Transportation of critically ill patients on extracorporeal membrane oxygenation (ECMO) started in a few reference centers over 30 years ago, but there has been an exponential growth since 2009, the year when the influenza A pandemic consolidated this therapy to fight against severe heart failure.1 Thanks to the technological advancements made with ECMO devices and the specialization of health professionals, ECMO has extended its applications to other situations like cardiogenic shock, cardiorespiratory support as a bridge therapy to heart or lung transplantation, cardiac arrest or organ donor support in Maastricht type III patients.2

Resource centralization with the creation of reference centers specialized in ECMO support has improved the results regarding survival by providing better safety and cost-efficiency. Therefore, to guarantee universal access to ECMO therapy transportation among different hospitals is required. In patients in need, not starting ECMO support prior to transportation is associated with higher morbidity and mortality rates.3 Still, high risks are associated with ECMO transportation for the patient. According to a study published by the Karolinska University Hospital (Stockholm, Sweden), severe complications have been reported in up to 20% of transportations under 3h and in up to 45% of aerial transportations over 3h. However, transportation was not associated with higher mortality rates at the intensive care unit (ICU) setting.4

ECMO transportation is not a common thing, and the volume of cases varies depending on the population that is being assisted. Most of the studies published so far are based on the description of the experience of different centers with a variable number of nearly 20 annual cases per ECMO center in periods not ffected by respiratory virus-related pandemics. Worldwide, the Karolinska Karolinska University Hospital has been reporting on the largest number of transportations with a series of over 900 cases (equivalent to 80 cases per year.1) This low incidence rate is associated with a risk of diminishing the specialization of healthcare teams, their equipment, and personnel available.

ECMO transportation demands a proper analysis to establish the needs of both the adult and pediatric populations. Also, it requires a high level of planning and communication among the different centers involved to reduce activation times and guarantee the correct sedation of the patients. Transportation vehicles should be adapted to meet this goal due to the larger number of health professionals and equipment that should be transferred. Also, a good selection of the means of transportation should be made to reduce transfer times with the highest possible safety. Finally, both the training and experienced gained by the ECMO team are essential to minimize the risks both for the patient and the healthcare professional. These principles had already been agreed on by the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and Spanish Society of Emergency Medicine (SEMES) due to the COVID-19 pandemic.5 The great impact caused by the COVID-19 pandemic has increased the incidence rate of these cases. In Spain, publications on ECMO transportation are scarce and the number of patients included in these publications is <20. The largest series ever recorded is that of Hospital Universitario Vall d’Hebron, Barcelona, Catalonia, Spain. This hospital reported on its experience within the first 3 months of the pandemic regarding the transfer of 19 COVID-19 patients on ECMO support.6 Many more centers have also started or consolidated their ECMO transportation programs. For all this, we believe it is necessary to provide a series of recommendations that should be taken as a guide, although it is still an area without much scientific evidence available.

Transportation of ECMO patients has distinctive characteristics that are different from other transportations among hospitals, which is why the correct interpretation of this document is necessary to define interrelated terms we’ll be seeing along the document.

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  Primary ECMO transportation: type of transportation where the patient who requires ECMO remains in a hospital without capabilities to start such therapy. Therefore, there is this need for a mobile expert team on cannulation and ECMO start followed by the transfer of the patient to the center where he will receive support therapy.

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  Secondary ECMO transportation: type of transportation between two hospitals of a patient who is already on ECMO support therapy.

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  Referral hospital: center where the patient remains hospitalized prior to transportation

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  Destination hospital: center to which the patient is being transferred while on ECMO support.

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  Ground transportation: transportation through ground-based means of transportation (mainly ambulances or other similar vehicles).

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  Aerial transportation: transportation through aerial-based means of transportation. It can be categorized as pitched-fixed propeller aircraft (airplanes) transportation or rotational blade aircraft (helicopters) transportation. Most aerial transportations include ground transportation between hospitals and airports/heliports too.

Within the different types of ECMO transportation available, primary transportation is the most complex of all; it is always a risky process that is sometimes very prolonged in time. It starts with a contact, usually a phone call, between the 2 hospital centers involved followed by a first examination. Afterwards, the patient is welcome at the destination hospital. Therefore, we can define a series of stages that are common to primary transportation:

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  Stage 1. Activation of the ECMO team: the referral hospital calls the destination hospital. Patient’s status is then assessed over the phone. An early decision is made of indication, contraindication or no indication (patient without contraindications but who does not meet the criteria to be started on ECMO at present time). At this stage, indications to optimize patient’s treatment and keep follow-ups over the phone until the indication are often given.

