202

Interhospital Transport of Children Requiring Extracorporeal

Membrane Oxygenation Support for Cardiac Dysfunction chd_506 202..208

Antonio G. Cabrera, MD,*1 Parthak Prodhan, MBBS,†1 Mario A. Cleves, PhD,†

Richard T. Fiser, MD,† Michael Schmitz, MD,† Eudice Fontenot, MD,† Wesley Mckamie, CCP,‡
Carl Chipman, CRNFA,‡ Robert D.B. Jaquiss, MD,‡ and Michiaki Imamura, MD, PhD‡
*Department of Pediatrics, The Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children’s Hospital,
Baylor College of Medicine. Houston, Tex, USA; †Department of Pediatrics, Sections of Cardiology, Pediatric Critical
Care Medicine, Congenital Cardiac Anesthesiology and ‡Pediatric Cardiothoracic Surgery, College of
Medicine–University of Arkansas Medical Sciences, Arkansas Children’s Hospital, Little Rock, Ark, USA

ABSTRACT

Objective. Many centers are able to emergently deploy extracorporeal membrane oxygenation (ECMO) as support
in children with refractory hemodynamic instability, but may be limited in their ability to provide prolonged
circulatory support or cardiac transplantation. Such patients may require interhospital transport while on ECMO
(cardiac mobile [CM]-ECMO) for additional hemodynamic support or therapy. There are only three centers in the
United States that routinely perform CM-ECMO. Our center has a 20-year experience in carrying out such
transports. The purpose of this study was twofold: (1) to review our experience with pediatric cardiac patients
undergoing CM-ECMO and (2) identify risk factors for a composite outcome (defined as either cardiac transplan-
tation or death) among children undergoing CM-ECMO.
Design. Retrospective case series.
Setting. Cardiovascular intensive care and pediatric transport system.
Patients. Children (n = 37) from 0–18 years undergoing CM-ECMO transports (n = 38) between January 1990 and
September 2005.
Interventions. None.
Measurements and Main Results. A total of 38 CM-ECMO transports were performed for congenital heart disease
(n = 22), cardiomyopathy (n = 11), and sepsis with myocardial dysfunction (n = 4). There were 18 survivors to
hospital discharge. Twenty-two patients were transported a distance of more than 300 miles from our institution. Ten
patients were previously cannulated and on ECMO prior to transport. Thirty-five patients were transported by air
and two by ground. Six patients underwent cardiac transplantation, all of whom survived to discharge. After adjusting
for other covariates post-CM-ECMO renal support was the only variable associated with the composite outcome of
death/need for cardiac transplant (odds ratio = 13.2; 95% confidence interval, 1.60–108.90; P = 0.003). There were
two minor complications (equipment failure/dysfunction) and no major complications or deaths during transport.
Conclusions. Air and ground CM-ECMO transport of pediatric patients with refractory myocardial dysfunction is
safe and effective. In our study cohort, the need for post-CM-ECMO renal support was associated with the
composite outcome of death/need for cardiac transplant.

