**1. Introduction**

This text is now the third volume in a series of books focused on extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) [1]. With each volume, it becomes clearer that there has been a rapid evolution in the technology and the applications of it with regard to indications, management, outcomes, and the challenges in offering a very resource-intensive (and expensive) therapy in which the overall benefits are still questioned. Nevertheless, without a doubt, there has been an ongoing evolution of the use of ECMO as a salvage therapy offered only in extreme and potentially inherently futile cases, to now a mainstream therapy that can be routinely offered in well-defined cases of acute cardiac and respiratory failure. Early experiences resulted in few survivors and poor outcomes, but the reasons for this were clearly complex and multifactorial etiologies [2]. The development of more advanced pumps and circuits, better resources and guidelines for patient selection and management, and a broader understanding of the complex interactions between humans and an extracorporeal pump circuit for longer periods of time all have contributed to the advances in ECMO as an appropriate and reasonable therapy—even, as some would debate, standard of care for acute respiratory failure and/or cardiogenic shock. As these three volumes illustrate, over the years, there has been tireless improvements in all aspects of the use of ECMO. However, as the chapters in this text clearly illustrate, there is still much to be learned and understood. Challenges remain as clinicians continue to push the envelope of this technology to better define a patient population that might benefit from ECMO and how to apply and manage a very complex therapy to optimize outcomes [3].

As the indications for therapy evolve, there continues to be unusual and challenging clinical situations that deserve special attention for many reasons. For example, the chapter by Professor Nandini highlights the very complex issue that is becoming more common—the role of ECMO as a bridge to transplant. It was only a few years ago (and illustrated in the previous texts in this series) that the concept of ECMO as bridge to transplant was discouraged and difficult to justify due to the risks, concerns of limited resource allocation, and technical difficulties to a concept and management pathway that is routinely considered and offered to selected patients.

Additional chapters focus on the growing literature and experiences in other specific disease state or clinical situations for which ECMO might be considered. One area that is particularly challenging is incorporating ECMO into the management of patients who develop acute cardiopulmonary collapse. ECMO-assisted CPR (eCPR) is one of the fastest growing uses of ECMO, and many rapid response/code teams are increasingly using ECMO in the management of patients who develop cardiac arrest. The data, experiences, and outcomes in this very complex area are rapidly evolving, and the controversies are substantial. The chapter by Dr. Lakshmi illustrates the current state of the art in this area and how patients can be selected and managed, with a focus on illustrating the improved outcomes in a patient population that was historically considered unsalvageable. Other similar unique applications for ECMO discussed in this text include a chapter on carbon dioxide removal by Dr. Morales-Quinteros. The very unusual role of normothermic regional perfusion in the setting of solid organ transplantation is discussed by Dr. Constantino.

A major focus of this volume is the specific management challenges that complicate the use of ECMO, especially in high-risk patient populations. Despite a greater awareness, peripheral cannulation techniques that are often used are associated with high rates of limb complications including amputation. Such concerns are discussed in the chapter by Dr. Prashant. Imaging of patients on ECMO, with an emphasis on assessing for cardiac recovery and prognosis, is especially important and discussed by Dr. Luigi, while the actual techniques, concepts, and applications of various weaning strategies are the focus of another chapter. Meanwhile, Dr. Weller's chapter on anticoagulation in the pediatric patient and Dr. Pinto's chapter on neurologic complications and monitoring revisit some of the difficult topics addressed in the previous editions and emphasize the growing experiences and literature in these complex topics [4, 5]. As some aspects of these topics have been addressed in the earlier books in this series, the contemporary experiences highlight that there remains much to understand and learn about many of these topics.

Again, it is also clear that to successfully offer ECMO as a viable therapy and especially to strive for reasonable outcomes—there must be alignment of all key stakeholders. Without a doubt, ECMO requires an extensive team of providers at all levels working together in a manner that respects professionalism, competencies, compassion, and strict attention to details. The substantial and tireless efforts of the entire team must be recognized and appreciated by all and at all levels [6].

A frequently asked question is "how do we start an ECMO program?" Offering ECMO as a therapy involves so much more than just purchasing capital equipment and some disposable supplies. The chapter on program development emphasizes the many administrative aspects that must be considered within an appropriate framework to establish a program. This chapter considers the importance of physician, nursing, and administrative leadership and collaboration as a foundation for a successful program. While a great deal has been written on the extensive medical and surgical aspects of the management of a patient on ECMO, the chapter by Mr. Botsch and colleagues reviews the many aspects of the nursing bedside care. Of course, these topics continue to illustrate the importance of teamwork which cannot be overemphasized.

As discussed in the previous editions, a highly functioning "ECMO team" is a cornerstone in building a successful program. The ability to initiate therapy at any time and place is increasingly considered an important component of a well-organized team. While the makeup of an ECMO team can vary across institutions; each requires a champion to provide leadership and help with structure and organization. A fundamental principle is effective communication and a multidisciplinary approach to all aspects of management. Just as importantly, all

**5**

*Introductory Chapter: ECMO – Rapidly Evolving Technology, Expanding Indications…*

• Surgeons (cardiothoracic, general, trauma, emergency medicine)

• Medical specialists (infectious disease, neurology, cardiology, nephrology)

• C-suite executives (chief executive, financial, operating, and other officers)

It is critical that even with dedicated, hardworking, and engaged clinical teams, there must be support and encouragement from hospital leadership and administra-

Many of the chapters in these volumes discuss the various indications for ECMO

(veno-venous and venoarterial) support and special patient populations and circumstances. However, a critical component of any program remains the role of striving for optimal clinical outcomes. Regardless of the indications and populations, outcomes and clinical complications (e.g., renal failure, limb complications,

• Critical care intensivists (pulmonary, surgical)

• Nursing (bedside, advanced practice providers)

members of the team—regardless of experiences, education, training, degrees, and titles—need to have respect and trust and place value on all aspects of the contributions of all members. This is the basis of crew resource management (CRM). The key concept of CRM is that every team member has input and that each voice is valued and respected. Every member of the team needs to be empowered to speak up, particularly when there are concerns about safety. The different disciplines that are represented in an ECMO Team, as mentioned, can vary from program to program, but given the complexities of patient selection and management—including, the least of which are the technical aspects of cannulation and cannula management—membership must be comprehensive with regard to surgical and medical expertise. Membership should include, but

*DOI: http://dx.doi.org/10.5772/intechopen.89475*

clearly, not be limited to:

Advanced providers

• Pharmacists

• Perfusionists

Palliative care

• Quality managers

• Marketing

tion (**Figure 1**) [7].

• Respiratory therapists

• Social workers/case management

• Often physician or advance practice nurses

Hospital leadership and administration

Physicians

*Introductory Chapter: ECMO – Rapidly Evolving Technology, Expanding Indications… DOI: http://dx.doi.org/10.5772/intechopen.89475*

members of the team—regardless of experiences, education, training, degrees, and titles—need to have respect and trust and place value on all aspects of the contributions of all members. This is the basis of crew resource management (CRM). The key concept of CRM is that every team member has input and that each voice is valued and respected. Every member of the team needs to be empowered to speak up, particularly when there are concerns about safety. The different disciplines that are represented in an ECMO Team, as mentioned, can vary from program to program, but given the complexities of patient selection and management—including, the least of which are the technical aspects of cannulation and cannula management—membership must be comprehensive with regard to surgical and medical expertise. Membership should include, but clearly, not be limited to:
