Intensive Care Med (2001) 27: 16431648

DOI 10.1007/s001340101060

NE ON ATA L A ND PE DI ATR IC IN TENS IVE CA RE

Inter-hospital transportation of patients

with severe acute respiratory failure on
extracorporeal membrane oxygenation
national and international experience

V. Lindn
K. Palmr
J. Reinhard
R. Westman
H. Ehrn
T. Granholm
B. Frenckner

Received: 5 February 2001

Final revision received: 18 June 2001
Accepted: 17 July 2001
Published online: 23 August 2001
 Springer-Verlag 2001

H. Ehrn T. Granholm B. Frenckner ( )

Department of Pediatric Surgery,
Astrid Lindgren Children's Hospital,
Karolinska Hospital, Karolinska Institutet,
SE-171 76 Stockholm, Sweden
E-mail: bjorn.frenkner@ks.se
Phone: +46-8-51 77 76 96
Fax: +46-8-51 77 77 12
V. Lindn K. Palmr J. Reinhard
R. Westman
Department of Pediatric Anesthesiology
and Intensive Care,
Astrid Lindgren Children's Hospital,
Karolinska Hospital, Karolinska Institutet,
Stockholm, Sweden

Abstract Objective: To evaluate the

experiences and results from interhospital transportation of patients
with acute respiratory failure on extracorporeal membrane oxygenation (ECMO).
Design: Observational, descriptive
study.
Setting: Tertiary referral center in a
University Hospital.
Subjects and methods: When standard ECMO criteria were fulfilled
and the patient considered too unstable for a conventional transport,
the mobile ECMO team cannulated
the patient for ECMO at the referring hospital. The patients were then
transported to our ECMO center by
ground ambulance, helicopter or
fixed-wing vehicle. Patients were
also transported on ECMO from
our ECMO center to other centers
due to shortage of available ECMO
beds.
Results: 29 patients (15 neonates,
seven pediatric, and seven adult patients) with acute respiratory failure
were transported on ECMO on a
total of 30 occasions. Median time
from arrival of the ECMO team at
the referring hospital until the patient was on ECMO (28 patients)

Introduction
Extracorporeal membrane oxygenation (ECMO) [1] is
used in the treatment of patients with extremely severe
but potentially reversible pulmonary disorders. Today

was 2.2 h (range 1.254.25 h). The

median time that the transport team
was out was 10 h (range 5.536.5 h)
and the median time with the patient was 6 h (range 330.5 h). The
distance of transport ranged from
41,500 km. Six transports were international. No patient complications occurred during the transports.
Two technical complications related
to the transport vehicle were encountered. One ambulance compressor malfunctioned. During one
helicopter transport, one out of two
electric supply circuits malfunctioned. The patients were not affected. Twenty-one of the 29 patients survived to discharge (72 %).
None of the deaths was transport
related.
Conclusions: Tertiary intensive care
units and ECMO centers require a
dedicated transport team. ECMO
transports can be performed safely
for all age groups for long distances,
probably throughout most of Europe.
Keywords ECMO Respiratory
failure Transportation Interhospital ARDS

over 22,000 patients have been reported by about 120

ECMO centers [2]. The overall survival rate is 86 %,
62 %, and 54 % in neonates, pediatric patients, and adult
patients with respiratory failure, respectively. In neonates several randomized studies have proven ECMO

1644

Methods and materials

Inter-hospital transportation of patients on ECMO involves transport to the referring hospital, cannulation, and transport to an
ECMO center. It requires suitable equipment and experienced
personnel.
Indications for transfer on ECMO
When the ECMO team was contacted by the referring hospital, a
decision was made to send the ECMO transport team if the patient
fulfilled standard ECMO criteria [1] and was considered too unstable for a conventional transport. Distance of transport, hemodynamic instability, mode of ventilation, and rate of deterioration
were all taken in consideration. If ECMO criteria were not met or
if the patient was considered stable enough to sustain a conventional transport safely this was arranged. Equipment for transports
on nitric oxide was not available during the study period.
Upon arrival at the referring hospital the patient was immediately reevaluated and a definitive decision was made if ECMO
should be initiated or not.
Equipment

