Essential Guidelines for ECMO Program Organization and Implementation

Institutional Requirements

The American College of Chest Physicians recommends that ECMO should only be performed at high-volume tertiary centers with dedicated multidisciplinary teams, 24/7 availability, and comprehensive infrastructure, as attempting ECMO without these resources significantly compromises patient outcomes 1, 2
Centers must perform at least 20-25 ECMO cases annually to achieve acceptable outcomes, with higher-volume centers demonstrating significantly better survival rates 1, 2
New ECMO centers should not be established in regions already well-served by existing high-volume programs 1, 2

The American Association for Respiratory Care recommends a nurse-to-patient ratio of at least 1:1 to 1:2 for ECMO patients 1, 2, 4
A physician ECMO program director must oversee all operations, including training, equipment maintenance, and quality improvement 1, 2

A wet-primed ECMO circuit must be available for immediate use 24/7, as circuit changes must occur in under 15 minutes during emergencies 2, 4
Essential equipment includes backup components for all circuit parts, Uninterrupted Power System (UPS) supporting all equipment for at least 45 minutes, Doppler and cardiac echocardiography machines, and mobile ECMO cart with portable monitoring 1, 4

Each ECMO network should create mobile retrieval teams available 24/7 with experienced personnel trained in critical care transport, cannula insertion, and circuit management 1, 4
Hospitals without ECMO capability must establish relationships with ECMO-capable institutions for timely patient transfer 5

The American Thoracic Society states that VV-ECMO should be considered only after all conventional therapies have failed, specifically for patients with severe respiratory failure and a PaO₂/FiO₂ ratio < 80 mmHg for ≥3 hours despite optimal ventilation 5
VA-ECMO is indicated for severe cardiogenic shock with very low cardiac output and reduced LV ejection fraction confirmed by echocardiography 3

All ECMO centers must submit data to large national or international databases, such as the ELSO registry, to cross-analyze results 2
The multidisciplinary ECMO team must have quality assurance review procedures for annual internal program evaluation 2

Bleeding complications are common and associated with high mortality rates, particularly intracranial hemorrhage 8, 3
Standardized neurological monitoring and neurological expertise are recommended for all ECMO patients 8