Developed in the 1970s, extracorporeal membrane oxygenation (ECMO) is increasingly being used to treat patients with respiratory or cardiac failure. This cardiopulmonary support system uses an artificial membrane lung to move blood forward and replace carbon dioxide with oxygen in venous blood.1 Today, over 700 ECMO centers across the world provide both veno-arterial and veno-venous ECMO, with the number of centers likely increasing over the next decades.2 Veno-arterial ECMO (VA ECMO) is used in patients with cardiogenic shock, cardiac arrest, or other conditions that require full cardiac and pulmonary support. Recent Extracorporeal Life Support Organization (ELSO) data show survival rates of 42% among patients undergoing VA ECMO.2 The use of veno-venous ECMO (VV ECMO) in adults is commonly used for patients with acute respiratory distress syndrome (ARDS) and has shown survival rates up to 58% in the past 10 years.3 Following the increase in patients with H1N1 influenza, the use of ECMO has increased and studies have shown a survival rate up to 78% in these patients.4 Critical care nurses play a critical role in the care of these high-acuity patients. In the cases of these high-acuity patients, providers rely heavily on the patient assessments completed by critical care nurses.
Indications differ for VA ECMO and VV ECMO. VA ECMO provides cardiopulmonary support and is used in patients with cardiogenic shock, cardiac arrest, or failure to wean from cardiopulmonary bypass following cardiac surgery. In these situations, VA ECMO is used as a bridge to recovery, a long-term device such as a left ventricular assist device, cardiac transplantation, or palliative care if the patient is not a candidate for the previous options.5 Patient selection is important, and several factors are taken into account when deciding whether or not to place a patient on VA ECMO. (See Contraindications.) ELSO guidelines identify the following as criteria suitable for VA ECMO:
- Cardiogenic shock as evidenced by hypotension and low cardiac output with inadequate tissue perfusion.
- Shock that persists despite volume resuscitation, inotropes, vasoconstrictors, and use of intra-aortic balloon pump counterpulsation if appropriate.
- Septic shock is an indication in some centers.
There are multiple causes of cardiogenic shock that require VA ECMO support, including acute myocardial infarction, decompensated chronic heart failure, cardiomyopathy, myocarditis, and post cardiac surgery shock.5 When physicians decide to place a patient on ECMO, they must consider patient age, candidacy for long-term devices or transplantation, comorbidities and other organ dysfunction, compliance with medical treatment, and prolonged CPR without adequate tissue and brain perfusion. In these situations, ECMO is never considered the final outcome and much consideration should be placed on the ultimate goals of therapy. Any contraindications to anticoagulation must also be considered.5
In contrast, VV ECMO is used in adults with severe hypoxic or hypercapnic respiratory failure despite the use of mechanical ventilation. ELSO guidelines for use include:
- Persistent hypoxemia with PaO2/FiO2 ratios of <100 on FiO2 >90% and a Murray score of 3 to 4. PaO2/FiO2 ratios are used to indicate abnormal gas exchange, with a normal value of 300 to 500 mm Hg. A PaO2/FiO2 ratio less than 300 indicates abnormal gas exchange, with a value less than 200 mm Hg indicating severe hypoxemia.6
- The Murray scoring system takes into consideration the severity of consolidation on chest X-rays, PaO2/FiO2 ratio, positive end-expiratory pressure, and lung compliance. A score of 0 to 4 is given for each criterion based on severity. The total score for each criterion is used to help determine a patient's candidacy for ECMO. A score greater than 2.5 indicates ARDS with a recommendation to consider VV ECMO.7
- Carbon dioxide (CO2) retention with a pH <7.20.
- Severe air leak syndrome.
- Immediate respiratory collapse such as pulmonary embolism or obstructed airway.
- Decompensation while awaiting lung transplantation.
