Manipulation of extracorporial gas exchange

ECMO is briefly covered in a short summary elsewhere on this site. One of these days, a more detailed exploration of this fascinating modality will become available. In the meantime, an excellent troubleshooting guide is offered by LITFL, and brilliant videos accompany a practical guide based at the venerable This page does not touch on the savage madness of troubleshooting the ECMO circuit, because that is another vastly different topic area.

Oxygenation via VV ECMO

  • Oxygenation of the VV ECMO patient is determined by
    • ECMO flow rate
    • ECMO output blood oxygen content
    • Patient's cardiac output
  • Total blood oxygen content = (patient's cardiac output ) + (ECMO output )
  • Even though the blood leaving the oxygenator might have a PaO2 of around 500mmHg, the patient may still be hypoxic if the ECMO flow rate is low.
  • Thus: increasing the VV ECMO flow rate increases the PaO2, right up until it begins to recirculate. In absence of recirculation and with maximum flow, adjusting the FiO2is the only option (i.e. increasing the fraction of oxygen in the "sweep" gas)


  • The return (atrial) line should NOT be close to the venous access line.
  • If it is too close, or the flow rate is too high, the jet of oxygenated returning blood will get sucked up into the venous circuit, and the systemic oxygenation will actually drop as a consequence.
  • One needs to carefully down-adjust the blood flow rate to achieve maximal PaO2. If the PaO2 is inadequate in spite of blood flow manipulation, only then does one attempt to manipulate the cannula position.
  • The minimum flow rate is about 1.0-1.5L/min; anything less results in circuit thrombosis.

Oxygenation via VA ECMO

  • Oxygenation of the VA ECMO patient -if their entire cardiac output is being supplemented by ECMO -is determined entirely by the gas exchange properties of the circuit.
  • The expected systemic PaO2 with 100% FiO2 is therefore around 400-500mmHg, if the oxygenator is working properly.

CO2 removal

CO2 is removed by "sweep". This is the countercurrent flow of oxygen-rich gas which circulates over the porous oxygenator membrane. It is measured in L/min, and adjusted by a gas flow regulator.


LITFL offer this excellent reference; unfortunately, fulltext is not available on CIAP, nor via the publisher.

Sidebotham, David. "Troubleshooting adult ECMO." The Journal of extra-corporeal technology 43.1 (2011): P27-32.

St Vincents Hospital, the House of ECMO, have an ECMO protocol for house staff. So does Westmead Hospital. These are not freely available online, and one must rely on friendly locals to supply them.

These protocols are particularly helpful, and much of the practical information included above is derived from these evidence-based guidelines.

The Royal Adelaide Hospital ICU ECMO Guidelines are also an excellent resource, and very much available online. I have used them more for the routine care of the ECMO patient.

Allen, Steve, et al. "A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients." Journal of intensive care medicine 26.1 (2011): 13-26.

Foley, Paul J., et al. "Limb ischemia during femoral cannulation for cardiopulmonary support." Journal of vascular surgery 52.4 (2010): 850-853.

Oliver, William C. "Anticoagulation and coagulation management for ECMO."Seminars in cardiothoracic and vascular anesthesia. Vol. 13. No. 3. SAGE Publications, 2009.

Davies, Andrew, et al. "Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome." JAMA: the journal of the American Medical Association 302.17 (2009): 1888-1895.

Eugene, J., et al. "Cardiac assist by extracorporeal membrane oxygenation with in-line left ventricular venting." ASAIO Journal 30.1 (1984): 98-102.

Seib, Paul M., et al. "Blade and balloon atrial septostomy for left heart decompression in patients with severe ventricular dysfunction on extracorporeal membrane oxygenation." Catheterization and Cardiovascular Interventions 46.2 (1999): 179-186.

Russo, Claudio F., et al. "Veno-arterial extracorporeal membrane oxygenation using Levitronix centrifugal pump as bridge to decision for refractory cardiogenic shock." The Journal of thoracic and cardiovascular surgery 140.6 (2010): 1416-1421.

Platts, David Gerard, et al. "The role of echocardiography in the management of patients supported by extracorporeal membrane oxygenation." Journal of the American Society of Echocardiography 25.2 (2012): 131-141.