CRITICAL CARE PERSPECTIVE
Position Paper for the Organization of Extracorporeal
Membrane Oxygenation Programs for Acute Respiratory
Failure in Adult Patients
Alain Combes
1
, Daniel Brodie
2
, Robert Bartlett
3
, Laurent Brochard
4
, Roy Brower
5
, Steve Conrad
6
, Daniel De Backer
7
,
Eddy Fan
8
, Niall Ferguson
8
, Jame s Fortenberry
9
, John Fraser
10
, Luciano Gattinoni
11
, William Lynch
3
,
Graeme MacLaren
12
, Alain Mercat
13
, Thomas Mueller
14
, Mark Ogino
15
, Giles Peek
16
, Vince Pellegrino
17
,
Antonio Pesenti
18
, Marco Ranieri
19
, Arthur Slutsky
4
, and Alain Vuylsteke
20
; The International ECMO Network
(ECMONet)
1
Institute of Cardiometabolism and Nutrition, Groupe Hospitalier Piti ´e–Salp ˆetri `ere, Pierre Marie Curie University, Paris, France;
2
Columbia
University, New York, New York;
3
University of Michigan, Ann Arbor, Michigan;
4
St. Michael’s Hospital, University of Toronto, Toronto,
Ontario, Canada;
5
Johns Hopkins University School of Medicine, Baltimore, Maryland;
6
Louisiana State University Health Sciences
Center, Shreveport, Louisiana;
7
Erasme Hospital, Universit ´e libre de Bruxelles, Bruxelles, Belgium;
8
Toronto General Hospital,
University of Toronto, Toronto, Ontario, Canada;
9
EmoryUniversitySchoolofMedicine,Atlanta,Georgia;
10
The Prince Charles
Hospital and The University of Queensland, Brisbane, Queensland, Australia;
11
Ospedale Maggiore Policlinic o, Milan, Italy;
12
National
University Hospital, Singapore, Singapore;
13
University of Angers, Angers, France;
14
University of Regensburg, Regensburg,
Germany;
15
Alfred I. duPont Hospital for Children, Wilmington, Delaware;
16
East Midlands Congenital Heart Centre, Leicester, United
Kingdom;
17
The Alfred Hospital and Monash Medical Centre, Melbourne, Victoria, Australia;
18
Universit `a di Milano-Bicocca, Monza,
Italy;
19
S. Giovanni Battista Molinette Hospital, Turin, Italy; and
20
Papworth Hospital NHS Foundation Trust, Papworth, United Kingdom
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for severe
acute respiratory failure (ARF) in adults is growing rapidly given
recent advances in technology, even though there is controversy
regarding the evidence justifying its use. Because ECMO is a complex,
high-risk, and costly modality, at present it should be conducted in
centers with sufficient experience, volume, and expertise to ensure
it is used safely. This position paper represents the consensus opinion
of an international group of physicians and associated health-care
workers who have expertise in therapeutic modalities used in the
treatment of patients with severe ARF, with a focus on ECMO. The
aim of this paper is to provide physicians, ECMO center directors and
coordinators, hospital directors, health-care organizations, and
regional, national, and international policy makers a description of
the optimal approach to organizing ECMO programs for ARF in
adult patients. Importantly, this will help ensure that ECMO is
delivered safely and proficiently, such that future observational and
randomized clinical trials assessing this technique may be performed
by experienced centers under homogeneous and optimal conditions.
Given the need for further evidence, we encourage restraint in the
widespread use of ECMO until we have a better appreciation for
both the potential clinical applications and the optimal techniques
for performing ECMO.
Keywords: extracorporeal membrane oxygenation; acute
respiratory distress syndrome; hospital organization; critical care
networks; position article
The use of extracorporeal membrane
oxygenation (ECMO) for severe acute
respiratory failure (ARF) in adults is
growing rapidly given recent advances in
technology, although there is controversy
regarding the evidence justifying its use
(1–9). The recent experience in 2009
using ECMO for pandemic influenza A
(H1N1)–associated acute respiratory
distress syndrome (ARDS) revealed that
many centers initiated ECMO programs
without significant experience and with
( Received in original form April 4, 2014; accepted in final form July 6, 2014 )
This position article has been endorsed by The Extracorporeal Life Support Organization. See Appendix for the list of physicians who approved the content of
this position paper.
