Home Educatione-Learning ECMO: An Update
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ECMO: An Update

PCCSU Volume 25, Lesson 30

PCCSU

The American College of Chest Physicians offers this lesson as a review of a previously offered self-study program. The program provides information on pulmonary, critical care, and sleep medicine issues. CME is no longer available for the PCCSU program.

Objectives

  • Update your knowledge and understanding of pulmonary medicine topics.
  • Update your knowledge and understanding of critical care medicine topics.
  • Update your knowledge and understanding of sleep medicine topics.
  • Learn clinically useful practice procedures.

CME Availability

Effective July 1, 2013, PCCSU Volume 25 is available for review purposes only.

Effective December 31, 2012, PCCSU Volume 24 is available for review purposes only.

Effective December 31, 2011, PCCU Volume 23 is available for review purposes only. CME credit for this volume is no longer being offered

Effective December 31, 2010, PCCU Volume 22 is available for review purposes only. CME credit for this volume is no longer being offered.

Accreditation Statement

The American College of Chest Physicians is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

CME Statement

Credit no longer available as of July 1, 2013.

Disclosure Statement

The American College of Chest Physicians (CHEST) remains strongly committed to providing the best available evidence-based clinical information to participants of this educational activity and requires an open disclosure of any potential conflict of interest identified by our faculty members. It is not the intent of CHEST to eliminate all situations of potential conflict of interest, but rather to enable those who are working with CHEST to recognize situations that may be subject to question by others. All disclosed conflicts of interest are reviewed by the educational activity course director/chair, the Education Committee, or the Conflict of Interest Review Committee to ensure that such situations are properly evaluated and, if necessary, resolved. The CHEST educational standards pertaining to conflict of interest are intended to maintain the professional autonomy of the clinical experts inherent in promoting a balanced presentation of science. Through our review process, all CHEST CME activities are ensured of independent, objective, scientifically balanced presentations of information. Disclosure of any or no relationships will be made available for all educational activities.

CME Availability

Volume 25 Through June 30, 2013
Volume 24 Through December 31, 2012
Volume 23 Through December 31, 2011
Volume 22 Through December 31, 2010

Hardware/software requirements: Web browsing device with working Web browser.

PCCSU Volume 25 Editorial Board

Editor-in-Chief
Steven A. Sahn, MD, FCCP

Director, Division of Pulmonary and Critical Care Medicine, Allergy, and Clinical Immunology
Medical University of South Carolina
Charleston, SC

Dr. Sahn has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within Volume 25.

Deputy Editor
Richard A. Matthay, MD, FCCP

Professor of Medicine
Section of Pulmonary and Critical Care Medicine
Yale University School of Medicine
New Haven, CT

Dr. Matthay has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within Volume 25.

Alejandro C. Arroliga, MD, FCCP
Professor of Medicine
Texas A&M Health Science Center
College of Medicine
Temple, TX

Dr. Arroliga has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within Volume 25.

Paul D. Blanc, MD, FCCP
Professor of Medicine
University of California, San Francisco
San Francisco, CA

Dr. Blanc has disclosed significant relationships with the following companies/organizations whose products or services may be discussed within Volume 25:

National Institutes of Health, Flight Attendants Medical Research Institute – university grant monies
University of California San Francisco, US Environmental Protection Agency, California Environmental Protection Agency Air Resources Board – consultant fee
Habonim-Dror Foundation Board of Trustees – fiduciary position

Guillermo A. do Pico, MD, FCCP
Professor of Medicine
University of Wisconsin Medical School
Madison, WI

Dr. do Pico has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within Volume 25.

Ware G. Kuschner, MD, FCCP
Associate Professor of Medicine
Stanford University School of Medicine
Palo Alto, CA

Dr. Kuschner has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within Volume 25.

Teofilo Lee-Chiong, MD, FCCP
Associate Professor of Medicine
National Jewish Medical Center 
Denver, CO

Dr. Lee-Chiong has disclosed significant relationships with the following companies/organizations whose products or services may be discussed within Volume 25:

National Institutes of Health – grant monies (from sources other than industry)
Covidien, Respironics, Inc. – grant monies (from industry-related sources)
Elsevier – consultant fee

Margaret Pisani, MD, MPH, FCCP
Assistant Professor of Medicine
Yale University School of Medicine 
New Haven, CT

Dr. Pisani has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within Volume 25.

