Extracorporeal life support (ECLS) was developed more than 50 years ago, initially with venoarterial and subsequently with venovenous configurations. As the technique of ECLS significantly improved and newer skills developed, complexity in terminology and advances in cannula design led to some misunderstanding of and inconsistency in definitions, both in clinical practice and in scientific research. This document is a consensus of multispecialty international representatives of the Extracorporeal Life Support Organization, including the North America, Latin America, EuroELSO, South West Asia and Africa, and Asia-Pacific chapters, imparting a global perspective on ECLS. The goal is to provide a consistent and unambiguous nomenclature for ECLS and to overcome the inconsistent use of abbreviations for ECLS cannulation. Secondary benefits are ease of multicenter collaboration in research, improved registry data quality, and clear communication among practitioners and researchers in the field.

Introduction: In severe respiratory and/or circulatory failure, extracorporeal membrane oxygenation (ECMO) may be a lifesaving procedure. Specialized departments provide ECMO, and these patients often have to be transferred for treatment. Conventional transportation is hazardous, and deaths have been described. Only a few centers have performed more than 100 ECMO transports. To date, our mobile ECMO teams have performed more than 700 transports with patients on ECMO since 1996. We describe 4 consecutive years (2010–2013) of 322 national and international ECMO transports and report adverse events. Methods: Data were retrieved from our local databases. Neonatal, pediatric and adult patients were transported, predominantly with refractory severe respiratory failure. Results: The patients were cannulated in 282 of the transports, and ECMO was started in these patients at the referring hospital and then they were transported to our ECMO intensive care unit. In 40 cases, the patient was already on ECMO. Of the transports, 60 % were by aircraft, and the distances varied from 6.9 to 13,447 km. In about 27.3 % of the transports, adverse events occurred. Of these, the most common were either patient-related (22 %) or equipment-related (5.3 %). No deaths occurred during transport, and transferred patients exhibited the same mortality rate as in-hospital patients. Conclusions: Long- and short-distance interhospital transports on ECMO can be safely performed. A myriad of complications can occur, but the mortality risk is very low. The staff involved should be highly competent in intensive care, ECMO physiology and physics, cannulation, intensive care transport and air transport medicine. They should also be skilled in recognition of risk factors involved in these patients.

The Extracorporeal Life Support Organization (ELSO) Maastricht Treaty for Nomenclature in Extracorporeal Life Support (ECLS) established consensus nomenclature and abbreviations for ECLS to ensure accurate, concise communication. We build on this consensus nomenclature by layering a framework of precise and efficient abbreviations for cannula configuration that describe flow direction, number of cannulae used, any additional ECLS-related catheters, and cannulation sites. This work is a consensus of international representatives of the ELSO, including those from the North American, Latin American, European, South and West Asian, and Asian-Pacific chapters of ELSO. The classification increases in descriptive capability by introducing a third (cannula tip position) and fourth (cannula dimension) level to those provided in the previous consensus on ECLS cannulation configuration nomenclature. This expansion offers the simplest level needed to convey cannulation information yet allows for more details when required. A complete nomenclature for ECLS cannulation configurations accommodating future revisions was developed to facilitate ability to compare practices and results, to promote efficient communication, and to improve quality of registry data.

Intracranial hemorrhage (ICH) is a recognized complication of adults treated with extracorporeal membrane oxygenation (ECMO) and is associated with increased morbidity and mortality. However, the predictors of ICH in this patient category are poorly understood. The purpose of this study was to identify predictors of ICH in ECMO-treated adult patients. We conducted a retrospective review of adult patients (≥18 years) treated with ECMO at the Karolinska University Hospital (Stockholm, Sweden) between September 2005 and June 2016, excluding patients with ICH upon admission or those who were treated with ECMO for less than 12 h. In a comparative analysis, the primary end-points were the difference in baseline characteristics and predictors of hemorrhage occurrence (ICH vs. non-ICH cohorts). The secondary end-point was difference in mortality between groups. Paired testing and uni- and multivariate regression models were applied. Two hundred and fifty-three patients were included, of which 54 (21%) experienced an ICH during ECMO treatment. The mortality for patients with ICH was 81% at 1 month and 85% at 6 months, respectively, compared to 28 and 33% in patients who did not develop ICH. When comparing ICH vs. non-ICH cohorts, pre-admission antithrombotic therapy (p = 0.018), high pre-cannulation Sepsis-related Organ Failure Assessment (SOFA) coagulation score (p = 0.015), low platelet count (p < 0.001), and spontaneous extracranial hemorrhage (p = 0.045) were predictors of ICH. In a multivariate regression model predicting ICH, pre-admission antithrombotic therapy and low platelet count demonstrated independent risk association. When comparing the temporal trajectories for coagulation variables in the days leading up to the detection of an ICH, plasma antithrombin significantly increased per patient over time (p = 0.014). No other temporal trajectories were found. ICH in adult ECMO patients is associated with a high mortality rate and independently associated with pre-admission antithrombotic therapy and low platelet count, thus highlighting important areas of potential treatment strategies to prevent ICH development.

Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, while bleeding complications continue to pose major challenges. To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO. International prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality. The study cohort included 652 patients, and 8471 days on ECMO were analyzed. Unfractionated heparin (UFH) was the initial anticoagulant in 77% of patients, and the most used anticoagulant during the ECMO course (6221 days, 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (39-61), but dropped by 5.3 seconds after the first bleeding event (95% CI -7.4 to -3.2, p< 0.01). Bleeding occurred on 1202 days (16.5 %). Overall, 342 patients (52.5 %) experienced at least one bleeding event (one episode every 215 hours on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20 seconds increase, hazard ratio 1.07). Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding, and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a rescue treatment for acute respiratory distress syndrome (ARDS) failing protective mechanical ventilation. It temporarily provides proper gas exchange: hypoxia is treated by adjusting the blood flow rate and fraction in spired oxygen over the ventilator (FiO₂) on the extracorporeal membrane oxygenation (ECMO) circuit while CO₂ removal is regulated by the ECMO fresh gas flow. Therefore, ventilator settings can be gradually reduced allowing the lungs to rest and recover. Nowadays, indications for ECMO referral and implantation are clearly formulated; on the contrary, little evidence currently exists to guide the process of weaning from ECMO support, especially concerning the timing during the course of lung healing. Therefore, indications to stop ECMO are less well standardized so that in clinical trials extracorporeal assistance is generally continued until lung recovery, with neither specific nor homogenous criteria for withdrawal. Notably, in almost all papers dealing with data on VV ECMO support, the management of weaning and the weaning procedure itself are not described. The aim of this paper is to make a picture of VV ECMO weaning, as it is performed in three European large volume intensive care units (ICUs) which represent referral centers for VV ECMO treatment. We focused on data concerning the timing of VV ECMO weaning and parameters at the time of weaning, in order to assess adequacy and safety of VV ECMO removal.