title: Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies.
abstract: BACKGROUND
  Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently "rescue" a significant proportion of those affected.
  
  
  CONCLUSIONS
  Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices.
  
  
  CONCLUSIONS
  Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.
authors.affiliation: Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA.
authors.forename: David B
authors.initials: DB
authors.lastname: Tulman
authors.affiliation: Department of Surgery, Division of Critical Care, Trauma, and Burn, Wexner Medical Center at The Ohio State University, 410 W 10th Ave, Columbus 43210, OH, USA.
authors.forename: Stanislaw P A
authors.initials: SP
authors.lastname: Stawicki
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, Wexner Medical Center at The Ohio State University, 410 W 10th Ave, Columbus 43210, OH, USA.
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Whitson
authors.affiliation: Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA ; Northeast Ohio Medical University, 4209 SR 44, PO Box 95, Rootstown 44272, OH, USA.
authors.forename: Saarik C
authors.initials: SC
authors.lastname: Gupta
authors.affiliation: Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA.
authors.forename: Ravi S
authors.initials: RS
authors.lastname: Tripathi
authors.affiliation: Cardiothoracic Surgery, Summa Akron City Hospital, 75 Arch St, Akron 44304, OH, USA.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Firstenberg
authors.affiliation: Pulmonary Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus 43205, OH, USA.
authors.forename: Don
authors.initials: D
authors.lastname: Hayes
authors.affiliation: Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical College, 2 Fuxue Road, 32500 Zhejiang, China.
authors.forename: Xuzhong
authors.initials: X
authors.lastname: Xu
authors.affiliation: Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Papadimos
mesh_terms: D004867:Equipment Design; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D012128:Respiratory Distress Syndrome / Q000628:therapy*
keywords: Adult; Cannulation; ECMO; Respiratory distress syndrome; Veno-venous
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