A system-wide extracorporeal membrane oxygenation quality collaborative improves patient outcomes.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) use in adult patient populations has grown rapidly with wide variation in practices and outcomes. We evaluated the impact on patient outcomes, resource use, and costs of an initiative to coordinate and standardize best practices across ECMO programs within a large integrated health care system. METHODS: The ECMO Collaborative Project brought clinicians and service-line leaders from 4 programs within a single health care system together with operational subject matter experts tasked with developing and implementing standardized guidelines, order sets, and an internal database to support an automated quarterly report card. Patient outcomes, resource use, and financial measures were compared for the 16 months before (January 2017 to April 2018; "precollaborative," n = 185) versus the 14 months after (November 2018 to December 2019, "postcollaborative," n = 243) a 6-month implementation and blanking period. Subset analyses were performed for venoarterial ECMO, venovenous ECMO, and extracorporeal cardiopulmonary resuscitation. RESULTS: Survival to discharge/transfer increased significantly (in-hospital mortality hazard ratio, 0.75; 95% confidence interval [95% CI], 0.58-0.99) for the postcollaborative versus the precollaborative period (107/185, 57.8% vs 113/243, 46.5%, P = .03), predominantly due to improvement among patients receiving venoarterial ECMO (hazard ratio, 0.61; 95% CI, 0.41-0.91). The percentage of patients successfully weaned from ECMO increased from 58.9% (109/185) to 70% (170/243), P = .02. Complication rates decreased by 40% (incidence rate ratio, 0.60; 95% CI, 0.49-0.72). No significant changes were observed in ECMO duration, intensive care unit or hospital length of stay, or cost-per-case; payment-per-case and contribution-margin-per-case both decreased significantly. CONCLUSIONS: The ECMO Collaborative Project improved survival to discharge/transfer, weaning rates and complications, without additional costs, through coordination and standardization across ECMO programs within a health care system.

Human factors in ECLS - A keystone for safety and quality - A narrative review for ECLS providers.

INTRODUCTION: Although the technology used for extracorporeal life support (ECLS) has improved greatly in recent years, the application of these devices to the patient is quite complex and requires extensive training of team members both individually and together. Human factors is an area that addresses the activities, contexts, environments, and tools which interact with human behavior in determining overall system performance. HYPOTHESIS: Analyses of the cognitive behavior of ECLS teams and individual members of these teams with respect to the occurrence of human errors may identify additional opportunities to enhance safety in delivery of ECLS. RESULTS: The aim of this article is to support health-care practitioners who perform ECLS, or who are starting an ECLS program, by establishing standards for the safe and efficient use of ECLS with a focus on human factor issues. Other key concepts include the importance of ECLS team leadership and management, as well as controlling the environment and the system to optimize patient care. CONCLUSION: Expertise from other industries is extrapolated to improve patient safety through the application of simulation training to reduce error propagation and improve outcomes.

Treatment of the lung injury of drowning: a systematic review.

BACKGROUND: Drowning is a cause of significant global mortality. The mechanism of injury involves inhalation of water, lung injury and hypoxia. This systematic review addressed the following question: In drowning patients with lung injury, what is the evidence from primary studies regarding treatment strategies and subsequent patient outcomes? METHODS: The search strategy utilised PRISMA guidelines. Databases searched were MEDLINE, EMBASE, CINAHL, Web of Science and SCOPUS. There were no restrictions on publication date or age of participants. Quality of evidence was evaluated using GRADE methodology. RESULTS: Forty-one papers were included. The quality of evidence was very low. Seventeen papers addressed the lung injury of drowning in their research question and 24 had less specific research questions, however included relevant outcome data. There were 21 studies regarding extra-corporeal life support, 14 papers covering the theme of ventilation strategies, 14 addressed antibiotic use, seven papers addressed steroid use and five studies investigating diuretic use. There were no clinical trials. One retrospective comparison of therapeutic strategies was found. There was insufficient evidence to make recommendations as to best practice when supplemental oxygen alone is insufficient. Mechanical ventilation is associated with barotrauma in drowning patients, but the evidence predates the practice of lung protective ventilation. There was insufficient evidence to make recommendations regarding adjuvant therapies. CONCLUSIONS: Treating the lung injury of drowning has a limited evidentiary basis. There is an urgent need for comparative studies of therapeutic strategies in drowning.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients.