Author Contributions: Drafting of the article: A.C. and D.B. Critical revision of the article for important intellectual content: A.C., D.B., R. Bartlett, L.B.,
R. Brower, S.C., D.D.B., E.F., N.F., J. Fortenberry, J. Fraser, L.G., G.M., W.L., A.M., T.M., M.O., G.P., V.P., A.P., M.R., A.S., and A.V. Final approval of the
article: All signatories.
Correspondence and requests for reprints should be addressed to Alain Combes, M.D., Ph.D., Service de R ´eanimation M ´edicale, iCAN, Institute of
Cardiometabolism and Nutrition, Groupe Hospitalier Piti ´e–Salp ˆetri `ere, 47, boulevard de l’H ˆopital, 75651 Paris, France. E-mail: alain.combes@psl.aphp.fr
Am J Respir Crit Care Med Vol 190, Iss 5, pp 488–496, Sep 1, 2014
Copyright © 2014 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.201404-0630CP on July 25, 2014
Internet address: www.atsjournals.org
488 American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5
|
September 1 2014
variable results (7, 9–16). Because ECMO is
a complex, high-risk, and costly modality,
at present it should be conducted in centers
with sufficient experience, volume, and
expertise to ensure it is used safely.
Additionally, further clinical trials are
essential for identifying and clarifying
the indications, contraindications, and
techniques for use of this technology.
Purpose of this Position
Paper
This position paper represents the
consensus opinion of an international group
of physicians and associated health-care
workers who have expertise in therapeutic
modalities used in the treatment of patients
with severe ARF, with a focus on ECMO.
The aim of this paper is to provide
physicians, ECMO center directors and
coordinators, hospital directors, health-care
organizations, and regional, national, and
international policy makers a description of
the optimal approach to organizing ECMO
programs for ARF in adult patients. This
will help ensure that ECMO is delivered
safely and proficiently at centers capable
of both providing high-quality ECMO
and participating in high-impact clinical
research. It is of the utmost importance
to ensure that future observational and
randomized clinical trials assessing this
technique be performed by experienced
centers under homogeneous and optimal
conditions Given the need for further
evidence, we encourage restraint in the
widespread use of ECMO until we have
a better appreciation for both the potential
clinical applications and the optimal
techniques for performing ECMO.
Definitions
Extracorporeal life support (ECLS) systems
are mechanical devices designed to
temporarily support the failing heart
or lungs (17). They differ from
cardiopulmonary bypass systems used in
the operating room for very short-term
support during surgery in both their
configuration and intent. The term ECMO
is often used interchangeably with ECLS,
as we will use it here, although it denotes
a form of ECLS in which the primary
purpose is to provide blood oxygenation.
There are two anatomic approaches that are
used to implement ECMO: venoarterial
(VA) and venovenous (VV). Virtually all
applications are variations on these.
d
VA ECMO drains the blood from the
right atrium via a femoral venous or
internal jugular venous cannula or, in
patients with an open chest, directly
from the right atrium (17). The blood
is pumped through a membrane
oxygenator allowing oxygen to be added
and carbon dioxide to be removed. After
passing through the oxygenator, blood is
then actively pumped into the arterial
system either via a cannula placed in
a peripheral artery, usually femoral or
subclavian (closed chest), or directly into
the aorta (open chest). VA ECLS is
typically a high blood flow extracorporeal
circuit that can pump up to 7 L/min and
provide full or partial cardiopulmonary
support (18–25). VA ECMO is a closed
system, which differs from standard
cardiopulmonary bypass used in the
operating room, which is an open system
with a blood–air interface.
d
VV ECMO drains blood from the venae
cavae via a femoral venous or right
internal jugular venous cannula (17). The
blood is, once again, pumped through
a membrane oxygenator; however, in this
case it is returned to the venous system
either via a femoral venous or right
internal jugular venous cannula. A single
bicaval double-lumen cannula inserted in
the internal jugular vein can be used for
venous drainage (26). VV ECMO is a high
blood flow (up to 7 L/min in some cases)
extracorporeal circuit that may provide
full or partial extracorporeal pulmonary
support (1, 7, 8, 11, 14, 16, 27–33).
d
Extracorporeal carbon dioxide removal
(ECCO
2
R) uses a venovenous (or
arteriovenous) extracorporeal device at
low blood flow rates (200–1,500 ml/min).
This low flow rate is adequate for
substantial CO
2
removal but will allow
only minimal blood oxygenation
(34–36). Cannulae types and insertion
location vary and are currently evolving.
