Extracorporeal Life Support Organization Registry International Report 2022: 100,000 Survivors

Pediatric Hematology and Oncology Patients on Extracorporeal Membrane Oxygenation: Outcomes in a Multicenter, Retrospective Cohort, 2009-2021

OBJECTIVE

To describe characteristics associated with survival for pediatric patients with an oncologic diagnosis or hematopoietic cell transplant (HCT) supported with extracorporeal membrane oxygenation (ECMO).

DESIGN

Multicenter, retrospective study.

SETTING

Sixteen PICUs in the United States and Israel.

PATIENTS

We included patients aged younger than 19 years with an oncologic diagnosis or HCT who required ECMO support between 2009 and 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 149 patients were included in the study cohort. There were 118 patients with an oncologic diagnosis and 31 that received HCT. The indications for ECMO were respiratory failure (46%), combined respiratory and cardiac failure (28%), and cardiac failure (25%). Venovenous (V-V) ECMO was used in 45% of patients, with 53% of patients being placed on venoarterial (V-A) ECMO. For oncologic and HCT groups, survival to ECMO decannulation was 52% (62/118) and 64% (20/31), and survival to hospital discharge was 36% (43/118) and 42% (13/31), respectively. After adjusting for other factors, requiring cardiopulmonary resuscitation was associated with greater odds ratio of mortality (3.0 [95% CI, 1.2-7.7]).

CONCLUSIONS

Survival to ECMO decannulation of pediatric oncologic and HCT patients in this study was 52-64%, depending upon diagnosis. However, survival to hospital discharge remains poor. Future research should prioritize understanding factors contributing to this survival gap within these patient populations.

Extracorporeal membrane oxygenation in critically ill patients with active hematologic and non-hematologic malignancy: a literature review

Combined progress in oncology and critical care medicine has led to new aspirations and discussions in advanced life support modalities in the intensive care unit. Over the last decade, extracorporeal membrane oxygenation, previously considered unsuitable for oncologic patients, has become increasingly popular, with more diverse applications. Nevertheless, mortality remains high in critically ill cancer patients, and eligibility for extracorporeal membrane oxygenation can be extremely challenging. This scenario is even more difficult due to the uncertain prognosis regarding the underlying malignancy, the increased rate of infections related to intensive care unit admission, and the high risk of adverse events during extracorporeal membrane oxygenation support. With advances in technology and better management involving extracorporeal membrane oxygenation, new data on clinical outcomes can be found. Therefore, this review article evaluates the indicators for extracorporeal membrane oxygenation in different types of oncology patients and the possible subgroups that could benefit from it. Furthermore, we highlight the prognosis, the risk factors for complications during this support, and the importance of decision-making based on a multidisciplinary team in the extracorporeal membrane oxygenation indication.

Acute Ischemic Stroke during Extracorporeal Membrane Oxygenation (ECMO): A Narrative Review of the Literature

Ischemic stroke (IS) is a severe complication and leading cause of mortality in patients under extracorporeal membrane oxygenation (ECMO). The aim of our narrative review is to summarize the existing evidence and provide a deep examination of the diagnosis and treatment of acute ischemic stroke patients undergoing ECMO support. The incidence rate of ISs is estimated to be between 1 and 8%, while the mortality rate ranges from 44 to 76%, depending on several factors, including ECMO type, duration of support and patient characteristics. Several mechanisms leading to ISs during ECMO have been identified, with thromboembolic events and cerebral hypoperfusion being the most common causes. However, considering that most of the ECMO patients are severely ill or under sedation, stroke symptoms are often underdiagnosed. Multimodal monitoring and daily clinical assessment could be useful preventive techniques. Early recognition of neurological deficits is of paramount importance for prompt therapeutic interventions. All ECMO patients with suspected strokes should immediately receive brain computed tomography (CT) and CT angiography (CTA) for the identification of large vessel occlusion (LVO) and assessment of collateral blood flow. CT perfusion (CTP) can further assist in the detection of viable tissue (penumbra), especially in cases of strokes of unknown onset. Catheter angiography is required to confirm LVO detected on CTA. Intravenous thrombolytic therapy is usually contraindicated in ECMO as most patients are on active anticoagulation treatment. Therefore, mechanical thrombectomy is the preferred treatment option in cases where there is evidence of LVO. The choice of the arterial vascular access used to perform mechanical thrombectomy should be discussed between interventional radiologists and an ECMO team. Anticoagulation management during the acute phase of IS should be individualized after the thromboembolic risk has been carefully balanced against hemorrhagic risk. A multidisciplinary approach is essential for the optimal management of ISs in patients treated with ECMO.

