I ran into something at the bedside that didn’t make sense at first.

We had a patient on higher ECMO flows, and the pressure drop across the oxygenator (delta P) was elevated but appropriate for the settings we were running. About a week later, we had weaned the flow down, and the delta P dropped.

Looking at the numbers, it looked like an improvement.

But the oxygenator didn’t look better. If anything, it looked worse, fibrin on the faceplate, thrombus starting to show in the corners.

That created a mismatch I couldn’t ignore. The circuit looked worse, but the number looked better.

The Problem With Delta P Alone

I was taught that delta P is tied to flow. If you increase flow, the delta P increases. If you decrease the flow, delta P decreases.

So when we lowered the flow, the drop in delta P didn’t necessarily mean the oxygenator improved. It just meant we were asking less of it.

The Question We Always Ask

When delta P starts to rise, experienced ECMO specialists usually ask:

• “Is the flow the same?”

That’s the right question. Because if flow increases, a higher delta P may mean nothing at all. But here’s the problem: most of the time, that’s where the conversation ends. We acknowledge that flow matters, but we don’t have a simple way to account for it at the bedside.

So we’re left guessing:

• Was the change in delta P expected because of the change in ECMO flow?

• Or is the circuit actually getting worse?

Adding One Simple Layer

Out of curiosity, I started looking at delta P relative to flow:

• delta P ÷ ECMO flow = mmHg/LPM

At the start, this value was around 6 mmHg/LPM. About a week later, even though delta P had decreased, that number had risen to around 10 mmHg/LPM.

That changed the picture.

The circuit now required more pressure per unit of flow than before. And that matched what I was seeing.

What That Suggests

As an oxygenator develops clot or fibrin buildup, blood flow becomes less efficient. Pathways narrow, resistance increases, and more pressure is needed to move the same amount of blood.

If flow is decreased at the same time, that increase in resistance can be hidden. The raw delta P looks better, but the underlying problem may still be progressing.

Keep It in Perspective

This isn’t a perfect measurement. Hematocrit, temperature, and viscosity all affect the delta P.

And it doesn’t replace what we already watch: gas exchange, hemolysis, or visual inspection of the circuit.

But it adds one useful question:

• Is the circuit requiring more pressure than it used to for the same flow?

Bedside Takeaway

A lower delta P doesn’t always mean a better oxygenator, especially if flow has changed.

Sometimes you have to look one step deeper.

Learn more

For more practical ECMO articles and study tools, visit ECMO 143: AI-Assisted Journey.

I also built AI ECMO Educator, a free-to-use tool that provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. It draws from sources such as ELSO, PubMed, AmSECT, and leading centers.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

The Truck Analogy

When a patient isn’t improving, it’s easy to chase the PaO₂.

But oxygen delivery depends on three things.

Think of hemoglobin like a truck carrying oxygen to tissues.

The Three Levers

1. Load the trucks → increase saturation (SaO₂)

• FiO₂ / FdO₂

• Oxygenation

2. Add more trucks → increase hemoglobin (Hgb)

• Transfusion

• Oxygen-carrying capacity

3. Move them faster → increase flow (Q)

• ECMO flow (see note below)

• Cardiac output

Quick Bedside Check

If oxygen delivery is low, ask:

• Is saturation adequate?

• Is hemoglobin adequate?

• Is the flow adequate?

Look at the problem with an open mind and fix it.

Common Mistake

Low PaO₂ → increase FiO₂

Helps—but only to a point.

Beyond that:

• Minimal gain in delivery

• Rising PaO₂ may be harmful

Think: Hb + Flow + Saturation—not PaO₂ alone.

Important Note: VV vs VA ECMO Response

Takeaway

Saturation + Hemoglobin + Flow = Oxygen Delivery

Don’t chase PaO₂ in isolation.

Learn More

Subscribe to LifeSupport.Training to receive updates and read the ECMO 143: AI-Assisted Journey newsletter, along with the new ECMO Tools section.

You can also use AI ECMO Educator, a free Custom GPT designed to support ECMO and ECPR learning for ICU clinicians and trainees.

Educational content only. Follow your institutional protocols and clinical judgment.

Key Points

• Ventilator withdrawal often involves unresponsive patients; emotional connections are primarily with family members.

• ECMO withdrawal may involve awake and interactive patients, creating deeper, more personal clinician-patient bonds.

• Clinical triggers for both include lack of recovery and complications, but ECMO decisions often hinge on transplant eligibility or irreversible organ failure.

• Emotional weight differs: Ventilator withdrawal leans on familiarity and structure; ECMO withdrawal often feels raw, personal, and ethically complex.

• Professional growth as an ECMO specialist challenges long-held norms from decades in respiratory therapy.

After 20 years as a respiratory therapist and now stepping into my role as an ECMO specialist, I’ve begun to see just how different these worlds can be, especially when it comes to withdrawing life support.

Through ECMO 143: AI-Assisted Journey, I’ve been documenting what I’m learning in real time. One experience I’ll never forget: a patient who was awake, smiling, and walking while on ECMO—who got married in the hospital chapel just days before she died. That moment was sacred. Beautiful. And it broke me a little.

It also taught me something no textbook ever could: stopping ECMO is not the same as stopping a ventilator. Not by a long shot.

Ventilator Withdrawal: Connection Through Families

Ventilators support patients with brain injuries, sepsis, or advanced terminal illness. When those patients are unresponsive, comatose, or brain-dead, I don’t form a personal bond. My role is focused and technical: manage the ventilator, adjust settings, and watch the numbers.

The emotional connection, when it comes, is with their loved ones.

Common Triggers:

• Brain death confirmed via EEG or imaging

• Advance directives or clearly communicated goals of care

• Lack of improvement over weeks or months

My Role:

Withdrawal is a team effort. Family meetings, ethics consults, and palliative care support help create clarity. We explain what happens during extubation. We manage sedation. I control the ventilator’s final settings. And then I stay in the room.

I’ve seen spouses whisper final prayers. Daughters hold their father’s hand while jazz plays softly in the background. It’s often peaceful, sometimes fast, and almost always surreal.

Emotionally?

I carry the family’s grief, not the patient’s. These moments are solemn, but familiar. I’ve done it hundreds of times. There’s structure. There’s closure.

ECMO Withdrawal: Bonds With Everyone

ECMO is different. It doesn’t just keep someone alive, it becomes the reason they’re alive. And many ECMO patients aren’t unconscious. They’re awake. Smiling. Talking. Living.

That changes everything.

Common Triggers:

• No recovery after lung or heart assessment

• Transplant is no longer viable

• Infections or complications make continuation futile

• Shared decision-making with patients or families choosing quality over quantity

My Role

We speak with the patient, if they’re awake, or with their family. The physician in charge and various team members explain that continuing ECMO is no longer helping and that it may now be causing more harm than good.

Stopping flow means death, usually within minutes. We sedate. We clamp the circuit. We stay by the bedside. But this time, we are not just supporting the family. We are grieving with them.

Because I knew her. I was elated when she stood up for the first time. PT, OT, the nurse, and I helped her into a chair. I listened to her joke with her husband—watched him tease her, make her laugh. She was real to me. And now, I’m part of letting her go.

Emotionally?

It’s different. Harder. Watching a fully alert human being die is tough. Sadness. Like I’m stepping away from someone I knew. The loss is heavier because the bond is deeper.

Years ago, I worked in international TV news. I was in places where people died right in front of me—disasters, conflict zones, moments that never leave you. This felt strangely familiar. The stillness. The heartbreak. The helplessness.

Key Differences

In ventilator withdrawal, my connection is usually with the patient’s family. The patient is often unresponsive, and the clinical decision is based on clear signs of non-recovery, brain death, or prolonged lack of improvement. Emotionally, the process is familiar, structured, and centered around helping the family say goodbye. My role feels practiced, technically grounded, and confident.