If proven to be effective, ECCO
2
R could
potentially be used in an approach
that is similar to continuous renal
replacement techniques and available in
most intensive care units (ICUs). This
paper does not specifically address
the appropriate use of ECCO
2
R.
d
Extracorporeal gas exchange refers to
VV ECMO and ECCO
2
R techniques.
Nationwide/Regional
Organization of ECMO
for ARF
d
ECMO is a high-risk and complex
therapy that may be considered for the
sickest patients with ARF. Potential
indications for the use of ECMO
include severe ARF from: severe
ARDS, status asthmaticus, bridge to
lung transplantation, post lung
transplantation primary graft failure,
diffuse alveolar hemorrhage, pulmonary
hypertensive crisis, pulmonary
embolism, severe bronchopleural fistula,
and other forms of severe ARF.
d
Although some evidence suggests that
ECMO may be life-saving in severe ARF,
the risk-to-benefit ratio of ECMO in this
setting has yet to be fully elucidated, and
theevidenceforabenefit for less severe
forms of ARF is lacking. The occurrence
of ARDS severe enough to warrant
consideration of ECMO (except in
the context of large pandemics) may
not exceed 5 to 10 cases per million
population per year (our personal data,
greater Paris Area, 2012). Because of this
relatively infrequent level of activity, we
propose that ECMO should be organized
at regional and national levels to provide
the best care possible in high-volume,
dedicated centers, because inappropriate
use of ECMO may markedly increase
hospital costs and expose individual
patients to important risks.
d
Referral to an expert ECMO center,
where ECMO is offered as part of a larger
management protocol for ARF, may be
associated with improved outcomes
(7, 8). This is also consistent with the
literature on the number of mechanically
ventilated ICU patients, where again,
the more cases a center performs, the
better the outcome (37).
d
Because of the many advantages of
shared knowledge, training, personnel,
and facilities, the organization and
experience of an ECMO referral center is
important in considering the case volume
needed to maintain competence. Such
a center should be able to maintain the
skills and institutional support to justify
the expense of a comprehensive program.
Because ECMO for adult respiratory
failure may be one component of the full
spectrum of extracorporeal support
provided at a given medical center, the
CRITICAL CARE PERSPECTIVE
Critical Care Perspective 489
presence of other groups of patients in
the hospital with indications for other
forms of extracorporeal circulation
(cardiac failure, cardiac surgery,
neonates, and so on) will facilitate such
a program. Centers providing ECMO
for adult respiratory failure should also
maintain robust expertise in the care and
ventilatory management of patients with
severe ARF.
d
Based on the neonatal and pediatric
literature, recent data demonstrated that
ECMO centers caring for more than 20
to 25 cases per year have significantly
better outcomes than centers that have
either 10 to 20 cases per year or
fewer than 10 cases per year (38, 39).
Moreover, the learning curve to establish
competence requires at least 20 cases for
optimal results (38–40).
d
The question of the minimum acceptable
volumeforanECMOcenterisanareaof
considerable controversy. The concept of
a minimum annual volume as a surrogate
for experience is a common measure
in other specialties, and the pediatric
ECMO literature supports the use of
such thresholds. However, it is not clear
that the relationship between volume and
outcomes in ECMO for adult ARF
demonstrates a positive inflection point
in the annual volume of cases. It is
also true that volume alone does not
guarantee best practices or good
outcomes. Other factors should be taken
into account, including the cumulative
experience of the center over time and
the entire center’s ECMO volume (adult
and pediatric, respiratory and cardiac).
Consideration should also be given for
centers that routinely perform continuing
medical education and training in ECMO,
as this will serve to maintain a degree
of competency over time. The annual
number of patient days on ECMO may
be an alternative measure of center
experience. These alternative approaches
to evaluating the quality of a given center
are particularly important considerations
for programs covering sparsely populated
areas where ECMO referral to a major
center is not always feasible. We therefore
recommend that centers adhere to best
practices, perform continuing medical
education and training in ECMO, and
work closely with their pediatric and
cardiac ECMO colleagues.
d
We recommend that for most centers,
an annual volume for the entire center
should be at least 20 cases per year and
that at minimum of 12 ECMO cases for
ARF should be performed per year.