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

Allocation of resources and development of guidelines for extracorporeal membrane oxygenation (ECMO): Experience from a pediatric center in the epicenter of the COVID-19 pandemic.

The rapid spread of coronavirus disease 2019 (COVID-19) has exceeded the standard capacity of many hospital systems and led to an unprecedented scarcity of resources, including the already limited resource of extracorporeal membrane oxygenation (ECMO). With the large amount of critically ill patients and the highly contagious nature of the virus, significant consideration of ECMO candidacy is crucial for both appropriate allocation of resources as well as ensuring protection of health care personnel. As a leading pediatric ECMO program in the epicenter of the pandemic, we established new protocols and guidelines in order to continue caring for our pediatric patients while accepting adult patients to lessen the burden of our hospital system which was above capacity. This article describes our changes in consultation, cannulation, and daily care of COVID-19 positive patients requiring ECMO as well as discusses strategies for ensuring safety of our ECMO healthcare personnel and optimal allocation of resources. LEVEL OF EVIDENCE: Level V.

Management of Right Ventricular Failure in Pulmonary Embolism.

Acute right ventricular failure remains the leading cause of mortality associated with acute pulmonary embolism (PE). This article reviews the pathophysiology behind acute right ventricular failure and strategies for managing right ventricular failure in acute PE. Immediate clot reduction via systemic thrombolytics, catheter based procedures, or surgery is always advocated for unstable patients. While waiting to mobilize these resources, it often becomes necessary to support the RV with vasoactive medications. Clinicians should carefully assess volume status and use caution with volume resuscitation. Right ventricular assist devices may have an expanding role in the future.

Ecmo pediátrico: una puesta al día / Pediatric ecmo up to date

Extracorporeal membrane oxygenation (ECMO) is an ever more available technique for reversible catastrophic heart or pulmonary failure that requires permanent training and actualization. This article reviews inclusion criteria, basic concepts, anticoagulation management, use of vasoactive drugs, respiratory support, laboratory tests and weaning. An up to date and easy to use reference material we hope will facilitate the study and implementation of ECMO in centers that are, or look to be, providers. The authors have made an exhaustive review of published literature and have also referenced the Extracorporeal Life Support Organization (ELSO) guidelines.

La oxigenación de membrana extracorpórea (ECMO) es una técnica indicada para falla cardiológica y/o pulmonar catastrófica de etiología recuperable, cada vez más disponible, lo que hace necesario que los prestadores de cuidados intensivos estén actualizados en esta técnica. Este artículo repasa conceptos, criterios de inclusión, manejo de anticoagulación, uso de drogas vasoactivas, apoyo ventilatorio, exámenes paraclínicos y destete de la asistencia. El tener una referencia actualizada, fácil y concreta facilita el estudio e implementación de ECMO en centros que van a disponer del mismo o que ya la están desarrollando. Los autores hicieron una revisión exhaustiva de la literatura publicada y de la normativa internacional disponible de la Organización del soporte de vida extracorpóreo (ELSO por su sigla en inglés Extracorporeal Life Support Organization).

Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study.

PURPOSE: We assessed feasibility and safety of extracorporeal carbon dioxide removal (ECCO2R) to facilitate ultra-protective ventilation (VT 4 mL/kg and PPLAT ≤ 25 cmH2O) in patients with moderate acute respiratory distress syndrome (ARDS). METHODS: Prospective multicenter international phase 2 study. Primary endpoint was the proportion of patients achieving ultra-protective ventilation with PaCO2 not increasing more than 20% from baseline, and arterial pH > 7.30. Severe adverse events (SAE) and ECCO2R-related adverse events (ECCO2R-AE) were reported to an independent data and safety monitoring board. We used lower CO2 extraction and higher CO2 extraction devices (membrane lung cross-sectional area 0.59 vs. 1.30 m2; flow 300-500 mL/min vs. 800-1000 mL/min, respectively). RESULTS: Ninety-five patients were enrolled. The proportion of patients who achieved ultra-protective settings by 8 h and 24 h was 78% (74 out of 95 patients; 95% confidence interval 68-89%) and 82% (78 out of 95 patients; 95% confidence interval 76-88%), respectively. ECCO2R was maintained for 5 [3-8] days. Six SAEs were reported; two of them were attributed to ECCO2R (brain hemorrhage and pneumothorax). ECCO2R-AEs were reported in 39% of the patients. A total of 69 patients (73%) were alive at day 28. Fifty-nine patients (62%) were alive at hospital discharge. CONCLUSIONS: Use of ECCO2R to facilitate ultra-protective ventilation was feasible. A randomized clinical trial is required to assess the overall benefits and harms. CLINICALTRIALS.GOV: NCT02282657.

