Run the circuit. Treat the patient.
Thirty ELSO-style cases with a live console: drainage, recirculation, dual-lumen Avalon, V-AV / V-VA Hoffman-clamp splits, membrane efficiency, and VA complications — numbers move continuously, not as quiz deltas.
Introductory session
A stable patient. Just the circuit.
No briefing, no guided questions, no free-play goals. Turn RPM, FdO₂, and sweep — switch VV or VA. Watch flow, gases, and vitals — a small screen names what changed.
Case library
30 scenarios
- VVintro6 min
Case 01 — Freshly cannulated
Severe ARDS, just started on VV-ECMO. SpO₂ 82%, pH 7.18, PaCO₂ 68. Console: RPM 2500, flow 2.8 L, FdO₂ 0.6, sweep 2 L.
Open console - VVintro5 min
Case 03 — Persistent hypercarbia
VV-ECMO. Monitor SpO₂ 92% but ABG: pH 7.10, PaCO₂ 78. Flow 4.0 L, FdO₂ 0.8, sweep still 1.5 L from cannulation.
Open console - VAintro6 min
Case 07 — Low-flow shock
Refractory cardiogenic shock on VA-ECMO. Left at RPM 2200, flow 2.2 L, MAP 52, lactate 6.5.
Open console - VVintro6 min
Case 21 — Weaning trial
VV-ECMO day 10. Native FiO₂ 0.4 / PEEP 10. Circuit FdO₂ 0.3, low sweep, SpO₂ 95%. Team is asking about a wean trial versus pulling it.
Open console - VVintermediate7 min
Case 02 — Still hypoxemic
VV-ECMO day 1. FdO₂ 1.0, RPM 3800, flow 4.2 L. SpO₂ stuck ~84%. Pre-oxygenator SvO₂ reads 88%. ΔP modest. Post-membrane gas not drawn.
Open console - VVintermediate6 min
Case 04 — Chattering circuit
VV-ECMO after aggressive diuresis. Flow falling at fixed RPM, Pven deeply negative, tubing chatters. CVP 4.
Open console - VVintermediate7 min
Case 05 — Rising circuit gradient
Hours into VV-ECMO. Same RPM, lower flow. ΔP alarming. Membrane looks mottled. ACT 160.
Open console - VAintermediate7 min
Case 08 — Differential saturations
Femoral VA-ECMO. Native output recovering. Legs well saturated; right-hand SpO₂ 78%. Membrane looks fine.
Open console - VAintermediate7 min
Case 09 — Narrow pulse pressure
VA-ECMO with rising support. Pulse pressure 6 mmHg, high CVP, climbing lactate. Yesterday’s echo: AV barely opening.
Open console - VAintermediate6 min
Case 11 — Limb check
VA-ECMO day 2, femoral arterial cannula. Foot cooler, weak Doppler. Systemic MAP acceptable. No distal perfusion catheter at cannulation.
Open console - VAintermediate7 min
Case 12 — Dark urine
VA-ECMO. Tea-colored urine, pfHb up, high negative Pven at RPM 4000. Flowsheet still says stable.
Open console - VVintermediate6 min
Case 13 — Bleeding on circuit
Day 3 VV-ECMO. Cannula sites and NG bleeding. ACT 320, Hb falling, MAP soft. Circuit flowing well, ΔP quiet.
Open console - VVintermediate6 min
Case 16 — Membrane check
VV-ECMO with FdO₂ 1.0. Patient SpO₂ low-80s. Post-membrane PaO₂ 90 mmHg. ΔP mildly up. Pre-oxy sat is not high.
Open console - VAintermediate6 min
Case 17 — Hypertension on VA
VA-ECMO. MAP 105 on residual pressors, pulse pressure tight, lungs wetter, CVP high. Flow already 4.8 L. AV barely opening.
Open console - VVintermediate7 min
Case 20 — Day 8 fevers
VV-ECMO day 8. New fevers, rising vasopressor need, falling SVR. Gases were stable yesterday. Cultures pending.