Therefore, taking into account that
potential indications may not exceed
5 to 10 cases per million population per
year, one such center should cover
a catchment area of at least 2 to 3 million
population. These recommendations, as
noted, are not currently based on data in
adult patients who received ECMO, and
a lower case volume may be acceptable,
as described above. Although further
data are needed to continue to provide
guidance in this area, establishing new
centers in regions well served by existing
high-volume ECMO centers should be
discouraged.
d
Centers referring patients with ARF but
without rapid access to a mobile ECMO
team may be trained to perform ECMO
cannulation and initiation under
supervision of the referral center until
prompt transfer to the closest regional
ECMO center can be arranged. Close
coordination with the receiving ECMO
center is essential to maintain quality
control over indications, techniques
for cannulation, and maintenance on
ECMO. Indeed, the difficulty in
developing and maintaining the
necessary clinical expertise in a center
performing a low volume of annual
ECMO cases, combined with the likely
diminished cost-effectiveness of a low-
volume program, must be taken into
account when developing a new
program. It is important that new
programs establish close partnerships
with more experienced, high-volume
centers.
d
Networks of hospitals at the local,
regional or interregional level should be
created around each ECMO center
located in tertiary referral hospitals.
Such networks have been successfully
organized in the UK (41), Italy (42), and
Australia (43) and have been associated
with encouraging results for the
treatment of the most severe forms of
influenza A(H1N1)–associated ARDS (7,
11, 16). The feasibility of a network-wide
system to evaluate the daily capacity for
receiving patients receiving ECMO at
individual centers was also demonstrated
in Germany (44) and in France (9, 45).
d
Hospitals in these networks should
adhere to written standardized protocols
detailing criteria for both the initiation of
ECMO (indications and exclusions) (17)
as well as optimization of conventional
treatments to be undertaken before the
consideration of ECMO (such as low-
volume, low-pressure, lung-protective
ventilation or the use of prone
positioning [46] in patients with severe
ARDS).
d
Comprehensive plans regarding access to
mobile ECMO should be created within
networks.
d
Referral centers and other network
members should hold regular meetings
to discuss network activity, including
review of ECMO cases as well as those
patients who were deemed inappropriate
for ECMO.
Mobile ECMO Team
Each ECMO network should ideally create
mobile ECMO teams to retrieve patients
and to deal with patients who have critical
cardiopulmonary failure refractory to
conventional therapy. Their coordination
would run through the tertiary ECMO
referral center. This mobile team should be
available 24 hours a day, 7 days a week and
employ exper ienced person nel trained in the
transport of critically ill patients, insertion of
ECMO cannulae, as well as circuit and
patient management. The team variably
includes a mix of physicians, transport
specialists, nurses, perfusionists, or other
ECMO specialists. Imaging requirements at
the referring hospital should be considered,
and a clinician trained in echocardiography
should be considered for some transfers.
Portable ultrasound equipment should
also be considered. Highly successful
transportation of patients on cardiopulmonary
support has been described for short and
long distances by ambulance, helicopter,
and airplane (47–53).
Intrahospital Transport of the
Patient Receiving ECMO
ECMO centers should develop specific
guidelines and train staff to provide
24-hour-a-day intrahospital transport of the
patient receiving ECMO. Checklists should
be considered for equipment (Table 1)
and vital actions performed before and
during transport as well as for equipment.
Briefings before transport and after-action
reviews are recommended.
CRITICAL CARE PERSPECTIVE
490 American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5
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General Structure of an
ECMO Tertiary Referral
Center
d
The ECMO center should be located in
a tertiary-level ICU with experience in
the care of patients with severe ARF (17).
The ICU should conform with the
relevant national guidelines and be able
to offer supportive therapy for
multiorgan failure. This is particularly
important for the pre-ECMO
management as well as the on-ECMO
handling of the lungs, which includes the
interaction between the ECMO circuit
and the contribution of the lungs.
d
To maximize efficiency and to benefit
from the expertise and experience of all
professionals, ECLS programs for cardiac
and respiratory failure should be located
in the same institution, although not
necessarily in the same ICU department.
d
An ECMO referral center devoted strictly
to the care of ARF might be set up
independent of a cardiac ECMO
program if its anticipated annual case
volume exceeds 20 cases. However, as
noted above, establishing new centers
in regions well served by existing high-
volume ECMO centers should be
discouraged. Additionally, because some
patients with ARF may have refractory
cardiac failure necessitating the use of
VA ECLS for some days during the
patient’s course, it is best to combine the
expertise for respiratory and cardiac
failure at a single center.
d
The ECMO program director should be
a physician with responsibility for the
overall operation of the center, including
assuring appropriate continued specialist
training and performance, maintenance
of equipment, as well as directing
quality-improvement meetings and
projects (17).
d
Policies and procedures outlining the
indications and contraindications for
ECMO, clinical management of the
patient receiving ECMO, maintenance
of equipment, termination of ECMO
therapy, and follow-up of the patient
receiving ECMO should be available (17).
d
The ICU must be able to provide 24-hour
access to renal replacement therapy.
