A long way from the mothership

Everything ECMO 047: ECMO Retrieval in Victoria

Author: Dr Chris Parry
Peer reviewers: Dr David Anderson
, Dr Andy Paton

You are doing a Locum ICU shift in Mildura.

It’s 23:30 on a Friday and you have just intubated a 160 kg 50yo male for respiratory failure.

Despite a PEEP of 18 cmH20 and an Fi02 100% you can’t adequately oxygenate the patient. His saturations are hovering in the high 80’s.

You’ve optimized the ventilator as best as you can, but you are concerned the patient may require ECMO.

Q1. When should you initiate the referral?


Mobilising the resources for an ECMO patient takes time. Mobilising a team to travel to Mildura takes even longer. A timely referral can expedite the escalation of the patients care.

Patients this sick often exhaust the capability and comfort levels of regional centres. They are often being managed by the most senior clinician and the referral may have to be relayed by more junior medical staff. Whilst waiting for help to arrive, experienced staff maybe able to provide additional clinical advice to help optimise patient care.

Q2. How do you make a referral?

In Victoria, you would call the Victorian ECMO Service (VECMOS) on 1300 832 667 (1300 VECMOS) to establish an ECMO teleconference call with an ECMO Advice Specialist.

Often multiple people are included on this call. These may include but are not limited to: referring clinician, ARV Clinical coordinator, ECMO Advice Specialist/s, Retrieval Physician, +/- CCRN (Critical Care Registered Nurse.)

On initial contact, the referring clinician needs to provide the patients details and vital signs before relaying the pertinent clinical information. This can take a few minutes, so have the information at hand prior to referral. Don’t forget the weight. At 160kg this patient might not even fit on an ambulance stretcher!

Q3. What information are you going to relay?

It’s important to establish the patient’s suitability for ECMO.

  • Are there any contraindications? (e.g multi organ dysfunction, severe sepsis, age, frailty, co-morbidities)
  • What investigations and treatment has the patient had to date?
  • What has been the patient’s trajectory?
  • Current ventilator settings
  • Recent pathology, radiology and ABG results
  • What central access does the patient have? (Can a femoral CVC be re-sited whilst awaiting the retrieval team?)
  • Any infection control concerns? (e.g. has SARS-CoV-2 PCR been performed?)

Patient selection considerations used in Victoria are available on ECMO.ICU:

Q4. What logistical challenges can you anticipate in this scenario?

Bariatric transfers provide additional layers of complexity.

For morbidly obese patients, dimensions are required to ensure the patient fits on a conventional ambulance stretcher. ARV will provide a bariatric sizing chart to guide measurements. Organising a CPAV (Complex Patient Ambulance Vehicle) for bariatric transfers is convoluted and takes time. Unfortunately, their weight forgoes them travelling via Fixed or Rotary wing. Mildura is one of the furthest hospitals from Melbourne. Routinely we would ideally fly by fixed wing due to their superior speed and range. It’s a long drive in a CPAV!


Often referrals come through at an antisocial time of day. Fatigue management can influence your decision on how to dispatch your team.  Restrictions on pilot hours, changes in shifts and unacceptable overtime can alter what is the best course of action. In some situations, delaying the transfer to the following morning maybe the best option. If safe to do so.

Infection control

In this post-pandemic world, anyone with respiratory failure has COVID-19 until proven otherwise. This already adds a further layer of complexity to what is already a challenging case.

Q5. How are you going to move this patient?

Currently, in the state there are 5 helicopters. HEMS 1 + 5 are based in Melbourne. HEMS 2 in Traralgon, HEMS 3 in Bendigo and HEMS 4 in Warnambool. They are staffed by a Flight MICA paramedic and crewman. Overnight there are 2 fixed wings available from Essendon. Currently, there is one ARV ambulance staffed with a CCRN and PTO (patient transport officer) until 01:00.

Moving a complex patient like this is rarely done using an ALS (Advanced Life Support) ambulance. Moving a patient on ECMO, a ventilator and 6 infusions brings it’s own challenges if you have nowhere to secure your equipment. CPAVs are a scarce resource scattered across the state. They are staffed by Ambulance attendants to help operate specialized bariatric equipment.

To form the retrieval team you need the following people:

  • ECMO team (2 intensivists +/- fellow or Intensivist and ECMO CCRN),
  • Retrieval Physician or Senior Registrar,
  • Retrieval CCRN, and
  • Patient transport officer (PTO).

Q6. You’ve finally arrived in Mildura and have successfully initiated VV ECMO. After displaying your Jedi-like cannulation skills you have to check yourself and think…. what do I need to get to Melbourne safely?

This is not an exhaustive list but includes important things to remember.


  • secured ETT, lines and devices
  • medication (ample to get you to Melbourne, emergency drugs relaxant/sedation/vasopressors)
  • fully charged ventilator, infusions and monitor (with external power supply)  


  • hand crank
  • adequate oxygen supply (portable and ambulance)
  • multiple clamps
  • fully charged console and external power supply


  • empty bladder
  • fed and watered

As the pandemic unfolded and the Victorian ECMO service became  established, there was an increasing number of ECMO retrievals.

Q7. Which hospitals currently have the capacity to initiate and manage patients on ECMO in Victoria?

ECMO centres in Victoria are categorised by VECMOS as follows:

  • Level 1/Comprehensive (Initiate, sustain and retrieve VA, VV and ECPR) – The Alfred
  • Level 2/Intermediate (Initiate and sustain selected ECMO. May potentially receive patients retrieved by Level 1 centre) – Royal Melbourne Hospital and University Hospital Geelong.
  • Level 3/Initiation (Initiate and transfer patient to Alfred Health) – St Vincent’s, Austin, Box Hill and Monash Medical Centre/ Victorian Heart Hospital


  1. Adult extracoroporeal membrane oxygenation (ECMO) in Victoria: Centralisation and retrieval model evidence review (Safer Care Victoria 27 May 2019) [pdf]
  2. Adult Retrieval Victoria manual
  3. ECMO.ICU (Alfred ICU ECMO Guidelines)
  4. Victorian ECMO Service (VECMOS) [website]

All case-based scenarios on INTENSIVE are fictional. They may include realistic non-identifiable clinical data and are derived from learning points taken from clinical practice. Clinical details are not those of any particular person; they are created to add educational value to the scenarios.

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