ECPR-the evolving role in cardiac arrest

Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore blood circulation in patients during refractory cardiac arrest. So far, ECPR is not the standard of care but has become part of clinical routine for select patients in many places. As ECPR is a highly invasive support option associated with considerable risks for fatal complications, premature use in patients who may have return of spontaneous circulation should be avoided. However, the selection criteria for ECPR are still evolving, as the search for evidence is ongoing. Recent randomized controlled trials of different ECPR strategies support its use within integrated systems built around highly specialized ECPR centers. The ECPR caseload is an important predictor of patient survival, and continuous training is key for evidence-based quality of care. Typical complications after ECPR include vascular injury or malposition of cannulas, thrombotic complications, hemolysis, and bleeding events that require early detection and interdisciplinary management. When provided by highly specialized and well-trained expert teams in dedicated ECPR centers within integrated pre-hospital and intra-hospital emergency care systems, ECPR may improve survival in select patients with refractory cardiac arrest. This article is freely available.

A narrative review on antimicrobial dosing in adult critically ill patients on extracorporeal membrane oxygenation

The optimal dosing strategy of antimicrobial agents in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) is unknown. We conducted comprehensive review of existing literature on effect of ECMO on pharmacokinetics and pharmacodynamics of antimicrobials, including antibacterials, antifungals, and antivirals that are commonly used in critically ill patients. We aim to provide practical guidance to clinicians on empiric dosing strategy for these patients. Finally, we discuss importance of therapeutic drug monitoring, limitations of current literature, and future research directions.

[Peripheral extracorporeal membrane oxygenation in perioperative medicine : Principles, indications and challenges]

In recent years the number of patients treated in intensive care units by extracorporeal membrane oxygenation (ECMO) due to severe respiratory failure or cardiogenic shock has steadily increased [1]. Consequently, the number of invasive procedures and operations in these patients has also increased. A fundamental understanding of these systems and the clinical indications is therefore helpful for the practicing (non-cardiac) surgeon. This review article focuses on peripheral ECMO procedures: venovenous (V-V) ECMO for patients with respiratory failure and venoarterial (V-A) ECMO for circulatory support in cardiogenic shock.

Short-Term Neurologic Complications in Patients Undergoing Extracorporeal Membrane Oxygenation Support: A Review on Pathophysiology, Incidence, Risk Factors, and Outcomes

Regardless of the type, extracorporeal membrane oxygenation (ECMO) requires the use of large intravascular cannulas and results in multiple abnormalities including non-physiologic blood flow, hemodynamic perturbation, rapid changes in blood oxygen and carbon dioxide levels, coagulation abnormalities, and a significant systemic inflammatory response. Among other sequelae, neurologic complications are an important source of mortality and long-term morbidity. The frequency of neurologic complications varies and is likely underreported due to the high mortality rate. Neurologic complications in patients supported by ECMO include ischemic and hemorrhagic stroke, hypoxic brain injury, intracranial hemorrhage, and brain death. In addition to the disease process that necessitates ECMO, cannulation strategies and physiologic disturbances influence neurologic outcomes in this high-risk population. For example, the overall documented rate of neurologic complications in the venovenous ECMO population is lower, but a higher rate of intracranial hemorrhage exists. Meanwhile, in the venoarterial ECMO population, ischemia and global hypoperfusion seem to compose a higher percentage of neurologic complications. In what follows, the literature is reviewed to discuss the pathophysiology, incidence, risk factors, and outcomes related to short-term neurologic complications in patients supported by ECMO.