Key Words. ECMO; Mobile; Cardiac; Children; Transplant

Background patients with refractory hemodynamic instability,

which can develop in the setting of congenital heart
E xtracorporeal membrane oxygenation
(ECMO) is an important support modality for disease, systemic illness, or postcardiotomy.1–5
Many centers are capable of emergently deploy-
ing ECMO support in children with significant
Institution where study was performed: Arkansas Chil-
dren’s Hospital. hemodynamic instability, but may not have the
Financial Disclosure: None. resources to provide prolonged circulatory support
1
Both authors contributed equally to the work. or perform cardiac transplantation. Transport of
© 2011 Copyright the Authors
Congenit Heart Dis. 2011;6:202–208 Congenital Heart Disease © 2011 Wiley Periodicals, Inc.
Mobile ECMO in Children with Cardiac Disease
these patients to a center with the resources
to provide prolonged circulatory support or
cardiac transplantation could potentially be bene-
ficial. Even though significant experience exists
with ECMO support in children,1–4 very few
reports describe transport of these children while
supported on ECMO.6–8
Currently, in the United States, the Arkansas
Children’s Hospital (ACH) is one of the few insti-
tutions with the capability to transport patients
while on ECMO support. ACH began perform-
ing mobile ECMO (M-ECMO) transports for
children in 1990.9 The purpose of this study
is to identify risk factors for a composite out-
come (defined as either cardiac transplantation or
death) among children undergoing cardiac mobile
(CM)-ECMO.
Materials and Methods
After approval from the institutional review board,
we conducted a retrospective analysis of conse-
cutive pediatric patients (0–18 years) requiring
CM-ECMO to ACH from January 1990 to Sep-
tember 2005. Cardiac mobile extracorporeal mem-
brane oxygenation transports by our M-ECMO
team from one institution to an institution other
than ACH were excluded.
Subjects were identified by querying the
ACH ECMO database, the pediatric cardiova-
scular surgery database, and medical records.
Data relating to pretransport variables (demo-
graphics, deployment type: emergent or nonemer-
gent, ECMO indication: postcardiotomy/systemic
illness/cardiomyopathy, site of cannulation, pres-
ence of open chest, multiorgan system dysfunction
[more than four organs], infection [indicated as
positive urine, blood, tracheal, or cerebrospinal
fluid culture], medical support and gas exchange
variables: inotropes/vasopressors administered,
pH, partial pressure of carbon dioxide in the
arterial blood [PaCO2], and partial pressure of
oxygen in the arterial blood [PaO2]), intratransport
variables (air/ground transport; administration of
blood product and inotropes; laboratory values:
pH, PaCO2, and PaO2, bicarbonate, hematocrit,
platelets, blood lactate, coagulation parameters;
ECMO flow rate; mechanical complication or
bleeding during transport; additional sedation/
muscle relaxant) and posttransport variables (need
for surgical intervention or cardiac catheterization,
recognition of previously unrecognized car-
diac lesions, more than four organ dysfunction
[renal: creatinine >1.2 mg/dL or use of dialysis;
203
liver: aspartate aminotransferase or alanine amino-
tranferease >200 U/dL; respiratory: on mechanical
ventilation; cardiac: on inotropes or ECMO;
central nervous system: head bleed/stroke or sei-
zures] need of renal replacement therapy, develop-
ment of new infection, neurologic complication)
were abstracted from the medical record.
The primary outcome variable for the study was
a composite outcome (either death or cardiac
transplantation prior to hospital discharge) after
CM-ECMO transport.
CM-ECMO Procedures
The planning and mobilization of a CM-ECMO
transport at ACH is instituted in two phases: (1)
pre-CM-ECMO evaluation and (2) CM-ECMO
transport.
During the pre-CM-ECMO evaluation, re-
quests for CM-ECMO support are referred to
the cardiovascular intensive care (CVICU) attend-
ing physician-on-call. The medical history,
current active problems, extent of therapy, ECMO
eligibility, and potential for conventional transport
are reviewed with the referring physician before
the possibility of CM-ECMO transport is consid-
ered. The CVICU attending physician contacts
the ECMO surgical consultant-on-call who evalu-
ates the eligibility of the patient for ECMO
support and CM-ECMO transport. Candidates
for CM-ECMO are considered on a case-by-case
basis, with input from a pediatric intensivist or
cardiologist as warranted. If the patient is consid-
ered as a CM-ECMO transport candidate, the
referring center is notified and a CM-ECMO
team is mobilized and the mode of transport is
determined. Referral centers either have the
patient already on ECMO support or the patient