The many causes of respiratory failure include, but are not limited to, ARDS, H1N1 influenza, pneumonia, pulmonary fibrosis, chest trauma, chronic obstructive pulmonary disease, and pulmonary hypertension.8 Length of time on mechanical ventilation, with elevated plateau pressures (>30 cm H2O), has been shown to worsen outcomes, while early VV ECMO placement within 1 to 2 days of onset has been shown to improve survival.8
Basic components of the ECMO circuit consist of venous (inflow) and arterial (outflow) cannulas, a blood pump, oxygenator, and tubing. Monitors, alarms, and heat exchangers may also be included.8
In VA ECMO, one cannula is present in an artery, and one in a vein. The venous cannula is placed in the femoral vein and advanced near the right atrium in the inferior vena cava (IVC). The blood is then oxygenated through the circuit and returned via the arterial cannula in the femoral artery, allowing for full cardiopulmonary support. In this configuration, oxygenated blood is delivered to the aorta in a retrograde fashion, competing with the blood being ejected by the heart. At times, this can pose a problem, such as left ventricular distension or pulmonary edema.9 Another problem with retrograde flow is dual circulation, or “North South Syndrome.” This phenomenon refers to when the remainder of the circulating blood volume that is not being oxygenated by ECMO enters through the heart and is ejected. In this situation, the poorly oxygenated blood is being perfused to the brain via the carotid arteries, placing the patient at risk for cerebral hypoxia. A solution to this potentially catastrophic complication would be to add an additional cannula into the jugular vein to return oxygenated blood via a Y connector.10 Finally, VA ECMO may be cannulated centrally, typically seen after cardiac surgery. The venous or inflow cannula is typically placed in the right atrium or ventricle, and the arterial or outflow cannula is placed in the aorta. This technique is complex and must be performed by a cardiothoracic surgeon via sternotomy but does eliminate the risk of “North South Syndrome.” Other ECMO configurations exist, but those discussed are the most common.9
In VV ECMO, both cannulas are placed in the vein. (See Cannula position for VV-ECMO.) Adult ECMO cannulas used are typically between 15-23 French (Fr) for arterial and 19-25 Fr for venous. The femoral-jugular cannulation may be used for VV ECMO, where the drainage cannula enters through the femoral vein removing poorly oxygenated blood from the IVC. The return cannula in the internal jugular vein is returning oxygenated blood to the patient. Another common configuration consists of cannulas in the bilateral femoral veins, known as femoral-femoral cannulation. In this setup, the drainage cannula is in the lower IVC, and the return cannula is in the IVC near the right atrium. Another cannulation technique for VV ECMO is the use of the single bicaval dual lumen cannula. This type of cannula in inserted into the right internal jugular vein using fluoroscopy to ensure adequate positioning.10
ECMO settings will include pump speed, or rotations per minute (RPMs), and sweep gas. Other than RPMs, factors affecting flow include cannula size, preload, and afterload. The ECMO circuit is a preload-dependent and afterload-sensitive system. Adequate blood volume, or adequate preload, is essential in maintaining flows. On the other hand, increases in afterload, or forward resistance, will also inhibit flow. Sweep gas determines CO2 removal and is set in liters per minute (L/min). A higher sweep gas setting will allow for more CO2 removal. Finally, FiO2 will typically be at 100%, unless weaning from VV ECMO.11 Regardless of the type of ECMO cannulation, the goal is to maintain adequate flow. (See Diagrammatic representation of peripheral VV-ECMO and peripheral VA-ECMO.)
Proper monitoring of patients treated with ECMO requires considerable training and expertise, as these patients are very complex. Critical care nurses should have knowledge of the patient's disease process and indication for ECMO support. Hemodynamic monitoring should be continuous, and should include heart rate and rhythm, BP, pulmonary artery catheter monitoring (if in place), pulsatility of arterial waveforms, temperature, and oxygen saturations. Pulsatility refers to the ability to generate a pulse pressure or opening of the aortic valve. Low pulsatility on the arterial waveform, or narrow pulse pressure, may indicate worsening cardiac contractility, excessive VA ECMO support, inadequate preload, or RV failure. The result may be thrombus formation above the aortic valve, myocardial ischemia, or pulmonary edema. Providers should be notified of changes in arterial waveforms.12
Temperature monitoring is important, as patients on ECMO tend to become hypothermic due to the blood removal from the body into a room temperature circuit. Heaters can be added to the ECMO circuit to maintain normothermia. In collaboration with your ECMO specialist, or perfusionist, ECMO flows should be closely monitored, as well as alarms or “chattering” from the circuit. Chattering is a phenomenon where the inlet or venous cannula becomes occluded due to high pressures, and may occur with hypovolemia, increased intrathoracic pressures, or thrombus formation.11 Knowing a patient's volume status is essential, as ECMO is preload-dependent. Knowledge of the sites and configuration of the ECMO cannulation is also important in identifying possible complications.