Retrospective ANalysis of multi-drug resistant Gram-nEgative bacteRia on veno-venous extracorporeal membrane oxygenation. The multicenter RANGER STUDY

BACKGROUND

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a rapidly expanding life-support technique worldwide. The most common indications are severe hypoxemia and/or hypercapnia, unresponsive to conventional treatments, primarily in cases of acute respiratory distress syndrome. Concerning potential contraindications, there is no mention of microbiological history, especially related to multi-drug resistant (MDR) bacteria isolated before V-V ECMO placement. Our study aims to investigate: (i) the prevalence and incidence of MDR Gram-negative (GN) bacteria in a cohort of V-V ECMOs; (ii) the risk of 1-year mortality, especially in the case of predetected MDR GN bacteria; and (iii) the impact of annual hospital V-V ECMO volume on the probability of acquiring MDR GN bacteria.

METHODS

All consecutive adults admitted to the Intensive Care Units of 5 Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records, survival < 24 h after V-V ECMO. A standard protocol of microbiological surveillance was applied and MDR profiles were identified using in vitro susceptibility tests. Cox-proportional hazards models were applied for investigating mortality.

RESULTS

Two hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall MDR GN bacteria percentage was 50%: 21% (n.59) detected before and 29% (n.80) after V-V ECMO placement. The overall 1-year mortality was 42%, with a higher risk observed in predetected patients (aHR 2.14 [1.33-3.47], p value 0.002), while not in 'V-V ECMO-acquired MDR GN bacteria' group (aHR 1.51 [0.94-2.42], p value 0.090), as compared to 'non-MDR GN bacteria' group (reference). Same findings were found considering only infections. A larger annual hospital V-V ECMO volume was associated with a lower probability of acquiring MDR GN bacteria during V-V ECMO course (aOR 0.91 [0.86-0.97], p value 0.002).

CONCLUSIONS

21% of MDR GN bacteria were detected before; while 29% after V-V ECMO connection. A history of MDR GN bacteria, isolated before V-V ECMO, was an independent risk factor for mortality. The annual hospital V-V ECMO volume affected the probability of acquiring MDR GN bacteria. Trial Registration ClinicalTrial.gov Registration Number NCTNCT06199141, date 12.26.2023.

Metabolic support for patients on extra-corporeal membrane oxygenation

PURPOSE OF REVIEW

The purpose of the review is to summarize recent research on metabolic support during extracorporeal membrane oxygenation. In this review, we cover the evidence on nutritional supplementation, both the route of supplementation, timing of initiation of supplementation as well as quantities of supplementation needed. In addition, we discuss the recent trend in awake extracorporeal membrane oxygenation (ECMO) and its benefits to patients.

RECENT FINDINGS

As ECMO use continues to increase over the last few years, for both cardiovascular as well as respiratory failure, the need to optimize the metabolic states of patients has arisen. Increasing evidence has pointed towards this hitherto unexplored domain of patient care having a large impact on outcomes. Additionally, strategies such as awake ECMO for select patients has allowed them to preserve muscle mass which could aid in a faster recovery.

SUMMARY

There is a role of optimal metabolic support in the early recovery of patients on ECMO that is currently under-recognized. Future directions of research that aim to improve post ECMO outcomes must focus on this area.

