# Extracorporeal Membrane Oxygenation — GCMD Library living collection

Updated: n/a · 4 episodes · 47 cited statements

## Episodes
### Tools

### In-depth Review
- [ECMO Podcast](https://library.globalcastmd.com/watch/ecmo-podcast-1740) — podcast · [machine version](https://library.globalcastmd.com/watch/ecmo-podcast-1740.md)

### Work-up and Treatment

### Updates
- [Pediatric ECMO: Update Course 2018](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341) — video · 42:58 · [machine version](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341.md)
- [Update Course Rewind: ECMO 2018](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419) — podcast · 12:32 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419.md)
- [Central Line Placement at ECMO Decannulation: A Missed Opportunity](https://library.globalcastmd.com/watch/central-line-placement-at-ecmo-decannulation-a-missed-opportunity-3731) — article · [machine version](https://library.globalcastmd.com/watch/central-line-placement-at-ecmo-decannulation-a-missed-opportunity-3731.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=0) Case presentation and introduction to pediatric ECMO program implementation (Ep 2)
- [2:49](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=169) ECMO equipment selection: pumps and oxygenators (Ep 2)
- [7:20](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=440) VV versus VA ECMO modality selection (Ep 2)
- [10:42](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=642) Converting VV to VA and anticoagulation strategies (Ep 2)
- [14:55](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=895) VA ECMO cannulation site selection and stroke risk (Ep 2)
- [22:31](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1351) Preventing lower extremity ischemia in femoral arterial cannulation (Ep 2)
- [27:49](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1669) VV ECMO cannulation strategies and drainage optimization (Ep 2)
- [31:22](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1882) Neonatal VV cannulation and Avalon catheter safety (Ep 2)
- [36:24](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=2184) ECPR and chest tube management on ECMO (Ep 2)
- [39:32](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=2372) Summary of key clinical points (Ep 2)
- [0:03](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=3) Introduction and conference promotion (Ep 3)
- [1:18](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=78) Case presentation: 14-year-old with H1N1 ARDS (Ep 3)
- [2:37](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=157) VV versus VA ECMO selection (Ep 3)
- [4:07](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=247) VA ECMO cannulation sites and complications (Ep 3)
- [6:48](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=408) Cannulation by patient size and limb ischemia prevention (Ep 3)
- [8:12](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=492) VV ECMO configurations (Ep 3)
- [9:42](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=582) Management of pneumothorax on ECMO (Ep 3)
- [10:24](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=624) Summary and closing (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Centrifugal pumps are now magnetically levitated (maglev), eliminating bearings and reducing heat generation and hemolysis compared to older bearing-based designs. — Herschel (clinical) [Ep 2 · 3:39](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=219)
- Hollow fiber oxygenators now have coatings that prevent plasma leakage, allowing long-term support (previously limited to ~40 hours). — Herschel (clinical) [Ep 2 · 3:39](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=219)
- Centrifugal pumps are non-occlusive: clamping the outlet does not cause circuit rupture, and clamping the inlet does not cause significant hemolysis. — Herschel (clinical) [Ep 2 · 3:39](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=219)
- Some centers now have nurses manage both patient care and ECMO circuit management, with one respiratory therapist covering all ECMO patients in the unit. — Herschel (clinical) [Ep 2 · 3:39](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=219)
- Adult ECMO case volume is two- to threefold higher than neonatal or pediatric, driven by H1N1 and technological advances. — Herschel (epidemiological) [Ep 2 · 5:58](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=358)
- Neonatal ECMO volume has decreased approximately 5% due to the introduction of nitric oxide. — Herschel (epidemiological) [Ep 2 · 5:58](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=358)
- VA ECMO increases left ventricular afterload, which can lead to transient cardiac standstill (electrical activity without ejection) for 1–2 days in severely compromised patients; function typically recovers. — Herschel (clinical) [Ep 2 · 7:20](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=440)
- VV ECMO provides normal left ventricular afterload and eliminates risk of systemic emboli from the circuit, as blood returns to the venous system. — Herschel (clinical) [Ep 2 · 7:20](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=440)
- VV ECMO avoids arterial cannulation, eliminating limb ischemia and carotid-related stroke risk. — Herschel (clinical) [Ep 2 · 7:20](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=440)
- Registry data show VV ECMO use in pediatrics has increased substantially in recent years compared to historical cumulative data. — Herschel (epidemiological) [Ep 2 · 7:20](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=440)
- Reducing ventilator settings on ECMO may allow weaning of pressors, so VV may be adequate even in patients initially requiring significant vasopressor support. (opinion) [Ep 2 · 9:46](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=586)
- On VV ECMO, oxygen saturations typically run in the low-to-mid 80s and mixed venous saturation around 60%, which is adequate for tissue oxygen delivery. (clinical) [Ep 2 · 9:46](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=586)