Stephen I. Rennard, MD, FCCP
Professor of Medicine
University of Nebraska Medical Center
Omaha, NE

Dr. Rennard has disclosed significant relationships with the following companies/organizations whose products or services may be discussed within Volume 25:

AstraZeneca, Biomark, Centocor, Novartis – grant monies (from industry-related sources)

Almirall, Aradigm, AstraZeneca, Boehringer Ingelheim, Defined Health, Dey Pharma, Eaton Associates, GlaxoSmithKline, Medacrop, Mpex, Novartis, Nycomed, Otsuka, Pfizer, Pulmatrix, Theravance, United Biosource, Uptake Medical, VantagePoint – consultant fee/advisory committee

AstraZeneca, Network for Continuing Medical Education, Novartis, Pfizer, SOMA – speaker bureau

Ex Officio
Gary R. Epler, MD, FCCP

Clinical Associate Professor of Medicine
Harvard Medical School
Brigham & Women's Hospital
Boston, MA

Dr. Epler has disclosed no significant relationships with the companies/organizations whose products or services may be discussed within Volume 25.

Lilly Rodriguez
ACCP Staff Liaison

By Pablo Garcia, MD; and Michel Boivin, MD, FCCP

Dr. Garcia is a Critical Care Medicine Fellow; and Dr. Boivin is an Assistant Professor; University of New Mexico; Albuquerque, New Mexico.

Drs. Garcia and Boivin have disclosed no significant relationships with the companies/organizations whose products or services may be discussed within this lesson.

Objectives

  1. Identify the components of a venovenous extracorporeal membrane oxygenation (ECMO) circuit.
  2. Understand how ECMO is used in the treatment of acute respiratory distress syndrome.
  3. Describe the inclusion/exclusion criteria and controversy associated with the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure trial.
  4. Understand how ECMO is used in the setting of cardiac arrest.
  5. Describe the potential complications experienced by patients who receive ECMO.

Key Words: adult respiratory distress syndrome; cardiopulmonary resuscitation; extracorporeal membrane oxygenation; heart arrest; influenza A virus, H1N1 subtype; respiratory insufficiency

Abbreviations: ECMO = extracorporeal membrane oxygenation; ECPR = extracorporeal cardiopulmonary resuscitation; PEEP = positive end-expiratory pressure; VA = venoarterial; VV = venovenous

Introduction

ECMO is an intervention that provides total cardiovascular and respiratory support for patients whose own organ systems have failed. It is similar to cardiopulmonary bypass used in the operating room but is designed to be administered in the ICU for a period of days to weeks rather than hours. The specifics of the ECMO technique have been refined at specialized centers and vary between institutions; however, there are certain basic principles. In essence, ECMO removes venous blood, performs gas exchange through an artificial membrane lung device, and then uses a pump to return oxygenated blood to either the venous or arterial system with enough flow to provide circulatory support. When hemodynamic support is required and arterial return is used, the ECMO intervention is categorized as being venoarterial (VA) ECMO.1 When only gas exchange is required and blood is returned via the venous system, this intervention is described as being venovenous (VV) ECMO.2 Ideally, vessels are cannulated percutaneously using the Seldinger technique, but surgical cutdown is required in some cases. The draining cannula is often advanced through a central vein to a position in or near the right atrium. Arterial cannulas are usually inserted into the femoral artery and flow is directed retrograde (toward the heart). While the patient is receiving ECMO, the overall ventilator strategy is lung rest and prevention of atelectasis with the use of a peak inspiratory pressure of 20 cm H2O, positive end-expiratory pressure (PEEP) of 10 cm H2O, and a respiratory rate of 10 (Fig 1).2


PCCSU Volume 25 Lesson 30 Figure 1

Figure 1. Schematic depicting a venoarterial extracorporeal membrane oxygenation circuit. Blood drained from a venous cannula is pumped through a membrane oxygenator and returned to the patient at a high flow rate through an arterial cannula. Gas exchange occurs in the membrane oxygenator. Reproduced with permission from Younger et al.1


Case reports of prolonged extracorporeal circulation with a membrane lung first appeared in the literature in the late 1960s.3 Unfortunately, many of the first patients initially treated with ECMO died shortly after being removed from ECMO due to severe cardiac disease, pulmonary disease, or both. The first randomized trial of ECMO was published in 1979.4 Since that time, the technology and technique have dramatically changed. A voluntary, international registry of ECMO interventions has documented more than 40,000 cases from 170 centers worldwide.5 The vast majority of these cases involve neonatal patients, and it is in these types of patients in which the most evidence for the use of ECMO exists. Despite a lack of definitive data in the realm of ECMO utilization for adults, there may be an emerging role for ECMO in conditions, such as acute respiratory distress syndrome and cardiopulmonary arrest, as research in this field continues to expand.

