Extracorporeal Membrane Oxygenation Simulation


The medical profession has an established history of team-based approaches to managing varying complexities of patients.  Effective communication between team members has been recognized as a key factor to safer healthcare delivery.[1] There have been multiple studies highlighting the role of simulation-based training in healthcare settings that need rapid assessment, implementation of protocols, and efficient medical care delivery.[2] In medical simulation training, the use of high-fidelity mannequins has also evolved as they can now provide physiologic feedback as well as have computer-generated programming that can provide the appropriate pathologic findings and responses to interventions.[3] Simulation-based training has been used in various professions and continues to be a method of teaching in the medical field.  Hospital-based emergencies that require a team-based approach are of interest for simulation professionals. These scenarios are examples of situations that need group input, standardization of algorithms, and effective delivery of the appropriate treatments.[4]  


Patients who have developed or at risk of cardiorespiratory arrest require a multidisciplinary team approach for their care. Extracorporeal membrane oxygenation (ECMO) has become increasingly common for patients who have developed cardiac failure, respiratory failure, or a combination of both. This development is evidenced by the growing number of centers that now offer ECMO as a means of therapy.[5] In pediatrics, the American Heart Association recommends ECMO as a consideration in patients with refractory cardiac arrest with a potentially reversible etiology.[6] ECMO is a method of supporting the cardiorespiratory system by mechanical means. Its use has been heavily described in the pediatric medical world and is now growing popularity in the adult medical world. ECMO can provide support of both cardiac and respiratory support utilizing cannulae that are placed in large venous and arterial vessels in the body that then bypasses the blood via a circuit that has an oxygenator and a means to remove carbon dioxide. The newly oxygenated blood is then circulated through the arterial cannula back to the patient.  ECMO also can provide respiratory support alone through a specialized cannula that is inserted into one of the vena cava that can divert venous return through the ECMO circuit, where it will be oxygenated and returned through the same cannula in a different lumen towards the patient’s right heart.  The former method is referred to as veno-arterial ECMO, and the latter is veno-venous ECMO.[7][8] As ECMO is a highly specialized form of life support that requires technical expertise to recognize not only patients that qualify, but also surgical expertise to place a patient on ECMO, specialists, critical care physicians, and nurses that are comfortable managing the patient and the circuit upon placing the patient on extracorporeal support. 

Curriculum Development

When developing a simulation-based curriculum, it is important to assess the staffing that would be present and necessary for the scenario provided. In the case of ECMO, one would anticipate that there would be a need for multiple disciplinary teams during each step. At one center, the teams that were recognized as essential in developing an ECPR simulation-based curriculum included 1) the ICU team (nurses, respiratory therapists, intensive care physicians, and support staff) 2) a surgical team (cardiovascular or general surgeon, assistants, and nurses), and 3) ECMO team (that consisted of personnel that had specialized in preparing and maintaining the ECMO circuit).[9] There must be a dedicated investment in participating in this curriculum repeatedly and accepting real-time feedback. Protocols must exist for the simulation that can easily relate to a real-life scenario. Such protocols may include the development of a checklist to assure the patient is a proper candidate for ECMO therapy, a checklist for all the equipment that is necessary, assigned roles to key team members, and standardization of techniques for the surgical team. 

Assessment of Procedural Skills

Methods utilized to assess the effectiveness of a simulation program for ECMO cannulation include but are not limited to pre- and post-surveys of participants assessing their comfort with their role during the simulation, timing of when to decide to place a patient on ECMO to following successful cannulation, testing and timing ECMO specialists to prepare a circuit, and conducting chart reviews of ECMO cannulation times in patients before and after implementation of an ECMO simulation curriculum.[9] One program saw a decrease in medical errors with the implementation of simulation-based training.[10]

Clinical Significance

Medical errors continue to and remain a significant cause of death.[11]  Simulation-based training continues to become significant in healthcare settings, where there are often complex and multidisciplinary approaches to decision-making.  The placement of a patient on extracorporeal support demands that there be adequate staffing and support, which can then lead to having numerous individuals in a room where a profoundly ill patient needs guided and efficient medical care. Often, the placement of patients onto ECMO, whether they be in a CPR situation or not, can be chaotic and stressful. The significance of developing a curriculum whose focus is to organize a large group of people of various degrees of training to communicate and work together effectively is essential in centers wanting to achieve excellence and efficiency in ECMO. A situation where a patient is unstable enough to require extracorporeal support is a highly stressful environment. Without effective communication and methods developed by simulation training, it could be a situation that would potentiate medical errors. There remains a difference in survival in pediatric and adult patients when it comes to extracorporeal support.  The Extracorporeal Life Support Organization (ELSO) registry states that the survival rate for adults with pulmonary complications on ECMO is 66% and 55% for those with cardiac complications versus in pediatrics where the survival rates are 67% for pulmonary and 68% cardiac complications.[5] With these rates of survival, there is always room for improvement regarding resuscitation length, time to ECMO cannulation, and fewer errors in assembling, setting up, and maintaining the ECMO circuit. These potential focuses are addressable with simulation.

