Disclaimer: The use of venovenous extracorporeal membrane oxygenation (VV ECMO) in adults has rapidly increased worldwide. This ELSO guideline is intended to be a practical guide to patient selection, initiation, cannulation, management, and weaning of VV ECMO for adult respiratory failure. This is a consensus document which has been updated from the previous version to provide guidance to the clinician.

Disclaimer: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.

The Extracorporeal Life Support Organization (ELSO) maintains the world’s largest extracorporeal membrane oxygenation (ECMO) registry by volume, center participation, and international scope. This 2022 ELSO Registry Report describes the program characteristics of ECMO centers, processes of ECMO care, and reported outcomes. Neonates (0–28 days), children (29 days–17 years), and adults (≥18 years) supported with ECMO from 2009 through 2022 and reported to the ELSO Registry were included. This report describes adjunctive therapies, support modes, treatments, complications, and survival outcomes. Data are presented descriptively as counts and percent or median and interquartile range (IQR) by year, group, or level. Missing values were excluded before calculating descriptive statistics. Complications are reported per 1,000 ECMO hours. From 2009 to 2022, 154,568 ECMO runs were entered into the ELSO Registry. Seven hundred and eighty centers submitted data during this time (557 in 2022). Since 2009, the median annual number of adult ECMO runs per center per year increased from 4 to 15, whereas for pediatric and neonatal runs, the rate decreased from 12 to 7. Over 50% of patients were transferred to the reporting ECMO center; 20% of these patients were transported with ECMO. The use of prone positioning before respiratory ECMO increased from 15% (2019) to 44% (2021) for adults during the coronavirus disease-2019 (COVID-19) pandemic. Survival to hospital discharge was greatest at 68.5% for neonatal respiratory support and lowest at 29.5% for ECPR delivered to adults. By 2022, the Registry had enrolled its 200,000th ECMO patient and 100,000th patient discharged alive. Since its inception, the ELSO Registry has helped centers measure and compare outcomes across its member centers and strategies of care. Continued growth and development of the Registry will aim to bolster its utility to patients and centers.

To develop and validate a score to accurately predict the probability of death for adult ECPR. Extracorporeal cardiopulmonary resuscitation (ECPR) is being increasingly utilized to treat refractory in-hospital cardiac arrest (IHCA), but survival varies from 20-40%. Adult patients with ECMO for IHCA (ECPR) were identified from the American Heart Association Get With The Guidelines – Resuscitation registry. A multivariate survival prediction model and score built to predict hospital death. Findings were externally validated in a separate cohort of patients from the Extracorporeal Life Support Organization Registry who underwent ECPR for IHCA. A total of 1075 patients treated with ECPR were included. Twenty eight percent survived to discharge in both the derivation and validation cohorts. A total of 6 variables were associated with in-hospital death: age, time of day, initial rhythm, history of renal insufficiency, patient type (cardiac vs non-cardiac and medical vs surgical), and duration of the cardiac arrest event which were combined into the RESCUE-IHCA score. The model had good discrimination (area under the curve [AUC]) of 0.719 (95% confidence interval [CI] 0.680, 0.757) and acceptable calibration (Hosmer and Lemeshow Goodness of Fit) p=0.079). Discrimination was fair in the external validation cohort (AUC of 0.676 (95% CI: 0.606, 0.746) with good calibration (p=0.66), demonstrating the model’s ability to predict in-hospital death across a wide range of probabilities. The RESCUE-IHCA score can be used by clinicians in real-time to predict in-hospital death among patients with IHCA who are treated with ECPR.