97230 PRF28610.1177/0267659113497230PerfusionMongero et al.

Original Paper

Perfusion
28(6) 552­–554
Managing the extracorporeal membrane © The Author(s) 2013
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DOI: 10.1177/0267659113497230
safety utilizing the perfusionist as the prf.sagepub.com

“ECMO Specialist”

LB Mongero, JR Beck and KA Charette

Abstract
Extracorporeal membrane oxygenation (ECMO) is an extracorporeal technique of providing both cardiac and respiratory
support to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their
function. Neonatal and pediatric ECMO was accepted as practice in the early 1990s and according to the Extracorporeal
Life Support Organization, ELSO; of the >50,000 patients registered, 73% have survived extracorporeal life support
(ECLS). It is not uncommon to find initial cannulation of a patient receiving ECMO performed by a surgeon and then the
maintenance of the patient being left in the hands of various others deemed as the “ECMO Specialists”. The specialist
has a broad base of professionals, including: nurses, respiratory therapists, perfusionists and physicians. Each institution,
having its own unique training for these individuals, has provided a milieu for education, but does not share an established
standard of care. From 2009, after the surge of the H1N1 epidemic, adult ECMO has been increasing; n=53 in 2010 to
n=110 in 2012 at our institution. The perfusionist has been the “specialist” for ECMO at our institution since the early
1990s and remained at bedside during ECMO. We have now developed a safe circuit and fiscally responsible staffing
model that utilizes a perfusionist and a telemetry-based electronic record keeper, permitting the perfusionist to leave the
bedside and interact with the circuit when necessary. This has permitted an expansive growth of ECMO in our intensive
care units at our facility incorporating a multidisciplinary collaboration system wide.

Keywords
extracorporeal membrane oxygenation; ECMO specialist; perfusionist; ECLS; ECMO

Introduction
Extracorporeal membrane oxygenation (ECMO) is a
form of cardiopulmonary bypass used to treat severe
pulmonary or cardiopulmonary failure. Neonatal ECMO
has been the prevalent population for the past two
decades as reported by the Extracorporeal Life Support
organization (ELSO). Recent experience with ECMO for
severe cases of adult respiratory distress syndrome
(ARDS) during the 2009 influenza A (H1N1) pandemic
increased interest in this technique. In fact, with the use
of modern ECMO technology, our institution has
increased its use three-fold since 2009. (Fig. 1)
Guidelines for the use of extracorporeal life support
(ECLS) have been addressed extensively by the ELSO,
established in 1989. However, there is no standard of care
that addresses personnel, training and the use of ECMO
and quality assurance.1 In a 2008 survey of ELSO center
device use and team roles, it was identified that ECMO
specialists often come from a variety of departments to
form a multidisciplinary team.2 According to Lawson
et al., 22% of perfusionists currently are acting in the role
of “ECMO specialist”, most often due to the inability of
the perfusionist to handle both cardiac surgical cases and
outside the operating room intensive care unit ECMO
cases. In many perfusion teams’ roles, 33% were respon-
sible for circuitry setup, priming, initiation and trouble-
shooting only. Regardless of the involvement, in 54% of
the responding neonatal ELSO centers, the perfusionists
were listed among the ECMO specialists in a 2008 survey
New York Presbyterian MC-Columbia, New York, NY, USA
Corresponding author:
LB Mongero
NYPH Columbia Campus
177 Fort Washington Avenue Milstein Hospital 4-350
New York, NY 10032
USA.
Email: mongero@nyp.org
Presented at the 34th Annual Seminar of The American Academy of
Cardiovascular Perfusion, Los Angeles, California, 24-27 January 2013.
Mongero et al. 553

Adult ECMO YTD

16
14
12
10
8
2009
6
2010
4 2011
2 2012
0 2013
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2009 5 1 2 2 0 5 2 4 0 5 9 1
2010 1 3 7 6 5 4 4 6 5 5 4 3
2011 5 5 8 4 4 7 9 8 9 5 5 8
2012 8 5 10 9 5 15 7 11 13 7 11 9
2013 10 4 10 13 12 2

Figure 1.  Adult ECMO Year To Date (YTD).

