January 19, 2026

    ECMO

    Admin03 mins

    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)

    Default

    • 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.

    Hold/lighten if

    • Active bleeding, expanding cranial bleed, severe coagulopathy or thrombocytopenia, unstable cannulation site
    • Consider heparin-sparing VV ECMO if high-bleed phenotype

    ECMO Troubleshooting

    ProblemLikely CausesKey Actions
    Low SpO₂ (VV ECMO)• Recirculation (cannula malposition)
    • Inadequate blood flow
    • Hypovolemia
    • Oxygenator dysfunction    		• Check cannula position and flows
    • Increase blood flow
    • Optimize preload (volume)
    • Inspect oxygenator ΔP and color change
    • Reduce patient O₂ demand (sedation, temp)
    Hypercapnia• Inadequate sweep
    • Gas line obstruction
    • Oxygenator failure    		• Increase sweep gas flow
    • Check gas line and blender
    • Minimize ventilator dead space
    • Replace oxygenator if unresponsive
    Hypotension• VV: vasodilation or low preload
    • VA: LV distension, tamponade, RV failure, sepsis, bleeding    		• VV: give volume, titrate vasopressors
    • VA: evaluate with echo
    • Unload LV (IABP/Impella), treat underlying cause
    Drainage insufficiency• Hypovolemia
    • Cannula malposition
    • Obstruction or collapse of drainage line    		• Trend circuit pressures
    • Lower head, give volume
    • Reduce pump RPM
    • Reposition or flush cannula
    Return obstruction / Oxygenator failure• Thrombus formation
    • High pre- to post-oxygenator ΔP
    • Oxygenator clot burden    		• Inspect oxygenator visually
    • Check ΔP and post-membrane gases
    • Exchange circuit/oxygenator if needed
    North–South (Harlequin) syndrome (VA ECMO)• Differential oxygenation (native LV ejecting deoxygenated blood)• Monitor right radial ABG
    • Increase ECMO flow and O₂ delivery
    • Add vent or convert to V-A-V configuration

    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
    • Right-radial ABG (VA), lactate, urine output, perfusion endpoints