators are employed in
many European and Asian ECMO centers, and it is reported
that they have a failure rate of 18.3% and 0%, respectively.
Polymethylpentene oxygenators may have significantly fewer
complications resulting in failure than silicone membrane oxy-
genators. Polypropylene oxygenators have also been improved
in recent times, but plasma leakage and subsequent diffusion
blockage are still inevitable with these devices, which have a

limited operational lifetime. Clot formation within the mem-
brane is the main reason that the oxygenator may need to be
changed.
Tubing Rupture or Leakage
Tubing rupture is a rare mechanical complication (0.3%) (5).
However, polyvinyl chloride tubing, used for all other tubing
requirements aside from the raceway in roller pump circuits,
may become damaged or cracked. The use of guarded tub-
ing clamps will decrease the damage that may be done to the
bridge and other tubing pieces. Careful use of nonpenetrating
towel clamps will also prevent accidental piercing of tubing.
Tubing connectors are often used throughout the ECMO
circuit. It is recommended that every connection is tie banded,
even manufactured connections. This will prevent the leakage
of blood from any weak point in the event of overpressuriza-
tion of the blood path. The use of a servoregulated system will
also prevent the accidental increase in pressure, preventing
accidental tubing separation.
Cannula Problems
Cannulas are inserted during a sterile surgical procedure, and
care must be undertaken to avoid vascular injury. The poten-
tial vascular injuries during cannula insertion include tearing
of the vein, as well as intimal dissection of the artery, prevent-
ing proper cannula placement and potentially leading to lethal
dissection. Even after appropriate cannula placement, cannula
obstruction due to kinking can occur. After insertion, cannula
position can be assessed by radiography or echocardiography.
Initially, effective placement allows attainment of calculated
blood flow (100–150 mL/kg/min). Inability to achieve appro-
priate flows may be due to suboptimal venous cannula place-
ment and should be remedied at the time of cannulation. High
arterial return pressures indicate a problem with the arterial
inflow cannula (e.g., poor positioning or kinking).
Accidental Decannulation
Accidental decannulation is an uncommon complication and
one that is usually preventable. Inadvertent decannulation can
have serious consequences, including catastrophic hemorrhage
or air embolism, in addition to the sudden loss of ECMO sup-
port. To prevent this, it is vital to secure the cannulas to a fixed
object and to ensure correct placement of the cannulas by
recording the depth of insertion of each cannula at the inci-
sion site.
Sedation, neuromuscular blockade, and physical restraints
may be used to prevent the patient from dislodging cannulas.
Extra care should be taken during patient transport (6).
Equipment Failure
Using an uninterruptible power source with battery backup
can prevent loss of power to the pump head. The battery should
engage immediately with any power loss and will ensure that
pump flow is maintained until the situation is remedied. How-
ever, in the event that the battery fails or is fully discharged,
manual hand cranking can be done with most pumps. The
Pediatric Critical Care Medicine www.pccmjournal.org S17
Mechanical Circulatory Support
efficacy of the hand cranking in the absence of power can be
assessed clinically by noting the patient’s color and blood pres-
sure, as well as the volume of the bladder (if present).
Miscellaneous Circuit Components
There are many different components in ECMO circuits and all
are reported to have failed at some point. The heat exchanger
may fail due to thrombosis and occlusion of blood flow, tem-
perature probe cracking and blood leaks. The arterial filter is
another disposable component that some ECMO centers use.
Failure of this component occurs with excessive clotting. Cen-
trifugal pumps have a disposable pump head, which may fail in
a variety of ways, although the newest generation of centrifugal
pumps has extremely low failure rates. Consumptive coagulop-
athy or increased hemolysis may indicate that the pump head
has clot in it. Individual pieces have also been known to crack
or fail from frequent use and fatigue. These include the pigtails
and the stopcocks. Avoiding overtightening of stopcocks onto
pigtails and pigtails onto connectors will lessen the chance of
cracking the Luer-Lok connections. Using gauze to protect
pigtails when clamping them will prevent the tubing clamps’
“teeth” from indenting and cracking the miniature tubing.