- Converting from VV to VA involves adding arterial return while maintaining venous drainage; if using a double-lumen catheter, both venous limbs can drain to the new arterial cannula. — Herschel (clinical) [Ep 2 · 10:42](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=642)
- Timing of VV-to-VA conversion requires clinical judgment; observing the patient for 1–2 days often clarifies the need rather than converting prematurely. — Herschel (opinion) [Ep 2 · 10:42](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=642)
- Echocardiography aids in deciding between VV and VA by assessing ventricular function. — Herschel (clinical) [Ep 2 · 13:03](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=783)
- Bivalirudin is easier to manage than heparin for ECMO anticoagulation and may reduce bleeding in some patient populations (e.g., congenital diaphragmatic hernia post-repair), though data are mixed. — Herschel (clinical) [Ep 2 · 13:25](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=805)
- Some adult centers use bivalirudin as first-line anticoagulation in hundreds of ECMO cases; experience is concentrated in select institutions rather than widespread. — Herschel (epidemiological) [Ep 2 · 13:25](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=805)
- Central (transthoracic) cannulation for VA ECMO carries risks of bleeding and mediastinitis and is impractical for patients who may require ECMO for months. — Herschel (clinical) [Ep 2 · 10:45](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=645)
- Registry analysis of 30,000 patients shows stroke rate is ~5% with carotid cannulation versus ~4% without, indicating some stroke risk is inherent to the disease process. — Herschel (epidemiological) [Ep 2 · 14:55](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=895)
- Carotid-related stroke can occur ipsilateral or contralateral to the cannulated side and may be embolic or ischemic in mechanism. — Herschel (clinical) [Ep 2 · 21:37](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1297)
- North-South syndrome occurs with femoral VA ECMO: deoxygenated blood from the native heart perfuses the upper body (brain, heart, arms) while oxygenated ECMO blood perfuses the lower body. — Herschel (clinical) [Ep 2 · 14:55](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=895)
- North-South syndrome can be mitigated by adding an IJ cannula to infuse oxygenated blood into the right atrium; a Hoffman clamp adjusts flow distribution between the IJ (for oxygenation) and femoral artery (for blood pressure support). — Herschel (clinical) [Ep 2 · 14:55](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=895)
- At the speaker's institution, VA ECMO in children <35 kg uses carotid-IJ cannulation; in those >35 kg, femoral or carotid-IJ is chosen based on clinical context, with preference for VV whenever possible. — Herschel (clinical) [Ep 2 · 14:55](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=895)
- In one series of femoral arterial cannulation (ages 2–22 years), 50% developed limb ischemia; even with distal perfusion cannulas, 9 of 11 had ischemia, and at least one required below-knee amputation. — Herschel (epidemiological) [Ep 2 · 22:31](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1351)
- Prophylactic posterior tibial artery cannulation (via cut-down) for distal perfusion is now routine at the speaker's institution; 58% cannulated <6 hours had no ischemia, versus 42% cannulated >6 hours who had complications. — Herschel (clinical) [Ep 2 · 22:31](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1351)
- Alternative strategies to prevent leg ischemia include sewing a Gore-Tex side graft to the femoral or subclavian artery for ECMO cannulation ('stovepipe' technique). — Herschel (clinical) [Ep 2 · 22:31](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1351)
- For VV ECMO, draining from the femoral vein and reinfusing into the right atrium (via IJ) minimizes recirculation compared to the reverse configuration. — Herschel (clinical) [Ep 2 · 27:49](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1669)
- The Avalon double-lumen catheter is the preferred VV access method nationally and internationally due to single-site cannulation and improved patient mobility. — Herschel (clinical) [Ep 2 · 27:49](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1669)
- Avalon catheter placement requires the distal tip to be positioned in the IVC, which is technically challenging and requires fluoroscopic and/or wire-guided techniques. — Herschel (clinical) [Ep 2 · 27:49](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1669)
- In neonates, right atrial perforation with Avalon catheters increased from 0.1% to 3.2% in one series and reached 6.9% in another (Leicester, England). — Herschel (epidemiological) [Ep 2 · 31:22](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1882)
- Avalon catheters <19 French are no longer used at the speaker's institution due to perforation risk and difficulty maintaining IVC position; the Origin catheter (which sits in the right atrium) is used instead for smaller neonates. — Herschel (clinical) [Ep 2 · 31:22](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1882)
- Fluoroscopy is mandatory for Avalon placement at the speaker's institution; echocardiography alone is insufficient because wires can loop within the heart chambers, leading to perforation during catheter advancement. — Herschel (clinical) [Ep 2 · 31:22](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=1882)
- Extracorporeal CPR (ECPR) achieves 30–40% survival in select in-hospital cardiac arrest cases, particularly in cardiac patients with correctable lesions. — Herschel (clinical) [Ep 2 · 36:24](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=2184)
- Out-of-hospital ECPR programs are expanding in the United States, Japan, and elsewhere, with patients cannulated in the emergency department and often taken directly to the catheterization lab; early data suggest improved survival compared to standard resuscitation. — Herschel (epidemiological) [Ep 2 · 36:24](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=2184)
