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Critical Care Anesthesiologists as Members of an Interdisciplinary ECMO Cannulation Teamby Christopher Ortiz MD, PhD, E-AEC Volume 36 | Issue 4 | Dec 2025 As the use of Extracorporeal Membrane Oxygenation (ECMO) to support critically ill patients grows, one challenge of placing patients on this potentially lifesaving therapy is ensuring the availability of trained physicians to perform the cannulations when needed. Percutaneous techniques have been established as a reliable method of ECMO cannulation as compared to a surgical approach, and can be safely performed by intensivists in locations across the hospital including the ICU, cardiac catheterization laboratory, or emergency department.1,2 As described in the March 2025 issue of the SOCCA Interchange, critical care anesthesiologists (CCAs) are leaders in cardiovascular critical care medicine with not only the medical expertise but also the procedural and leadership skills to direct the multidisciplinary teams caring for complex patients in the cardiovascular intensive care unit who require ECMO support.3,4 With expertise in vascular access and management of acute cardiac and respiratory compromise, CCAs can not only oversee the hemodynamic management of ECMO initiation and maintenance but directly perform percutaneous ECMO cannulation procedures. Several groups have published their experience with the development of training pathways for intensivist-led cannulation teams, with data showing outcomes noninferior to those of surgeon-led cannulation teams.1,5,6 Here, we will briefly describe our recent and ongoing experience with starting an intensivist-led ECMO cannulation team. Our institution is a quaternary referral center for patients requiring complex cardiac surgery, advanced interventional and structural cardiology interventions, heart and lung transplant, and placement of temporary and durable mechanical circulatory support, with steadily increasing ECMO volume in recent years. To support the growing clinical need for ECMO while minimizing additional surgeon workload and the associated disruption to operating room availability, we recently established a formal pathway for training and credentialing our multidisciplinary group of Intensive Cardiac Care attendings for ECMO cannulation. The group consists of anesthesia critical care faculty as well as critical care cardiologists. All members are credentialed and experienced in management of patients on ECMO. Components of the pathway include completion of an Extracorporeal Life Support Organization (ELSO)-certified cannulation course and 10 in-vivo cannulation procedures, which are directly proctored by either cardiothoracic surgical attendings or intensivist cannulators who have completed credentialing requirements. Cardioathoracic surgical backup remains available for those cases without a surgeon present. Our standard cannulation approach consists of percutaneous ultrasound-guided femoral access for venoarterial cannulation including placement of a distal perfusion cannula. For venovenous support a femoral vein to internal jugular vein approach is used with availability of TEE guidance. Since formally starting this effort in Spring 2025, six faculty have entered the pathway, with two so far completing the requirements for cannulation credentialing. To date, trainees have been involved in 41 cannulations, of which 85% were venoarterial cannulation for cardiogenic shock and 12% venovenous cannulation for respiratory failure. Of these, only one case involved development of lower extremity ischemia requiring arterial cutdown to re-establish distal flow. There were no cases of major hemorrhage or inability to cannulate. Ongoing outcomes are being closely tracked to allow comparison of intensivist-led cannulation to the standard surgeon-led approach. The initiation and ongoing success of this effort has required multidisciplinary cooperation. Close collaboration with cardiothoracic surgery is required as they provide ongoing procedural proctoring of cases, which have included peripheral cannulation in the operating room when needed for cardiac bypass to supplement the variable and unpredictable volume of training opportunities. Significant personal dedication to the effort is required as the often unplanned nature of cannulation opportunities requires trainees to make themselves available for cases on short notice. Once an established cohort of enough trained and credentialed faculty has been achieved, we anticipate our effort will establish a team of intensivist ECMO cannulators who are available around the clock on a formalized call system to provide support to unstable patients within the hospital. The next logical step will be the development of a mobile cannulation and retrieval team to extend the ability to provide ECMO support to patients at hospitals within our health system and in the local area. Ongoing efforts of the program include development of an in-house cannulation training course using simulation to not only familiarize new providers with the procedure, but also to optimize the team approach to both straightforward and complex cannulation scenarios. This effort highlights a natural extension of the value anesthesia intensivists can provide in a coordinated multidisciplinary effort expanding the ability to deliver ECMO support to unstable patients whenever it is indicated and wherever they are. References
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