ECMO for Acute Respiratory Distress Syndrome

In the most severe cases of ARDS, gas exchange is so compromised that life-threatening hypoxemia and respiratory acidemia develop despite total respiratory support by mechanical ventilation. In theory, ECMO is implemented in these cases as a temporary substitute for the lungs. By performing gas exchange through a process independent of the patient, the hope is that the lungs will recover their functioning with time and eventually take over the role of gas exchange. Presently, due to a lack of proven benefit and a high rate of complications, ECMO should only be considered as one of a few potential rescue therapies for patients who fail conventional ARDS treatment.

Over the past 30 years, there have been several research articles published on the efficacy of ECMO in this setting. Most of the research comes from uncontrolled observational studies with survival as the primary outcome. The first trial, which was published in 1979 by Zapol and colleagues,4 observed a 10% survival rate in the ECMO treatment group and an 8% survival rate in the conventional treatment arm. Since that time, much has changed in both the use of ECMO for ARDS and conventional ARDS treatment by mechanical ventilation. These advancements require physicians to focus the interpretation of data for this intervention on the more recent trials.

The survival rate across several observational studies published on the use of ECMO as a rescue therapy for severe refractory ARDS ranges from 45% to 66%.2,6,7-12 These studies are difficult to compare because the criteria to initiate ECMO for ARDS vary across institutions and individual providers. Most patients in these studies met consensus criteria for ARDS and experienced either severe hypoxemia or respiratory acidosis despite aggressive ARDS treatment. Since the late 1990s, ventilator strategy for these patients has focused on lung protective ventilation with a survival rate of 63%.13 Further complicating the analysis, many of the patients in these ECMO studies received other rescue therapies such as intermittent prone positioning, inhaled nitric oxide, and/or supported by high-frequency oscillator ventilation. The timing of when to determine that these treatments are ineffective and to consider ECMO is unclear. It has been observed that survival on ECMO is higher in patients who have received fewer days of support by mechanical ventilation, but this may reflect a bias toward patients with less severe disease.9 The Murray Score, which factors in a patient’s oxygenation, positive end-expiratory pressure (PEEP), chest radiologic findings, and compliance has been used frequently to assess ARDS disease severity and ECMO consideration (Table 1).14 Most patients receiving ECMO in these studies had a Murray Score higher than 3 at the time of ECMO initiation. Despite the limitations of research in this area, a recent observational study described the use of ECMO for influenza-associated ARDS.


Table 1Murray Score

Quadrants With Lung Consolidation on Radiograph Range Score (0-4)
Pao2/Fio2 225-299 1
175-224 2
100-174 3
<100 4
PEEP (cm H2O) <6 0
6-8 1
9-11 2
11-13 3
13-15 4
Static compliance (mL/cm H2O) >79 0
60-79 1
40-59 2
20-39 3
<20 4

Final score is the average of the four sections; maximum score is 4.
Adapted from Murray et al.14


Investigators in Australia and New Zealand have described their experience in the use of ECMO at 15 centers during the 2009 influenza epidemic.11 Of the 201 patients with influenza-related respiratory failure who required support by mechanical ventilation, 68 were treated with ECMO. At the time of publishing, 46 of these patients had either died or survived to hospital discharge. The survival rate among this group of 46 patients was 70%, but 22 of the 68 patients who received ECMO still remained in the hospital. The median age of the patients receiving ECMO was 34 and the average Murray Score was 3.8, indicating severe ARDS. A total of 32% of these patients received inhaled nitric oxide and 20% were placed in prone positioning as part of their ARDS management before initiating ECMO. The average duration of ECMO support was 10 days (interquartile range: 7-15). This study provides physicians with an approximate idea of the ECMO survival rates in a young population with severe ARDS; however, the study did not have a randomized control group to measure efficacy against ARDS management without ECMO.