Fig. 1 The mobile ECMO cart for inter-hospital transportation

to be a life-saving therapy [3, 4]. In adult patients several

non-randomized studies have shown promising results
[5, 6, 7, 8]. A prospective randomized study is currently
being undertaken in order to evaluate survival compared to conventional therapy [9].
The patients should ideally be transported to an
ECMO center before they become critically unstable
and impossible to transport by conventional means.
Sometimes, however, the course is unexpected and the
patients may deteriorate extremely quickly. The addition of inhaled nitric oxide and high-frequency oscillatory ventilation in modern intensive care has also contributed to the complexity of patient transportation. Several
ECMO centers [10, 11, 12, 13] have therefore developed
techniques for inter-hospital transportation of patients
on ECMO. Since 1996 this facility with mobile ECMO
has been available in our center.
The aim of the present report is to retrospectively review the technique and equipment for inter-hospital
ECMO transport and to evaluate the patient outcome.

A mobile ECMO cart for inter-hospital transports has been developed and customized (Fig. 1). A Stckert roller pump (10-00-00)
was mounted on the cart together with a bladder box (Seebrooke
SMS 3200), heating device (Seebrooke SMS 3000), blood pressure
(pre-oxygenator) monitoring device (Stckert control unit), and a
device for intracircuit saturation measurements (Baxter Oxysat).
The cart was equipped with handles so that it can easily be lifted
into the transport vehicle and firmly attached inside the vehicle.
A separate battery (Fiskars PS 20/1.6, 220 V, sine curve, 1,100 W,
5 Ah) was used for power backup during transport between the
ICU and transport vehicle. Standard ECMO disposables (Avecor
membrane oxygenator, Avecor heat exchanger, PVC tubing, Supertygon for raceway tubing, Avecor silicone rubber bladder) were
used with the size of the devices adjusted to the weight of the patient. An additional length of tubing was added to the circuit to facilitate patient movement while onloading and offloading in the
transport vehicle.
All electric items were tested individually regarding the electromagnetic field, after which the assembled total equipment was
tested together. The test protocols were scrutinized by The Swedish Board of Civil Aviation and the equipment was approved for
use in helicopter and aircraft.
Personnel
The transport team on call (24 h/day, all year round) consisted of
one ECMO physician, one ECMO coordinator, and one cannulating surgeon. The team had several years of ECMO experience,
were very familiar with transports, and were ready for take off
within 60120 min.
Transport to referring hospital
The transport to the referring hospital aimed to bring the personnel and equipment as quickly as possible to the patient. The mode
of transport depended upon the distance, the availability of the

1645

Table 1 Data of patients transported on ECMO. Diagnosis is given in neonates and cause of ARDS in pediatric and adult patients.
Distance refers to the distance patient has been transported on
ECMO. Transit time (h) includes on- and offloading of the patient
and ECMO machine. [MAS meconium aspiration syndrome, pnth
Patient no. Age

Neonates
1
< 1 day
2
3 days
3
1 day
4
3 days
5
19 days
6a
< 1 day
7
1 day
8
1 day
9
< 1 day
10
< 1 day
11
< 1 day
12
14 days
13
< 1 day
14
2 days
15b
< 1 day
Pediatric patients
16
10 years
17b
1 year

Sex

Diagnosis

OI

M
M
M
M
M
F
F
F
M
M
M
F
F
F
F

MAS+pnth
Sepsis
PPHN
PPHN+pnth
CDH
MAS
MAS
CDH
MAS
MAS
CDH
CDH
MAS
CDH
CDH

59
43
85
63
44
117
110
138
140
88
50
57
160
114
135

M
M

Post-trauma
ALL+BMX+viral pneumonia
Post-burn
Aspiration
Hodgkin+BMX+viral pneumonia

pneumothorax, PPHN persistent pulmonary hypertension of the

newborn, CDH congenital diaphragmatic hernia, ALL acute lymphatic leukemia, BMX bone marrow transplantation, OI oxygenation index, P/F ratio PaO2/FiO2 (mmHg)]

P/F
Murray
ratio score

Distance Transit Mode of

(km)
time (h) transport
to referring
hospital

Mode of
transport
to ECMO
center

Total
time on
ECMO
(h)