can be cannulated by our CM-ECMO transport
team. The ACH CM-ECMO transport team
is individually tailored for specific missions.
The essential personnel roster for a CM-ECMO
transport includes one ECMO staff physician
(cardiologist/intensivist), one staff surgeon if
on-site cannulation is required, and one ECMO
coordinator. Often, a cardiovascular surgical first
assistant nurse accompanies the team. Depending
on whether the ECMO coordinator is a nurse
or respiratory therapist, an additional pediatric
transport nurse or therapist may accompany the
team, based on the perceived patient’s and
team’s needs. The team composition is, however,
modified to the specific CM-ECMO transport
needs. Air transports are performed using either a
helicopter (Sykorski 76) or a fixed-wing aircraft
Congenit Heart Dis. 2011;6:202–208
204
(Learjet 35) with aeromedical capability, with air-
craft choice based on availability and distance of
the transport. Vehicles required for ground trans-
port include an ambulance or a large van to carry
transport personnel and equipment to and from
airports if fixed-wing transport is required. No
ground vehicles are necessary if the referring
institution has a helipad on site and is within
helicopter range from ACH.
Once the team is en route, communication
is maintained with the referring physician by
a second ECMO coordinator at our center. This
coordinator relays instructions regarding blood
product needs, availability of family members
for consent, and surgical equipment and space
required for the initiation of ECMO. The coordi-
nator also arranges for temporary medical staff
privileges for the ECMO physician and the
surgeon at the referring hospital prior to their
arrival. On arrival at the referring hospital, the
CM-ECMO transport physician evaluates the
patient’s condition and confirms previous
information. The CM-ECMO team can perform
ECMO cannulation or transfer of the patient from
the existing circuit to the CM-ECMO circuit.
During transport to ACH, mechanical ventila-
tion is performed with bag/peep valve or portable
ventilators, and patients are monitored according
to standard procedures. The patient’s laboratory
parameters are monitored frequently using a
point-of-care device to analyze blood gases,
lactate, serum electrolytes, and hematocrit during
the transport.
ECMO Transport Logistics
The ACH ECMO transport has a custom stret-
cher for ground/helicopter and another stretcher
customized for fixed-wing jet. The stretcher
dimensions are 183 cm long by 66 cm wide for both
helicopter and fixed-wing versions, and the height
is 84 cm on the stretcher used in fixed-wing jet and
102 cm on the helicopter stretcher (Figure 1). In
its neonatal configuration, a bassinette tray is
bolted to the top. This tray can be removed and
a pad placed to carry a larger pediatric patient.
The cart is designed so that all of the required
CM-ECMO equipment is secured on the shelf
space below the patient bed. The CM-ECMO
equipment includes a roller pump with pressure
monitoring, water heater, bladder box, cardiores-
piratory monitor, and three uninterruptible power
sources. An oxygen cylinder is also housed on the
transport cart. All of the listed equipment has
Federal Aviation Administration approval, has
Congenit Heart Dis. 2011;6:202–208
Cabrera et al.
Figure 1. Mobile extracorporeal membrane oxygena-
tion (ECMO) transport cart. (A) Battery-powered ECMO
pump, (B) membrane oxygenator, (C) centrifugal pump, (D)
pressure monitors, and (E) back-up battery.
been tested, and meets or exceeds all national air-
worthiness standards for aeromedical equipment.
Standard manometers are used to monitor pre-
membrane and postmembrane pressures. Other
essential equipment is contained in three large
rolling containers. In recent years, some transports
have been accomplished with a centrifugal pump,
but these are not included in the current analysis.
Data Analysis
Continuous variables are presented as median
and ranges whereas categorical variables are pre-
sented as counts and percentages. The Fisher
exact test was used to test significance of
categorical variables, and the nonparametric
Mann–Whitney U/Wilcoxon rank-sum test for
continuous variables. A P value of ⱕ0.05 was
considered significant. Adjusted odds ratios
(OR) and corresponding 95% confidence inter-
vals (CI) were computed using logistic regres-
sion. All analyses were performed using STATA
statistical software version 10, (StataCorp LP,
College Station, TX, USA).
Results
From January 1990 to September 2005, the ACH
ECMO transport team performed a total of 90
transports within the continental United States.
Fifty-two transports were for respiratory failure
and 38 were CM-ECMO transports carried out in
37 patients.
Patients undergoing CM-ECMO transports
included 22 with a primary diagnosis of congenital