In ECMO withdrawal, the relationship shifts. I often know the patient well, and they’ve been awake, talking, and even mobilizing. The triggers for withdrawal are more complex: irreversible organ failure, transplant no longer an option, or complications like sepsis or bleeding. The emotional burden is heavier. It feels raw, personal, and centered not just on the family’s loss, but my own. My role is newer, more uncertain, and deeply vulnerable.

Final Thoughts

Ventilator withdrawal gives me a script to follow, a structure. I’ve rehearsed it, refined it, and lived it for years.

ECMO withdrawal? There’s no script. Each case writes its own story. Sometimes the ending is peaceful. Other times, it hits like a punch to the chest.

I once had a family ask if another ECMO Specialist could be present for the withdrawal instead of me. They felt closer to that person. I quickly agreed and stepped aside; it’s not about us. It’s about them—the patient and their family. Our job isn’t just to save lives—it’s to honor them. Even when that means quietly stepping out of the room.

Through ECMO 143 and LifeSupport.Training, I’ll keep sharing these lessons—because maybe someone else out there is just starting to see the contrast, too.

📝 Note: This article is for educational purposes only and is not a substitute for professional medical advice. Always consult with qualified healthcare professionals for clinical decisions and patient care.

🚀 Join the ECMO 143 Learning Journey. Enjoyed this? Subscribe to my free newsletter, ECMO 143: AI-Assisted Journey, on LinkedIn, where I share ongoing lessons as I learn and grow in ECMO and critical care.

🧠 Resources & Acknowledgments

I created this article using a mix of AI-assisted research and personal study. I’ve built two custom GPTs to support this work:

• AI ECMO Educator

• Micro Definitions (MD-GPT)

Special thanks to:

• OpenEvidence

• Claude 4.6 Sonnet

• Perplexity AI

• Gemini 3.1 Pro

• Stanford’s STORM

• Grammarly

• Leonardo AI

• DALL·E 3

• Microsoft Designer

• Adobe Express

🌐 My Other Links

• ECMO 143: A Patient & Family Guide

• LifeSupport.Training

• YouTube – ECMO 143 Channel

• LinkedIn – ECMO 143 Company Page

• Facebook – ECMO 143 Page

• X (Twitter) – ECMO 143 – UpToDate List

I met Shane in an ECMO survivor support group. His story stopped me. I reached out and asked if he’d be willing to share it here, and he said yes. What follows is his account of what it felt like from the inside — waking, recovering, and understanding what his team had done to keep him alive.

Shane went to bed one night thinking about the coming weekend. Hours later, he was in cardiac failure, on a ventilator, then on ECMO. What followed was survival — and a journey most clinicians never fully see from the patient’s side.

When Shane woke from the coma, nothing made sense. His world had shrunk to a narrow strip of glass, six feet by two feet. He couldn’t speak. He couldn’t move. He was losing track of words halfway through sentences. “I felt small, like I had lost something fundamental,” he writes.

But one thing stood out to him: the advocate at his bedside. His partner asked what they were giving him. Why. What each step meant. “Those questions helped bring clarity in the middle of chaos, when everything was moving quickly, and understanding felt just out of reach.”

Shane’s recovery took him through complications most of us hope our patients never face. He lost a leg to the brutal tradeoff of pressors. He gained forty pounds of fluid. He had to relearn how to breathe.

And here’s what he understands now that matters most for your team: “No one comes back from something like this alone. Survival does not belong to one person. It belongs to the families who stayed, the friends who hoped, and the doctors, respiratory therapists, nurses, techs, specialists, and teams who never gave up, even while living through hell themselves and praying for a miracle.”

That’s professional knowledge. Your patient sees it. They feel it. They remember it.

Read Shane’s full story on ECMO 143: A Patient & Family Guide, my free patient and family resource for anyone navigating ECMO.

Learn more

For a deeper dive into ECMO for professionals, subscribe to this Newsletter ECMO 143: AI-Assisted Journey, a free resource for specialists and trainees.

I also built AI ECMO Educator, a free Custom GPT providing evidence-based guidance on physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Built on ELSO, PubMed, AmSECT, and leading centers. Version 5.2 | Supports 50+ languages.

As an ECMO specialist, I often find myself dealing with a variety of terms used to describe ECMO circuit components. I found out that different centers, teams, and even individual providers may use different language for the same part of the ECMO circuit. To ensure clear communication and avoid confusion, it’s helpful to recognize the most commonly used terms and be aware of less common alternative names.

ECMO Drainage vs. Return: What’s the Difference?

The ECMO circuit consists of two primary functions: drainage and return.

• Drainage: Deoxygenated blood is withdrawn from the patient into the ECMO circuit, usually via a venous cannula.

• Return: Oxygenated blood is returned to the patient via a vein (VV-ECMO) or an artery (VA-ECMO).

There are many names for these functions, so I compiled a chart to clarify the most commonly used terminology, along with less common alternatives.

Why Does This Matter?

Clear communication is critical in ECMO management. If team members use different terminology, it can lead to misunderstandings during patient handoffs, troubleshooting, and emergencies.

• The most commonly used terms align with ELSO guidelines and ECMO specialist training manuals.

• The less common terms may still be used in certain ECMO centers, among perfusionists, or in specialized discussions.

If you work in an ECMO center that uses alternative terms, it’s worth clarifying and ensuring everyone on the team understands the same terminology.

Final Thought:

Whether you’re new to ECMO or a seasoned specialist, having a clear grasp of ECMO circuit terminology ensures effective collaboration and patient safety. If you’re ever unsure, ask for clarification—communication is just as important as technical skills in ECMO care!

Learn more

For a deeper dive into becoming an ECMO Specialist, sign up for this free website: ECMO 143: AI-Assisted Journey.

I built a Custom GPT, AI ECMO Educator. It is free to use and provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Built on sources like ELSO, PubMed, AmSECT, and leading centers. Version 5.2 | Supports 50+ languages.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

Over several recent ECMO orientation shifts, I was reminded of how much the role changes when you are helping someone else orient.

At the beginning, I stay close to the center of the action. I demonstrate procedures, explain decisions, and guide things step by step.

As the orientee gains experience, that starts to shift. I step back more. They lead the workflow, and I watch the patient and the circuit. Eventually, my role becomes supervision. They do the work, and I become the safety net. That part takes discipline. The natural urge is to jump in and do it yourself. Good orientation means resisting that urge while still keeping the patient safe.

In this case, the orientees were already experienced ICU nurses, and over several shifts, it was easy to see their confidence grow. What I appreciate about ECMO orientation is that it often becomes shared discovery. They asked good questions, and not every answer was obvious. That gave us a chance to pause, look things up, and learn together.

I’ve been fortunate to work with physicians, nurses, and ECMO specialists who take time to teach. Being on the receiving end of that makes it easier to pass something along. In critical care, the goal is not to know everything. It is to protect the patient, stay curious, and keep learning. Some of those questions also led us back to the lab signs of hemolysis in ECMO patients, which I wrote more about in “Hemolysis on ECMO: What It Means at the Bedside.”

Learn more

For a deeper dive into becoming an ECMO Specialist, visit my website: ECMO 143: AI-Assisted Journey.

I built a Custom GPT, AI ECMO Educator. It is free to use and provides evidence-based ECMO and ECPR guidance for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Built on sources like ELSO, PubMed, AmSECT, and leading centers. Version 5.2 | Supports 50+ languages.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

To understand how blood moves through the heart, we can number the valves in the order in which the blood passes through them as it travels from the venous to the pulmonary and then to the arterial side.

The Sequential Order of Heart Valves

1. Tricuspid Valve: The first valve. It allows deoxygenated blood to flow from the Right Atrium into the Right Ventricle. Tri=3 leaflets for the valve

2. Pulmonary Valve: The second valve in the sequence. It opens to allow blood to be pumped from the Right Ventricle into the Pulmonary Artery on its way to the lungs. There are 3 leaflets for the pulmonary valve.

