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Critical care · United Kingdom

ECMO — advanced life support for the failing lungs or heart.

A clinically reviewed guide to extracorporeal membrane oxygenation — what it does, where in the UK it’s delivered, who it’s for, and what the ICU experience is like for the family at the bedside.

UK ECMO centres
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

How ECMO care is organised

  • 01

    A commissioned NHS ECMO centre

    ECMO in the UK is delivered by five NHS-commissioned adult centres. Your loved one is looked after in one of them, not in a district hospital ICU trying to improvise.

  • 02

    A retrieval team that comes to you

    The recipient centre sends a mobile ECMO team — surgeon, intensivist, perfusionist — to cannulate at the referring hospital and transfer the patient already on the circuit.

  • 03

    A full MDT at the bedside

    Cardiac surgery, intensivist, perfusionist and specialist ECMO nurse review every day. Decisions on weaning, tracheostomy and prognosis are shared, and shared with you.

UK ECMO centres

Where adult ECMO is delivered in the UK.

ECMO is a nationally commissioned NHS service. Every UK adult centre runs a 24/7 retrieval team that can travel to the referring hospital.

In short

Five commissioned adult centres in England, plus Papworth for cardiac and Aberdeen for Scotland — all 24/7, all with mobile retrieval.

Centre Service
Guy’s & St Thomas’, London Adult VV + VA
Royal Brompton, London Adult VV + VA
Glenfield, Leicester Adult VV + VA
Wythenshawe, Manchester Adult VV + VA
University Hospital Birmingham Adult VV + VA
Aberdeen Royal Infirmary Adult VV (Scotland)
Papworth, Cambridge Adult VA + transplant bridge
Great Ormond Street / Evelina Paediatric ECMO

Referring hospitals speak to the on-call ECMO consultant at the recipient centre. Acceptance depends on eligibility scores, comorbidities and bed availability — decisions are typically made within hours.

The problem

When ventilation and inotropes aren’t enough.

ECMO exists for the small group of patients whose lungs or heart cannot keep them alive on maximal conventional support — but where the underlying disease is potentially reversible or bridgeable.

  • Refractory hypoxia

    Blood oxygen falls despite lung-protective settings, prone position and neuromuscular blockade — the classic ARDS pathway to VV-ECMO.

  • Cardiogenic shock

    Cardiac output cannot be sustained on inotropes, IABP or Impella — VA-ECMO takes over pump and gas-exchange work.

  • Refractory cardiac arrest

    Selected witnessed arrests with a reversible cause: ECPR started during ongoing CPR to buy time for correction.

The journey

From referral to weaning — what happens, in order.

Every ECMO run follows a similar arc: referral, retrieval, ICU care, and either weaning, transplantation or a shift to comfort.

  1. 01

    Referral

    Referral from the home ICU

    Your loved one’s ICU consultant refers to the national ECMO service — usually after prone position, neuromuscular blockade and lung-protective ventilation are already in.

  2. 02

    Referral

    NHS ECMO panel review

    A senior clinician from the recipient centre reviews eligibility against the RESP score (respiratory) or SAVE / PRESERVE score (cardiac) — usually within hours.

  3. 03

    Referral

    Retrieval team dispatched

    If accepted, a mobile ECMO team travels — often by land ambulance, sometimes by air — with the pump, oxygenator and cannulae to the referring hospital.

  4. 04

    Cannulation & ICU

    Cannulation at the bedside

    Large cannulae are placed under ultrasound into the femoral and internal jugular veins (VV) or femoral vein and artery (VA). The circuit is started and stability confirmed.

  5. 05

    Cannulation & ICU

    Transport on ECMO

    The patient is transferred to the recipient centre already supported by the circuit, with the retrieval team at the bedside for the whole journey.

  6. 06

    Cannulation & ICU

    Recipient centre ICU

    Deep sedation initially, sometimes awake ECMO for lung-transplant candidates. Daily physiotherapy, tracheostomy if a longer run is expected, and daily family updates.

  7. 07

    Wean

    Weaning and decannulation

    A trial off the sweep gas (VV) or a slow reduction of flows (VA). If the lungs or heart recover, cannulae are removed. If not, honest conversations about transplant, LVAD or ceiling of care.

Typical VV-ECMO run: 1–3 weeks. VA-ECMO: days to 2 weeks. Bridge-to-transplant runs can be much longer.

When it helps

The situations that lead to ECMO.

Eligibility is scored with the RESP tool for respiratory failure and SAVE / PRESERVE for cardiac. Every case is individualised.

