Early ECMO Initiation and Team Approach
Research suggests that initiation of ECMO within 24 hours of when the patient meets ECMO criteria leads to improved survival rates and enhanced functional status, particularly for individuals suffering from ARDS or cardiogenic shock.
“For a while, some have viewed ECMO as something of an expensive and risky last resort, and so they would wait until the lungs or heart were too far gone to benefit from ECMO,” explained Dr. Scott. “But because the benefit of ECMO is its ability to rest the lung or support a failing heart, you should be thinking about initiating ECMO as soon as your patient meets criteria. The sooner that ECMO gets involved, the more likely you are to see organ recovery.”
Timely execution of ECMO—specifically after cardiopulmonary resuscitation (CPR) has failed to restore oxygenation and circulation—also is essential. “If the indications for ECMO are after CPR, which has failed for a prolonged period of time, say 30 to 40 minutes, those patients are not likely to have a good outcome,” said Dr. Aziz. “On the other hand, if you look at a select group of patients where ECMO was performed earlier, specifically before the cardiac arrest has happened, they generally have better outcomes. I think if patients who are extremely sick have a bad outcome, it’s not because of ECMO, it’s because of the time point when ECMO was started.”
Successful ECMO programs typically engage in a multidisciplinary approach that can include surgeons, intensivists, perfusionists, ECMO specialist nurses, palliative care services, and other consulting specialists that play an essential role in the decision to administer this rescue therapy as early as possible for properly vetted patients.
A retrospective review of adult ECMO patient charts at Massachusetts General Hospital in Boston examined mortality rates before and after 2014, when a multidisciplinary approach to ECMO was launched. Prior to that year, patients were treated independently by intensivists with specific training for this intervention.
A total of 279 charts was reviewed, and survival to discharge for patients before the team-based approach was formalized at this institution was 37.7% compared to a survival to discharge of 52.3% between 2014 and 2017.2
“I am very proud of the highly collaborative approach that we take at Harborview Medical Center. Every time we consider putting a patient on ECMO, we discuss the case briefly on a just-in-time group call with all of our ECMO faculty. Because there’s always some nuance and there’s always intricacies, it would take decades to acquire all of the necessary expertise for these highly complex patients,” said Dr. Scott. “But our system means that we can quickly, in one call, determine if the patient meets the criteria for ECMO, talk through any patient-specific details, and get things going for a rapid and smooth cannulation.”
Emerging Role of ECMO in Trauma Care
ECMO is a rescue therapy that provides temporary support for select trauma patients, particularly for individuals with severe lung injuries, ARDS, or those suffering from severe trauma-related cardiopulmonary failure (e.g., massive pulmonary embolism).
However, some view the use of this modality in the trauma setting as somewhat controversial, largely due to high costs and limited resources, and the potential for complications related to anticoagulation.
“The science is there. Current evidence supports that trauma centers should offer ECMO to appropriate patients—it is often a lifesaving intervention,” said Dr. Scott, a trauma surgeon. “It doesn’t matter if the patients are suffering from traumatic brain injury (TBI) or if they are at risk of hemorrhaging; these no longer qualify as absolute contraindication. While patient selection remains important, essentially all injured patients with ECMO indications can benefit significantly from this intervention.”
One of the main barriers to ECMO use in trauma, according to Dr. Scott, is the perceived lack of data. He cited a systemic review published in 2023, that examined 36 observational studies with 1,822 patients, including studies with a focus on TBI patients.3
“The overall survival rate for trauma patients with TBI who went on ECMO was 66%, and that is right in line with ECMO survival rates for non-trauma patients,” Dr. Scott said. “I think it’s key for people to realize that trauma patients on ECMO are not at an increased risk for poor outcomes.”
The authors of the systemic review also noted the benefits of this modality for this cohort, asserting that, “ECMO is now considered beneficial for severely traumatized patients, improving prognosis, and serving as a valuable tool in managing trauma-related severe cardiorespiratory failure, hemorrhagic shock, and cardiac arrest.”3
Another barrier to ECMO use in trauma patients is the increased risk of bleeding associated with anticoagulation, although innovations in ECMO technology and anticoagulation have made this approach more feasible for these individuals.
“The reasons most people don’t want to put a trauma patient on ECMO tend to focus on bleeding risks, and yet, the data show that a trauma patient who gets ECMO does better than a trauma patient who needs ECMO and doesn’t get it. Just as an injured patient with a pulmonary embolism may need anticoagulation, most trauma patients tolerate lower-dose anticoagulation with ECMO. And for those who cannot be anticoagulated, there is increasing experience that shows it is safe to run VV ECMO without anticoagulation as long as the flow rates aren’t too low,” Dr. Scott said.