Open console - Avalonintermediate7 min
Case 23 — Dual-lumen, still hypoxemic
31-Fr dual-lumen cannula via the right IJ. RPM 3600, flow 3.9 L, FdO₂ 1.0. SpO₂ 83%. Pre-oxy SvO₂ 91%. No imaging since insertion. Return mark rotated toward the pillow.
Open console - Avalonintermediate6 min
Case 24 — After repositioning
Dual-lumen day 3, overnight sats 94%. After sitting for PT the circuit chatters, Pven −92, flow fell at the same RPM, abdomen tense. Pre-oxy SvO₂ climbed.
Open console - V-AVintermediate6 min
Case 27 — Overnight clamp change
Hybrid circuit, both return limbs balanced last night. Overnight the venous-return gate was tightened. Qven 0.3 L, Qart 4.2 L. Right-hand sat sliding, venous limb dark and sluggish.
Open console - Avalonintermediate6 min
Case 29 — Dual-lumen position check
31-Fr dual-lumen. Morning echo: jet on the tricuspid. Overnight RPM was chased to 4300. Flow 4.7 L, pre-oxy SvO₂ 86%, Pven −78, pfHb 28, circuit starting to chatter. Patient sat 84%.
Open console - VAadvanced7 min
Case 06 — Console emergency
VA-ECMO. Abrupt air-detect alarm. Flow plummets, MAP falling, foam in the tubing.
Open console - VVadvanced8 min
Case 10 — Overnight change
VV-ECMO overnight. SpO₂ falling despite high RPM and FdO₂ 1.0. Patient febrile and agitated. Hb drifted down. ΔP only modestly up.
Open console - VAadvanced6 min
Case 14 — Pump stop
Sudden zero flow on VA-ECMO. Console drive error, pump head not spinning. Backup drive and hand crank are on the crash cart.
Open console - VAadvanced8 min
Case 15 — After VA cannulation
VA-ECMO shortly after initiation. Rising CVP, falling flow, narrow pulse pressure. Fluids help for a minute, then don’t.
Open console - VVadvanced8 min
Case 18 — Oliguria on VV
ARDS on VV-ECMO with decent gases. Rising CVP, oliguria. Yesterday’s echo showed RV strain. Sats dip when the vent is dropped.
Open console - VAadvanced6 min
Case 19 — Cannula emergency
VA-ECMO. During a turn the arterial cannula comes out. The bed is red, air in the line, no effective flow.
Open console - VAadvanced8 min
Case 22 — Two issues at once
Femoral VA-ECMO. Right hand desatting as native output returns. Cannulated foot is cool with a weak Doppler. MAP acceptable.
Open console - V-AVadvanced8 min
Case 25 — Hybrid circuit, falling MAP
Fem-fem VA. Native output recovered and the right hand desatted, so the team spliced a RIJ venous return. Right-hand sat 93% now, MAP 52 and falling. Total flow 4.6 L. No clamp on the Y. Doppler: Qven 3.5 L, Qart 1.1 L.
Open console - V-VAadvanced8 min
Case 26 — Hybrid circuit, uneven split
VV-ECMO for ARDS. Overnight MAP 48, rising lactate, echo D-sign. An arterial return was Y’d off the post-membrane tubing. Total flow 4.3 L; almost all of it still returns to the RA. The new 17-Fr arterial cannula barely registers.
Open console - VAadvanced8 min
Case 28 — Hybrid conversion
Fem-fem VA, native output returning. Right-hand sat 76%, legs pink. The RIJ is prepped and a Y is on the field. No clamp is on the table yet. MAP 76 on modest pressor.
Open console - VVadvanced8 min
Case 30 — Hybrid circuit, day 2
VV-ECMO day 4 for viral ARDS. Overnight MAP 46, lactate 4.6, D-sign, cool mottled knees. Arterial sheath is in. The team wants to add an arterial return. The existing 21-Fr IJ return is still wide open.
Open console