3. Mitral Valve (also called the Bicuspid Valve): After the blood is oxygenated in the lungs, it returns to the Left Atrium and passes through this third valve into the Left Ventricle. Bi (cuspid) = 2 leaflets for the valve.

4. Aortic Valve: The final valve. It opens to allow oxygen-rich blood to leave the Left Ventricle and enter the Aorta, which distributes it to the rest of the body. 3 leaflets for the aortic valve.

Two Quick Memory Tricks

Here are a few solid memory tricks to help you remember the right-to-left valve sequence

(Tricuspid → Pulmonary → Mitral → Aortic):

Bonus Valve Information

The Rule of Three

3 valves have 3 leaflets:

• Tricuspid

• Pulmonary

• Aortic

This design allows a wide opening for flow and tight closure under pressure.

The Mitral Exception

The Mitral valve has 2 leaflets.

It sits on the left side of the heart and handles the highest pressures (transvalvular).

It is supported by chordae tendineae and papillary muscles, which prevent it from prolapsing back into the left atrium.

Why This Matters at the Bedside

If you understand the sequence, you can troubleshoot faster.

Example:

• Pulmonary edema? Think Mitral or left side problem

• High CVP and congestion? Think Tricuspid or right side problem

• No pulse pressure on VA ECMO? Think Aortic valve not opening

Start with flow. Then find where it’s blocked or leaking.

Learn more

If you want more ECMO breakdowns like this, make sure you are subscribed to this newsletter, ECMO 143: AI-Assisted Journey. I’ll keep sharing what I’m learning along the way.

You can also use my free Custom GPT, AI ECMO Educator, an evidence-based ECMO and ECPR educator for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting. Sources include ELSO, PubMed, AmSECT, and leading centers. Version 5.2 (2/21/26) | Supports 50+ languages.

Both nursing and respiratory therapy backgrounds provide distinct, highly valuable skill sets that uniquely prepare clinicians for the role of an ECMO Specialist. While both professions work in high-stakes critical care environments, they approach the therapy from different foundational strengths.

The Nurse’s Advantage: Holistic Patient Management. Critical care nurses excel at comprehensive patient management and bring a distinct advantage in treating the body as a whole system. Their unique contributions include:

• Holistic Assessment: Nurses are trained to perform thorough head-to-toe assessments, allowing them to notice subtle changes, such as decreased urine output, mottling, or pupillary asymmetry, that may indicate underlying circuit or perfusion issues.

• Complex Pharmacology: ECMO patients require careful combinations of sedatives, paralytics, vasopressors, and anticoagulants. Nurses already understand how these complex medications interact, how to safely titrate them, and how to monitor for side effects.

• Line and Wound Care: Nurses are highly experienced with invasive lines (central lines, arterial lines, chest tubes) and sterile techniques. This translates directly to monitoring ECMO cannulas, securing sites, preventing infection, and managing localized bleeding.

• Hemodynamic Management: Nurses, particularly those from cardiac ICUs, are adept at walking the tightrope of balancing blood pressure and perfusion, which is crucial when managing circuit flow alongside a patient’s native cardiac function.

• Care Plan Execution and Family Communication: Nurses are experts at integrating the multidisciplinary care plan, including nutrition, skin care, and mobility, and serve as a crucial, compassionate bridge for families who are overwhelmed by the ECMO machinery.

The Respiratory Therapist’s Edge: Mastering the Mechanics. Respiratory therapists (RTs) bring an unparalleled expertise in gas exchange and cardiopulmonary mechanics, which form the core of what ECMO actually does. Their unique contributions include:

• Gas Exchange and ABG Mastery: RTs deal with gas exchange physiology daily. They can swiftly interpret arterial blood gas (ABG) panels, including pre-oxygenator and post-oxygenator gases, and immediately determine the appropriate interventions.

• Sweep Gas Management: The tasks of adjusting sweep gas to clear carbon dioxide and adjusting FiO₂ to optimize oxygenation mirror what RTs already do with mechanical ventilators. This gives them a major head start in manipulating the ECMO circuit’s artificial lung.

• Mechanical Ventilation and ECMO Integration: In VV ECMO, the goal is often to “rest” the lungs. RTs are uniquely skilled at balancing extracorporeal support and protective mechanical ventilation (e.g., low tidal volumes or minimal PEEP) to prevent lung trauma.

• Oxygenator Troubleshooting: When a patient desaturates, RTs naturally follow a methodical sequence to diagnose the issue (e.g., checking gas flow, FiO₂, or looking for clotting), mirroring how they troubleshoot a deteriorating patient on a ventilator.

Ultimately, becoming an ECMO specialist requires both professions to bridge their knowledge gaps. Nurses must deepen their understanding of circuit physics and advanced gas exchange, while RTs must expand their scope to encompass total-body hemodynamics, broad-spectrum pharmacology, and comprehensive patient care.

Learn more

If you want more ECMO breakdowns like this, subscribe to this newsletter, ECMO 143: AI-Assisted Journey. I’ll keep sharing what I’m learning along the way.

You can also use my free Custom GPT, AI ECMO Educator.
An evidence-based ECMO and ECPR educator for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting.
Sources include ELSO, PubMed, AmSECT, and leading centers. Version 5.2 (2/21/26) | Supports 50+ languages.

I understood the basics of hemolysis on ECMO. Watch for rising plasma-free hemoglobin, clots, and high negative inlet pressures.

What I had not fully worked through were the consequences. How free hemoglobin contributes to kidney injury, vasoconstriction, and oxidative stress. Or how to interpret labs like haptoglobin in a meaningful way.

So I did an AI-assisted deep dive and turned it into a practical breakdown for the bedside.

What is hemolysis?

Hemolysis is the destruction of red blood cells. On ECMO, it usually means the circuit is stressing the blood due to suction, turbulence, or clot.

When red blood cells rupture, hemoglobin is released into the plasma. This is intravascular hemolysis.

A small amount of hemolysis can occur even in a normal circuit. The concern is when it increases or begins trending upward.

Why it matters

Hemolysis is often the first warning that the ECMO circuit is developing a mechanical problem.

On ECMO, hemolysis is usually circuit-related, not just patient-related. It can point to high shear stress, very negative drainage pressure, suction events, fibrin deposition, pump thrombosis, or oxygenator clot burden before the situation becomes a full circuit emergency.

Free hemoglobin is directly harmful.

Once hemoglobin is released into plasma, it is no longer contained. Free hemoglobin, heme, and free iron contribute to oxidative injury, deplete nitric oxide, promote vasoconstriction, and can lead to renal tubular injury and abnormal coagulation. This can progress to organ dysfunction.

Hemolysis also reduces effective oxygen delivery.

Red blood cell destruction contributes to anemia, but more importantly, rising plasma-free hemoglobin is associated with worse clinical outcomes during ECLS. It reflects both a blood problem and a system problem.

How to recognize hemolysis on ECMO

No single lab confirms hemolysis on its own. You need a pattern and a trend.

The most important question is not “is this abnormal?” but “is this getting worse?”

What to look for

Strongest indicator:

Plasma-free hemoglobin (pfHb)

This is the principal biomarker for intravascular hemolysis.

• <10 mg/dL: Normal

• 10-50 mg/dL: abnormal in some studies

• >50 mg/dL: widely used threshold for significant hemolysis

• 100 mg/dL: severe and should prompt immediate action

A rising trend is the most important signal

Supportive indicators:

These support the diagnosis but are not specific on their own.

Lactate Dehydrogenase (LDH)

LDH is released when cells break down.

It supports the diagnosis of hemolysis, but it is not specific. LDH also rises in shock, liver injury, and tissue damage.

Use LDH as a supporting signal, not a primary one.

Haptoglobin

Haptoglobin binds free hemoglobin.

When hemolysis occurs, haptoglobin is consumed and levels fall.

Low or undetectable haptoglobin supports hemolysis, but it is unreliable in critically ill patients. Many ECMO patients already have low levels at baseline.

Think of it as supportive evidence only.

