ECMO & ECPR

High-Quality Mechanical CPR & ECPR Code Activation (After 3rd Shock / 10–15 Min Refractory Arrest)
• Apply mechanical chest compression device (LUCAS-3 or AutoPulse) immediately.
• Activate institutional ECPR / Code ECMO Team before Minute 15 so circuit flow starts within ≤ 60 minutes of arrest onset [1,2,3].
• Secure endotracheal tube and monitor continuous waveform capnography (ETCO₂ ≥ 10 mmHg) [1,2].

• Mechanical CPR piston/band device
• Waveform capnography
• Bilateral femoral groins exposed & prepped from umbilicus to mid-thigh with 2% chlorhexidine

Eliminates interruptions during ultrasound-guided femoral cannulation, preserves coronary and cerebral perfusion pressure during low-flow state, and confirms metabolic viability (ETCO₂ < 10 mmHg indicates irreversible cellular necrosis) [1,2,3].

Dual-Operator Ultrasound-Guided Percutaneous Femoral Access
• Operator 1 (Venous — Right Common Femoral Vein): Insert 18G needle 1–2 cm below the inguinal ligament under US guidance; advance 0.035-inch J-tip guidewire to the right atrium/SVC.
• Operator 2 (Arterial — Left Common Femoral Artery): Puncture above the superficial/profunda femoral artery bifurcation and below the inguinal ligament [1,2].

• Linear vascular ultrasound probe (7–13 MHz) with sterile sheath
• Percutaneous micro-puncture or 18G Seldinger introducer kit
• 150–180 cm stiff 0.035-inch Amplatz Super-Stiff guidewires

Puncture strictly into the Common Femoral Artery (CFA): high puncture above the inguinal ligament into the external iliac artery causes lethal non-compressible retroperitoneal hemorrhage; low puncture into the superficial femoral artery (SFA) causes acute ipsilateral lower limb ischemia [1,2].

Systemic Anticoagulation & Serial Fascial Dilation
• Unfractionated Heparin (UFH) Bolus: 50 to 100 Units/kg IV (3,500 to 5,000 Units IV push in average adult) given immediately once guidewires are confirmed intravascularly (target ACT 180–220 sec) [1,2].
• Sequentially dilate subcutaneous tract and vessel wall (12 Fr → 16 Fr → 20 Fr) over the stiff wire while verifying free wire movement after each pass [1,2].

• IV Unfractionated Heparin (1,000 U/mL vials)
• Serial hydrophilic vascular dilators
• Point-of-care Activated Clotting Time (ACT) analyzer

Inhibits antithrombin III-mediated Factor Xa and thrombin (Factor IIa) activation before foreign PVC cannulae and polymethylpentene oxygenator fibers trigger catastrophic circuit thrombosis [1,2].

Cannula Insertion & Mandatory Distal Perfusion Catheter (DPC)
• Venous Drainage Cannula (Multi-stage): 21 to 25 Fr (55–65 cm length) advanced until tip sits at the IVC-Right Atrial junction [1,2].
• Arterial Return Cannula: 15 to 19 Fr (15–23 cm length) advanced into the distal aorta / common iliac artery.
• Distal Perfusion (“Back-Bleed”) Catheter: Insert a 6 to 8 Fr wired antegrade sheath into the ipsilateral Superficial Femoral Artery (SFA) and connect to the arterial cannula side-port [1,2].

• 21–25 Fr Venous Cannula
• 15–19 Fr Arterial Cannula
• 6–8 Fr antegrade SFA reperfusion cannula
• Crystalloid-primed ECMO circuit (600–800 mL Plasmalyte/LR)

Per Hagen-Poiseuille physics (Q ∝ r⁴), a 23–25 Fr drainage cannula maximizes venous return (4–5 L/min). The 15–19 Fr arterial cannula occludes 70–90% of the native femoral lumen; the antegrade 6–8 Fr SFA catheter provides 150–250 mL/min oxygenated blood to prevent compartment syndrome and limb amputation [1,2].

Wet-to-Wet Connection, Circuit Initiation & Target Flow Titration
• Perform bubble-free wet-to-wet connection using sterile saline irrigation.
• Unclamp venous line, ramp centrifugal pump to 2,500–3,500 RPM to achieve Blood Flow 3.5–4.5 L/min (≥ 2.2–2.5 L/min/m²), and set Sweep Gas Flow at 1:1 with Blood Flow (3–4 L/min at FdO₂ 1.0, then titrate immediately to prevent extreme hypocapnia/hyperoxia) [1,2,4].
• Stop mechanical CPR once MAP ≥ 65 mmHg is achieved; obtain Right Radial Arterial Blood Gas [1,2].

• Centrifugal ECMO pump & polymethylpentene membrane oxygenator
• Gas blender (Sweep gas flowmeter + FdO₂ dial)
• Right Radial Arterial Line + Right Hand Pulse Oximeter

Right Radial Line is Mandatory: Retrograde femoral VA-ECMO blood meets antegrade native LV blood in the aorta. Because the innominate (brachiocephalic) artery is the first branch of the aortic arch, the right radial PaO₂ reflects true cerebral and coronary oxygenation (detecting Harlequin / North-South Syndrome) [1,2].