Aside from monitoring specific to the ECMO circuit, daily nursing care may become a challenge given the acuity of the patient. For example, providing a complete bed bath poses risks due to the patient's dependency on the ECMO flow, risk of cannula dislodgment, and risk of bleeding due to anticoagulation. For example, cannula dislodgment could be detrimental to a patient relying on ECMO for full life support. Safety precautions must be taken when bathing and changing linens to avoid cannula kinking, dislodgment, or bleeding from the cannula sites. The clinical nurse should have help from several staff members when bathing or changing linens to ensure there are no complications. The nurse's role in providing patient comfort may also be challenging in this patient population. Pain control and sedation are important, especially early on due to the demand for oxygenation and need to reduce oxygen consumption. The avoidance of cannula dislodgment may also be an indication for sedation. It has been shown that critically ill patients undergoing ECMO have an increased sedation requirement. The exact cause of this is unknown, but it suspected that increased sedation requirements are due to increased volume of distribution, decreased clearance, and absorption of the medications in the circuit.13
ECMO patients are at a higher risk for infection, with increased risk occurring with longer duration of ECMO, older patient age, and immunosuppression. It is important for the clinical nurse to monitor for signs and symptoms of infection, but he or she must be aware that the typical signs of infection may be blunted. For example, fever may not be observed in the patient due to the use of the heater on the ECMO circuit, which controls the patient's temperature. Small signs of infection, such as a slight raise in temperature, or variations in hemodynamics should raise suspicion of possible infection. Biomarkers of infection such as C-reactive protein and procalcitonin may be helpful. Transparent dressings at the cannulation site should also be used to allow for close observation for both infection and bleeding.14
Nutrition in the patient requiring ECMO is important in order to keep up with the patient's metabolic demands. Nutrition can be provided by both enteral and parenteral routes. Although no specific guidelines exist, these patients are often critically ill with prolonged ICU stays, increasing their need for adequate nutrition. Barriers to adequate nutrition are commonly GI disturbances such as vomiting, constipation, and abdominal distension. Patients with severe organ dysfunction who are critically ill are typically at higher risk for malnutrition.15
Monitoring of renal function is also an important role of the critical care nurse, as worsening renal function has been associated with a poorer prognosis. Continuous renal replacement therapy (CRRT) may be indicated early on to reduce the risk of fluid overload. CRRT may be provided to the patient by traditional means, such as hemodialysis via a dialysis catheter, or via the ECMO circuit. When using the ECMO circuit, the nurse must be diligent in troubleshooting alarms, monitoring pressures of the CRRT circuit, and avoiding air entry into the ECMO circuit.14
Diagnostic testing in the patient undergoing ECMO may consist of chest X-rays and ultrasounds, which can be done at the bedside. Chest X-rays are useful in evaluating cannula position as well as evaluation of possible improvement in the pulmonary process that lead to ECMO placement. Ultrasounds such as echocardiograms or vascular studies can be used to help guide patient management and are able to be done at the bedside, minimizing patient transportation.16 If the provider orders a CT Scan, careful transportation must be taken when leaving the ICU. The risk and benefit of the testing must be taken into consideration.14 The transport team may include the critical care nurse, respiratory therapist, perfusionist or ECMO specialist, and transport team members. All members must carefully watch equipment to avoid accidental removal or dislodgment of the ECMO cannulas or other life-saving support lines. MRI is contraindicated in the patient undergoing ECMO due to the metal contained in the pump.
As with transportation outside the unit, similar precautions should be taken when performing physical therapy. Deconditioning and muscle weakness are common in patients receiving ECMO. When the patient is deemed ready for mobilization from a medical standpoint, physical therapy may begin. Several reports show improved outcomes and decreased length of stay with ambulatory ECMO, typically allowed with use of the single bicaval dual lumen cannulation in VV ECMO.17
Frequent lab draws such as arterial blood gases (ABGs), mixed venous oxygen saturation (SvO2), complete blood cell count, and plasma hemoglobin can be expected when monitoring a patient's ECMO therapy. Free plasma hemoglobin (fHb) is a sign of hemolysis, or red blood cell (RBC) destruction from shear stress, high ECMO flow, or pressure changes within the oxygenator. fHb can be cytotoxic and can lead to tissue hypoxia and cell death as well as renal failure and multiorgan failure. Hemolysis is defined as fHb >10 mg/dL.18 These lab results may help identify bleeding, hemolysis, and hypoxemia. Anticoagulation will be administered either via the ECMO circuit or I.V. to the patient. Additional lab work may be required more frequently, such as activated clotting times or prothrombin time to assess anticoagulation level. Protocols for anticoagulants such as heparin are typically prescribed for patients undergoing ECMO.19 Finally, an important role of the clinical nurse is to monitor for complications of ECMO support.