Mobile ECMO in Children with Cardiac Disease
heart disease (Table 1), 11 with cardiomyopathy/
myocarditis, and four with myocardial dysfunction
associated with refractory septic shock. Thirty-
three CM-ECMO transports in 32 patients were
indicated for cardiac dysfunction/shock and five
for profound hypoxemia.
The median age and weight were 5.7 months
(range: 1 day to 12 years) and 5.4 kg (range:
2.6–81.3 kg) respectively. All patients requiring
CM-ECMO transport underwent veno-arterial
cannulation. Transport mode was by air for 35
patients and by ground for two patients. Of the
patients requiring air transport, 33 were trans-
ported by helicopter and two by fixed-wing
aircraft. Ten patients were already on ECMO
support at the referring institution. In 22 cases, the
referring institution was located more than 300
miles from our center.
Group comparisons of patients who underwent
CM-ECMO transport were made between those
who had a composite outcome (either death or
cardiac transplantation prior to hospital discharge)
vs. those who did not. There were no differences
during CM-ECMO transport between patients
with a composite outcome versus those without a
composite outcome for intratransport variables,
which included pH (median 7.44 [7.21–7.69] vs.
7.46 [7.28–7.61]; P = 0.58), PaCO2 (36 [20–62] vs.
39 [27–65]; P = value 0.51), bicarbonate (24.1
[17.5–32.2] vs. 26.4 [18.6–34.7]; P = 0.17), hema-
tocrit (37.8 [29–44] vs. 39.5 [32–57]; P = 0.38),
platelet count (180 [74–453] vs. 207 [117–382];
P = 0.42), and ECMO flow (102 [50–175] vs. 108
[75–170], P = 0.59). No significant differences
Table 1. Diagnoses of Patients with Congenital Heart
Disease
Diagnosis Nonsurvivor Transplanted Survivor
TAPVR 3 1
d-TGA/VSD 1 transplantation with one undergoing heart and
TOF 2
TOF/AVCD 1 1
DORV 1 patients, three had a diagnosis of cardiomyopathy,
TA/VSD 1 one had neonatal myocarditis, one had iatrogenic
TA/PA 1
Shone complex 1 3
ALCAPA 1 1
PA/IVS 1 dysfunction, and one was postcardiotomy for
PA/VSD 2
IAA/VSD 1 Shone’s complex. All these patients survived
SVC to LA 1 cardiac transplantation and were discharged. At
ALCAPA, anomalous origin of the left coronary artery from the pulmonary
artery; AVCD, atrioventricular canal defect; d-TGA, dextro-transposition of the
great arteries; DORV, double outlet right ventricle; IAA, interrupted aortic arch;
IVS, intact ventricular septum; PA, pulmonary atresia; SVC to LA, superior
vena cava to left atrium; TA, tricuspid atresia; TAPVR, totally anomalous
pulmonary venous return; TOF, tetralogy of Fallot; VSD, ventricular septal
defect.
205
between the two groups for interventions (i.e.,
need for blood platelet, fresh frozen plasma, cryo-
precipitate transfusions, additional muscle relaxant
doses, change in sedation therapy, or excessive
bleeding during transport) were observed during
CM-ECMO transport (data not shown).
Nineteen patients (54%) died and 18 (46%)
survived to hospital discharge. Of the 18 patients
surviving to hospital discharge, five received heart
transplantation. Thus, the composite outcome
(death prior to hospital discharge and heart trans-
plantation) was seen in 24 patients. Survival for
postcardiotomy CM-ECMO transported patients
was only 17%.
A total of 10 patients with structural heart
disease underwent cardiac catheterization after
being transported to our institution. Five patients
(50%) had incorrect or incomplete cardiac diag-
nosis found after echocardiogram/catheterization
at our institution (total anomalous pulmonary
venous return n = 2, interrupted aortic arch n = 1,
anomalous connection of the superior vena cava to
the left atrium n = 1, severe left pulmonary artery
stenosis with right ventricle to pulmonary artery
conduit stenosis n = 1).
As summarized in Table 2, pretransport ECMO
(P = 0.03) and shock as the primary indication
for ECMO (P = 0.01) were associated with the
composite outcome. Among the post-transport
ECMO variables, the presence of more than four
organ system dysfunction (P = 0.007) and the
need for renal replacement therapy (P = 0.001)
were significantly associated with the composite
outcome in the study cohort. After adjusting for
other covariates, post-CM-ECMO renal support
was the only variable associated with the compos-
ite outcome of death/need for cardiac transplant
(OR = 13.2; 95% CI, 1.60–108.90; P = 0.003;
Table 3).
Six patients underwent orthotropic cardiac
kidney transplant at another institution. Of these
coronary artery injury during radiofrequency abla-
tion with subsequent intractable left ventricular
the end of the study period, there had been three
late deaths: one of liver failure 63 days postdis-
charge, one of sudden death at home 3 years post-
discharge, and one of transplant rejection 9 years
after discharge.
Congenit Heart Dis. 2011;6:202–208
206 Cabrera et al.

