Written by Clay Smith
What Is ECLS?
Extracorporeal life support (ECLS, aka ECMO) in its simplest form is taking out a patient’s blood, sending it through a pump and membrane to oxygenate and remove CO2, and putting it back in. There are two main types: veno-venous (V-V) and veno-arterial (V-A).
V-V is most common and is used for inability to oxygenate despite maximal ventilator settings in the absence of cardiovascular collapse. In V-V, blood is sucked out of a femoral vein (FV) or internal jugular vein (IJ), sent through the pump to a membrane to remove CO2 and add oxygen, and returned to the right atrium (RA). It is returning oxygenated blood to the RA since the lungs aren’t working. There are single cannula systems via the IJ with a proximal port in the RA and distal in the IVC. Flow rate is up to 6L/min.
V-A is used for situations with poor perfusion and need for circulatory support. In V-A, a FV cannula sucks blood out, into the pump, to the membrane for oxygenation and removal of CO2, and returns it to the femoral artery (FA). It can provide up to 10L/min flow.
There is also a hybrid model, V-AV for severely compromised cardiac and pulmonary function. With these, blood is sucked out of the IVC, oxygenated, and pumped back to both the RA (for oxygenation) and FA (for circulatory support).
Newer cannulas, better pumps, and miniaturized ECLS devices, have made this heroic procedure more accessible and feasible for use in the ED.
Why Do ECLS?
It should be used in conditions causing cardiac or pulmonary failure that are reversible. It can buy time for diagnostics or procedures. ECLS is estimated to be appropriate in about 2.5 patients per 10,000 ED visits.
ECLS is useful as a temporary bridge for potentially reversible conditions for which a definitive fix is available or possible. Survival with good neurological outcome is better in select patients than those with standard CPR.
Arrest needing PCI
MI with shock
Aortic dissection with tamponade
Sepsis related cardiac dysfunction
Hypothermia with refractory VT
Bridge to damage control surgery/procedure
PE with CV collapse
Other refractory shock or arrest
Amniotic fluid/fat embolism
Cardiogenic shock with severely compromised lung function, i.e. pumonary edema/ARDS
Prolonged or unwitnessed arrest with brain injury
Other end stage illness or condition incompatible with life
Intracranial bleed or irreversible brain injury
Advanced age (relative contraindication)
Anatomic issues with cannula sites
This requires a team of nurses, RTs, and physicians with specialized training in ECLS and the ability to troubleshoot and manage sudden circuit failure.
What Could Possibly Go Wrong?
These are quoted directly from the cited article, Table 2.
Failure to complete cannulation
Major vessel perforation or dissection
Cannulation of the wrong vessel
Cannula malposition or migration
Distal limb ischemia
Pump or oxygenator malfunction or failure
Cannula site bleeding
Systemic fibrinolysis and coagulopathy
Thromboembolism (arterial or venous)
Hypoperfusion (end-organ injury including multiple organ failure)
LV distension and pulmonary edema (VA support)
Cannula site infection
Cannula-related bloodstream infection
Logistics for Transport
Trained ECLS team members
Backup circuit components pre-primed
Back up batteries/fully charged power sources
Secure all cannulas
Transport pack: “clamps, scissors, gloves, fluids, hand ventilation bag, monitor, ventilator, small procedure tray, chest tubes”
Full O2 tank(s)
Emergency drugs, IV pumps
LITFL has the quickest, simplest summary of ECLS.
There is an entire website called edecmo.org.
And the Reanimate Conference focuses on cutting edge resuscitation topics, such as ECLS.
Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation. 2018 Dec;133:108-117. doi: 10.1016/j.resuscitation.2018.10.014. Epub 2018 Oct 15.
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