ECMO

ECMO Troubleshooter

Select the circuit and bedside problem. The interpretation updates automatically.

Bedside assessment

ECMO mode
Choose VV or VA support
Bedside problem
Problems change based on the ECMO mode

When to choose VV ECMO?

  • Severe, potentially reversible respiratory failure (ARDS) refractory to optimal management
  • Hypoxemia or hypercapnia despite lung-protective ventilation, proning, paralysis, or inhaled vasodilator
  • Intact or manageable hemodynamics without need for circulatory support
    • Typical setup: femoral–IJ or dual-lumen cannulation
    • Targets: SaO₂ > 88–92%
    • Goal: Rest the lung

When to choose VA ECMO?

  • Cardiogenic shock or cardiac arrest with potential for recovery or bridge
  • Severe biventricular failure or refractory VT/VF, post-cardiotomy shock
  • Need for hemodynamic support (MAP/perfusion) beyond vasoactives
    • Typical setup: femoral VA
    • Watch for: LV distension, Harlequin (north–south) syndrome
    • Adjuncts: vent, Impella, or IABP if needed

Contraindications

  • Irreversible disease without bridge or exit plan
  • Multi-organ failure without recovery path
  • Prohibitive bleeding/coagulopathy, devastating neuro injury
  • Prolonged no-flow/low-flow arrest, advanced frailty, or poor baseline

Initial setup & targets

VV ECMO (oxygenation/CO₂)

  • Blood flow ~5 L/min (up to 7–8). Aim > 60–70% of CO for SpO₂ > 90%
  • Sweep 2–3 L/min, titrate to pCO₂
  • Vent: tidal 3–4 mL/kg IBW, Pplat ≤ 25, PEEP individualized, FiO₂ minimal
  • Goals: SpO₂ 88–92% (ok 85–88% if perfusion OK), pH > 7.25
    Pearl: if sats low, check recirculation → flow → Hb/SaO₂/oxygenator

VA ECMO (perfusion/oxygenation)

  • Flow titrated to MAP and end-organ perfusion. Treat LV distension early
  • Monitor right radial ABG for Harlequin syndrome; add vent or V-A-V if needed
  • Minimize catecholamines; optimize preload/afterload; unload LV if required

Anticoagulation

Heparin

  • UFH unless bleeding risk → low-dose or no-anticoagulation strategy
  • Anti-Xa preferred; aPTT/ACT adjunctive
    • Anti-Xa: 0.3–0.7 IU/mL
    • aPTT: 50–70 s
    • ACT: 160–180 s
    • Platelets: > 75–100 K
    • Fibrinogen: > 150–200 mg/dL
      Reassess after circuit change, bleeding, or oxygenator dysfunction.

ECMO Troubleshooting

ProblemLikely causesKey actions
Low SpO₂ VV ECMO
  • Recirculation or cannula malposition
  • Inadequate blood flow
  • Hypovolemia
  • Oxygenator dysfunction
  • Check cannula position, circuit flow, and drainage
  • Increase blood flow if feasible
  • Optimize preload if drainage limited
  • Check oxygenator ΔP and post-membrane gas
  • Reduce oxygen demand
Hypercapnia
  • Inadequate sweep
  • Gas line or blender problem
  • Oxygenator failure
  • Increase sweep gas flow
  • Check gas source, blender, and tubing
  • Minimize unnecessary ventilator dead space
  • Replace oxygenator if gas transfer remains poor
Hypotension
  • VV: vasodilation or low preload
  • VA: low flow, bleeding, sepsis, tamponade, RV failure, or LV distension
  • Assess perfusion and circuit flow
  • Use echo when unstable
  • Treat preload, vasoplegia, bleeding, or obstructive physiology
  • Unload the LV if distension is contributing on VA ECMO
Drainage insufficiency
  • Hypovolemia
  • Cannula malposition
  • Drainage-line obstruction or collapse
  • Excess RPM
  • Trend drainage pressure and flow
  • Reduce RPM during suction events
  • Optimize preload
  • Reposition patient or cannula
  • Correct tubing obstruction
Oxygenator failure / high ΔP
  • Oxygenator thrombosis
  • Membrane dysfunction
  • Progressive clot burden
  • Inspect the oxygenator
  • Trend ΔP and post-membrane gas
  • Check anticoagulation and hemolysis markers
  • Exchange oxygenator or circuit when indicated
Harlequin syndrome VA ECMO
  • Recovering native LV output with persistent severe lung failure
  • Upper body receives poorly oxygenated native output
  • Monitor right radial ABG and right-hand SpO₂
  • Optimize lung oxygenation and ECMO flow
  • Consider V-A-V or alternate reinfusion strategy if persistent