Fetal endoscopic tracheal occlusion reduces pulmonary hypertension in severe congenital diaphragmatic hernia.

OBJECTIVE: Fetal endoscopic tracheal occlusion (FETO) is associated with increased perinatal survival and reduced need for extracorporeal membrane oxygenation (ECMO) in fetuses with severe congenital diaphragmatic hernia (CDH). This study evaluates the impact of FETO on the resolution of pulmonary hypertension (PH) in fetuses with isolated CDH. METHODS: We reviewed retrospectively the medical records of all fetuses evaluated for CDH between January 2004 and July 2017 at a single institution. Fetuses with additional major structural or chromosomal abnormalities were excluded. CDH cases were classified retrospectively into mild, moderate and severe groups based on prenatal magnetic resonance imaging indices (observed-to-expected total fetal lung volume and percentage of intrathoracic liver herniation). Presence of PH was determined based on postnatal echocardiograms. Logistic regression analyses were performed to evaluate the relationship between FETO and resolution of PH by 1 year of age while controlling for side of the CDH, use of ECMO, gestational age at diagnosis, gestational age at delivery, fetal gender, sildenafil use at discharge and CDH severity. Resolution of PH by 1 year of age was compared between a cohort of fetuses with severe CDH that underwent FETO and a cohort that did not have the procedure (non-FETO). A subanalysis was performed restricting the analysis to isolated left CDH. Parametric and non-parametric tests were used for comparisons. RESULTS: Of 257 CDH cases evaluated, 72% (n = 184) had no major structural or chromosomal anomalies of which 58% (n = 107) met the study inclusion criteria. The FETO cohort consisted of 19 CDH cases and the non-FETO cohort (n = 88) consisted of 31 (35%) mild, 32 (36%) moderate and 25 (28%) severe CDH cases. All infants with severe CDH, regardless of whether they underwent FETO, had evidence of neonatal PH. FETO (OR, 3.57; 95% CI, 1.05-12.10; P = 0.041) and ECMO (OR, 5.01; 95% CI, 2.10-11.96; P < 0.001) were independent predictors of resolution of PH by 1 year of age. A higher proportion of infants with severe CDH that underwent FETO had resolution of PH by 1 year after birth compared with infants with severe CDH in the non-FETO cohort (69% (11/16) vs 28% (7/25); P = 0.017). Similar results were observed when the analysis was restricted to cases with left-sided CDH (PH resolution in 69% (11/16) vs 28% (5/18); P = 0.032). CONCLUSION: In infants with severe CDH, FETO and ECMO are independently associated with increased resolution of PH by 1 year of age. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Non-pulsatile blood flow is associated with enhanced cerebrovascular carbon dioxide reactivity and an attenuated relationship between cerebral blood flow and regional brain oxygenation.