Bilirubin

Indirect bilirubin may rise as hemoglobin is broken down.

This is a slower marker and not specific. It helps support the overall picture but should not drive decisions on its own.

Hemoglobin (Hb)

A falling hemoglobin can suggest hemolysis, but it is not specific.

On ECMO, hemoglobin can drop for several reasons: bleeding, dilution, or lab draws.

If hemoglobin is falling and plasma-free hemoglobin is rising, that combination is more concerning.

Hemoglobinuria

Pink, red, or tea-colored urine can suggest hemoglobinuria.

This is a useful bedside clue but not diagnostic on its own.

Falling hemoglobin without bleeding

Suggests red cell destruction but requires context.

Circuit clues

These increase suspicion for circuit-related hemolysis:

• Very negative drainage pressure

• Suction events or chatter

• Rising transmembrane pressure (>60 mmHg)

• Fibrin deposition or visible clot

• Worsening oxygenator gas transfer

Why hemolysis happens

Most causes fall into three categories:

1. Drainage problems

• High negative inlet pressure

• Suction events

• Hypovolemia

• Cannula malposition

2. Flow and shear

• High RPM

• Excessive flow for cannula size

• Turbulent flow

3. Circuit or device issues

• Oxygenator clot or fibrin buildup

• Pump head thrombosis

• Tubing kinks or obstruction

4. Other mechanical support devices

Hemolysis is not limited to ECMO.

Devices like Impella can also contribute due to shear stress, especially with high support levels, suction events, or malposition.

In patients on combined support (ECMO + Impella), both systems should be evaluated.

What to do at the bedside

Start with one question:

Why is this circuit or device damaging blood?

1. Assume the circuit until proven otherwise

Review pump flow, RPM, drainage pressures, and recent suction events.

Hemolysis worsens with high flow, high shear, poor preload, and unstable drainage.

2. Inspect the circuit

Use a bright light. Look at the oxygenator and tubing for fibrin or clot.

If there is visible clot, rising pressures, or worsening gas exchange, treat that as part of the problem.

3. Reduce contributing forces

• Improve preload if appropriate

• Minimize suction events

• Reduce excessive flow or RPM

• Stabilize drainage conditions

4. Escalate early if the trend is worsening

If hemolysis is severe, rising, or associated with thrombosis:

• Consider oxygenator exchange

• Consider full circuit exchange

5. Evaluate other devices

If present:

• Check Impella position

• Reduce support level if appropriate

• Address suction or malposition

6. Monitor the patient closely

Follow:

• Plasma-free hemoglobin

• Kidney function

• Urine color

• Hemoglobin trend

• LDH and bilirubin

Hemolysis can quickly shift from a circuit issue to a patient injury issue.

The bedside framework

When plasma-free hemoglobin is rising, narrow it down:

• Too little drainage

• Too much shear

• Or clot forming

Most problems fall into one of these three.

Final thought

Hemolysis is one of the clearest signals that the ECMO circuit or support device may be harming the patient.

If plasma-free hemoglobin is rising, something is wrong.

Find it early. Fix it early.

Learn more

If you want more ECMO breakdowns like this, subscribe to ECMO 143: AI-Assisted Journey. I’ll keep sharing what I’m learning along the way.

You can also use my free Custom GPT, AI ECMO Educator.
An evidence-based ECMO and ECPR educator for ICU clinicians and trainees, covering physiology, cannulation, anticoagulation, circuit management, and troubleshooting.
Sources include ELSO, PubMed, AmSECT, and leading centers.
Version 5.2 (2/21/26) | Supports 50+ languages.

Disclaimer

This content is for educational purposes only and does not replace clinical judgment, institutional protocols, or consultation with your ECMO team.

This year, I’m opening the ECMO 143 Newsletter to guest contributors. I’ll still be writing regularly, but now I want to feature voices from across the field: specialists, nurses, RTs, perfusionists, physicians, educators... anyone involved in ECMO or mechanical circulatory support who has something useful to share.

What can you write about?

If you’ve learned something, built something, want to explain a concept, or tried something that made a difference, this is your invite to write. You don’t need to be an expert, and your draft doesn’t have to be perfect. You just need a clear point and a willingness to share it. I’ll help shape it from there.

The focus remains ECMO, but I’m also open to related mechanical support, such as Impella, IABP, or VADs. Case studies, troubleshooting tips, training workflows, bedside insights, protocol reflections: anything practical, grounded, and clinically useful. It can be something that interests you, and it does not have to be complicated.

Here is how it works

Articles should be around 600 to 1,000 words—enough for a solid 3- to 5-minute read. If you want to contribute, DM me. You can send a rough draft or just a few notes. I’ll help edit for clarity, format it for the ECMO 143 newsletter, and send it back to you for approval. Nothing gets published without your final sign-off, and you’ll be listed as the author. My role is to help you shape it and make it clean. Your role is to bring your real-world experience to the table and help others learn.

Let’s grow this together. Jon

TLDR

• Interviews with 9 ECMO nurses in Colombia.

• Training varied a lot across settings, so readiness varied too.

• Supervised practice and simulation built confidence more than lectures.

• Nurses saw competence as technical skill plus stress control and communication.

The setup

This study didn’t measure patient outcomes. It asked nurses to describe the training process in their own words.

Study snapshot

• Location: Colombia, South America

• Participants: 9 nurses involved in ECMO care

• Approach: Qualitative interviews (experience-focused)

What nurses said, in plain terms

1. The pathway isn’t consistent. Some nurses described formal education routes. Many described local, institution-built training. When programs expanded fast (especially during COVID), onboarding could get compressed. The result was uneven preparation. In ECMO, uneven preparation shows up when the first real crisis becomes the first real learning moment.

2. The theory foundation can be thin. Nurses described a gap between the complexity of ECMO and how much structured teaching they received up front. Many tried to fill that with self-study. That helps, but it also creates variability. Two nurses can “self-study” and end up with two very different mental models.

3. Resources aren’t automatically usable. Being handed a reference is not the same as being taught. Nurses described barriers like dense material and language limitations. When learning materials feel out of reach, people shift toward shortcuts: memorized steps, copied notes, or partial understanding. That works until the case deviates from the script.

4. Mentorship and reps are what change confidence. Nurses valued supervised bedside time with experts. They described how coaching helped them connect the why to the what, and how psychological safety mattered. If a nurse can ask questions early and often, they build pattern recognition faster and make fewer silent mistakes.

5. Simulation mattered when patient exposure was limited. Nurses who had meaningful simulation described feeling more prepared when real problems occurred. Simulation gave them a safe place to practice recognition, communication, and response structure. It reduced panic. It helped them show up calmer when the room got chaotic.

6. Competence includes the human part of the job. Nurses described fear, insecurity, and emotional load, especially early on and during complications. They also described the pressure of team coordination and family communication. They saw these as real skills that training should address, not optional extras.

What this suggests for training programs

Standardize what “ready” means across sites and preceptors. Build a progression that includes supervised bedside reps and simulation before independent coverage. Make learning materials accessible and usable for the actual learners. Assess competence in a way that reflects real performance, not just completion.

Summary

In Colombia, nine ECMO nurses described training as uneven and often too dependent on local resources and timing. They emphasized supervised practice, strong mentorship, and simulation as the fastest route to real readiness. They also made it clear that safe ECMO care requires more than technical competence. It requires stress control, clear communication, and steady team function when things go wrong.

Your Turn

How does your unit currently train nurses and RTs for ECMO?

1. What’s non-negotiable before someone takes independent coverage?

2. How do you use simulation (if you do)?

3. What’s the biggest gap you still see in new ECMO specialists?

If this was useful, hit Like so more ECMO folks see it. If you want more posts like this, make sure you’re subscribed to this newsletter.

I also offer a free, additional newsletter for Families + ECMO patients: ecmo.life

Complete reference (open access)

Madariaga M, Moreno F, Vergel J. Nurses’ Experiences in the ECMO Training Process: A Qualitative Study. Revista Cuidarte. 2025;16(3):e4605. doi:10.15649/cuidarte.4605. Open access.