The only randomized control trial involving the use of ECMO for the treatment of ARDS since the acceptance of lung protective ventilation is the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure trial, which was published in 2009.15 This rather complicated trial randomized 180 patients with severe ARDS throughout the United Kingdom to either treatment without ECMO, at the discretion of providers outside of the main referral institution, or transfer to one referral institution with advanced ECMO experience. There was no standardized treatment for patients who were not transferred, but the data collected indicate that 70% were supported by low-volume, low-pressure ventilation, 64% received steroids, and 46% were placed in prone positioning. Of the group transferred to the referral institution, 75% received VV ECMO and the other 25% were supported by lung-protective ventilation, received packed red blood cell transfusions to maintain a hematocrit level of 40%, and were placed in prone positioning. Criteria for study entry included adults under the age of 65 with ARDS and a Murray Score above 3 or a pH below 7.2 despite support by optimal mechanical ventilation. The primary exclusion criteria were supported by mechanical ventilation with high pressure (>30 cm H2O peak inspiratory pressure) or high Fio2 (>0.8) for more than 7 days or patients with diagnoses that precluded anticoagulation. The difference in the primary end point of survival without severe disability at 6 months was 63% in the group transferred to the ECMO center vs 47% in the group of patients receiving treatment outside of the referral institution. The rate of survival without severe disability among the 68 patients who received ECMO was 63%, and the average duration of ECMO was 9 days (interquartile range: 6-16). This study establishes that patients with severe ARDS have higher survival rates when transferred to a referral center with advanced experience in ECMO. It also presents another data point for survival rates for patients with ARDS who were treated with VV ECMO at one institution. Unfortunately, it does not conclusively answer whether patients with severe ARDS should be treated with ECMO to improve survival.

ECMO as Resuscitation for Prolonged Cardiac Arrest

ECMO has also been investigated as an intervention for cardiac arrest. This use of ECMO is often referred to as extracorporeal cardiopulmonary resuscitation (ECPR). Typically, institutions with an ECPR protocol use ECMO for patients who have an in-hospital witnessed cardiac arrest requiring external chest compressions for longer than 10 minutes and whose underlying condition is cardiac in nature. ECMO is implemented and used as a bridge to a cardiac intervention such as percutaneous coronary intervention, cardiac surgery, placement of a ventricular assist device, or transplant. Several articles have been published from institutions worldwide, and rates of neurologically intact survival have ranged from 20% to 40%.1,16-21 These survival rates are higher than those published for in-hospital cardiac arrest22; however, since these patients were selected by physicians for their likelihood to benefit from ECMO, there is considerable selection bias. To counter this bias, the authors have used propensity-based analyses to determine the efficacy of this intervention and have observed that there may be a survival benefit.20

A recently published study20 described the efficacy of ECPR at a university hospital in South Korea. A total of 406 patients who experienced an in-hospital witnessed cardiac arrest were analyzed based on their propensity to receive ECMO. Of the 406 patients, 85 actually received VA ECMO as part of their cardiac arrest resuscitation. Using propensity-based analysis, 60 patients receiving ECMO were paired with 60 patients who had a similar propensity score to receive ECMO but did not receive this intervention. The primary end point was mortality or significant neurologic disability. The odds ratio for this end point was 0.17 (P= .012), thus favoring the ECMO intervention. The rates of discharge without neurologic disability between the two groups were 23% for the ECMO group and 5% for the propensity-matched control group who did not receive ECMO (P = .013).

ECMO for Other Indications in Adults

Beyond severe ARDS and refractory cardiac arrest, ECMO has been used for many other conditions involving cardiovascular failure, respiratory failure, or both. These conditions include postcardiotomy cardiogenic shock,23,24 lung transplant graft failure,25 heart transplant graft failure,26 hypothermic cardiac arrest,27 status asthmaticus,28 trauma,29 Hantavirus cardiopulmonary syndrome,30 and as a bridge to lung transplant.31The indications for implementing ECMO for these conditions are uncertain, and outcomes vary considerably among case series. Presently, only a few centers have the resources or expertise needed to implement ECMO, and, with the possible exception of severe ARDS, it is unclear under what conditions it would benefit a patient to be transferred to an ECMO referral center.

Hantavirus cardiopulmonary syndrome is an interesting disease state for which VA ECMO is believed to be quite effective. In a single-institution case series of 38 patients diagnosed with severe Hantavirus cardiopulmonary syndrome, survival to hospital discharge was observed to be 61%.30 All 38 patients met previously published criteria (shock refractory to vasopressors, need for external chest compressions, or Pao2/Fio2 ratio < 60) that prognosticated a near 100% mortality rate without ECMO.32 The complications from ECMO treatment reported in this case series included severe bleeding at cannulation sites, circuit rupture, pump malfunction, and limb ischemia requiring amputation. The average duration of ECMO treatment in this patient group was 132 hours. Based on these data, ECMO could be an effective treatment for patients with severe Hantavirus cardiopulmonary syndrome.