BACKGROUND: Systemic blood flow in patients on extracorporeal assist devices is frequently not or only minimally pulsatile. Loss of pulsatile brain perfusion, however, has been implicated in neurological complications. Furthermore, the adverse effects of absent pulsatility on the cerebral microcirculation are modulated similarly as CO2 vasoreactivity in resistance vessels. During support with an extracorporeal assist device swings in arterial carbon dioxide partial pressures (PaCO2) that determine cerebral oxygen delivery are not uncommon-especially when CO2 is eliminated by the respirator as well as via the gas exchanger of an extracorporeal membrane oxygenation machine. We, therefore, investigated whether non-pulsatile flow affects cerebrovascular CO2 reactivity (CVR) and regional brain oxygenation (rSO2). METHODS: In this prospective, single-centre case-control trial, we studied 32 patients undergoing elective cardiac surgery. Blood flow velocity in the middle cerebral artery (MCAv) as well as rSO2 was determined during step changes of PaCO2 between 30, 40, and 50 mmHg. Measurements were conducted on cardiopulmonary bypass during non-pulsatile and postoperatively under pulsatile blood flow at comparable test conditions. Corresponding changes of CVR and concomitant rSO2 alterations were determined for each flow mode. Each patient served as her own control. RESULTS: MCAv was generally lower during hypocapnia than during normocapnia and hypercapnia (p < 0.0001). However, the MCAv/PaCO2 slope during non-pulsatile flow was 14.4 cm/s/mmHg [CI 11.8-16.9] and 10.4 cm/s/mmHg [CI 7.9-13.0] after return of pulsatility (p = 0.03). During hypocapnia, non-pulsatile CVR (4.3 ± 1.7%/mmHg) was higher than pulsatile CVR (3.1 ± 1.3%/mmHg, p = 0.01). Independent of the flow mode, we observed a decline in rSO2 during hypocapnia and a corresponding rise during hypercapnia (p < 0.0001). However, the relationship between ΔrSO2 and ΔMCAv was less pronounced during non-pulsatile flow. CONCLUSIONS: Non-pulsatile perfusion is associated with enhanced cerebrovascular CVR resulting in greater relative decreases of cerebral blood flow during hypocapnia. Heterogenic microvascular perfusion may account for the attenuated ΔrSO2/ΔMCAv slope. Potential hazards related to this altered regulation of cerebral perfusion still need to be assessed. TRIAL REGISTRATION: The study was retrospectively registered on October 30, 2018, with Clinical Trial.gov (NCT03732651).

[The Semmelweis University extracorporeal membrane oxygenation program - 5 years' results and perspectives]. / A Semmelweis Egyetem extracorporalis membránoxigenizációs programja ­ az 5 éves Városmajori-eredmények függvényében.

The mechanical circulatory support (MCS) program of the Semmelweis University Heart and Vascular Centre has become established over the last five years. The main requirements of our MCS program to be developed first were the Heart Transplantation and Heart Failure Intensive Care Unit and a well trained medical team. The wide range of mechanical circulatory support devices provides suitable background for the adequate treatment of our patients in all indications. In this review, we present our results related to extracorporeal membrane oxygenation (ECMO) supports performed in the last five years. Between 2012 and 2017, we applied MCS support in 140 cases, among them 111 patients received ECMO support. The leading indications of ECMO support were the following: primary graft failure after heart transplantation (33 cases), postcardiotomy cardiogenic shock (18 patients), acute decompensation of end-stage heart failure (14 patients), acute myocardial infarction complicated with refractory cardiogenic shock (37 patients), cardiogenic shock developed after transcatheter aortic valve implantation (3 patients), malignant arrhythmia due to drug intoxication (1 patient) and acute respiratory distress syndrome (4 cases). The mortality of patients receiving ECMO support was 46%. The analysis of the results of ECMO support needs to change our approach. The mortality results show that we lost the half of our patients. However, the mortality in the conventionally treated patients would have been 100% without ECMO. In fact, we could save the life of half of these patients. Orv Hetil. 2018; 159(46): 1876-1881.

Advances in Left Ventricular Assist Devices and Mechanical Circulatory Support.

Recent technologic advances have resulted in the availability of percutaneous and minimally invasive surgical devices for temporary mechanical circulatory support. These may be deployed rapidly without the requirement for sternotomy or cardiopulmonary bypass. In addition, third generation implantable left ventricular assist devices have been compared with second generation devices in 2 recent randomized controlled trials. The aim of this article is to provide a current review of the recent literature relating to left ventricular assist devices and mechanical circulatory support.

Implementing and Assessing a Standardized Protocol for Weaning Children Successfully From Extracorporeal Life Support.

