Extracorporeal membrane oxygenation (ECMO) is a resource-intensive rescue strategy, which is powered by a centrifugal pump and serves as a mechanical circulatory support (MCS) device. The two most common indications are either life-threatening pulmonary or cardiac failure or some combination of the two. ECMO can be used in the field as a temporizing measure providing supportive care, if the right team and equipment are available for placement and a safe transfer plan to an ECMO-capable center is readily available. Importantly, ECMO serves as a temporizing measure awaiting either organ recovery or a more permanent device or surgery, such as organ transplant. Effective use of ECMO requires a specialized team of providers to monitor both the patient and the circuit. A team approach reduces ECMO complication rates, which are predominantly renal failure and coagulation disorders—both bleeding and clotting.
Depending on the indication, different configurations of ECMO can be used. For example, in cases of out-of-hospital cardiac arrest, venoarterial (VA) ECMO has been used successfully. In the context of acute and severe respiratory failure, venovenous (VV) ECMO has been employed in the treatment of trauma, burning, and drowning victims, as well as epidemic diseases such as 2009 H1N1 influenza, Middle East Respiratory Syndrome (MERS), and the SARS-CoV-2 pandemic.
This chapter summarizes the technological evolutions in ECMO, its common configurations and indications, as well as covering common complications. At the close of the chapter, considerations for disaster preparedness and crisis applications of ECMO are discussed.
OVERVIEW OF THE EVOLUTION OF ECMO TECHNOLOGY
ECMO was developed to serve as a cardiopulmonary bypass circuit for use outside of the confines of the operating room for longer durations of supportive care. In 1953, almost 20 years after the case that inspired the idea, Gibbon successfully used the first external perfusion and oxygenation support to perform the first successful heart operation.1 In 1972, Hill and colleagues described a case of a thoracic trauma patient who developed refractory respiratory distress post-thoracic surgery. His treatment team took the unprecedented step of using peripheral cannulation to support him for 75 hours.2
ECMO has continued to evolve since that time, both in technological advancements and in its applications.3,4 For example, the initial pumps used for ECMO were constructed of roller pumps with silicon oxygenators and had higher complication rates than the new hollow-fiber polymethylpentene oxygenators and centrifugal pumps.5–8 Using polymethylpentene instead of silicone in the oxygenators reduces platelet consumption and decreases resistance to blood flow.6 These oxygenators are less prone to damage and last longer, as a result of the nonmicroporous consistency of these fibers. Ultimately, liquid, which causes oxygenator failure, is less likely to diffuse across than previous oxygenators.7 In addition, the new pumps consist of polycarbonate housing with a magnetically-rotated impeller, which decreases sheer stress on the blood cells.7 Finally, the connecting PVC tubing is now ...