ECMO in Pediatric Patients With Respiratory Failure

Similar to its use in adults, ECMO has been successfully used in the treatment of pediatric patients with respiratory failure who fail conventional therapies. No clinical trial has ever established clear, high-quality evidence for using ECMO in the pediatric patient population with respiratory failure, but there have been observational trials that support its use in patients with severe refractory respiratory failure. In a retrospective review of 331 pediatric patients with acute respiratory failure, ECMO was associated with improved survival.33 The data were analyzed with two distinct strategies. In the first analysis, all 331 patients underwent a logistic regression analysis to determine which clinical factors were associated with improved survival. Treatment with ECMO was associated with a 22% improvement in survival. The second analysis matched 29 patients who received ECMO with 53 patients who had similar diagnoses and disease severity and who did not receive ECMO. A 26% mortality rate was seen in the patients receiving ECMO compared with a 47% mortality rate seen in the non-ECMO matched pairs. The limitations of this study include its lack of randomization or adjustment for propensity scores, the use of only one worst value data point to define disease severity and its lack of long-term patient follow-up for clinically significant variables.33 ECMO can be beneficial for pediatric patients who have severe hypoxemia and hypercarbia despite maximal conventional therapies, a potentially reversible lung condition, those without multiorgan failure, and those who do not have contraindications to anticoagulation.34

Complications of ECMO

Since ECMO is a highly invasive intervention, there are many potential complications surrounding its implementation.35 In general, VV ECMO is associated with fewer complications than VA ECMO. One of the most common complications is failure of the ECMO system, which can lead to a temporary loss of support for the patient. During any loss of ECMO support, the patient is vulnerable to the conditions that led to ECMO, such as hypoxemia or hemodynamic collapse. Complications from the anticoagulation needed while on ECMO include hemorrhage from cannulation sites or other surgical incisions and intracranial hemorrhage. The adoption of heparin-treated circuits has reduced the need for anticoagulation and has resulted in fewer bleeding complications. Other complications include limb ischemia requiring amputation, renal failure requiring renal replacement therapy, and infections.

Conclusion

Currently, the use of ECMO is limited to large hospitals and academic medical centers with the expertise and resources to efficiently and safely implement ECMO. Since the technology has evolved and providers have refined their technique, this intervention has yielded fewer complications and better outcomes.35 Referral to a specialized center offering ECMO for patients with severe ARDS would seem reasonable based on current evidence. For cardiac arrest, hospitals with the right combination of resources may consider starting an ECPR protocol as part of their response to in-hospital witnessed cardiac arrest. The French Ministry of Health has gone so far as to publish guidelines for ECPR use.36 Overall, this is an emerging intervention with a continued need for additional research to further define its optimal role in the care of patients who are critically ill.