  • Severe ARDS unresponsive to ventilation

    Life-threatening hypoxia despite lung-protective ventilation, prone position and neuromuscular blockade — the classic VV-ECMO indication.

  • COVID-19 pneumonitis

    Selected patients with refractory hypoxaemia from severe COVID-19 remain eligible where prognosis and comorbidities support a run.

  • Bridge to lung transplant

    Awake VV-ECMO can keep a patient with end-stage lung disease alive — and mobile — while a donor organ is found.

  • Drowning and hypothermia

    Severe drowning or profound hypothermia with cardiac arrest can be supported on VA-ECMO, with rewarming through the circuit.

  • Cardiogenic shock

    Acute myocardial infarction, myocarditis or decompensated cardiomyopathy where inotropes and mechanical support alone are not enough.

  • ECPR — refractory cardiac arrest

    Extracorporeal CPR in selected witnessed arrests with rapid cannulation, aiming to buy time for reversible causes.

  • Primary graft dysfunction post-transplant

    Severe early graft failure after heart or lung transplantation, supported until the graft recovers or a decision is made.

  • Red flag: intracranial haemorrhage

    A new bleed on the brain scan is the most feared complication. It usually prompts an urgent conversation about ceiling of care.

ECMO modalities

The main configurations, and what each is for.

The choice between VV, VA and hybrid circuits is driven by whether the failing organ is the lung, the heart, or both.

  • VV-ECMO (veno-venous)

    Two venous cannulae. Takes deoxygenated blood, adds oxygen and removes CO₂, returns it to the venous side. For isolated severe respiratory failure.

  • VA-ECMO (veno-arterial)

    A venous drainage cannula and an arterial return. Provides both gas exchange and full cardiac output. For cardiogenic shock and cardiac arrest.

  • ECPR (extracorporeal CPR)

    VA-ECMO started during ongoing CPR for a witnessed, reversible arrest — a small selected group with the best chance of neurological recovery.

  • Hybrid VAV / VVA configurations

    A third cannula added when a patient on one modality develops the opposite problem — for example, upper-body hypoxia on femoral VA-ECMO.

  • Awake ECMO

    Sedation lifted so the patient can sit up, do physiotherapy and, occasionally, walk — usually as a bridge to lung transplantation.

  • Bridge to transplant

    ECMO used to keep a patient alive and, ideally, mobile until a suitable donor heart or lung becomes available.

  • Bridge to LVAD

    Short-term ECMO support while a longer-term left-ventricular assist device is planned and implanted.

  • Bridge to decision / comfort

    When it is not yet clear whether recovery, transplant or withdrawal is the right path — ECMO buys the time to work that out with the family.

The UK ECMO service

A commissioned service, not an ad-hoc one.

NHS England commissions ECMO nationally so that every eligible adult in the country can be retrieved to a centre with the volumes, teams and equipment to run the therapy safely.

Service standards

What every commissioned ECMO centre provides.

A UK intensive care unit with a patient supported on an ECMO circuit
Commissioned NHS service

  • One of five NHS-commissioned adult ECMO centres (plus Scottish and paediatric services)

  • Consultant intensivists and cardiac surgeons on-call for cannulation 24/7

  • Mobile retrieval team with pump, oxygenator and cannulae ready to travel

  • Full MDT — perfusionist, ECMO nurse, physiotherapy, chaplaincy and bereavement care

Risks and complications

The honest picture — bleeding, stroke, mortality.

ECMO is powerful and dangerous in the same breath. Every centre is transparent about the complication profile because families deserve to understand what they’re agreeing to.

  • Intracranial haemorrhage

    The most feared complication. Anticoagulation to keep the circuit clot-free raises bleeding risk everywhere — the brain most of all. Daily neurological checks, and imaging when concerning.

  • Ischaemic stroke

    Clot embolism from the circuit or from a low-flow heart can cause stroke. Neurological assessment is difficult under sedation, which is one reason for daily wake-up trials where safe.

  • Bleeding at cannula sites

    Oozing around the femoral or jugular cannulae is common and usually managed with pressure and blood products. Significant bleeding may need surgical revision.

  • Limb ischaemia (VA-ECMO)

    A large femoral arterial cannula can obstruct blood flow to the leg. A distal perfusion cannula is often placed at the time of cannulation to prevent this.

  • Oxygenator failure

    The gas-exchange membrane can clot or fail — usually anticipated on daily inspection and swapped out under controlled conditions before it becomes an emergency.

  • Heparin-induced thrombocytopenia (HIT)

    A rare immune reaction to heparin causing paradoxical clotting. Managed with alternative anticoagulants and full haematology input.