If you’re reading this from an ICU waiting room, you’re doing something hard. You showed up. You stayed. That matters.

Today might not look like Christmas. The day can feel slow, loud, confusing, and unfair. Machines beep. Plans change. Updates come in pieces. You may feel calm one minute and wrecked the next. That’s normal.

Here’s what I hope you remember today:

1. Your presence helps, even when you don’t know what to say.

2. It’s okay to take breaks. Eating, sleeping, and stepping outside are part of staying strong.

3. You don’t need to understand every number on the screen to be a good advocate.

If you want something practical to do today, try this:
Ask the bedside nurse or provider these three questions:

1. What are the main goals for the next 24 hours?

2. What would make today a “good day” medically?

3. What signs would mean we’re moving in the right direction?

Then write the answers down. It helps when you’re tired. It also helps when different family members rotate in.

If your loved one is awake, even a little, simple is best:
“I’m here. You’re safe. We’re taking it one step at a time.”

If your loved one is sedated, talk anyway. Familiar voices can still matter:
“It’s Christmas. I love you. I’m staying close.”

And if you’re carrying guilt, fear, or anger today, you don’t need to fix it in one sitting. Just get through the next hour. Then the next.

Merry Christ mas. You’re not failing because this is hard. This is hard because it matters.

When your patient gets cold, hemoglobin holds onto oxygen tighter. Cooling shifts the oxyhemoglobin curve to the left, so at a given PaO2, you may see a higher SaO2, but less oxygen gets unloaded to the tissues. On ECMO, that means the “numbers” can look reassuring while perfusion and tissue oxygenation are not. If you’re fighting hypothermia, it’s worth thinking beyond the saturation and watching the whole picture: temperature, lactate trend, perfusion, and venous oxygen data if you have it.

Merry Christ-mas

Jeffrey Scott, DO, MBA, FASE, one of the guest editors of this newsletter, recently told me about “Echo In Cardiac Mechanical Support,” an online course which he helped create. It is a new online course from the American Society of Echocardiography. ASE added this video to its educational site that covers echocardiography and critical care ultrasound for mechanical support, including VA and VV ECMO, intra-aortic balloon pumps, and left ventricular assist devices. Developed by an international team of intensivists specializing in cardiothoracic ICU care, the course costs $85.00 and offers about 4 hours of CME credit.

• Cardiac stun is a reversible myocardial dysfunction. The heart is alive but temporarily unable to contract.

• It shows up on VA-ECMO as low EF, no pulsatility, poor MAP, and rising lactate.

• It happens because of ischemia–reperfusion, severe hypoxia, prolonged shock, and sudden afterload spikes when starting VA flows too fast.

• Cold prime and metabolic instability can worsen the picture — the problem isn’t Plasmalyte, it’s temperature and how fast I increase the ECMO flow.

• You resolve it by slow-controlled ECMO initiation, correcting metabolic problems, supporting perfusion, and letting the myocardium recover.

• The heart isn’t dead. It just needs time. ECMO gives it that time.

A few days ago, someone asked me a simple question:

“Hey Jon, what exactly is cardiac stun?”

I knew the usual bedside signs — weak squeeze, low stroke volume, almost no pulse pressure, lactate creeping up even with “good” circuit flow. But when I tried to give a clear, confident explanation, I realized I was only describing what it looks like, not what it is or why it happens.

So I went back, reviewed the physiology, double-checked the ECMO guidance, and asked my AI ECMO Educator GPT to help me tighten the concept. What came out is the version I wish I had ready in the moment, and the version I think early ECMO clinicians deserve: something practical, accurate, and actually usable at the bedside.

Here it is.

1. What Cardiac Stun Is

Cardiac stun is a temporary myocardial dysfunction after a major physiologic insult.
The myocardium is alive and well-perfused, but the muscle can’t generate an effective squeeze. It’s not infarction, it’s not permanent damage — it’s a ventricle recovering from shock, hypoxia, or reperfusion.

On VA-ECMO, it typically looks like:

• Very low EF on echo

• Minimal or absent pulsatility on the arterial line

• Tiny stroke volume, even with full coronary perfusion

• MAPs are completely dependent on ECMO flow and vasoactive support

• Lactate that rises or clears slowly because forward flow is insufficient

The key idea:
The heart has oxygen. It has perfusion. It just doesn’t have the contractile strength yet.

ECMO doesn’t fix the heart — it carries the circulation while the heart repairs itself.

2. Why Cardiac Stun Happens

Several pathways lead to cardiac stun, and most ICU clinicians have seen at least one of them. The physiology is straightforward once you look at the sequence.

Ischemia–Reperfusion After Arrest

After downtime, the heart gets blood flow back — but the myocytes aren’t ready to contract. They need time to recover, redistribute calcium, normalize pH, and restore ATP levels.

Severe Hypoxia or Prolonged Shock

A ventricle exposed to prolonged underperfusion loses contractile reserve. Even after restoring oxygen delivery, mechanical output lags behind.

Abrupt Hemodynamic Shifts During VA-ECMO Initiation

This one is under-taught but very real:

When you start VA flows too fast, you instantly increase LV afterload.
A stunned or borderline heart may not be able to open the aortic valve against that pressure.

The result is:

• No pulsatility

• No forward stroke volume

• A ventricle that looks even worse after ECMO is started

This isn’t ECMO “hurting” the heart — it’s ECMO exposing how little native output was left.

Systemic Inflammation and Vasoplegia

Post-arrest and septic physiology depress contractility globally. ECMO restores perfusion, but it doesn’t instantly reverse the inflammatory myocardial depression.

What About the Prime? (The Accurate Version)

I’ve heard (and once believed) the idea that:

“Plasmalyte doesn’t carry oxygen, so it can stun the heart if you start VA too fast.”

Here’s the fact-checked version:

• Crystalloid prime doesn’t carry oxygen, but it mixes immediately with circulating blood.

• The heart is not perfused with pure crystalloid in isolation.

• ELSO does not list crystalloid prime as a cause of stunning.

The real factors are:

• Cold prime: can transiently depress myocardial function

• Rapid flow initiation: spikes afterload

• Metabolic instability: acidosis, hypothermia, low calcium

So the teaching point is this:

Temperature and how fast you increase your ECMO flow matter far more than whether the prime is Plasmalyte.

3. How Cardiac Stun Resolves

You can’t “treat” stun directly — the myocardium simply needs time to recover. But you can create the conditions for recovery.

Controlled Flow Initiation

Start VA-ECMO gradually. Build flow slowly, allowing the LV to adjust and preventing an abrupt afterload hit.

Correct Metabolic Problems

The stunned ventricle won’t recover if the environment is hostile:

• Normalize calcium

• Correct acidosis

• Maintain temperature

• Optimize electrolytes

Many centers give calcium at initiation for this reason.

Support Perfusion

While the heart rests:

• Maintain appropriate ECMO flow

• Use vasoactive support judiciously

• Monitor lactate and regional perfusion

• Avoid unnecessary LV distention

Unload the LV When Needed

If the aortic valve isn’t opening and the LV begins to distend, intervene early:

• Reduce afterload

• Consider inotropes, IABP, Impella, or surgical venting, depending on your program

Watch for Signs of Recovery

You’ll know the heart is coming back online when you see:

• The aortic valve opens intermittently

• Pulse pressure returning

• Stroke volume rising

• Improved lactate clearance

Once you see pulsatility, the heart is re-engaging.

Closing Thoughts

Cardiac stun used to feel vague to me — something people mentioned, assumed, and moved past without a clear explanation. Being asked directly forced me to clarify what it actually is and why it shows up the way it does, especially during VA-ECMO initiation.

Here’s where I landed:

Cardiac stun is the myocardium saying, “I’m viable — I just need time.”
Our job is to protect the patient while the heart rebuilds its ability to generate mechanical work.