Extracorporeal life support (ECLS) weaning is a complex interdisciplinary process with no clear guidelines. To assess ventricular and pulmonary function as well as hemodynamics including end-organ recovery during ECLS weaning, we developed a standardized weaning protocol. We reviewed our experience 2 years later to assess its feasibility and efficacy. In 2015 we established an inter-professional, standardized, stepwise protocol for weaning from ECLS. If the patient did not require further surgery, weaning was conducted bedside in the intensive care unit (ICU). Most of the weaning procedures are guided via echocardiography. Data acquisition began at baseline level, followed by four-step course (each step lasting 10 min), entailing flow-reduction and ending 30 min after decannulation. Moreover, data from the preprotocol era are presented. Between May 2015 and 2017, 26 consecutive patients (18 male), median age 177 days (2 days-20 years) required ECLS with median support of 4 (2-11) days. Excluding eight not weanable patients, 21 standardized weaning procedures were protocolled in the remaining 18 children. Our generally successful protocol-guided weaning rate (with at least 24-h survival) was 89%, with a discharge home rate of 58%. Practical application of the novel standard protocol seems to facilitate ECLS weaning and to improve its success rate. The protocol can be administered as part of standard bedside ICU assessment.

Management of Surge in Extracorporeal Membrane Oxygenation Transport.

BACKGROUND: Transporting patients receiving extracorporeal membrane oxygenation (ECMO) support is safe and reliable with a dedicated program and established management protocols. As our program has grown, our teams have had to adapt to manage surges in transport volume while maintaining patient safety. We assessed the outcomes at peak use of our ECMO transport services during surges. METHODS: We conducted a single-center retrospective review of all patients transported to our institution while supported with ECMO from September 2008 to September 2016. Survival to discharge was the primary outcome. Surge patients were defined as those transported during months with at least 8 transports or patients transported within 24 hours of another patient in nonsurge months. RESULTS: From 2008 to 2016, 222 patients were transported to our institution while supported with ECMO. Baseline characteristics and indices of disease severity were comparable between surge and nonsurge patients. Of the 84 patients transported during surges, 59 surge patients (70%) survived to hospital discharge vs 86 (63%) of nonsurge patients (p = 0.31). Multivariable logistic regression showed that age and APACHE II (Acute Physiology and Chronic Health Evaluation) severity index score were predictors of in-hospital death (p < 0.05), but transportation during a surge was not (odds ratio, 0.91; 95% confidence interval, 0.46 to 1.80; p = 0.79). CONCLUSIONS: Patient safety and clinical outcomes can be maintained during surges in ECMO transport volume if the ECMO program has developed plans for handling transient increases in volume and considers staff fatigue and burnout. Standardizing interhospital communication, patient selection, and management protocols are critical to maintaining quality of care.

Implementation of a Standardized Transfusion Protocol for Cardiac Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Decreased Blood Component Utilization and May Improve Clinical Outcome.

BACKGROUND: Extracorporeal membrane oxygenation supplies oxygenated blood to the body supporting the heart and lungs. Survival rates of 20% to 50% are reported among patients receiving ECMO for cardiac arrest, severe cardiogenic shock, or failure to wean from cardiopulmonary bypass following cardiac surgery. Bleeding is one of the most common complications in ECMO patients due to coagulopathy, systemic anticoagulation, and the presence of large bore cannulas at systemic pressure. Absence of a standardized transfusion protocol in this population leads to inconsistent transfusion practices. Here, we assess a newly developed dedicated transfusion protocol in this clinical setting. METHODS: Data were retrospectively reviewed for the first 30 consecutive cardiac ECMO patients prior and post implementation of the ECMO transfusion protocol. Diagnoses, laboratory results, blood component utilization, and outcomes were collected and analyzed. RESULTS: Comorbidities were similar between the 2 eras, as well as the pre-ECMO ejection fraction (P = .568) and duration on ECMO (P = .278). Transfusion utilization data revealed statistically significant decreases in almost all blood components and a savings in blood component acquisition costs of 51% ($175, 970). In addition, an almost 2-fold increase in survival rate was observed in the post-ECMO transfusion protocol era (63% vs 33%; relative risk = 1.82; 95% confidence interval, 1.07-3.10; P = .028). CONCLUSIONS: Our data indicate that implementation of a standardized transfusion protocol, using more restrictive transfusion indications in cardiac ECMO patients, was associated with reduced blood product utilization, decreased complications, and improved survival. This multidepartmental approach facilitates better communication and adherence to consensus clinical decision making between intensive care unit, surgery, and transfusion service and optimizes care of complicated and acutely ill patients.

