Because of technological advancements and encouraging experiences during the 2009 influenza A (H1N1) epidemic, many critical care clinicians consider extracorporeal membrane oxygenation (ECMO) a reasonable strategy for managing patients with refractory hypoxemia when standardized therapies have failed. Although the literature remains unclear as to whether it should be considered a routine or a rescue strategy in the management of patients with severe acute respiratory distress syndrome, experts agree that ECMO therapy is most likely to result in positive outcomes and fewer complications when provided at regional ECMO centers. Some institutions have developed the expertise and resources required to provide this sophisticated therapy, but significantly more facilities may choose to send their patients to a tertiary ECMO center when they do not respond to usual care. This article provides information essential for health care teams who refer their patients to such centers. The clinical indications for, and the use of, ECMO therapy in the management of refractory hypoxemia is briefly reviewed, followed by a description of how ECMO works to provide gas exchange and tissue perfusion. The primary considerations for circuit management, hemodynamic support, and pulmonary care are described, and significant complications of the therapy are identified. The remainder of the article focuses on the patient care and preparatory activities that occur before and during ECMO initiation, so that health care teams, patients, and their families can be confident of an efficient, safe, and highly skilled transfer of care between institutions.

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