Intensive Care Med (2001) 27: 1643±1648

DOI 10.1007/s001340101060 NE ON ATA L A ND PE DI ATR IC IN TENS IVE CA RE

V. LindØn Inter-hospital transportation of patients

K. PalmØr
J. Reinhard with severe acute respiratory failure on
R. Westman
H. EhrØn extracorporeal membrane oxygenation ±
T. Granholm
B. Frenckner national and international experience

Received: 5 February 2001

Final revision received: 18 June 2001
Accepted: 17 July 2001
Published online: 23 August 2001
 Springer-Verlag 2001
)
H. EhrØn ´ 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. LindØn ´ K. PalmØr ´ 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 inter-
hospital transportation of patients
with acute respiratory failure on ex-
tracorporeal membrane oxygen-
ation (ECMO).
Design: Observational, descriptive
study.
Setting: Tertiary referral center in a
University Hospital.
Subjects and methods: When stan-
dard ECMO criteria were fulfilled
and the patient considered too un-
stable for a conventional transport,
the mobile ECMO team cannulated
the patient for ECMO at the refer-
ring 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 pa-
tients) 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 pa-
tient was on ECMO (28 patients)
was 2.2 h (range 1.25±4.25 h). The
median time that the transport team
was out was 10 h (range 5.5±36.5 h)
and the median time with the pa-
tient was 6 h (range 3±30.5 h). The
distance of transport ranged from
4±1,500 km. Six transports were in-
ternational. No patient complica-
tions occurred during the transports.
Two technical complications related
to the transport vehicle were en-
countered. One ambulance com-
pressor malfunctioned. During one
helicopter transport, one out of two
electric supply circuits malfunc-
tioned. The patients were not af-
fected. Twenty-one of the 29 pa-
tients 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 Eu-
rope.
Keywords ECMO ´ Respiratory
failure ´ Transportation ´ Inter-
hospital ´ ARDS

over 22,000 patients have been reported by about 120

Introduction
Extracorporeal membrane oxygenation (ECMO) [1] is
used in the treatment of patients with extremely severe
but potentially reversible pulmonary disorders. Today
ECMO centers [2]. The overall survival rate is 86 %,
62 %, and 54 % in neonates, pediatric patients, and adult
patients with respiratory failure, respectively. In neo-
nates several randomized studies have proven ECMO
1644
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 com-
pared 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 addi-
tion of inhaled nitric oxide and high-frequency oscillato-
ry ventilation in modern intensive care has also contrib-
uted 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 re-
view the technique and equipment for inter-hospital
ECMO transport and to evaluate the patient outcome.
Methods and materials
Inter-hospital transportation of patients on ECMO involves trans-
port 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 unsta-
ble for a conventional transport. Distance of transport, hemody-
namic 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 conven-
tional 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 immedi-
ately reevaluated and a definitive decision was made if ECMO
should be initiated or not.
Equipment
A mobile ECMO cart for inter-hospital transports has been devel-
oped and customized (Fig. 1). A Stöckert 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 (Stöckert 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, Sup-
ertygon for raceway tubing, Avecor silicone rubber bladder) were
used with the size of the devices adjusted to the weight of the pa-
tient. An additional length of tubing was added to the circuit to fa-
cilitate patient movement while onloading and offloading in the
transport vehicle.
All electric items were tested individually regarding the elec-
tromagnetic field, after which the assembled total equipment was
tested together. The test protocols were scrutinized by The Swed-
ish 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 cannulat-
ing surgeon. The team had several years of ECMO experience,
were very familiar with transports, and were ready for take off
within 60±120 min.
Transport to referring hospital
The transport to the referring hospital aimed to bring the person-
nel 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 giv- pneumothorax, PPHN persistent pulmonary hypertension of the
en in neonates and cause of ARDS in pediatric and adult patients. newborn, CDH congenital diaphragmatic hernia, ALL acute lym-
Distance refers to the distance patient has been transported on phatic leukemia, BMX bone marrow transplantation, OI oxygen-
ECMO. Transit time (h) includes on- and offloading of the patient ation index, P/F ratio PaO2/FiO2 (mmHg)]
and ECMO machine. [MAS meconium aspiration syndrome, pnth
Patient no. Age Sex Diagnosis OI P/F Murray Distance Transit Mode of Mode of Total Outcome
ratio score (km) time (h) transport transport time on
to referring to ECMO ECMO
hospital center (h)
Neonates
1 < 1 day M MAS+pnth 59 207 5.0 Helicopter Ground 77 Survived
2 3 days M Sepsis 43 4 0.8 Taxi-cab Ground 65 Survived
3 1 day M PPHN 85 207 3.0 Helicopter Ground 22 Survived
4 3 days M PPHN+pnth 63 411 4.5 Taxiplane Ground 86 Survived
5 19 days M CDH 44 585 4.0 Helicopter Helicopter 126 Died
6a < 1 day F MAS 117 4 1.0 Taxi-cab Helicopter 107 Survived
7 1 day F MAS 110 313 2.0 Helicopter Helicopter 76 Survived
8 1 day F CDH 138 585 4.0 Helicopter Helicopter 114 Died
9 < 1 day M MAS 140 760 4.5 MD-80 Helicopter 78 Survived
10 < 1 day M MAS 88 207 2.3 Helicopter Ground 45 Survived
11 < 1 day M CDH 50 800 4.0 Taxiplane Helicopter 447 Survived
12 14 days F CDH 57 1,200 5.3 Hercules Hercules 122 Survived
13 < 1 day F MAS 160 313 1.25 Helicopter Helicopter 140 Died
14 2 days F CDH 114 70 2.0 Taxi-cab Ground 52 Survived
15b < 1 day F CDH 135 585 4.5 Taxiplane Hercules 109+181 Survived
Pediatric patients
16 10 years M Post-trauma 68 3 4 1.0 Taxi-cab Ground 187 Survived
17b 1 year M ALL+BMX+- 40 - 70 1.5 Taxi-cab Helicopter 122+774 Died
viral pneumo-
nia
18 3 years M Post-burn 36 4 70 2.0 Taxi-cab Helicopter 111 Died
19 0.4 yearsF Aspiration 32 3 650 4.0 Taxiplane Helicopter 18 Survived
20b 17 M Hodgkin+BM- 55 3.5 4 2.0 Taxi-cab Ground 167+1016 Died
X+viral pneu-
monia
Adult patients
21 37 years F Sepsis 50 3 180 6.0 Helicopter Ground 258 Survived
22 17 years F Post-trauma 35 4 180 1.0 Helicopter Helicopter 66 Survived
23 42 years M Pneumonia 54 3.75 70 1.5 Taxi-cab Ground 295 Survived
24 42 years M Pneumonia 54 3.5 663 3.5 Helicopter Helicopter 280 Survived
25b 23 years F Pulm embo- 46 3.75 723 3.5 Taxiplane Hercules 350+144 Survived
lism
26 30 years M Post-trauma, 52 3.5 70 2.0 Taxi Helicopter 259 Died
septicemia
Transports to other ECMO centers
27c 38 M Pneumonia 43 3.75 70 1.0 Taxi-cab Helicopter Died
1,400 6.0 - Jet 216
28 4 years M ALL+aspira- 50 - 1,500 4.0 Hercules Hercules 168 Survived
tion
29 14 years F Wegener 51 4 700 4.5 - Helicopter 192 Survived
a c
The ICU ambulance used for ECMO transports was out of order This patient was transported twice, first from referring hospital to
on this occasion Stockholm and eventually to a British ECMO center
b
Patients have had two ECMO runs