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  Stage 2. Preparation and transportation of the ECMO team: once ECMO support is indicated over the phone, the equipment coming from the referral hospital should be reviewed. Also, an initial plan on the type of ECMO support and cannulation needed should be defined. Also, the ECMO team and the equipment should both be transferred to the destination hospital.

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  Stage 3. In situ reassessment, optimization, and indication and initiation of ECMO: at the referral hospital, and upon the arrival of the ECMO team, the patient is examined in situ, medical support is optimized if indicated, and a final decision is made on cannulation and the start of the therapy. If indication is confirmed, a cannulation strategy should be defined, problems should be anticipated with alternative plans in case of complications, the circuit should be purged, and the different roles distributed between the teams of both hospitals. Also, cannulation and ECMO support should be started.

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  Stage 4. Stabilization and preparedness of transportation: once ECMO support has been started, the patient needs to be stabilized, and the necessary additional tests need to be performed before proceeding with transportation. After that, the patient is prepared for ECMO support and transportation.

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  Stage 5. Transportation of patient on ECMO support from the referral to the destination hospital: it requires treating the patient during transportation and managing complications, diagnosis, and solution.

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  Stage 6. Arrival of the patient to the destination hospital: upon arrival to the destination hospital, the patient is admitted to the ICU, and information is transferred from the transportation team to the referral team.

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  Stage 7. Transportation assessment: after completing transportation, the team should meet to discuss and reassess the case, talk about the problems that may have happened, and give options for improvement so the team can review, modify, improve, and validate their ECMO transportation protocol.

Due to the growing demand and the existence of different experiences in the field of critical care transportation and specifically the transportation of patients treated with ECMO, SEMICYUC, and the Spanish Society of Pediatric Intensive Care (SECIP) commissioned their working groups to elaborate a few recommendations on this field. SEMICYUC participated through its Critical Care Transportation Working Group. SECIP did so through its ECMO Virtual Group. Therefore, a group of writers including adult and pediatric intensivists of different regions and representative of the scientific community was created. To participate in this team a declaration of the possible conflicts of interest was required. In its first meeting, the team determined a methodology to review the references, provide local experience, and plan the main aspects on which recommendations should be based.

A structured bibliographic search was conducted on MEDLINE/PubMed using extracorporeal membrane oxygenation and transportation of patients as keywords, as well as mobile extracorporeal membrane oxygenation, and combinations of sub-headings. Articles published in English or Spanish between 2001 and 2020 were included. Articles with descriptions of individual cases were not included. Out of the 66 articles selected in the first place, a secondary bibliography was added, as well as routine guidelines and recommendations until a 135 citation-bibliography would be reached.

Seven different groups on issues on which recommendations should be given were agreed on: patient selection; reference centers; means of transportation; selection and risks; characteristics of the means of transportation and equipment used, health personnel; necessary experience and models, preparation, training, and clinical safety.

Once the bibliographic body and the questions that would be analyzed were selected, inter-group recommendations were made followed by a consensus document that was submitted to the writing team. Given the lack of comparative studies in this field, the GRADE methodology was not followed.7 The text with the recommendations was submitted to the writing team—and using the modified Delphi methodology8—each recommendation was analyzed and replanned with a high enough level of agreement. If consensus was not reach at some point an additional writing effort was made until it would be accepted by the entire group.

Each recommendation was graded according to the strength of recommendation and the quality of tests used (Table 1). When the work from the writing team was done, the manuscript first draft was submitted to SEMICYUC and SECIP members through their scientific committes so they could make additional comments or suggestions for 15 days. After this time, the manuscript final draft was submitted for publication (Tables 2–5).

The justification of each recommendation is available in the supplementary data.

Recommendations for the transfer of critically ill patients on ECMO designed by SEMICYUC and SECIP critical care transportation working groups attempt to reduce variability in the management of critical care patients—adults and children alike—and contribute to the standardization of care, which has the potential of bringing clinical benefits to these patients.

Since no clinical trials or other experimental studies have been conducted on the transfer of patients on ECMO, one of the main limitations of this manuscript is that some recommendations have a low level of evidence. Therefore, it is adviseable to analyze the degree of compliance to these recommendations and the evolution of the routine clinical practice within the next few years.

These recommendations try to be a useful tool for the decision-making process in the context of the creation of reference centers, transportation equipment, and resource selection. Their implementation will depend on the availability of resources in every region.

None whatsoever.

None reported.