by Lawson et al.2 A 2007 survey by Sutton et al. examined
the qualification of ECMO specialists at ECMO centers
across the United States.3 This study showed that the
majority of team members were nurses and that ELSO
“ECMO guidelines” state that ECMO specialists should
have a subspecialty credentialing in nursing, respiratory
therapy or perfusion.3 Additionally, Freeman et al.
reported that a limiting factor for ECMO is people with
expertise in the technique and they expanded their
resources through utilization of a Primary Care Giver
model. Staffing ECMO is provided by the trained multi-
disciplinary team on a continual 24 hour basis; it is
important to provide well-rounded care. It is well docu-
mented that the nurse provides direct one-to-one patient
care for the critically ill ECMO patient, which includes:
intravenous therapy, analgesia and sedation if necessary,
positioning and continuous monitoring and assessment.4
According to Searles et al., the reporting mechanism
to ELSO may not have considered every institution that
performed ECMO in 2004 and, therefore, (79% of cent-
ers responded vs. 14% in 1990 survey) using perfusion-
ists was due to differences in survey populations.5 This is
an important reason why it may be under-reported.
Perfusionist as ECMO specialist
The perfusionist has documented competency in every
facet of extracorporeal circulation technology by virtue
of their didactic and clinical training. Monitoring and
safety device utilization are second nature to the perfu-
sionist, whereas it would need to be taught and reviewed
periodically to non-perfusion staff. The perfusionist has
a minimum of 18-24 months of circulatory physiology
and clinical application technology as a novice and
ECMO is part of this comprehensive training.
Extracorporeal life support circuitry is complex and the
perfusionist is the most capable personnel for trouble-
shooting techniques.
Rounding model
After the patient is placed on ECMO and situated in the
intensive care unit (ICU), the multidisciplinary consid-
erations for well-rounded care begin. A team approach is
employed, with the nurse practitioner leading the ECMO
team to communicate critical care assessment skills that
will provide the best possible care to patients with acute
respiratory distress as well as post-cardiotomy ECMO
patients. The perfusionist will round every 2-4 hours and
may be called at any moment to make changes to the
ECMO circuit. Very often, the patients are awake and
having physical therapy during their ECMO run. The
team approach to this early mobilization has been a key
to the success. Clinical evidence indicates that physical
activity in the ICU significantly improves outcomes such
as reduced functional impairment and sedation-associ-
ated delirium, as well as improved quality of life after dis-
charge.7 The same rounding practice by the perfusionist
is employed for post-cardiotomy ECMO patients in our
other ICUs. This enables the perfusion department to
round on every ECMO patient and interface with the cir-
cuit, either bedside or with telemetry.
554 Perfusion 28(6)
Telemetry-based record keeper
The electronic record keeper used for ECMO procedures
is provided by Viper and Vision technology. (Spectrum
Medical, Ft. Mills, SC) The open-design and web-based
system allows it to work with all manufacturers’ products
in the ICU and provides information in real time and
generates an electronic chart, utilizing compliance strat-
egies, customized pre-sets, manually inputted data and
data automatically downloaded from various devices in
the clinical unit. The electronic chart can then be stored
in various locations, including the hospital information
system. Charts may also be stored in the Vision online
database and then queried and used to generate a range
of management and compliance reports. The reports are
tailored to meet the needs of each clinical program and
can be re-designed at any time.
Discussion
ECMO is cardiopulmonary bypass; perfusionists are
uniquely qualified to perform this task. Historically, it may
have been a matter of necessity that respiratory therapists
and nurses were trained to manage ECMO as there were
not enough perfusionists to meet the demand. In some
instances, it may have been that perfusionists were not
interested in embracing the technology since it was out of
the operating room and not under the jurisdiction of the
cardiac surgeon.6 Regardless of the staffing guidelines
employed, it is important to understand that the expertise
required to manage critically ill ECMO patients is not
benign. Additionally, providing increments of advanced
training, competency review and simulation education to
nurses and respiratory therapists who are not perfusion-
ists is time consuming. Every effort should be made to uti-
lize the perfusionist as an “ECMO specialist” since they
practice these techniques every day. The perfusion team in
our hospital is available for many procedures that require
the use of extracorporeal circulation and are available 24
hours per day. The rigors of component change-out and
troubleshooting are second nature to the perfusionist and,
although it may seem reasonable to select familiar equip-
ment specific for ECMO, such as a centrifugal pump as
mentioned in Freeman et al.,5 the truth is that there may
always be variations in the equipment used and the perfu-
sionist is the most capable ECMO specialist. Owing to the
fact that this institution did 33 adult ECMO in 2009 and
then 110 in 2012 without the addition of perfusion staff
correlates well with our hypothesis that rounding in the
ICU every 2-4 hours enables cross-coverage of ECMO
cases and other cases performed by the perfusionist. It is
important to note that an adequate perfusion staff must
incorporate the ability to continue without interruption all
the original responsibilities of the perfusion staff. It will be
easier in the larger perfusion practice to incorporate new
procedures, such as ECMO, without additional resources.
This is one of the reasons the perfusionist had to defer to
other allied professionals for managing ECMO support
when it was first described by Bartlett et al. in the late
1970s.8 In addition, our institution has performed neona-
tal and pediatric ECMO since 1987 and our perfusionists
have been sitting by the bedside during the entire run.
This is the preference of the pediatric surgeon. It was not
until 2009 and the H1N1 epidemic that adult ECMO
impacted our practice and enabled this model for our
adult patients. Our experience justifies the use of the per-
fusionist as the “ECMO specialist” and other team roles
enhance the bedside care of the ECMO patient.
Declaration of conflicting interest
The author declares that there is no conflict of interest.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
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