Table 2. Demographics, Pre-CM-ECMO, and Post-CM-ECMO Variables

Deceased/ Alive/Not
Transplanted Transplanted
Variable N (n = 24) (n = 13) P value
Pre-ECMO variables
Age more than 1 year 37 10 3 0.27
Male gender 37 12 8 0.50
Air transport 31 10 19 0.66
Pretransport ECMO 37 12 1 0.03
Diagnosis
CHD 37 13 9 0.38
Myocarditis/DCM 37 9 1 0.08
Sepsis 37 2 3 0.22
Prior cardiac surgery 37 6 0 0.32
Presenting with shock 36 20 6 0.01
Post-ECMO variables
Post-transport surgery 35 13 7 0.98
Surg interv in first 24 hours 35 9 2 0.13
Cath intervention 30 14 7 0.68
Change diagnosis 37 4 3 0.64
Organ dysfunction > 4 33 13 1 0.00
Post-ECMO renal support 35 17 1 0.00
Positive blood culture 34 6 1 0.17
CNS complication 34 8 2 0.17

Cath/Surg interv, catheter/surgical intervention; CHD, congenital heart disease; CNS, central nervous system; CM-ECMO, cardiac mobile extracorporeal
membrane oxygenation; DCM, dilated cardiomyopathy; N, number of patients with complete data available.

Table 3. Adjusted Odds Ratios and 95% Confidence Interval for the Association between Composite Outcome and
Selected Patient Characteristics
Variable Odds Ratio P value 95% Confidence Interval
Posttransport renal support 77.71 0.003 4.61 1310.71
Diagnosis of myocarditis/DCM 15.06 0.081 0.71 317.44
Posttransport CNS complication 7.20 0.165 0.44 116.63

Variables included in the stepwise logistic regression model were a diagnosis of myocarditis/dilated cardiomyopathy, shock as an indication for ECMO support,
posttransport need for surgical intervention within the first 24 hours, renal support, presence of posttransport organ dysfunction ⱖ4, blood stream infection and CNS
complication. N = 31; Models area under receiver operating characteristic (ROC) curve = 0.932; Models Hosmer–Lemeshow c2 = 0.33.
CNS, central nervous system; DCM, dilated cardiomyopathy.