  • Infection and multi-organ failure

    Long ICU stays, invasive lines and immunosuppression all raise infection risk. Sepsis and secondary organ failure account for many later deaths on ECMO.

  • Tracheostomy

    If a longer run is expected, a tracheostomy allows lighter sedation, better mouth care, and — for some patients — awake rehabilitation on the circuit.

  • Mortality remains high

    Around 30–50% mortality for VV-ECMO in respiratory failure, higher for VA-ECMO in cardiogenic shock. ECMO is a bridge, not a cure — the underlying disease still has to recover.

Reading the daily ICU update

The ECMO chart, in four parts. The plan is the important one.

Every ECMO team keeps a daily record the same way. If you sit down with the consultant, this is roughly the order they’ll walk you through.

A UK intensivist reviewing ECMO circuit observations at the bedside

A quiet reminder

ICU language is precise and can sound harsh — ask the team to translate.

Nurses, chaplains and bereavement teams at ECMO centres are used to sitting with families for as long as it takes.

  1. 01 Indication

    Why ECMO was started

    The precise clinical reason — refractory ARDS, cardiogenic shock, cardiac arrest, primary graft dysfunction — and the RESP or SAVE score at the point of referral.

  2. 02 Circuit

    Modality, cannulae and settings

    VV or VA, the cannula sites and sizes, blood flow (l/min), sweep gas, and anticoagulation targets. The perfusionist keeps a daily record of these.

  3. 03 Progress

    Daily observations and complications

    Ventilator settings, arterial gases, imaging findings, and any bleeding, neurological events, infection or oxygenator issues that arise during the run.

  4. 04 Plan

    Wean, transplant, LVAD or comfort

    The most important part. Where the team is heading — weaning trial, listing for transplant, LVAD referral, or a shift to comfort care if recovery is not possible.

Guidelines and evidence base

NHS England ECMOELSO RegistryIntensive Care SocietyScottish ECMOPapworthGOSH PaediatricRESP scoreSAVE scoreNHS England ECMOELSO RegistryIntensive Care SocietyScottish ECMOPapworthGOSH PaediatricRESP scoreSAVE scoreNHS England ECMOELSO RegistryIntensive Care SocietyScottish ECMOPapworthGOSH PaediatricRESP scoreSAVE score

Sources include ELSO, the Intensive Care Society, NHS England ECMO commissioning documents and the EOLIA trial (Combes et al., NEJM 2018).

Frequently asked

Everything families ask us about ECMO.

What it is, where it’s delivered, who it’s for, how long it lasts, and what can go wrong.

  • What is ECMO?

    Extracorporeal membrane oxygenation is a form of advanced life support. Large cannulae connect the patient to an external pump, an oxygenator (a gas-exchange membrane) and a heat exchanger. It takes over the work of the lungs (VV-ECMO), or of the heart and lungs (VA-ECMO), while the underlying disease is treated.

  • Where in the UK is adult ECMO available?

    NHS England commissions five adult ECMO centres in England — Guy’s & St Thomas’, Royal Brompton, Glenfield (Leicester), Wythenshawe (Manchester) and University Hospital Birmingham — plus Papworth (Cambridge) for cardiac and transplant bridging. Aberdeen Royal Infirmary runs the Scottish adult service. Paediatric ECMO is delivered by Great Ormond Street, Birmingham Children’s and the Evelina.

  • How does the retrieval team work?

    The recipient centre operates a mobile team — a consultant intensivist or surgeon, a perfusionist and an ECMO nurse — who travel to the referring hospital, cannulate at the bedside, and transfer the patient to their unit already supported on the circuit.

  • Who is a candidate for ECMO?

    Eligibility uses scoring systems — RESP for respiratory failure, SAVE and PRESERVE for cardiogenic shock — alongside age, comorbidities, duration of prior ventilation and reversibility of the underlying disease. Every case is discussed individually with the family.

  • How long does a patient stay on ECMO?

    Typical VV-ECMO runs are one to three weeks; VA-ECMO is usually shorter — days to a couple of weeks. Bridge-to-transplant runs can be much longer. The team reviews the plan daily rather than committing to a fixed duration.

  • What are the main risks of ECMO?

    Intracranial haemorrhage and ischaemic stroke are the most feared. Bleeding at cannula sites, oxygenator failure, heparin-induced thrombocytopenia, limb ischaemia (with femoral VA cannulation), infection and multi-organ failure are all recognised. Mortality remains high — around 30–50% for VV-ECMO and higher for VA-ECMO in cardiogenic shock.

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