Portable Devices as Bridge to Critical Care Support
While traditional ECMO systems can be cumbersome and unwieldy, typically occupying a large footprint at the patient’s bedside, portable systems allow enhanced ambulation with a single cannulation site. One of the most transformative benefits of these smaller circuits is the ability for well-trained staff to administer this therapy in the field or in resource-challenged settings.
“I think ECMO portability is a big game changer because it fits in the helicopter, it fits in the ambulance, and now patients who were ‘too sick to travel’ can get the care they need,” explained Dr. Scott. “We have all of our cannulation equipment and our pump in a backpack and a wagon, and we can quickly drive down the road to another hospital to cannulate the patient, and then we take the ambulance back to our hospital once they are on VV ECMO.”
Interfacility transport is a primary advantage of mobile ECMO therapy because it enhances timely access to centers with advanced capabilities and expertise.
“As surgeons, we cannot live in an isolated world. We have to keep ourselves updated, especially with advancements like portable ECMO,” urged Dr. Aziz. “The traditional ECMO machines are huge, with big tubes attached to big machines, which makes transporting a patient a nightmare—especially if you are putting someone in a helicopter. If something disconnects, especially when you are in the air, it could be fatal. While portable ECMO is not ideal, it certainly makes the transport process easier and safer.”
It also is pertinent to note that, while mobile ECMO services enhance interfacility transport, they also increase access within the center itself by providing cardiac and respiratory support outside the ICU, allowing some patients to receive a computed tomography scan or magnetic resonance imaging services.
Currently, limited data exist on patient outcomes related to portable ECMO therapy; however, more programs across the US are investing in this mobile rescue intervention.
In a survey published in 2024, researchers examined US programs registered with ELSO. According to the survey, it is estimated that 63 out of 274 adult ECMO centers offer mobile ECMO services. The following are two examples of centers that have provided yearslong portable ECMO therapy with promising results.4
The Penn Lung Rescue Program in Philadelphia, which includes portable ECMO services, has transported more than 700 patients since its inception in 2014.5 The program is managed by Penn Medicine, an academic medical center that comprises the University of Pennsylvania Health System and the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. The survival rate for patients who received mobile VV ECMO has exceeded the ELSO average since the program began, according to Penn Medicine administrators.
The University of Utah Health in Salt Lake City, one of the only academic medical centers in the state, also has an ECMO program that includes portable ECMO systems. In an article published in 2022 in the Journal of Clinical Medicine, study authors affiliated with the university concluded the following: “Developing an in-hospital, primed, and portable VA ECMO program resulted in increased clinical volume with equivalent patient survival despite a sicker cohort of patients. We conclude that more rapid deployment of VA ECMO may extend the treatment eligibility to more patients and improve patient outcomes.”6
Insights for Achieving Sustainable ECMO Program Success
The provision of ECMO services can cost as much as $73,000 per patient, according to a recent survey, although those expenditures can vary by institution and the care required to treat individual cases.7 Expensive equipment and a specialized team of physicians, surgeons, nurses, and perfusionists are the primary factors driving these costs.
“I think the biggest issue, in terms of getting buy-in from hospital administrators to start an ECMO program, is the budget,” said Dr. Aziz. “How do we justify starting this program? Do we have enough resources? One important thing to consider is that hospital billing typically goes up when the case mix index (CMI) goes up. When patients are on ECMO, it generally adds to the CMI. You may need to acquire more resources in the beginning as you launch the program, but once it is place it has the potential to increase hospital reimbursements.”
In other words, implementing an ECMO program can be a financially sustainable endeavor, not to mention its potential to generate a halo effect through referrals and transfers to billable critical care services such as cardiovascular services, trauma, and neonatology.8
“All the things it takes to build a successful ECMO program are the same things needed to build a successful trauma program,” added Dr. Scott. “Trauma programs are so well-suited to develop ECMO programs because multidisciplinary collaboration across the entire hospital and using data to drive quality improvement are in a trauma program’s DNA. The same patient-centered, team-based, and data-driven approach that underlies successful trauma programs is a perfect platform upon which to build an ECMO program.”
Further research regarding the development of standardized guidelines for ECMO treatment, and strategies to optimize cost effectiveness are essential for achieving hospital leadership support and expanding these programs across the US.
“If you are taking care of patients who are sick enough to have indications for ECMO, then I hope you’re part of a program that is able to get this lifesaving intervention to them when they need it,” Dr. Scott said. “There are a lot of creative ways to do this, but it starts with people opening their minds and looking past some of the outdated beliefs about this treatment that aren’t actually backed by data. Don’t let a failure of imagination hold you back from giving your patients the lifesaving care that they need.”