All ECMO cannulations performed by our
team at the referring hospitals were uneventful.
No major life-threatening complications occurred
during the 38 CM-ECMO transports. All patients
were transported from the referring institution
with stable hemodynamics, satisfactory blood
gases, and activated clotting time levels. There
were two minor complications due to equipment
failure/dysfunction during transport (one cannula
readjustment and one syringe pump failure).
There were no inadvertent decannulations, major
complications, or deaths during these CM-ECMO
transports.
Discussion
This report constitutes the single largest CM-
ECMO transport experience in children. We show
Congenit Heart Dis. 2011;6:202–208
that CM-ECMO transport can be undertaken
safely and effectively on these patients.
Since the first report of M-ECMO transport by
Bartlett et al.,7 other centers have reported
M-ECMO transport for neonates,4,6,10 pediat-
ric,6,10,11 and adult patients.12,13 In the United
States, only three centers have the logistical capa-
bility of undertaking mobile ECMO transport11 by
ground ambulance, helicopter, and fixed-wing
vehicles for all age groups. The ACH’s mobile
ECMO neonatal transport experience for the
years 1990–1994 was reported by Heulitt et al.6
Survival was 70% (9/13) among neonatal patients,
and 89% (8/9) patients of those who had
post-ECMO brain magnetic resonance imaging
had normal findings. No major transport-related
complications occurred during the CM-ECMO
transports. The consolidated experience of ACH
Mobile ECMO in Children with Cardiac Disease
from1990 to 2008 has been recently described.
The overall survival to discharge was 58% (61/
104), with a mortality of 46% for patients with
cardiac failure8
Our study shows that among those undergoing
CM-ECMO transport, the need for renal replace-
ment therapy after transport was significantly
associated with subsequent death or the need for
cardiac transplant. These observations are similar
to those reported by Meliones et al. among non-
transported ECMO-supported patients.14 They
also found that there was no significant statistical
difference between survivors and nonsurvivors
when compared for mechanical complications.
Our study highlights the need to strongly
consider additional investigations such as cardiac
catheterization in cardiac patients undergoing
M-ECMO transport especially when the etiology
of the cardiac pathology causing the need for
ECMO support is unclear. In our study, 50% of
patients among those who required posttransport
cardiac catheterization had either an incorrect or
incomplete diagnosis. A study by desJardins et al.
have similarly reported unexpected findings of
clinical importance found after cardiac catheter-
ization in approximately 40% of intrainstitutional
ECMO-supported pediatric patients.15 Previously,
Palmisano et al. found that underlying congenital
heart disease “masked” by respiratory failure
occurred in 2% among neonates supported on
ECMO. More importantly, up to 9% of neonates
with a diagnosis of persistent fetal circulation prior
to placement on ECMO support were found
to have an underlying previously undiagnosed
congenital heart disease.16
Our experience shows that CM-ECMO trans-
ports, while labor intensive and requires sig-
nificant logistic support, can be carried out safely
even over distances of more than 300 miles. The
present experience, as well that of other mobile
ECMO centers, confirms the value of detailed
protocols and an extensive coordination between
the two involved centers. The mobile ECMO
team must be trained continuously because the
need for such transports is rare and unpredictable.
The team must be prepared to face unexpected
situations and be constantly evaluating the poten-
tial value of technical modification. For example,
we have recently converted to a centrifugal pump
for mobile ECMO, after first evaluating the pump
in our in-house program, with a resultant decrease
in the weight of the stretcher.
The current study is limited by its retrospec-
tive nature and small sample size. Further, data
207
related to the number of requests rejected for
CM-ECMO transports could not be collected,
making the mortality associated with ECMO
referral unknown.
Conclusion
Our CM-ECMO transport experience demon-
strates the feasibility, efficacy, and safety of
CM-ECMO transports in pediatric cardiac
patients. We believe that there will continue to be
a subset of neonatal and pediatric patients with
cardiac diseases whose clinical state will require
the use of this modality. However, despite the
absence of significant complications and an
acceptable survival in our experience, CM-ECMO
transport remains an extremely risk-laden and
expensive tool that should not replace early refer-
ral to an ECMO center of potential patients
who are not responding to conventional therapy.
Careful and timely selection and referral of poten-
tial ECMO candidates with critical cardiac disease
to a center where heart transplantation is available
significantly impacts survival.
Corresponding Author: Michiaki Imamura, MD,
PhD, Associate Professor, Pediatric Cardiothoracic
Surgery College of Medicine-University of Arkansas
Medical Sciences, Arkansas Children’s Hospital, 3
Children’s Way, Slot 512, Little Rock, AR 72202.
Tel: 501-364-2962; Fax: 501-364-5869; E-mail:
imamuramichiaki@uams.edu
Conflict of interest: None for any of the authors.
Accepted in final form: January 19, 2011.
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