Polyuria in COVID-19 Patients Undergoing Extracorporeal Membrane Oxygenation

Background: The COVID-19 pandemic caused an unprecedented number of patients requiring veno-venous extracorporeal membrane oxygenation (VV ECMO) therapy. Clinical polyuria was observed at our ECMO center during the pandemic. This study aims to investigate the incidence, potential causes, and implications of polyuria in COVID-19 patients undergoing VV ECMO therapy. Methods: Here, 68 SARS-CoV-2 positive patients receiving VV ECMO were stratified into the following two groups: polyuria (PU), characterized by an average urine output of ≥3000 mL/day within seven days following initiation, and non-polyuria (NPU), defined by <3000 mL/day. Polyuria in ECMO patients occurred in 51.5% (n = 35) within seven days after ECMO initiation. No significant difference in mortality was observed between PU and NPU groups (60.0% vs. 60.6%). Differences were found in the fluid intake (p < 0.01) and balance within 24 h (p = 0.01), creatinine (p < 0.01), plasma osmolality (p = < 0.01), lactate (p < 0.01), urea (p < 0.01), and sodium levels (p < 0.01) between the groups. Plasma osmolality increased (p < 0.01) after ECMO initiation during the observation period. Results: Diuresis and plasma osmolality increased during VV ECMO treatment, while mortality was not affected by polyuria. Conclusions: Polyuria does not appear to impact mortality. Further investigations are warranted to elucidate its underlying mechanisms and clinical implications in the context of VV ECMO therapy and COVID-19 management.

Flexible fibreoptic bronchoscopy is beneficial in children on extracorporeal membrane oxygenation support

BACKGROUND

Flexible fibreoptic bronchoscopy (FFB) has the potential to enhance diagnostic capabilities and improve pulmonary function in children on extracorporeal membrane oxygenation (ECMO).

OBJECTIVES

The objective of this study was to evaluate the benefits (clinical, radiological, and microbiological) of FFB and assess associated complications in children on ECMO.

METHODS

We conducted a single-centre retrospective observational cohort study in a tertiary paediatric intensive care unit. All FFB episodes performed during the study period on children aged 0-18 years on ECMO were included.

RESULTS

Out of the 155 children who received ECMO, 36 (23%) underwent a total of 92 episodes of FFB. FFB provided anatomical and pathological information in 53% (19/36) of cases and proved beneficial in clearing the airways in 62% (54/87) of the episodes. Overall, patients exhibited transient increases in ECMO and mechanical ventilation support 1 h post FFB in 14% (13/92) and 9.7% (9/92) episodes, respectively. At 6 h, the mean fraction of inspired oxygen on the mechanical ventilator was lower (0.46 [±0.21] vs 0.53 [±0.21] p < 0.01), with no change in mean airway pressure. Similarly, compared to pre-FFB, the fraction of inspired oxygen on the mechanical ventilator on ECMO was lower at 6 h and 24 h (0.65 [±0.25] vs 0.71 [±0.23] p < 0.01 and 0.006, respectively), with no significant change in the sweep gas flow and ECMO flow. The radiological imaging indicated improved or stable findings in 91% (83/91) of FFB episodes. FFB contributed to the identification of new and previously unknown microbiological information in 75% (27/36) of the patients. The incidence of major complications was 7.6%. Minor self-resolving bleeding occurred in 25% (23/92) episodes, and major bleeding occurred in two episodes, with a total of 10 episodes needing blood product transfusion.

CONCLUSIONS

FFB is a valuable adjunct in managing children with severe respiratory failure on ECMO, offering clinical benefits with a low rate of major complications. Further studies should aim to develop a consensus approach encompassing criteria and clinical management around FFB in patients on ECMO.

Pa o2 and Mortality in Neonatal Extracorporeal Membrane Oxygenation: Retrospective Analysis of the Extracorporeal Life Support Organization Registry, 2015-2020

OBJECTIVES

Extracorporeal life support can lead to rapid reversal of hypoxemia but the benefits and harms of different oxygenation targets in severely ill patients are unclear. Our primary objective was to investigate the association between the Pa o2 after extracorporeal membrane oxygenation (ECMO) initiation and mortality in neonates treated for respiratory failure.

DESIGN

Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry data, 2015-2020.

PATIENTS

Newborns supported by ECMO for respiratory indication were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pa o2 24 hours after ECMO initiation (H24 Pa o2 ) was reported. The primary outcome was 28-day mortality. We identified 3533 newborns (median age 1 d [interquartile range (IQR), 1-3]; median weight 3.2 kg [IQR, 2.8-3.6]) from 198 ELSO centers, who were placed on ECMO. By 28 days of life, 731 (20.7%) had died. The median H24 Pa o2 was 85 mm Hg (IQR, 60-142). We found that both hypoxia (Pa o2 < 60 mm Hg) and moderate hyperoxia (Pa o2 201-300 mm Hg) were associated with greater adjusted odds ratio (aOR [95% CI]) of 28-day mortality, respectively: aOR 1.44 (95% CI, 1.08-1.93), p = 0.016, and aOR 1.49 (95% CI, 1.01-2.19), p value equals to 0.045.