Outcome

207
4
207
411
585
4
313
585
760
207
800
1,200
313
70
585

5.0
0.8
3.0
4.5
4.0
1.0
2.0
4.0
4.5
2.3
4.0
5.3
1.25
2.0
4.5

Helicopter
Taxi-cab
Helicopter
Taxiplane
Helicopter
Taxi-cab
Helicopter
Helicopter
MD-80
Helicopter
Taxiplane
Hercules
Helicopter
Taxi-cab
Taxiplane

Ground
Ground
Ground
Ground
Helicopter
Helicopter
Helicopter
Helicopter
Helicopter
Ground
Helicopter
Hercules
Helicopter
Ground
Hercules

77
65
22
86
126
107
76
114
78
45
447
122
140
52
109+181

Survived
Survived
Survived
Survived
Died
Survived
Survived
Died
Survived
Survived
Survived
Survived
Died
Survived
Survived

4
70

1.0
1.5

Taxi-cab
Taxi-cab

Ground
187
Survived
Helicopter 122+774 Died

68
40

3
-

36
32
55

4
3
3.5

70
650
4

2.0
4.0
2.0

Taxi-cab
Taxiplane
Taxi-cab

Helicopter 111
Died
Helicopter 18
Survived
Ground
167+1016 Died

50
35
54
54
46

3
4
3.75
3.5
3.75

180
180
70
663
723

6.0
1.0
1.5
3.5
3.5

Helicopter
Helicopter
Taxi-cab
Helicopter
Taxiplane

Ground
Helicopter
Ground
Helicopter
Hercules

52

3.5

70

2.0

Taxi

Helicopter 259

Died

Transports to other ECMO centers

38
M
Pneumonia
27c

43
50

70
6.0
1,500

1.0
4.0

Taxi-cab
Jet
Hercules

Helicopter
216
Hercules
168

Died

28

3.75
1,400
-

Survived

51

700

4.5

Helicopter 192

Survived

18
19
20b

3 years M
0.4 yearsF
17
M

Adult patients
21
37 years
22
17 years
23
42 years
24
42 years
25b
23 years
26

29

F
F
M
M
F

30 years M

4 years M
14 years F

Sepsis
Post-trauma
Pneumonia
Pneumonia
Pulm embolism
Post-trauma,
septicemia

ALL+aspiration
Wegener

258
66
295
280
350+144

Survived
Survived
Survived
Survived
Survived

The ICU ambulance used for ECMO transports was out of order
on this occasion
b
Patients have had two ECMO runs

This patient was transported twice, first from referring hospital to

Stockholm and eventually to a British ECMO center

transport vehicle, and the weather. The following modes have been
used: Taxi-cab, ground ambulance, helicopter (Sikorsky S-76), regular aircraft (SAS MD-80), taxiplane, and military cargo aircraft
(Hercules) (Table 1).

Transport to ECMO center on ECMO

The mode of transport to the ECMO center also depended upon
the distance, the availability of the transport vehicle, and the
weather. Ground ambulance (a specially designed ICU ambulance
with enough space for the ECMO cart), helicopter (Sikorsky S-76),

1646

Fig. 2 The ICU ambulance

with an ECMO patient entering
the Hercules military cargo aircraft

jet plane (Citation 3), and military cargo aircraft (Hercules) have
been used (Table 1).
The transport vehicle was equipped with an adequate power
supply (220 V, sine curve, 2,000 W in ground ambulance, 1,500 W
in helicopter and aircraft) to support the ECMO machine, including heater and other medical equipment.
The patient was loaded into the ground ambulance or helicopter at the referring hospital and brought directly back to the
ECMO center. When transporting with the military cargo aircraft
the patient was loaded into the ground ambulance which, after
having driven to the airport, entered the aircraft itself (Fig. 2) and
after landing the ambulance brought the patient to the ECMO center. The patient, therefore, had to be on- and offloaded only once.
Patient care
Standard indications for ECMO were used [1]. Initially, all patients
who were to be transported on ECMO were cannulated for venoarterial (v-a) bypass [14], but towards the end of the period, patients who were hemodynamically stable were instead cannulated
for veno-venous (v-v) bypass. V-a cannulation was performed as a
surgical cut-down procedure, while v-v cannulation either was
done with a cut-down procedure or with a percutaneous technique.
As soon as the patient was stable on ECMO, transport back to the
ECMO center was prepared.
The patients were ventilated with a Siemens 300 ventilator on
rest settings during transport and were monitored according to
standard routines [8].
Materials
From January 1996 until December 2000 the ECMO transport
team was launched for ECMO transportation on 36 occasions. On
28 of these 36 occasions the patient (15 neonatal, seven pediatric
and seven adult patients) was cannulated for ECMO at the referring hospital. Twenty-seven of the 28 cannulated patients were
transported to our own center (Table 1, patients 127). One cannu-