Bleeding. Bleeding occurs in 30% to 50% of patients on ECMO and may occur for several reasons.19 Recognizing and controlling bleeding is an essential part of care for patients on ECMO. Systemic bleeding may also occur due to anticoagulation and platelet dysfunction. The mechanism of platelet dysfunction is not well understood but is likely multifactorial.20 ECMO circuits are artificial and induce sheer stress. Both factors induce platelet adhesion and activation. Lukito and colleagues reported a reduction in glycoprotein Ib platelet subunit alpha (GPIbalpha) and glycoprotein (GP)VI surface levels compared with healthy patients.21 The loss of these receptors reduces the ability of platelets to bind to von Willebrand factor and collagen, leading to impaired platelet adhesion and platelet activation.22 This impairment in platelet function decreases the platelets' ability to adhere and form clots, increasing bleeding risk.20 Along with the reduced efficacy of circulating platelets, it has also been shown that overall platelet counts while on ECMO are reduced. When blood interacts with the artificial ECMO circuit, there is protein absorption, including fibrinogen. As fibrinogen binds to the surface, the cycle of platelet aggregation occurs resulting in thrombus formation, therefore reducing the circulating platelets. Within the first 4 hours of ECMO, platelet counts may decrease by as much as 40%.23 Per ELSO guidelines, platelet should be kept above 80,000/mm3 (normal, 150,000 to 450,00/mm3).19
The most common bleeding in patients on ECMO occurs locally at the site of cannulation, whether in the femoral vessels or jugular vein. The likelihood of bleeding from arterial cannulas is greater due to the higher-pressure nature of arteries. In this case, the ECMO physician or surgeon may place sutures around the cannula to achieve hemostasis. Bleeding from central cannulation sites requires surgical intervention and may lead to cardiac tamponade.11
Management of systemic bleeding may be more challenging. Systemic bleeding can occur in the form of gastrointestinal bleeding, intra-abdominal bleeding, intrathoracic bleeding, or intracranial bleeding. Even routine procedures such as suctioning, causing slight trauma, may cause bleeding that is difficult to control.24 The use of anticoagulation to maintain the ECMO circuit, as well platelet dysfunction, contributes to the bleeding risk. The critical care nurse should monitor for bleeding closely and notify the provider with any suspicions.
Hemolysis. Hemolysis is defined as the destruction of RBCs leading to the release of hemoglobin found within RBCs into the plasma. In patients undergoing ECMO, hemolysis can be caused by sheer stress and destruction of RBCs by several mechanisms. These mechanisms include increased flow through the circuit and oxygenator and are increased when clots are present in the oxygenator or venous pressures are high.11 Hemolysis can lead to anemia, kidney failure, and multiorgan failure. For critical care nurses, monitoring for hemolysis includes close observation of urine output, including color, as pink-tinged urine may be an early sign of hemolysis. Monitoring of lab values includes both plasma-free hemoglobin (>10 mg/dL) and lactate dehydrogenase (normal, 313-618 IU/L), which are markedly elevated in hemolysis.11
Neurologic complications. Neurologic complications increase mortality in patients undergoing ECMO and have been seen in approximately 10% of patients. These include seizures, stroke, and intracranial hemorrhage.19 Intracranial hemorrhage has been reported in about 5% of patients and is a potentially devastating complication.20 As mentioned earlier, the ECMO circuit can induce platelet adhesion and activation, leading to thrombotic events such as acute ischemic strokes. Frequent and thorough neurologic assessments by the clinical nurse are important and should include, but are not limited to, level of consciousness, pupillary reactions to light, and assessment of facial symmetry and motor strength of all extremities, including the presence of pronator drift. Deviations from baseline and any new changes should be reported to the provider immediately. CT scans may also be used to evaluate for neurologic complications.