Staffing
d
Staff involved in ECMO should meet
the requirements of their subspecialty
training as set forth by their specific
governing national or regional board
(17).
d
The medical director should be
a board-certified critical care specialist;
cardiovascular specialist; thoracic,
vascular, or trauma surgeon; or other
board-certified specialist with specific
training and experience in ECMO
support (17).
d
Every member of the staff treating
patients receiving ECMO should have
received specific ECMO training and
demonstrate competencies on an
ongoing basis (17).
d
A physician comfortable with managing
patients receiving ECMO should provide
24-hour on-call coverage for the patient
receiving ECMO.
d
Selected physicians on the ECMO team
should be trained in vascular Doppler
echocardiography and cardiac Doppler
echocardiography for insertion,
maintenance, and surveillance of the
ECMO device when needed.
d
In clinical settings where the patient
receiving ECMO is primarily managed
by the ICU nurse (the single caregiver
model), the ICU nurse should be
specifically trained in management
of the patient receiving ECMO and the
ECMO circuit (17). Fully trained ECMO
personnel should be immediately available
for circuit-related concerns, which may
include ECMO circuit exchange.
d
The ratio of nurses to patients receiving
ECMO should be at least 1:1 to 1:2 (one
nurse for up to two patients receiving
ECMO where necessary based on unit
staffing standards) depending on local or
national regulations and organization.
d
The ECMO team should be as self-
sufficient as possible, and specifically
should be trained to prime and set up the
ECMO circuit. The ECMO specialist team
might also be responsible for managing
equipment and supplies, circuit
preparation, troubleshooting, daily rounds,
education, and service administration (17).
d
An ECMO coordinator (typically a nurse,
respiratory therapist, or perfusionist)
may assist the medical director with
organizing and implementing the
training of the ECMO team, staffing,
quality improvement, maintaining
equipment and supplies, and ensuring
that patient data are entered into the
Extracorporeal Life Support Organization
(ELSO) registry or other database.
Physical Facilities
and Equipment
The equipment that should be readily
available is listed in Table 1. Importantly,
a wet-primed circuit should be available for
immediate use around the clock, because
there is some evidence that an assembled
circuit can be stored for up to a few days to
weeks (54) without presenting an additional
risk of infection. It should be possible to
change the ECMO circuit in considerably
less than, but not exceeding, 15 minutes
in cases of sudden malfunction. In high-
volume centers, primed circuits are
routinely used in much less time, a further
advantage to concentrating volume.
Non-ICU Support Services
Table 2 lists medical-surgical and
laboratory personnel from the permanent
hospital staff who should be available
24 hours a day. The ECMO center
should be able to provide emergency
access (,30 min) to cardiovascular or
thoracic surgery, abdominal surgery,
Table 1. Physical Facilities and
Equipment Needed in the Extracorporeal
Membrane Oxygenation Unit
Backup components of the ECMO system
and supplies for all circuit components
Uninterrupted Power System (UPS)
supporting all equipment monitors and
pumps for at least 45 min
Adequate lighting to support surgical
interventions
Clamps
Surgical instrument set for revision of
cannulae or exploration for bleeding
complications
ECMO water heater
Doppler echocardiography machines
Fiberoptic bronchoscopes
Equipment for intrahospital transport
Mobile ECMO cart
Uninterrupted power system for all mobile
equipment
Mobile monitoring device
Emergency transport backpack, with
ECMO clamps and emergency drugs
Wet-primed circuit available for immediate
use
Definition of abbreviation: ECMO =
extracorporeal membrane oxygenation.
CRITICAL CARE PERSPECTIVE
Critical Care Perspective 491
esophagogastroduodenal endoscopic
interventions, and interventional radiology.
A biomedical engineer should maintain
ECMO equipment on a regular basis.
Staff responsible for data collection should
maintain the appropriate databases.
Nonemergent services, such as pastoral and
palliative care or other patient and family
support services, should be available.