lated patient (no. 28) was instead transported to Great Britain due
to a shortage of available ECMO beds.
Two patients (no. 27 and 29) have been transported on ECMO
from our own center. Due to a shortage of personnel, there was a
short period with no ECMO beds available and two patients had
to be transported on ECMO to Denmark and Great Britain, respectively.
In two instances the patient died before the team reached the
referring hospital and on four occasions the patients did not fulfill
ECMO entry criteria and could be transported or managed at the
referring hospital without ECMO.
One patient (no. 27) was thus transported twice, first from the
referring hospital and then after 2 days on ECMO in Stockholm
to Great Britain.
Consequently, a total of 29 patients have been transported on
ECMO on 30 occasions (Table 1). Age, sex, and diagnosis are given in the table. In neonates, oxygenation index, and in older patients, P/F ratio (PaO2/FIO2) and Murray score [15], were among
other parameters evaluated before initiation of ECMO and are
also given in Table 1.
During the same period a total of 91 patients were treated on
ECMO at our center. Twenty additional patients were transported
to us by conventional means for ECMO, but did not fulfill ECMO
criteria and were thus treated with conventional intensive care.

Results
Cannulations at referring hospitals were all uneventful.
Median time between ECMO request from the referring hospital and start of ECMO was 5.5 h (range
412 h), which also included mobilization of the transport team and transport to the referring hospital. Median time from arrival of the ECMO team until the patient was on bypass was 2.2 h (range 1.254.25 h). This
included time for reevaluation of the patient for
ECMO as well as for priming the ECMO circuit and

1647

cannulation. Median time that the transport team was

out was 10 h (range 5.536.5 h) and median time for
the team taking care of the patient was 6 h (range
330.5 h).
Five of the 30 transports on ECMO were performed
by fixed-wing vehicles, 15 by helicopter, and ten by
ground ambulance (Table 1). The distance from the referring hospital was on average 330 km (range
41200 km) among the 27 patients cannulated elsewhere and transported to our center. One patient (patient no. 28) was cannulated on Iceland (2,300 km from
Stockholm) and brought on ECMO to Great Britain
(1,500 km). Six transports were international (Norway,
Denmark, Iceland, and Great Britain) and 24 transports
were domestic. Twenty patients were transported on
veno-arterial bypass and seven on veno-venous bypass.
No patient complications occurred during the 30
transportations on ECMO. All patients arrived at the
ECMO center with stable extra corporeal bypass, stable
hemodynamics, desired blood gases, and ACT levels.
There were two technical complications with the
transport vehicles. In patient no. 21 the ambulance compressor malfunctioned, disabling the vehicle's shock absorbers. The speed of the ambulance was therefore reduced to 1015 mph, which increased the time for this
transport to 6 h. Extra oxygen had to be delivered to
the ambulance during the transport. The second complication was during transport of patient no. 29. One of the
two electric supply circuits in the helicopter went down
30 min after take off and was out of order during the remaining part of the transport. There was electric supply
for the pump but there were no lights in the cabin other
than flash lights. The patients were not affected by the
technical complications.
Eventually, 12 out of 15 neonates, four out of seven
pediatric patients, and five out of seven adult patients
survived. The total survival was thus 21 of 29 patients
(72 %). The cause of death was not related to the transport in any case.