Weaning

VV ECMO

  • Improving lung mechanics/oxygenation, minimal sweep
  • Sweep-down or clamp test with permissive targets

VA ECMO

  • Recovery of native CO: increasing pulse pressure, less inotrope, improving echo (LVOT VTI, aortic valve opening)
  • Stepwise flow reduction under echo and hemodynamic monitoring

Daily checklist

  • Indication still valid; exit strategy defined
  • Flows, sweep, vent targets documented
  • Anticoagulation and labs in range; hemolysis markers trended
  • Limb/neuro checks, cannula inspection, circuit visual check
  • Echo/ultrasound as needed for recirculation, function, effusions

References

  1. Combes, A., Peek, G. J., Hajage, D., Hardy, P., Abrams, D., Schmidt, M., Dechartres, A., Elbourne, D., & ECMO for Severe ARDS Systematic Review and Individual Patient Data Meta-analysis Investigators. (2020). ECMO for severe ARDS: Systematic review and individual patient data meta-analysis. Intensive Care Medicine, 46(11), 2048–2057. https://doi.org/10.1007/s00134-020-06248-3
  2. Combes, A., Hajage, D., Capellier, G., Demoule, A., Lavoué, S., Guervilly, C., Da Silva, D., Zafrani, L., Tirot, P., Veber, B., Maury, E., Levy, B., Cohen, Y., Richard, C., Kalfon, P., Bouadma, L., Mehdaoui, H., Beduneau, G., Lebreton, G., ... EOLIA Trial Group. (2018). Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. New England Journal of Medicine, 378(21), 1965–1975. https://doi.org/10.1056/NEJMoa1800385
  3. Peek, G. J., Mugford, M., Tiruvoipati, R., Wilson, A., Allen, E., Thalanany, M. M., Hibbert, C. L., Truesdale, A., Clemens, F., Cooper, N., Firmin, R. K., Elbourne, D., & CESAR Trial Collaboration. (2009). Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure: A multicentre randomised controlled trial. The Lancet, 374(9698), 1351–1363. https://doi.org/10.1016/S0140-6736(09)61069-2
  4. Makdisi, G., & Wang, I. W. (2015). Extra corporeal membrane oxygenation review of a lifesaving technology. Journal of Thoracic Disease, 7(7), E166–E176. https://doi.org/10.3978/j.issn.2072-1439.2015.07.17
  5. Extracorporeal Life Support Organization. (2021). ELSO guidelines for adult respiratory failure. ASAIO Journal, 67(5), 465–495. https://doi.org/10.1097/MAT.0000000000001430
  6. Lorusso, R., Shekar, K., MacLaren, G., Schmidt, M., Pellegrino, V., Meyns, B., Haft, J., Vercaemst, L., Pappalardo, F., Mueller, T., Burrell, A., Babatasi, G., Rycus, P., Barbaro, R. P., Thiagarajan, R. R., & ELSO Interim Guideline Writing Group. (2021). ELSO interim guidelines for venoarterial extracorporeal membrane oxygenation in adult cardiac patients. ASAIO Journal, 67(8), 827–844. https://doi.org/10.1097/MAT.0000000000001510
  7. Extracorporeal Life Support Organization. (2021). ELSO anticoagulation guideline. Extracorporeal Life Support Organization. https://www.elso.org/ecmo-resources/elso-ecmo-guidelines.aspx