Staff Training and Continuing
Education
d
Members of the ECMO staff should
receive regular training and education on
theoretical and practical aspects of
ECMO support. Participation of staff
members to this continuing education
program should be recorded and their
proficiency evaluated (17).
d
It is recommended that team members
not involved in ECMO management for
prolonged periods of time go through
a retraining process as defined by the
ECMO program (17).
d
All staff members caring for patients
receiving ECMO should be trained in
emergency procedures in case of sudden
circuit failure or other events that require
emergent discontinuation of ECMO
support.
d
There should be clearly articulated
delineations of responsibilities for who
manages specific aspects of the patient
care, including anticoagulation, blood
component transfusions, ECMO pump
speed adjustments, sweep gas flow rate
and mechanical ventilator changes,
ECMO cannula securing, and wound
management. Personnel responsible for
these components of care should be
specifically trained and internally
credentialed to be part of the ECMO
team.
Program Evaluation and
Quality Assurance
d
The multidisciplinary ECMO Team
should have quality assurance review
procedures in place for annual internal
ECMO program evaluation (17).
d
Each ECMO center should hold formal
meetings on a routine basis to analyze its
activity and review its equipment needs.
Minutes to these meetings should be
accessible for review (17).
d
Meetings, which include the referral
center and non-ECMO performing
centers within the ECMO network,
should be held regularly to discuss and
report the activities of the network (17).
d
A prompt review of any major
complication or death should be held
both with ECMO team members and
with the responsible Morbidity and
Mortality committee in the hospital,
if available. These reviews should be
conducted under the relevant quality
assurance laws for the location (e.g.,
state or province) where the center is
located (17).
d
Morbidity and mortality meetings should
be held rapidly to review any major
complication or death related to ECMO
support. These meetings should adhere to
relevant quality-assurance regulations of
the state in which the center is located (17).
d
Formal clinical-pathological case reviews
with a multidisciplinary approach should
be conducted regularly.
d
Records documenting maintenance of
equipment and supplies should be kept (17).
d
An Annual Data Report summarizing the
center’s collected data regarding ECMO
indications and results should be
available for quality assurance review.
d
ECMO centers are strongly encouraged
to submit their data to large national
or international databases, such as the
ELSO registry (55), to cross-analyze
their results with other national and
international institutions.
d
Regional and national accreditation
organizations should be created to
evaluate ECMO programs regularly.
Centers with poorer than expected
results should be encouraged to engage
in extensive practice evaluation and
improvement strategies.
d
There should be an ongoing mechanism
to assure sustainability of the program,
with financial performance evaluated
based on the anticipated business plan.
This review should be constructed to
identify strengths and weaknesses
within the program to help ensure its
sustainability.
d
We recommend that new programs
create an advisory committee consisting
of experts from outside the institution to
assist with program development and
quality review. Such a committee could
provide oversight for approximately
the first 1 to 2 years after launching
a program, depending on the volume and
success of the program.
Patient Follow-up
Each ECMO center should consider
a follow-up program for patients receiving
ECMO with establishment of customized,
patient-centered, rehabilitation programs
that might help improve long-term
outcomes.
Research
There is a clear need for further randomized,
controlled trials and other high-level
evidence with respect to the use of ECMO in
ARF. These data will help guide clinicians
with respect to specific indications and
contraindications of the various techniques.
As the number of ECMO cases is relatively
small at each center, national and
international organizations of ECMO
centers (such as ELSO and the International
ECMO Network) are vital to promote
research activity and further advance our
knowledge. The International ECMO
Table 2. Non–Intensive Care Unit
Support Services
Medical-surgical staff with emergency
access (,30 min)
Cardiovascular or thoracic surgery
Abdominal surgery
Esophagogastroduodenal endoscopic
interventions
Interventional radiology including specific
competencies in vascular embolization
Medical-surgical staff needed 24 h/d
Cardiology, with transthoracic and
transesophageal echocardiography
Anesthesiology
Pulmonology
Neurology
Neurosurgery
Nephrology
Gastroenterology
Ear nose throat surgery
Obstetrics
General radiology for emergency
ultrasound and CT scanning
Pharmacy
Laboratory staff needed 24 h/d
Blood gas laboratory
Blood chemistry and hematologic testing
laboratory
Blood coagulation testing laboratory
Blood bank with rapid blood product
delivery capacity
Microbiology laboratory
CRITICAL CARE PERSPECTIVE
492 American Journal of Respiratory and Critical Care Medicine Volume 190 Number 5
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