Discussion
ECMO is an extremely invasive therapy used in critically ill patients with life-threatening respiratory failure.
When patients deteriorate extremely quickly, or are
treated with inhaled nitric oxide, prone position and/or
high-frequency oscillatory ventilation (HFOV), a situation may arise where it is practically impossible to transport the patient by conventional means. In the authors'
experience, many patients on HFOV do not tolerate
conversion to conventional ventilation. This justifies
the development of transport facilities on ECMO.
Transport on extracorporeal bypass was first described by Cornish [16]. Since then, other centers have
transported neonates [11, 12], pediatric patients [13,

17], and adult patients [13, 17, 18]. To our knowledge

only a handful of ECMO centers are today offering a
complete transport facility including ground ambulance,
helicopter and fixed-wing vehicles for all age groups
[19]. Two centers have reported a larger experience
than the present. In the largest single ECMO material
[10] the vast majority of the 1,000 reported patients
were referred from other centers by conventional
means, but 10 % (100 patients) needed transport on
ECMO. The second largest experience on ECMO transports include 50 patients transported by ground, by
fixed-wing vehicles or by helicopter [20]. Essentially
the same indications for transport on ECMO were used
as outlined above. There were no life-threatening complications. Since the start of ECMO transports in our
center in 1996, 32 % (29 out of 91) of our ECMO patients were transported on ECMO.
The experience from the present 30 transports shows
that it is possible to safely transport neonates, children,
and adult patients on ECMO for up to at least 6 h. The
longest transport performed was 1,500 km by a Hercules
aircraft, taking 4 h including ground transports to and
from airports. The actual flight time was only about 2 h
indicating that on- and offloading the patient from the
ambulance, ground transports, and on- and offloading
the ambulance from the aircraft are time-consuming
procedures. However, only on- and offloading the patient from the ambulance affects the patient care and involves a potential risk. Adding 1 h to the transport time
will add an extra 700 km in transport range. It is easily
concluded that transporting patients on ECMO in this
way is possible for all age groups throughout all Europe.
Time from ECMO request until the patient is on ECMO
will, however, obviously increase with increasing distance.
The described transports have been performed with
a specially designed mobile cart using a roller pump
and an ECMO circuit much resembling the hospital
bedside setting used in our unit, although smaller and
more compact. It was considered an advantage using
equipment that the team was already used to when initiating the ECMO transports. Presently, another smaller
transport circuit based on a centrifugal pump is being
developed.
Transporting patients on extracorporeal support is
obviously more complicated and resource dependent
than a conventional transport of a stable critically ill patient. Ideally, patients who may become ECMO candidates should be transported to an ECMO center before
they become critically unstable. Transporting on
ECMO requires a larger transport team including a cannulation surgeon and more equipment. A larger transport vehicle may also be required. When evaluating the
costs of transportation, it should, however, be born in
mind that only patients fulfilling standard ECMO criteria have been cannulated. The additional costs for trans-

1648

porting patients on ECMO compared to a conventional

transport, can therefore be estimated as the additional
costs for the larger transport team and transport vehicle.
It is obvious from our own experience as well as from
others [19] that transporting patients on ECMO requires a strict organization resembling a military action
with all procedures described in detailed protocols. The
team has to be trained continuously and must be pre-

pared to face unexpected situations and be open for

technical innovations.
Tertiary intensive care units and ECMO centers require a dedicated transport team to transfer patients
long distances. It is concluded that transports with patients on ECMO can be performed safely for long distances, probably throughout most of Europe. However,
patients should ideally be transported at an earlier stage
when a conventional transport is still possible.

