From Concept to Implementation: Establishing Extracorporeal Membrane Oxygenation Services in Resource-limited Settings

Abstract

Extracorporeal membrane oxygenation (ECMO) can provide temporary respiratory or circulatory support for selected patients with otherwise refractory organ failure. Access, however, remains concentrated in experienced tertiary centres. Distance, limited critical-
care infrastructure, workforce shortages and high treatment costs can delay assessment and transfer for patients living outside major urban areas. This narrative review examines practical and ethical approaches to developing ECMO access in resource-limited and geographically remote settings, with emphasis on regional coordination rather than indiscriminate expansion of stand-alone services. The manuscript synthesizes selected clinical trials, professional guidance, registry-based literature and implementation-focused publications relevant to ECMO selection, service organisation, transport, training, safety and affordability. It is a narrative review and should not be interpreted as a systematic review. A hub-and-spoke pathway can support early recognition and consultation at peripheral
hospitals while concentrating complex cannulation, management and rescue capability in experienced centres. Mobile retrieval and tele-ECMO may extend access, but require trained teams, reliable transport systems, clear governance and predefined escalation pathways. Cost estimates and claims of large savings are highly context-dependent and should not be generalised without local economic evaluation. Patient selection, informed consent, transparent resource allocation, adverse-event review and prospective outcome reporting are essential. ECMO access beyond major cities is most defensible when built around regional networks, timely referral, competent multidisciplinary teams and auditable outcomes. The priority should be to strengthen safe pathways to established expertise; a local ECMO service should be introduced only when minimum clinical, logistical and financial safeguards can be
sustained.