Pearls and Other Issues

Simulation-based training has become an important and necessary field of education within the medical community. The need for the use of simulation with high-fidelity mannequins has become increasingly crucial in resuscitation training.  Complex medical scenarios that require numerous personnel, such as with ECMO simulation, can often be perceived as chaotic and loud. Utilizing simulation-based techniques to implement a curriculum can help streamline and assign roles in what may otherwise be an unorganized and physiologically complex situation. The goal would be to achieve a standardized approach to every step of the ECMO cannulation process - recognition of the proper candidates for ECMO therapy, checklists to assure adequate equipment, a method to efficiently contact each member necessary, continuing resuscitation measures with minimal interruptions up until the patient is officially cannulated and on ECMO, and approaching mechanical issues to the ECMO circuit. 

Enhancing Healthcare Team Outcomes

Simulation-based training has shown to be effective in multiple medical environments. With the rise of centers offering ECMO as therapy for patients with cardiac and respiratory failure, it has become increasingly important to standardize our approach to a patient that would need this level of support.[5] There is still room for improvement in the outcomes of patients that require ECMO.[5] By developing an ECMO simulation curriculum that involves multiple disciplines, coordination between the teams could be improved.  Placing a patient on ECMO, whether it is during cardiopulmonary resuscitation or not, can prove to be unorganized and stressful.  This is where the role of simulation with participation from everyone from each dedicated discipline can help each team practice interprofessional communication and coordinate care to the same goal of successfully placing a patient on ECMO. The goals should be the same, which would be to lower medical errors that can often happen in high-stress environments, improve outcomes of patients on ECMO as the time to placement, especially during CPR, could be lessened, and optimizing team performance.   Research related to  ECMO simulation has shown improvement in cannulation time, improvement in setting up ECMO circuits, and improvement in the perception of team dynamics.[9][12][13] [Level 4]

Article Details

Article Author

Rupal T. Bhakta

Article Editor:

Amal A. Alshuqayfi


5/8/2022 2:26:06 AM



Weaver SJ,Dy SM,Rosen MA, Team-training in healthcare: a narrative synthesis of the literature. BMJ quality & safety. 2014 May     [PubMed PMID: 24501181]


Armenia S,Thangamathesvaran L,Caine AD,King N,Kunac A,Merchant AM, The Role of High-Fidelity Team-Based Simulation in Acute Care Settings: A Systematic Review. Surgery journal (New York, N.Y.). 2018 Jul     [PubMed PMID: 30109273]


Cant RP,Cooper SJ, The value of simulation-based learning in pre-licensure nurse education: A state-of-the-art review and meta-analysis. Nurse education in practice. 2017 Nov     [PubMed PMID: 28843948]


Murphy M,Curtis K,McCloughen A, What is the impact of multidisciplinary team simulation training on team performance and efficiency of patient care? An integrative review. Australasian emergency nursing journal : AENJ. 2016 Feb     [PubMed PMID: 26614537]


Thiagarajan RR,Barbaro RP,Rycus PT,Mcmullan DM,Conrad SA,Fortenberry JD,Paden ML, Extracorporeal Life Support Organization Registry International Report 2016. ASAIO journal (American Society for Artificial Internal Organs : 1992). 2017 Jan/Feb;     [PubMed PMID: 27984321]


Kleinman ME,Chameides L,Schexnayder SM,Samson RA,Hazinski MF,Atkins DL,Berg MD,de Caen AR,Fink EL,Freid EB,Hickey RW,Marino BS,Nadkarni VM,Proctor LT,Qureshi FA,Sartorelli K,Topjian A,van der Jagt EW,Zaritsky AL, Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;     [PubMed PMID: 20956230]


Mosier JM,Kelsey M,Raz Y,Gunnerson KJ,Meyer R,Hypes CD,Malo J,Whitmore SP,Spaite DW, Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions. Critical care (London, England). 2015 Dec 17     [PubMed PMID: 26672979]


Rais-Bahrami K,Van Meurs KP, Venoarterial versus venovenous ECMO for neonatal respiratory failure. Seminars in perinatology. 2014 Mar     [PubMed PMID: 24580762]


Su L,Spaeder MC,Jones MB,Sinha P,Nath DS,Jain PN,Berger JT,Williams L,Shankar V, Implementation of an extracorporeal cardiopulmonary resuscitation simulation program reduces extracorporeal cardiopulmonary resuscitation times in real patients. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2014 Nov;     [PubMed PMID: 25162513]


Puślecki M,Ligowski M,Dąbrowski M,Stefaniak S,Ładzińska M,Ładziński P,Pawlak A,Zieliński M,Dąbrowska A,Artyńska A,Gezela M,Sobczyński P,Szarpak Ł,Perek B,Jemielity M, BEST Life-     [PubMed PMID: 30043501]


Makary MA,Daniel M, Medical error-the third leading cause of death in the US. BMJ (Clinical research ed.). 2016 May 3;     [PubMed PMID: 27143499]


Thomas F,Chung S,Holt DW, Effects of ECMO Simulations and Protocols on Patient Safety. The journal of extra-corporeal technology. 2019 Mar     [PubMed PMID: 30936583]


Alsalemi A,Tanaka L,Ogino M,Disi MA,Alhomsi Y,Bensaali F,Amira A,Alinier G, A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation. Perfusion. 2020 Mar     [PubMed PMID: 31303136]