VA-ECMO gives the heart the chance to recover, and when it does, it’s unmistakable:
Pulsatility returns, the aortic valve opens, and the circulation begins to shift back toward native output.

That moment never gets old.

The final two days of the ECMO Diploma Course were a solid mix of lectures and practical discussion. I picked up new ways to approach problems and left with a clearer understanding of how other centers manage similar cases. The class participation added just as much value as the lectures, sometimes more.

We had a strong international mix in the room, with representatives from India, Egypt, the U.S., New Zealand, Australia, Peru, and Eastern Europe. That diversity made the conversations richer and more grounded. Everyone brought something real to the table—different approaches, different system limitations, different habits, same pressure to do the right thing.

Topics covered on June 25:

• My patient remains hypoxemic on VV-ECMO (C.-E. Luyt)

• Neurologic complications of ECMO (C.-E. Luyt)

• COVID cardiac involvement (G. Hekimian)

• La Pitié experience of ECMO for COVID (M. Schmidt)

• Management of anticoagulation in ECMO patients (M. Schmidt)

• Bleeding on ECMO: causes and management (C.-E. Luyt)

• Infectious complications of ECMO (M. Schmidt)

• Tutorial: how to wean patients from VV-ECMO? (M. Schmidt)

• ECMO for refractory cardiac arrest, in-hospital, out-of-hospital, E-CPR results (A. Combes)

• Discussions of concrete cases at the bedside

Topics covered on June 26:

• Ethical aspects of ECMO (C.-E. Luyt)

• Long-term outcomes after ECMO (C.-E. Luyt)

• Indications and results of ECCO2R techniques (A. Combes)

• Fulminant myocarditis: diagnosis, outcomes, and results of ECMO (A. Combes)

• ECMO and immunocompromised patients (C.-E. Luyt)

• Intoxication with cardiotoxic drugs: indications and results of ECMO (G. Hekimian)

• Tutorial: how to wean patients from VA-ECMO (G. Hekimian)

• Circulatory assistance with the IMPELLA device (A. Combes)

We wrapped up with a short diploma ceremony. Alan Combes handed out the certificates with his usual calm and understated style. It was a good way to close—simple, meaningful, and appreciated.

Also worth mentioning: the food was excellent. Possibly too excellent. I’m just hoping Delta doesn’t charge me for the extra weight I’m bringing home, or flag me for a seat belt extension.

I highly recommend the course, which is offered several times per year. Full details here:

https://ecmo-courses.paris-ecostcs.com

AI and My ECMO Learning Journey

AI plays a significant role in how I research, understand, and communicate complex ECMO topics. From analyzing source materials to organizing ideas and generating podcast outlines, AI helps me stay curious and keep learning, so I can continue sharing insights with you.

ECMO 143: Projects and Tools

As part of ECMO 143, I’ve developed these resources to support both professionals and families in the ECMO space:

• lifesupport.training – Resources for ECMO and other professionals,

• ecmo.life – Information for ECMO patients and their loved ones

• YouTube: ECMO 143 – Occasional AI-supported podcasts

• LinkedIn Newsletter: ECMO 143: AI-Assisted Journey

Custom GPTs available on OpenAI:

• AI ECMO Expert – A custom GPT designed to assist with ECMO research and education.

• Micro Definitions (MD-GPT) – A custom GPT providing concise definitions for medical terminology

At ECOS-TCS 2025 in Paris, I had the chance to see Getinge’s CardioHelp 2 in person and speak directly with one of their reps. Below is a quick summary of what’s actually different from the original.

What’s New

Redesigned Interface
A larger touchscreen with an intuitive layout and guided workflows for setup, troubleshooting, and operation.

Integrated Gas Blender
Now built into the system—no more external blender needed, even during transport.

Weight Reduction
The unit is over 25% lighter than the original. Carbon fiber components help reduce weight while keeping it durable.

SvO₂ Probe Update
Still locked to the machine, but now redesigned to improve reliability and reduce probe failure—this was a known issue with the original.

NIRS Integration
CardioHelp 2 is designed to support near-infrared spectroscopy (NIRS) for cerebral and somatic oxygenation monitoring.

Other Specs

• Weight: ~12 kg (26 lbs)

• Dimensions: 255 x 315 x 427 mm

• Battery life: 90+ minutes

• Flow: Up to 8 LPM with HLS sets

• Supports VV and VA ECMO

• Not yet FDA approved (expected mid-2025)

Final Notes

I filmed a short video at the booth showing the new system.

More details are available at Getinge’s official site: getinge.com/int/campaigns/cardiohelp-2

Let me know if your team is planning to upgrade or stick with the original.

AI and My ECMO Learning Journey

AI plays a significant role in how I research, understand, and communicate complex ECMO topics. From analyzing source materials to organizing ideas and generating podcast outlines, AI helps me stay curious and keep learning, so I can continue sharing insights with you.

ECMO 143: Projects and Tools

As part of ECMO 143, I’ve developed these resources to support both professionals and families in the ECMO space:

• lifesupport.training – Resources for ECMO and other professionals,

• ecmo.life – Information for ECMO patients and their loved ones

• YouTube: ECMO 143 – Occasional AI-supported podcasts

• LinkedIn Newsletter: ECMO 143: AI-Assisted Journey

Custom GPTs available on OpenAI:

• AI ECMO Expert – A custom GPT designed to assist with ECMO research and education.

• Micro Definitions (MD-GPT) – A custom GPT providing concise definitions for medical terminology.

This week, I started the International Diploma in ECMO & Short-Term Respiratory/Circulatory Support course at La Pitié-Salpêtrière Hospital in Paris. It’s part of an ELSO-endorsed Step 1 program, taught by Dr. Alain Combes, Dr. Guillaume Hekimian, and Dr. Matthieu Schmidt. These are three physicians deeply involved in ECMO development, research, and frontline practice.

The course is divided into four days of in-person sessions (June 19–20 and 25–26), with the ECOS-TCS Congress happening in between.

Week One Summary

Thursday, June 19

• Overview of ECMO circuit components and coatings

• Cannulation techniques for VV-ECMO

• Lessons learned from the EOLIA trial

• Gas transfer mechanics in ECMO membranes

• Managing cardiogenic shock and peripheral VA-ECMO

• Bedside talk

• Practical simulation with the La Pitié team

Friday, June 20

• Mechanical ventilation of patients on VV-ECMO

• Proning while on ECMO: practical tips and risks

• ECMO for refractory septic shock (learned a lot)

• Nursing care and mobilization (nice to see how they manage the patient)

• Pharmacokinetics under ECMO

• Echo monitoring in ECMO (learned a lot)

• Bedside talk

What Stood Out

• The instructors have the ability to explain things in a very logical and straightforward way.

• It is not just guidelines, but your ability for bedside decision-making

• Dr. Combs was part of the EOLIA trial, and the results of the EOLIA trial continue to shape VV ECMO.

• Practical breakdowns of complications, from pulmonary edema to drug clearance

• Real-world stories that reflect the balance between aggressive support and patient trajectory. We visited patients currently on ECMO and we able to discuss their cases bedside.

What’s Next

We’ll spend June 23–24 at the ECOS-TCS International Congress at Cité Internationale Universitaire. Then it’s back to La Pitié for days three and four of the course next week, diving deeper into weaning, E-CPR, long-term outcomes, and advanced support options like ECCO2R and Impella.

More to come after the second week. Thanks to the team at La Pitié for the welcome and to everyone behind the scenes making this course possible.

AI and My ECMO Learning Journey

AI plays a significant role in how I research, understand, and communicate complex ECMO topics. From analyzing source materials to organizing ideas and generating podcast outlines, AI helps me stay curious and keep learning, so I can continue sharing insights with you.