transport vehicle, and the weather. The following modes have been
used: Taxi-cab, ground ambulance, helicopter (Sikorsky S-76), reg-
ular 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 air-
craft
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, includ-
ing heater and other medical equipment.
The patient was loaded into the ground ambulance or helicop-
ter 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 cen-
ter. 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 veno-
arterial (v-a) bypass [14], but towards the end of the period, pa-
tients 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 refer-
ring hospital. Twenty-seven of the 28 cannulated patients were
transported to our own center (Table 1, patients 1±27). 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, re-
spectively.
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 giv-
en in the table. In neonates, oxygenation index, and in older pa-
tients, 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 refer-
ring hospital and start of ECMO was 5.5 h (range
4±12 h), which also included mobilization of the trans-
port team and transport to the referring hospital. Medi-
an time from arrival of the ECMO team until the pa-
tient was on bypass was 2.2 h (range 1.25±4.25 h). This
included time for reevaluation of the patient for
ECMO as well as for priming the ECMO circuit and

cannulation. Median time that the transport team was
out was 10 h (range 5.5±36.5 h) and median time for
the team taking care of the patient was 6 h (range
3±30.5 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 re-
ferring hospital was on average 330 km (range
4±1200 km) among the 27 patients cannulated else-
where and transported to our center. One patient (pa-
tient 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 com-
pressor malfunctioned, disabling the vehicle's shock ab-
sorbers. The speed of the ambulance was therefore re-
duced to 10±15 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 compli-
cation 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 re-
maining 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 trans-
port in any case.
Discussion
ECMO is an extremely invasive therapy used in critical-
ly 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 situa-
tion may arise where it is practically impossible to trans-
port 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 de-
scribed by Cornish [16]. Since then, other centers have
transported neonates [11, 12], pediatric patients [13,
1647
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 trans-
ports 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 com-
plications. Since the start of ECMO transports in our
center in 1996, 32 % (29 out of 91) of our ECMO pa-
tients 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 pa-
tient from the ambulance affects the patient care and in-
volves 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 dis-
tance.
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 initi-
ating 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 pa-
tient. Ideally, patients who may become ECMO candi-
dates should be transported to an ECMO center before
they become critically unstable. Transporting on
ECMO requires a larger transport team including a can-
nulation surgeon and more equipment. A larger trans-
port vehicle may also be required. When evaluating the
costs of transportation, it should, however, be born in
mind that only patients fulfilling standard ECMO crite-
ria 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 re-
quires 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 re-
quire a dedicated transport team to transfer patients
long distances. It is concluded that transports with pa-
tients on ECMO can be performed safely for long dis-
tances, probably throughout most of Europe. However,
patients should ideally be transported at an earlier stage
when a conventional transport is still possible.

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