Use of Extracorporeal Membrane Oxygenation and Surgical Embolectomy for Massive Pulmonary Embolism in the Emergency Department.

BACKGROUND: Massive pulmonary embolism (PE) carries significant morbidity and mortality with current standard of care modalities. CASE REPORT: We present the case of a 63-year-old male status post abdominal surgery 2 weeks before presenting to the emergency department with a massive pulmonary embolism and subsequent acute cardiopulmonary failure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Here we describe a case of extracorporeal membrane oxygenation (ECMO) deployed in the emergency department as a bridge to embolectomy to successfully treat massive pulmonary embolism. This provided the opportunity to establish a "Code ECMO" protocol and algorithm for PE with cardiopulmonary instability so that patients can be rapidly triaged to the appropriate treatment modality.

Developing an Extracorporeal Membrane Oxygenation Program.

The development of a successful extracorporeal membrane oxygenation (ECMO) program requires an institutional commitment and the multidisciplinary cooperation of trained specialty personnel from nursing, internal medicine, anesthesiology, pulmonology, emergency medicine, critical care, and surgery and often pediatrics as well. The specialized training necessary to cultivate an integrated team capable of providing life-saving ECMO cannot be underestimated. The development of a successful ECMO program is best suited to a tertiary medical center that is centrally/regionally located and capable of financially supporting the level of expertise required as well as managing the program's overall cost effectiveness.

Extracorporeal Life Support for Refractory Cardiac Arrest from Accidental Hypothermia: A 10-Year Experience in Edinburgh.

BACKGROUND: Cardiac arrest caused by accidental hypothermia is a rare phenomenon with a significant mortality rate if untreated. The consensus is that these patients should be rewarmed with extracorporeal life support (ECLS) with the potential for excellent survival and neurologic outcomes. However, given the lack of robust data and clinical trials, the optimal management of such patients remains elusive. OBJECTIVE: In this single-center study, we looked at the outcomes of all adult patients undergoing salvage ECLS for cardiac arrest caused by accidental hypothermia over a 10-year period from June 2006 to June 2016. METHODS: These data were obtained from the Royal Infirmary of Edinburgh cardiothoracic surgery database. The patients' hard copy case notes, TrakCare (InterSystems Corp, Cambridge, MA), picture archiving and communications system (PACS), and WardWatcher databases were used to cross-check the accuracy of the acquired data. RESULTS: Eleven patients met the inclusion criteria. The etiology of hypothermia was exposure to cold air (64%) and cold water immersion (36%). Two (18%) were treated with extracorporeal membrane oxygenation and the rest with cardiopulmonary bypass. The mean age was 51 years (range 32-73), and the mean core body temperature on admission was 20.6°C (range <18-24°C). The overall survival rate to hospital discharge was 72%, with 75% of survivors having no chronic neurologic impairment. CONCLUSION: Our case series shows the remarkable salvageability of patients suffering prolonged cardiac arrest caused by accidental hypothermia, particularly in the absence of asphyxia, trauma, or severe hyperkalemia. ECLS is a safe and effective rewarming treatment and should be used to aggressively manage this patient group.

Contemporary extracorporeal membrane oxygenation therapy in adults: Fundamental principles and systematic review of the evidence.

Extracorporeal membrane oxygenation (ECMO) provides days to weeks of support for patients with respiratory, cardiac, or combined cardiopulmonary failure. Since ECMO was first reported in 1974, nearly 70,000 runs of ECMO have been implemented, and the use of ECMO in adults increased by more than 400% from 2006 to 2011 in the United States. A variety of factors, including the 2009 influenza A epidemic, results from recent clinical trials, and improvements in ECMO technology, have motivated this increased use in adults. Because ECMO is increasingly becoming available to a diverse population of critically ill patients, we provide an overview of its fundamental principles and a systematic review of the evidence basis of this treatment modality for a variety of indications in adults.