CONCLUSIONS

Early hypoxia or moderate hyperoxia after ECMO initiation are each associated with greater odds of 28-day mortality among neonates requiring ECMO for respiratory failure.

In-hospital mortality, comorbidities, and costs of one million mechanically ventilated patients in Germany: a nationwide observational study before, during, and after the COVID-19 pandemic

Background

Even more than hospital care in general, intensive care and mechanical ventilation capacities and its utilization in terms of rates, indications, ventilation types and outcomes vary largely among countries. We analyzed complete and nationwide data for Germany, a country with a large intensive care sector, before, during and after the COVID-19 pandemic.

Methods

Analysis of administrative claims data, provided by the German health insurance, from all hospitals for all individual patients who were mechanically ventilated between 2019 and 2022. The data included age, sex, diagnoses, length of stay, procedures (e.g., form and duration of mechanical ventilation), outcome (dead vs. alive) and costs. We included all patients who were at least 18 years old at the time of discharge from January 1st, 2019 to December 31st, 2022. Patients were grouped according to year, age group and the form of mechanical ventilation. We further analyzed subgroups of patients being resuscitated and those being COVID-19 positive (vs. negative).

Findings

During the four years, 1,003,882 patients were mechanically ventilated in 1395 hospitals. Rates per 100,000 inhabitants varied across age groups from 110 to 123 (18-59 years) to 1101-1275 (>80 years). The top main diagnoses were other forms of heart diseases, pneumonia, chronic obstructive pulmonary disease (COPD), ischemic heart diseases and cerebrovascular diseases. 43.3% (437,031/1,003,882) of all mechanically ventilated patients died in hospital with a remarkable increase in mortality with age and from 2019 to 2022 by almost 5%-points. The in-hospital mortality of ventilated COVID-19 patients was 53.7% (46,553/86,729), while it was 42.6% (390,478/917,153) in non-COVID patients. In-hospital mortality varied from 27.0% in non-invasive mechanical ventilation (NIV) only to 53.4% in invasive mechanical ventilation only cases, 59.4% with early NIV failure, 68.6% with late NIV failure, to 74.0% in patients receiving VV-ECMO and 80.0% in VA-ECMO. 17.5% of mechanically ventilated patients had been resuscitated before, of whom 78.2% (153,762/196,750) died. Total expenditure was around 6 billion Euros per year, i.e. 0.17% of the German GDP.

Interpretation

Mechanical ventilation was widely used, before, during and after the COVID-19 pandemic in Germany, reaching more than 1000 patients per 100,000 inhabitants per year in the age over 80 years. In-hospital mortality rates in this nationwide and complete cohort exceeded most of the data known by far.

Funding

This research did not receive any dedicated funding.

Extracorporeal Membrane Oxygenation for Respiratory Failure: A Narrative Review

Extracorporeal membrane oxygenation support for respiratory failure in the intensive care unit continues to have an expanded role in select patients. While acute respiratory distress syndrome remains the most common indication, extracorporeal membrane oxygenation may be used in other causes of refractory hypoxemia and/or hypercapnia. The most common configuration is veno-venous extracorporeal membrane oxygenation; however, in specific cases of refractory hypoxemia or right ventricular failure, some patients may benefit from veno-pulmonary extracorporeal membrane oxygenation or veno-venoarterial extracorporeal membrane oxygenation. Patient selection and extracorporeal circuit management are essential to successful outcomes. This narrative review explores the physiology of extracorporeal membrane oxygenation, indications and contraindications, ventilator management, extracorporeal circuit management, troubleshooting hypoxemia, complications, and extracorporeal membrane oxygenation weaning in patients with respiratory failure. As the footprint of extracorporeal membrane oxygenation continues to expand, it is essential that clinicians understand the underlying physiology and management of these complex patients.