ECMO 143: Projects and Tools

As part of ECMO 143, I’ve developed these resources to support both professionals and families in the ECMO space:

• lifesupport.training – Resources for ECMO and other professionals,

• ecmo.life – Information for ECMO patients and their loved ones

• YouTube: ECMO 143 – Occasional AI-supported podcasts

• LinkedIn Newsletter: ECMO 143: AI-Assisted Journey

Custom GPTs available on OpenAI:

• AI ECMO Expert – A custom GPT designed to assist with ECMO research and education.

• Micro Definitions (MD-GPT) – A custom GPT providing concise definitions for medical terminology.

Imagine being so sick that your heart or lungs (or both!) just can't work anymore. That's where ECMO (Extracorporeal Membrane Oxygenation) comes in. It's like a temporary artificial heart and lung machine that takes over these vital functions, giving your own organs a chance to rest and heal. In recent years, more and more adults have been using ECMO, and thankfully, many are surviving. But what happens to them after they leave the hospital? This is a huge question for doctors and specialists, and recent studies are giving us a clearer picture of their long-term recovery and quality of life.

When we talk about "quality of life," we mean how someone's health affects their daily living, including their physical abilities, mental well-being, and social life. For ECMO survivors, this journey is often complex and challenging.

Beyond the Hospital Doors: Survival and Getting Back to Life

The good news is that many adults who receive ECMO treatment survive to go home, and a large number continue to live for years afterward.

• One study looked at 241 ECMO patients and found that almost two-thirds (62.7%) survived to leave the hospital. Of those survivors, 85% were still alive almost three years later.

• For patients who used VV-ECMO (Veno-Venous ECMO), which primarily helps the lungs, about 45% survived their hospital stay. Among these hospital survivors, a very high number were still alive at 6 and 12 months (89% and 85%, respectively). Some studies even show a 68.5% survival rate for VV-ECMO survivors nearly 10 years after leaving the ICU.

• However, for patients on VA-ECMO (Veno-Arterial ECMO), which supports both the heart and lungs, the picture can be tougher. A study found that 70.6% of these patients either died or had new disabilities 12 months after starting ECMO. But there's a silver lining: between 6 and 12 months after VA-ECMO, more patients became independent in daily activities (like self-care) and fewer were unemployed due to health issues. This suggests that the biggest challenges with disability often happen in the first six months, and then things tend to stabilize.

A big part of getting back to life is being able to take care of yourself and, for many, returning to work.

• One study found that 80% of VV-ECMO survivors were able to return to work, with most going back to their old jobs.

• But in another study, only about 37.7% of all ECMO survivors (including VA-ECMO patients) were employed, and more than half (56.6%) had trouble with social activities. These differences might be because of the type of ECMO used or whether retirees were included in the "employed" group. In general, most ECMO survivors (72.65% in one study) eventually become independent in their self-care.

The Realities of Recovery: Quality of Life

While survival rates are encouraging, the daily lives of ECMO survivors can be significantly changed.

• Overall, ECMO survivors tend to have a lower quality of life across many areas compared to healthy people. This includes things like physical activity, managing daily tasks, bodily pain, overall health, energy levels, and even emotional well-being. Physical issues, like reduced movement and pain in the legs or feet, are common, sometimes because of the tubes placed in their veins during ECMO.

• However, some studies suggest that the reduced quality of life for VV-ECMO survivors might be similar to, or even better than, that of ARDS patients who didn't receive ECMO. This could be because ECMO allows for gentler breathing machine settings, which might prevent lung damage and other problems associated with traditional mechanical ventilation.

• Mental health is a big concern. Many ECMO survivors are at high risk for Post-Traumatic Stress Disorder (PTSD), with one study reporting that about 30.8% of survivors were in the highest risk group. Other studies found different rates, with one Chinese study reporting 17% experiencing high stress levels. Anxiety and depression are also common. However, some studies show that mental health levels in survivors can be similar to, or even better than, the general population. This might be because psychological states can improve over time after discharge.

What Affects the Journey? Key Influencing Factors

Several things can affect how well an ECMO patient recovers and their quality of life afterward:

• Why they needed ECMO: The original reason a patient needed ECMO can significantly impact their long-term survival. For example, patients with primary graft dysfunction (problems with a transplanted organ) or respiratory failure tended to have better long-term survival.

• How long they were on ECMO: The longer someone is on ECMO, especially VV-ECMO, was found to be the most important factor for survival in the months after hospital discharge.

• Other health problems: Conditions a patient had before ECMO, like lung fibrosis, liver disease, or a weakened immune system, were linked to higher death rates in the hospital. However, for those who survived to go home, these pre-existing conditions seemed to play a smaller role in their long-term survival. This suggests that patients with less severe pre-existing conditions are more likely to survive the initial critical period.

• Support at home and social factors:

  • Who takes care of them (e.g., a spouse) can affect their quality of life, possibly because of the emotional burden on spouses.

  • Being employed after discharge is strongly linked to a higher quality of life, both physically and mentally.

  • Where they live (city vs. rural area) can also influence quality of life, possibly due to access to healthcare and resources.

• How they're doing physically and mentally: Better ability to care for themselves (measured by tests like the Barthel Index), lower levels of PTSD, and better social functioning were all linked to an improved quality of life.

Looking Ahead: How We Can Improve Care

The findings clearly show that caring for ECMO survivors doesn't end when they leave the hospital. Here are some important steps suggested by the research:

• Ongoing Support and Rehabilitation: It's really important to have long-term follow-up and special rehabilitation programs for ECMO survivors. These programs should offer physical, mental, and social support specifically designed for their needs.

• Dedicated ECMO Clinics: Setting up specialized ECMO clinics where patients can get comprehensive care, including online check-ups and even home visits, is seen as vital for their long-term well-being.

• Focus on Early Recovery: Since a lot of disability can develop in the first six months after VA-ECMO, it's important to collect more information during this early period after discharge to understand changes and trends in their health.

• More Research: To truly understand how ECMO affects long-term health and to confirm these findings, we need larger studies involving many hospitals that follow patients over time. Also, since quality of life is very personal, studies that listen to patients' own stories are needed to understand their experiences and needs more deeply. Research is also needed in different parts of the world to see how healthcare quality and social factors play a role.

In conclusion, ECMO is a powerful tool that saves lives. But the journey of recovery for these patients is long and involves many different aspects of their health. By focusing on continued care, support, and rehabilitation, healthcare providers around the world can help ECMO survivors not just survive, but truly live well after their critical illness.

AI and My ECMO Learning Journey

AI plays a significant role in how I research, understand, and communicate complex ECMO topics. From analyzing source materials to organizing ideas and generating podcast outlines, AI helps me stay curious and keep learning, so I can continue sharing insights with you.

Explore More:

• lifesupport.training – Resources for ECMO and other professionals

• ecmo.life – Information for ECMO patients and their loved ones

• Occasional podcasts: youtube.com/@ecmo-143

• LinkedIn Newsletter: ECMO 143: AI-Assisted Journey

Custom GPTs I Created:

• AI ECMO Expert – A custom GPT designed to assist with ECMO research and education.

• Micro Definitions (MD-GPT) – A custom GPT providing concise definitions for medical terminology.

Disclaimer:

This article is for educational purposes only and reflects the author’s understanding and interpretation of available guidelines, literature, and bedside learning. It does not constitute medical advice or represent institutional protocols. Always consult your ECMO team and local policies when making clinical decisions.