Additionally, routinely changing stopcocks will prevent them
from becoming stiff with use and cracking.
PATIENT COMPLICATIONS
Bleeding
Minor bleeding on ECMO (due to heparinization, platelet
dysfunction, and other factors) is common and easily man-
aged with blood product administration or local measures (7).
Large volume bleeding or bleeding into internal organs is not
common and must be rapidly addressed immediately. Bleeding
from the sites of invasive procedures can also be a problem.
Planning for this is essential, and no unnecessary procedures
on noncompressible sites should be performed. If an invasive
procedure is essential, factors to consider before proceeding
include enhancing coagulation factors (consider administering
platelets, fibrinogen, and/or fresh frozen plasma), use of sys-
temic antifibrinolytics, and employing only senior personnel to
perform the procedure. If bleeding does occur, it is important
to distinguish between local bleeding and generalized bleeding,
as treatment is different. Localized bleeding can be managed
by a combination of pressure, local hemostasis with sutures, or
impregnated gauze. Occasionally, decreasing heparin and tar-
geting lower ACTs are appropriate. Generalized bleeding usu-
ally requires a combination of platelet and coagulation factor
replacement, and reducing the heparin dose. In more severe
cases, systemic antifibrinolytics can be considered. The use of
recombinant factor VII has been associated with both success-
ful resolution of bleeding and with acute circuit thrombosis
and death, and should only be used with extreme caution.
Occasionally, the circuit itself can be the prime stimu-
lus to DIC, when platelet aggregation leads to increased clot
formation in the circuit and fibrinolysis. The symptoms on
ECMO include decreased platelet count, widespread circuit
Butt et al
clot formation, increased ACTs, and bleeding. Treatment is to
change the ECMO circuit and transfusion of blood products.
Infection
Infection occurs in some ECMO patients (~12%, 6% if dura-
tion is <7 d, and 30% if duration is >30 d ) (8, 9). Major risk
factors are duration of ECMO, older age, and preexisting
immunocompromise. Patients who develop infections on
ECMO have worse multiple organ failure and higher mortality.
It is important to note that infection may come from sources
unrelated to the ECMO cannulas (e.g., ventilator-associated
pneumonia or urinary tract infection) or from the circuit. It
is essential to follow complete sterile precautions when access-
ing the circuit. The role for continuing prophylactic antibiotics
solely because of ECMO is not well supported, although some
centers routinely provide coverage against skin flora for open-
chest cannulations or after urgent, potentially unsterile can-
nulations, such as during CPR.
Hemolysis
Hemolysis is a frequent occurrence on ECMO but is usually
mild and requires no action. However, moderate to severe
hemolysis can lead to multiple organ failure and is associated
with increased mortality. Much effort is directed to prevention
of hemolysis; this is best achieved by having no clots in the cir-
cuit, excellent venous drainage, and continuous laminar blood
flow (10).
Neurological
Cerebral infarction or hemorrhage is a major potential com-
plication of ECMO. These complications can be minimized by
meticulous attention to the prevention of thromboembolism
and excess anticoagulation. Expediting initiation of ECMO in
patients with refractory hypotension, hypoxemia, or cardiac
arrest may reduce the risk of neurological injury.
Weaning
Weaning refers to the gradual decrease of VA ECMO blood
flow, with increasing dependence on native cardiopulmonary
function. It begins when sufficient organ function has returned
to suggest that ECMO support may be soon withdrawn. In VA
ECMO patients, increasing pulse pressure and end-tidal carbon
dioxide due to increasing ventricular ejection are encouraging
signs. Some centers pretreat with inodilators such as milrinone
or levosimendan (11) the day before weaning commences and
start inotropes such as epinephrine or dobutamine on the day
of weaning trial. Cardiac function can be assessed more com-
prehensively with echocardiography (12) or serial B-type nati-
uretic peptide (13). Before weaning commences, it is also very
important to assess lung function. As weaning is initiated, the
patient should be fully ventilated.