References

  1. Younger JG, Schreiner RJ, Swaniker F, Hirschl RB, Chapman RA, Bartlett RH. Extracorporeal resuscitation of cardiac arrest. Acad Emerg Med. 1999;6(7):700-707.
  2. Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK. Extracorporeal membrane oxygenation for adult respiratory failure. Chest. 1997;112(3):759-764.
  3. Hill JD, Bramson ML, Rapaport E, Scheinman M, Osborn JJ, Gerbode F. Experimental and clinical experiences with prolonged oxygenation and assisted circulation. Ann Surg. 1969;170(3):448-459.
  4. Zapol WM, Snider MT, Hill JD, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure: a randomized prospective study. JAMA. 1979;242(20):2193-2196.
  5. The Extracorporeal Life Support Organization. ELSO registry information. http://www.elso.med.umich.edu/Registry.html. Accessed September 21, 2012.
  6. Lewandowski K, Rossaint R, Pappert D, et al. High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation. Intensive Care Med.1997;23(8):819-835.
  7. Mols G, Loop T, Geiger K, Farthmann E, Benzing A. Extracorporeal membrane oxygenation: a ten-year experience. Am J Surg. 2000;180(2):144-154.
  8. Frenckner B, Palmer P, Linden V. Extracorporeal respiratory support and minimally invasive ventilation in severe ARDS. Minerva Anestesiol. 2002;68(5):381-386.
  9. Hemmila MR, Rowe SA, Boules TN, et al. Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg. 2004;240(4):595-607.
  10. Beiderlinden M, Eikermann M, Boes T, Breitfeld C, Peters J. Treatment of severe acute respiratory distress syndrome: role of extracorporeal gas exchange. Intensive Care Med. 2006;32(10):1627-1631.
  11. Davies A, Jones D, Bailey M, et al. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;302(17):1888-1895.
  12. Muller T, Philipp A, Luchner A, et al. A new miniaturized system for extracorporeal membrane oxygenation in adult respiratory failure. Crit Care. 2009;13(6):R205.
  13. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA.2010;303(9):865-873.
  14. Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis. 1988;138(3):720-723 [erratum: Am Rev Respir Dis. 1989;139(4):1065].
  15. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351-1363.
  16. Chen YS, Chao A, Yu HY, et al. Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation. J Am Coll Cardiol. 2003;41(2):197-203.
  17. Massetti M, Tasle M, Le Page O, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg. 2005;79(1):178-184.
  18. Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372(9638):554-561.
  19. Cardarelli MG, Young AJ, Griffith B. Use of extracorporeal membrane oxygenation for adults in cardiac arrest (E-CPR): a meta-analysis of observational studies. ASAIO J. 2009;55(6):581-586.
  20. Shin TG, Choi JH, Jo IJ, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med.2011;39(1):1-7.
  21. Jaski BE, Ortiz B, Alla KR, et al. A 20-year experience with urgent percutaneous cardiopulmonary bypass for salvage of potential survivors of refractory cardiovascular collapse. J Thorac Cardiovasc Surg.2010;139(3):753-757.
  22. Peberdy MA, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-792.
  23. Elsharkawy HA, Li L, Esa WA, Sessler DI, Bashour CA. Outcome in patients who require venoarterial extracorporeal membrane oxygenation support after cardiac surgery. J Cardiothorac Vasc Anesth.2010;24(6):946-951.
  24. Magovern GJ, Jr., Simpson KA. Extracorporeal membrane oxygenation for adult cardiac support: the Allegheny experience. Ann Thorac Surg. 1999;68(2):655-661.
  25. Glassman LR, Keenan RJ, Fabrizio MC, et al. Extracorporeal membrane oxygenation as an adjunct treatment for primary graft failure in adult lung transplant recipients. J Thorac Cardiovasc Surg.1995;110(3):723-727.
  26. D'Alessandro C, Aubert S, Golmard JL, et al. Extra-corporeal membrane oxygenation temporary support for early graft failure after cardiac transplantation. Eur J Cardiothorac Surg. 2010;37(2):343-349.
  27. Ruttmann E, Weissenbacher A, Ulmer H, et al. Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest. J Thorac Cardiovasc Surg. 2007;134(3):594-600.
  28. Mikkelsen ME, Woo YJ, Sager JS, Fuchs BD, Christie JD. Outcomes using extracorporeal life support for adult respiratory failure due to status asthmaticus. ASAIO J. 2009;55(1):47-52.
  29. Arlt M, Philipp A, Voelkel S, et al. Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock. Resuscitation. 2010;81(7):804-809.
  30. Dietl CA, Wernly JA, Pett SB, et al. Extracorporeal membrane oxygenation support improves survival of patients with severe Hantavirus cardiopulmonary syndrome. J Thorac Cardiovasc Surg.2008;135(3):579-584.
  31. Haneya A, Philipp A, Mueller T, et al. Extracorporeal circulatory systems as a bridge to lung transplantation at remote transplant centers. Ann Thorac Surg. 2011;91(1):250-255.
  32. Crowley MR, Katz RW, Kessler R, et al. Successful treatment of adults with severe Hantavirus pulmonary syndrome with extracorporeal membrane oxygenation. Crit Care Med. 1998;26(2):409-414.
  33. Green TP, Timmons OD, Fackler JC, Moler FW, Thompson AE, Sweeney MF. The impact of extracorporeal membrane oxygenation on survival in pediatric patients with acute respiratory failure. Pediatric Critical Care Study Group. Crit Care Med. 1996;24(2):323-329.
  34. Lequier L. Extracorporeal life support in pediatric and neonatal critical care: a review. J Intensive Care Med. 2004;19(5):243-258.
  35. Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med.2009;35(12):2105-2114.
  36. French Ministry of Health. Guidelines for indications for the use of extracorporeal life support in refractory cardiac arrest. Ann Fr Anesth Reanim. 2009;28(2):182-190.