Limb ischemia. Limb ischemia is a complication of VA ECMO but has been reported in VV ECMO as well. Studies have shown up to a 30% complication rate. The placement of the cannula in the femoral artery may occlude blood flow distally. Measures to prevent this, such as the insertion of distal perfusion catheters, are typically done to reduce the risk of limb ischemia.25 A distal perfusion catheter is typically a 6-8 Fr sheath placed in the superficial femoral artery. A connector is used to attach the sheath to the ECMO circuit on the arterial side. This will allow for oxygenated blood, coming from the high-pressure arterial system, to perfuse the distal limb.26 Proper assessment of the limb distal to the ECMO cannula is an essential role of the critical care nurse when caring for a patient on ECMO. Monitoring should include distal pulses, color, temperature, sensation, and motor strength. If a distal perfusion catheter is in place, monitoring for its patency may also be a role of either the clinical nurse, perfusionist, or ECMO specialist. Patency may be assessed by placing a Doppler on the tubing and evaluating for flow. Prompt intervention by the ECMO physician is essential if limb ischemia is identified.
Infection. As with any invasive device, infection remains a serious complication of ECMO support, increasing morbidity and mortality in this patient population. It is important to ensure proper hand hygiene is done by all staff and visitors. Avoidance of circuit breaks or manipulation of the cannulas should be limited, and sterile technique should be maintained during dressing changes to invasive lines or cannula sites. Close monitoring for signs of local infection at the cannulation site as well as fever or other signs of systemic infections is important.11 Based on ELSO guidelines, antibiotics should be administered at the time of cannulation, but there is no evidence to support the continuation of prophylactic antibiotics.11 Identification and prompt notification of changes to the provider is an important role of the clinical nurse.
Strategies for weaning patients from VA ECMO and VV ECMO differ, and close monitoring by the nurse during both of these is required. Removal of ECMO as early as possible is preferred, as longer ECMO durations are associated with increased bleeding and mortality.27 When weaning from VV ECMO, both FiO2 and sweep are weaned, while maintaining flow through the ECMO circuit. Evaluation of weaning trials is achieved by close monitoring of oxygenation, carbon dioxide removal, and hemodynamic changes. Frequent ABGs may be done during weaning to ensure adequate oxygenation and gas exchange remains. The critical care nurse should be aware of weaning attempts by providers, and monitoring of O2 saturation, vital signs, and ABGs are essential. When weaning from VA ECMO, sweep and flow are weaned. Hemodynamics should be closely monitored, which include heart rate and rhythm, BP, and cardiac output/cardiac index. Increased vasopressor requirements during the weaning process may indicate that the patient is not ready for decannulation. Echocardiography may also be used while weaning from VA ECMO to evaluate cardiac function.27 For both VA ECMO and VV ECMO, decannulation is typically done in the OR by a cardiothoracic or vascular surgeon.
End of life
When attempts at weaning are unsuccessful, or the patient is unable to be bridged to a long-term device, the decision may be made for palliative care with removal of ECMO. This decision may be accompanied by legal and ethical concerns. Involvement of the palliative care, ethics, or legal departments may be required. Critical care nurses must be comfortable collaborating with these departments, as well as providing the patient and/or family emotional support when necessary. A multidisciplinary team is critical when discussing futility of treatment and end of life. The responsibilities of the nurse may include facilitation of family meetings, communication with family members regarding the process and steps, identification and treatment of pain, anxiety or discomfort, and clarification of information given by the provider.28,29 If the decision is made to withdraw all life-sustaining measures, the critical care nurse plays an important role in ensuring comfort and peace for both the patient and family.
Critical care nurses caring for patients undergoing ECMO treatment require considerable expertise. Per ELSO guidelines, staff caring for patients requiring ECMO should receive continued education and training to ensure competency.30
ECMO is contraindicated in the following clinical conditions:
- significant aortic regurgitation
- severe peripheral artery disease
- bleeding diathesis
- recent stroke or head trauma
- uncontrolled sepsis.
Reproduced with permission from: Jeevanandam V, Eisen HJ, Pinto DS. Short-term mechanical circulatory assist devices. In: UpToDate, Post TW, eds. Waltham, MA: UpToDate. (Accessed on February 24, 2020.) Copyright © 2019 UpToDate, Inc. For more information visit www.uptodate.com.