As weaning continues, less flow goes through the ECMO
circuit and thus thrombosis is more likely, necessitating an
increase in anticoagulation or alternatively increased flow
through the bridge. Reasonable minimum flows are 200 mL/min
for a 1/4-inch or 3/8-inch circuit and 500 mL/min for a 1/2″
circuit.
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Trialing off ECMO
The trial-off procedure is the last test prior to decannulation.
The response of the patient once removed from all ECMO
support without actually removing the cannulas is a brief but
important step. It allows the clinician the opportunity to fine-
tune ventilator settings, inotropes, vasopressors, and other sup-
portive therapies. The final determination can then be made if
the patient is ready for decannulation. The trial-off procedure
varies with the type of ECMO and among centers. A reason-
able approach to VA ECMO weaning is as follows:
●● Appropriate ventilation and monitoring is initiated and
reviewed.
●● IV fluids are checked and administered.
●● The patient is removed from the circuit by clamping the
venous and arterial cannulas.
●● If a bridge is present, the flow is increased or maintained.
●● Close attention is paid to oxygenation, heart rate, and
blood pressure.
●● Echocardiography may be considered to assess myocardial
function and to evaluate for new or preexisting anatomical
problems.
●● An arterial blood gas is drawn. If the results are acceptable,
decannulation proceeds. Otherwise, decannulation is delayed
while further attempts to correct the problem are initiated.
●● The cannulas should be flushed every 5–10 minutes during
the trial off.
●● Circuit ACTs should be monitored every 15 minutes dur-
ing the trial-off procedure.
If a centrifugal pump is being used, it is possible to attempt
a trial by allowing retrograde flow to develop in the circuit then
increasing the pump speed to limit the amount of retrograde
flow to 50 to 150 mL/min for a 1/4-inch head and around 400–
800 mL/min for a 3/8-inch head (the transonic flow meter is
reversed to measure this flow). This amount of left-to-right
shunt is well tolerated by a patient whose heart has recovered
sufficiently to tolerate weaning from ECMO and reduces the
risk of circuit or cannula thrombosis, as there are no areas of
stasis in the circuit. It also obviates the need for a bridge.
Decannulation
As a general rule, blood vessels in children should be recon-
structed if possible but not if the cannulation site looks
infected. If it does look infected, then all prosthetic tissue must
be removed and the vessel ligated if there is good collateral
circulation (i.e., carotid) or reconstructed using autologous
tissue (vein patch or pericardium) if it is an end artery (i.e.,
the femoral). Veins are more difficult to reconstruct than arter-
ies as they are more fragile; this is the benefit of percutaneous
(or semi-Seldinger) venous cannulation, as the cannula can be
removed and a mattress suture placed in the skin. It is coun-
terproductive to press on the site as this ensures the underlying
vein becomes occluded and adds nothing to hemostasis. When
the artery has been cannulated percutaneously, it is usual to
perform open surgical decannulation and reconstruction of
the vessel. Percutaneous access substantially lowers the risk

of the vessel becoming infected. If the vessel has been recon-
structed, continue anticoagulation after decannulation with
heparin 10 U/kg/h and then aspirin for 3 months.
CONCLUSION
The clinical management of ECMO varies around the world
and is in a state of constant quality improvement. The condi-
tions for which ECMO are used are increasingly diverse and
many varied strategies are, thus, being employed. Local factors
influence some differences in practice but the fundamental
principles are similar. The technology has become safer (14)
and better, as has the understanding of what ECMO can and
cannot offer. Patient outcomes (survival and quality of life)
continue to improve. ECMO has become a routine part of care
for children before (15) and after (16) cardiac surgery, as well as
a standard resuscitation therapy (17) in many centers. ECMO
is a wonderful example of EBM: experience-based medicine.
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