References
1. Zwischenberger JB, Bartlett RH
(2000) ECMO extracorporeal cardiopulmonary support in critical care. Extracorporeal Life Support Organization, Ann Arbor
2. Anonymous (2001) ECMO Registry of
the Extracorporeal Life Support Organization (ELSO). Extracorporeal Life
Support Organization, Ann Arbor
3. Anonymous (1996) UK collaborative
randomised trial of neonatal extracorporeal membrane oxygenation. UK
Collaborative ECMO Trial Group.
Lancet 348: 7582
4. O'Rourke PP, Crone RK, Vacanti JP,
Ware JH, Lillehei CW, Parad RB, Epstein MF (1989) Extracorporeal membrane oxygenation and conventional
medical therapy in neonates with persistent pulmonary hypertension of the
newborn: a prospective randomized
study. Pediatrics 84: 957963
5. Kolla S, Awad SA, Rich PB, Schreiner
RJ, Hirschl RB, Bartlett RH (1997)
Extracorporeal life support for 100
adult patients with severe respiratory
failure. Ann Surg 226: 544566
6. Lewandowski K, Rossaint R, Pappert
D, Gerlach H, Slama KJ, Weidemann
H, Frey DJ, Hoffmann O, Keske U,
Falke KJ (1997) High survival rate in
122 ARDS patients managed according
to a clinical algorithm including extracorporeal membrane oxygenation. Intensive Care Med 23: 819835
7. Peek GJ, Killer HM, Sosnowski AW,
Firmin RK (1998) Extracorporeal
membrane oxygenation: potential for
adults and children? Hospital Medicine
59: 304308

8. Lindn V, Palmr K, Reinhard J, Westman R, Ehrn H, Granholm T, Frenckner B (2000) High survival in adult patients with ARDS treated by extracorporeal membrane oxygenation, minimal sedation, and pressure supported
ventilation. Intensive Care Med 26:
16301637
9. Peek GJ (1999) 10th Annual meeting
of the extracorporeal life support organization. Extracorporeal Life Support
Organization, Ann Arbor
10. Bartlett RH, Roloff DW, Custer JR,
Younger JG, Hirschl RB (2000) Extracorporeal life support. The University
of Michigan experience. JAMA 283:
904908
11. Cornish JD, Carter JM, Gerstmann
DR, Null DMJ (1991) Extracorporeal
membrane oxygenation as a means of
stabilizing and transporting high risk
neonates. ASAIO Trans 37: 564568
12. Heulitt MJ, Taylor BJ, Faulkner S,
Baker LL, Chipman C, Harrell JH,
VanDevanter SH (1995) Inter-hospital
transport of neonatal patients on extracorporeal membrane oxygenation: mobile-ECMO. Pediatrics 95: 562566
13. Rossaint R, Pappert D, Gerlach H, Lewandowski K, Keh D, Falke K (1997)
Extracorporeal membrane oxygenation for transport of hypoxaemic patients with severe ARDS. Br J Anaesth
78: 241246
14. Bartlett RH (1995) Management of
ECLS in adult respiratory failure. In:
Zwischenberger JB, Bartlett RH (eds)
ECMO Extracorporeal cardiopulmonary support in critical care. Extracorporeal Life Support Organization,
Ann Arbor, pp 401414

15. Murray JF, Matthay MA, Luce JM,

Flick MR (1988) An expanded definition of the adult respiratory distress
syndrome [published erratum appears
in Am Rev Respir Dis (1989) 139:
1065]. Am Rev Respir Dis 138: 720723
16. Cornish JD, Gertsmann DR, Null DM,
Ackerman NB (1986) Inflight use of
extracorporeal membrane oxygenation
for severe neonatal respiratory failure.
Perfusion 1: 281287
17. Schreiner RT, Harrington HR, Chapman RA, Schreiner RJ, Bartlett RH
(1997) Transport of patients on
ECMO. 8th Annual meeting of the Extracorporeal Life Support Organization, Detroit
18. Bennett JB, Hill JG, Long WB, Bruhn
P, Haun M, Parsons JA (1994) Interhospital transport of the patient on extracorporeal cardiopulmonary support.
Ann Thorac Surg 57: 107111
19. Copenhaver WG, WinklerPrins AC
(1999) Transport on extracorporeal life
support. In: VanMeurs K (ed) ECMO
Specialist training manual. 2nd edn.
Extracorporeal Life Support Organization, Ann Arbor, pp 211236
20. Taylor BJ, Moss MM, Heulitt MJ
(2000) Referral and transport of
ECMO patients. In: Zwischenberger
JB, Steinhorn RH, Bartlett RH (eds)
ECMO Extracorporeal cardiopulmonary support in critical care. Extracorporeal Life Support Organization,
Ann Arbor, pp 645658

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