1. Jeevanandam V, Eisen HJ, Pinto DS. Short-term mechanical circulatory assist devices. UpToDate. 2019. www.uptodate.com
2. Extracorporeal Life Support Organization. International Report. 2020. www.elso.org/Registry/Statistics/InternationalSummary.aspx
3. Extracorporeal Life Support Organization. Home. 2020. www.elso.org
4. Noah MA, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A (H1N1). JAMA
6. Theodore AC. Oxygenation and mechanisms of hypoxemia. UpToDate. 2018. www.uptodate.com
7. Raghavendran K, Napolitano LM. ALI and ARDS: challenges and advances. Crit Care Clin
8. ELSO Guidelines for Adult Respiratory Failure. Extracorporeal Life Support Organization. 2017. www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respiratory%20Failure%201_4.pdf
9. Pavlushkov E, Berman M, Valchanov K. Cannulation techniques for extracorporeal life support. Ann Transl Med
10. Lindholm JA. Cannulation for veno-venous extracorporeal membrane oxygenation. J Thorac Dis
. 2018;10(suppl 5):S606–S612.
11. ELSO General Guidelines for all ECLS Cases. Extracorporeal Life Support Organization. 2017. www.elso.org/Portals/0/ELSO%20Guidelines%20General%20All%20ECLS%20Version%201_4.pdf
12. Chung M, Shiloh AL, Carlese A. Monitoring of the adult patient on venoarterial extracorporeal membrane oxygenation. ScientificWorldJournal
13. Shekar K, Roberts JA, Mullany DV, et al. Increased sedation requirements in patients receiving extracorporeal membrane oxygenation for respiratory and cardiorespiratory failure. Anaesth Intensive Care
14. Bombino M, Redaelli S, Patroniti N. Patient care during ECMO. In: Sangalli F, Patroniti N, Pesenti A, eds. ECMO-Extracorporeal Life Support in Adults
. New York, NY: Springer Science and Business; 2014:345–359.
15. Macgowan L, Smith E, Elliott-Hammond C, et al. Adequacy of nutrition support during extracorporeal membrane oxygenation. Clin Nutr
16. Douflé G, Roscoe A, Billia F, Fan E. Echocardiography for adult patients supported with extracorporeal membrane oxygenation. Crit Care
17. Garcia JP, Iacono A, Kon ZN, Griffith BP. Ambulatory extracorporeal membrane oxygenation: a new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg
18. Lehle K, Philipp A, Zeman F, et al. Technical-induced hemolysis in patients with respiratory failure supported with veno-venous ECMO—prevalence and risk factors. PLoS One
19. Mazzeffi M, Greenwood J, Tanaka K, et al. Bleeding, transfusion, and mortality on extracorporeal life support: ECLS working group on thrombosis and hemostasis. Ann Thorac Surg
20. Balle CM, Jeppesen AN, Christensen S, Hvas AM. Platelet function during extracorporeal membrane oxygenation in adult patients: a systematic review. Front Cardiovasc Med
21. Lukito P, Wong A, Jing J, et al. Mechanical circulatory support is associated with loss of platelet receptors glycoprotein Ib_ and glycoprotein VI. J Thromb Haemost
22. Bergmeier W, Piffath CL, Goerge T, et al. The role of platelet adhesion receptor GPIbalpha far exceeds that of its main ligand, von Willebrand factor, in arterial thrombosis. Proc Natl Acad Sci USA
23. Kasirajan V, Smedira NG, McCarthy JF, Casselman F, Boparai N, McCarthy PM. Risk factors for intracranial hemorrhage in adults on extracorporeal membrane oxygenation. Eur J Cardiothorac Surg
24. Rubino A, Haddon R, Corti F, Sangalli F. Complications of extracorporeal support and their management in ECMO-extracorporeal life support in adults. In: Sangalli F, Patroniti N, Pesenti A, eds. ECMO-Extracorporeal Life Support in Adults
. New York, NY: Springer Science and Business; 2014;345–359.
25. Nasr DM, Rabinstein AA. Neurologic complications of extracorporeal membrane oxygenation. J Clin Neurol
26. Ranney DN, Benrashid E, Meza JM, et al. Vascular complications and use of a distal perfusion cannula in femorally cannulated patients on extracorporeal membrane oxygenation. ASAIO J
27. Pappalardo F, Pieri M, Arnaez Corada B, et al. Timing and strategy for weaning from venoarterial ECMO are complex issues. J Cardiothorac Vasc Anesth
28. Kagan V, Rose R, Costantini H, et al. Destination to nowhere: the ethics of acute mechanical circulatory support. J Heart Lung Transplant
29. Anderson WG, Puntillo K, Cimino J, et al. Palliative care professional development for critical care nurses: a multicenter program. Am J Crit Care