- Femoral artery and vein cannulation is the typical approach for ECPR due to ease of ultrasound-guided access and minimal interference with CPR. — Herschel (clinical) [Ep 2 · 36:24](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=2184)
- Small pneumothoraces in anticoagulated ECMO patients should be observed rather than drained unless causing physiologic compromise; chest tube placement leads to thoracotomy for bleeding in approximately 50% of cases. — Herschel (clinical) [Ep 2 · 36:24](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=2184)
- VV ECMO is markedly preferred over VA ECMO unless there are specific reasons requiring VA support — Ron Herschel (clinical) [Ep 3 · 2:37](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=157)
- VV ECMO provides normal left ventricular afterload and reduced risk for systemic emboli compared to VA ECMO — Ron Herschel (clinical) [Ep 3 · 2:37](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=157)
- High stroke rates in ECMO patients may be due to patient illness severity rather than specifically carotid cannulation — Ron Herschel (opinion) [Ep 3 · 5:58](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=358)
- For VA ECMO in children less than 35 kg, carotid-IJ cannulation is used at University of Michigan — Ron Herschel (clinical) [Ep 3 · 6:48](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=408)
- For VA ECMO in patients over 35 kg, femoral cannulation or carotid-IJ may be used, though VV is strongly preferred — Ron Herschel (clinical) [Ep 3 · 6:48](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=408)
- At University of Michigan, posterior tibial artery cannulation is performed routinely in older ECMO patients for distal perfusion — Ron Herschel (clinical) [Ep 3 · 7:29](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=449)
- Side graft (cortex) onto the subclavian artery is used routinely by many adult practitioners for ECMO access, avoiding leg complications — Ron Herschel (clinical) [Ep 3 · 7:29](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=449)
- The Avalon catheter requires placement of the distal tip into the inferior vena cava, which is not easy to do — Ron Herschel (clinical) [Ep 3 · 9:28](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=568)
- The Avalon single cannula is well tolerated and allows more patient mobility — Ron Herschel (clinical) [Ep 3 · 9:28](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=568)
- Chest tubes should not be placed for pneumothorax in ECMO patients unless the patient is physiologically compromised or gas exchange is affected — Ron Herschel (clinical) [Ep 3 · 9:54](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=594)
- Approximately 50% of chest tubes placed in ECMO patients result in bleeding requiring thoracotomy with chest packing — Ron Herschel (epidemiological) [Ep 3 · 9:54](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=594)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- ARDS net guidelines recommend peak inspiratory pressures <30 cm H2O and tidal volumes around 6 mL/kg. — The host summarizing the discussion [Ep 2 · 2:00](https://library.globalcastmd.com/watch/pediatric-ecmo-update-course-2018-341?t=120)
- North-South syndrome occurs with femoral vein to femoral artery VA ECMO, where hypoxic blood from the heart perfuses the head and heart while oxygenated blood from ECMO perfuses the lower body — Alex Cassar summarizes what Dr. Ron Herschel said [Ep 3 · 4:07](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=247)
- North-South syndrome can be addressed by infusing oxygenated blood from the ECMO circuit into the right IJ to perfuse the upper torso — Alex Cassar summarizes what Dr. Ron Herschel said [Ep 3 · 4:07](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=247)
- A Hoffmann clamp can be placed on the ECMO circuit to adjust blood flow between the femoral artery (for blood pressure support) and right atrium (for upper body oxygenation) — Alex Cassar summarizes what Dr. Ron Herschel said [Ep 3 · 4:07](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=247)
- In a registry of 30,000 patients, stroke rate with carotid cannulation is about 5%, compared to about 4% (1% less) without carotid cannulation — Ron Herschel summarizing a resource [Ep 3 · 5:58](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=358)
- In a study of femoral artery cannulation in patients aged 2-22 years, 9 out of 11 patients developed limb ischemia even with distal perfusion cannula — Ron Herschel summarizing a resource [Ep 3 · 7:29](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=449)
- For VV ECMO with separate femoral and IJ cannulas, draining from femoral and reinfusing into atrial (IJ) minimizes recirculation compared to the reverse configuration — Ron Herschel summarizing a resource [Ep 3 · 8:40](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=520)
- The Avalon double-lumen catheter is the preferred VV ECMO access across the country and world — Rod Gerardo summarizes what Dr. Ron Herschel said [Ep 3 · 9:15](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=555)
- When a patient is physiologically deranged and very sick, it is acceptable to proceed directly to carotid-IJ cannulation rather than attempting other approaches — Rod Gerardo summarizes what Dr. Ron Herschel said [Ep 3 · 10:24](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=624)
- Posterior tibial artery should be cannulated prophylactically for distal perfusion when using femoral artery access, rather than waiting for ischemia to develop — Rod Gerardo summarizes what Dr. Ron Herschel said [Ep 3 · 10:24](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=624)
- For double-lumen VV catheter placement, it is acceptable to use the operating room, and fluoroscopy and echo should be used for guidance — Rod Gerardo summarizes what Dr. Ron Herschel said [Ep 3 · 10:24](https://library.globalcastmd.com/watch/update-course-rewind-ecmo-2018-4419?t=624)

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