As the use of extracorporeal membrane oxygenation (ECMO) expands, a systematic approach to the management of complex technical issues, such as drainage insufficiency, is essential to improving patient outcomes.

Due to the challenges in estimating blood flow requirement prior to ECMO cannulation, we recommend selecting large caliber drainage cannulae relative to the presumed needs of the patient, typically 25 to 29 French for patients with hypoxemic respiratory failure, for instance, to provide the necessary support at low drainage pressures.

Drainage insufficiency is overtly present when there is variation of ECMO blood flow in association with reduced pump preload. Clinically, there may be movement of the drainage tubing, a phenomenon variably termed “chatter,” “chugging,” or “kicking.”

Drainage pressure measurement may be insightful, but the lack of evidenced-based thresholds limits its utility as a standalone indicator.

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