References:

1. Harley O, Reynolds C, Nair P, Buscher H. Long-term survival, posttraumatic stress, and quality of life post extracorporeal membrane oxygenation. ASAIO J. 2020;66(8):909-914. doi:10.1097/MAT.0000000000001095

2. Serpa Neto A, Higgins AM, Bailey MJ, et al. Long-term functional outcomes in the first 12 months after VA-ECMO in adult patients: a prospective, multicenter study. Circ Heart Fail. 2025;18(4):e012476. doi:10.1161/CIRCHEARTFAILURE.124.012476

3. Zeng X, Yang F, Luo X, et al. Long-term health related quality of life in adult extracorporeal membrane oxygenation survivors: a single-centre, cross-sectional study. BMC Public Health. 2024;24(1):3243. doi:10.1186/s12889-024-20782-5

4. Rilinger J, Krötzsch K, Bemtgen X, et al. Long-term survival and health-related quality of life in patients with severe acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation support. Crit Care. 2021;25(1):410. doi:10.1186/s13054-021-03821-0

5. Kurniawati ER, Rutjens VGH, Vranken NPA, et al. Quality of life following adult veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review. Qual Life Res. 2021;30(8):2123-2135. doi:10.1007/s11136-021-02834-0

Key Points:

• Traditional coagulation tests provide static snapshots; TEG offers a dynamic, real-time assessment of clot formation and breakdown.

• TEG parameters—R time, K time, alpha angle, MA, and LY30—provide insights into different phases of coagulation and fibrinolysis.

• Heparinase-modified TEG helps differentiate between heparin effect and intrinsic coagulopathy.

• Simultaneous standard and heparinase TEG assays are essential for accurate interpretation in patients on heparin therapy.

I used to think I understood TEG. Then a nurse asked me to explain it, and I was trying to make sense of it as I was explaining it. I knew the R time had something to do with when the clot starts, and MA was the widest part of the graph, but beyond that? Blank.

So, I did what any good ECMO Specialist would do: I went home, pulled out my notes, rewatched some TEG videos, and realized something that changed everything:

Labs like PT, INR, fibrinogen, aPTT, platelets, and anti-Xa are snapshots. But TEG is a movie.

It doesn’t just tell you what’s in the blood. It shows you what the blood can do, from the moment fibrin starts to form to when the clot breaks down. For ECMO patients, especially those receiving multiple blood products, undergoing trauma resuscitation, or living on the edge of DIC, TEG offers a dynamic look at coagulation in real time.

Two Halves of the TEG Story

Think of the TEG tracing as the lifespan of a clot, split into two acts:

• Act 1: Clot formation (Coagulation)

• Act 2: Clot breakdown (Fibrinolysis)

The X-axis is time. The Y-axis is the strength of the clot, measured by the movement of a pin suspended in the blood sample.

The standard test takes about 30–60 minutes, but Rapid TEG compresses it into 15 minutes—ideal in trauma, surgery, or acute ECMO changes.

TEG Parameters Explained

R Time (Reaction Time)

• What it measures: Time to initial fibrin formation

• Reflects: Coagulation factor levels and thrombin generation

• Normal Range: 4–8 minutes

• Interpretation/Intervention:

Tip: Always check a heparinase TEG if R is prolonged. It helps separate drug effect from true deficiency.

K Time (Kinetics)

• What it measures: Time from R to reach 20 mm clot strength (speed in time it took to get to 20mm clot strength)

• Reflects: Fibrinogen and platelet interaction

• Normal Range: 1–4 minutes

• Interpretation/Intervention:

Alpha Angle (α)

• What it measures: Slope between R and 20 mm clot strength (speed to get to 20mm clot strength)

• Reflects: Speed of clot formation

• Normal Range: 47–74 degrees

• Interpretation/Intervention:

Note: K time and alpha angle are interrelated; abnormalities in one often reflect in the other.

Maximum Amplitude (MA)

• What it measures: The strongest point of the clot

• Reflects: Platelet number and function

• Normal Range: 55–73 mm

• Interpretation/Intervention:

Everything to the left of the MA is about building the clot. Everything to the right is about breaking it down.

LY30 (Lysis at 30 Minutes)

• What it measures: Percentage of clot lysis 30 minutes after MA

• Reflects: Fibrinolysis

• Normal Range: 0–8%

• Interpretation/Intervention:

Clinical Use Cases in ECMO

TEG is particularly helpful in:

• Pediatrics – where small changes in volume have significant impacts

• Liver disease – complex balance between bleeding and clotting

• Massive transfusion protocols – guiding FFP, cryoprecipitate, platelets, or antifibrinolytics

• ECMO – when conventional labs don’t explain bleeding or clotting tendencies

Heparinase-Modified TEG: Differentiating Heparin Effect from Coagulopathy

In patients receiving heparin therapy, interpreting coagulation status can be challenging. Standard TEG may show prolonged R times due to heparin's anticoagulant effect, potentially masking underlying coagulopathies. Heparinase-modified TEG addresses this by neutralizing heparin in the blood sample, allowing for accurate assessment of the patient's intrinsic coagulation function.

When to Use Heparinase TEG

Consider heparinase-modified TEG in the following scenarios:

• Post-Cardiopulmonary Bypass (CPB): To assess residual heparin effect and guide protamine reversal.

• Liver Transplantation: To evaluate coagulation status in the presence of endogenous heparin-like substances released during reperfusion.

• ECMO Management: To distinguish between heparin-induced anticoagulation and other coagulopathies.

• Unexplained Bleeding: When standard TEG shows prolonged R time, and heparin effect is suspected.

Performing Heparinase TEG

Heparinase TEG is conducted by running two assays simultaneously:

1. Standard TEG: Measures coagulation parameters in the presence of heparin.

2. Heparinase TEG: Measures coagulation parameters after neutralizing heparin with heparinase.

Comparing these results helps determine if prolonged clotting times are due to heparin or an underlying coagulopathy.

Interpreting Results

• Prolonged R Time in Standard TEG, Normal R Time in Heparinase TEG: Indicates heparin effect.

• Prolonged R Time in Both Assays: Suggests a coagulopathy unrelated to heparin.

This differentiation is crucial for guiding appropriate treatment, such as administering protamine for heparin reversal or providing specific blood products for coagulopathy management.

Should a Standard TEG Be Performed Simultaneously?

Yes, conducting both standard and heparinase TEG assays concurrently is essential. This dual approach allows for a direct comparison, facilitating accurate identification of heparin's role in any observed coagulopathy.

Final Thought

Most of us learned labs like INR and aPTT in school, but ECMO patients live in a different world. Their coagulation status is a moving target, and TEG is one of the only tools that lets you watch that target shift in real time. TEG should always be interpreted in the clinical context—trends over time are more important than isolated results, and normal ranges may vary by institution or patient population. When considering interventions, always address the underlying cause and clinical scenario before transfusing blood products. For those working internationally, note that ROTEM is a similar tool with some different parameters but the same core principle. Whether you’re adjusting blood products, titrating heparin, or trying to figure out why your patient is bleeding (or clotting) despite “normal” labs, TEG is a practical game changer. Once you learn how to read the curve, you’ll never want to go back to relying solely on traditional lab tests.

AI and My ECMO Learning Journey

AI plays a significant role in how I research, understand, and communicate complex ECMO topics. From analyzing source materials to organizing ideas and generating podcast outlines, AI helps me stay curious and keep learning, so I can continue sharing insights with you.

Explore More:

• lifesupport.training – Resources for ECMO and other professionals

• ecmo.life – Information for ECMO patients and their loved ones

• Occasional podcasts: youtube.com/@ecmo-143

• LinkedIn Newsletter: ECMO 143: AI-Assisted Journey

Custom GPTs I Created:

• AI ECMO Expert – A custom GPT designed to assist with ECMO research and education.

• Micro Definitions (MD-GPT) – A custom GPT providing concise definitions for medical terminology.

Disclaimer:

This article is for educational purposes only and reflects the author’s understanding and interpretation of available guidelines, literature, and bedside learning. It does not constitute medical advice or represent institutional protocols. Always consult your ECMO team and local policies when making clinical decisions.

References:

• Extracorporeal Life Support Organization (ELSO). Extracorporeal Life Support: The ELSO Red Book. 6th ed. Ann Arbor, MI; 2023.

• ELSO. ECMO Specialist Training Manual. 4th ed. Ann Arbor, MI; 2022.

• DellaVolpe J. The ECMO Book. San Antonio, TX: The Institute for Extracorporeal Life Support; 2024.

• All TEG tracings were created using MS PowerPoint.