Femoro-axillary versus femoro-femoral veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock: A monocentric retrospective study

RATIONALE

For veno-arterial extracorporeal membrane oxygenation (ECMO), the femoral artery is the preferred cannulation site (femoro-femoral: Vf-Af). This results in retrograde aortic flow, which increases the left ventricular afterload and can lead to severe pulmonary edema and thrombosis of the cardiac chambers. Right axillary artery cannulation (femoral-axillary: Vf-Aa) provides partial anterograde aortic flow, which may prevent some complications. This study aimed to compare the 90-day mortality and complication rates between VF-AA and VF-AF.

METHODS

Consecutive adult patients with cardiogenic shock who received peripheral VA-ECMO between 2013 and 2019 at our institution were retrospectively included. The exclusion criteria were refractory cardiac arrest, multiple VA-ECMO implantations due to vascular access changes, weaning failure, or ICU readmission. A statistical approach using inverse probability of treatment weighting was used to estimate the effect of the cannulation site on the outcomes. The primary endpoint was the 90-day mortality. The secondary endpoints were vascular access complications, stroke, and other complications related to retrograde blood flow. Outcomes were estimated using logistic regression analysis.

RESULTS

VA-ECMO was performed on 534 patients. Patients with refractory cardiac arrest (n = 77 (14%)) and those supported by multiple VA-ECMO (n = 92, (17%)) were excluded. Out of the 333 patients studied (n = 209 Vf-Aa; n = 124 VF-AF), the main indications for VA-ECMO implantation were post-cardiotomy (33%, n = 109), dilated cardiomyopathy (20%, n = 66), post-cardiac transplantation (15%, n = 50), acute myocardial infarction (14%, n = 46) and other etiologies (18%, n = 62). The median SOFA score was 9 [7-11], and the crude 90-day mortality rate was 53% (n = 175). After IPTW, the 90-day mortality was similar in the Vf-Aa and VF-AF groups (54% vs 58%, IPTW-OR = 0.84 [0.54-1.29]). Axillary artery cannulation was associated with significantly fewer local infections (OR = 0.21, 95% CI:0.09-0.51), limb ischemia (OR = 0.37, 95% CI:0.17-0.84), bowel ischemia (OR = 0.16, 95% CI:0.05-0.51) and pulmonary edema (OR = 0.52, 95% CI:0.29-0.92) episodes, but with a higher rate of stroke (OR = 2.87, 95% CI:1.08-7.62) than femoral artery cannulation.

CONCLUSION

Compared to VF-AF, axillary cannulation was associated with similar 90-day mortality rates. The high rate of stroke associated with axillary artery cannulation requires further investigation.

Meconium Aspiration Syndrome, Hypoxic-Ischemic Encephalopathy and Therapeutic Hypothermia-A Recipe for Severe Pulmonary Hypertension?

Hypoxic-ischemic encephalopathy (HIE) is the leading cause of mortality among term newborns globally. Infants born through meconium-stained amniotic fluid are at risk of developing meconium aspiration syndrome (MAS) and HIE. Simultaneous occurrence of MAS and HIE is a perilous combination for newborns due to the risk of persistent pulmonary hypertension of the newborn (PPHN). Moreover, therapeutic hypothermia (TH), which is the current standard of care for the management of HIE, may increase pulmonary vascular resistance (PVR) and worsen PPHN. Infants with MAS and HIE require close cardiorespiratory and hemodynamic monitoring for PPHN. Therapeutic strategies, including oxygen supplementation, ventilation, use of surfactant, inhaled nitric oxide and other pulmonary vasodilators, and systemic vasopressors, play a critical role in the management of PPHN in MAS, HIE, and TH. While TH reduces death or disability in infants with HIE, infants with MAS and HIE undergoing TH need close hemodynamic monitoring for PPHN.

The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO

Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.