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.
Case library
30 scenarios
- VVintro6 min
Freshly cannulated — sats won't climb
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. Stabilize gas exchange.
Open console - VVintro5 min
Pink sats, purple numbers
VV-ECMO. SpO₂ 92% but ABG: pH 7.10, PaCO₂ 78. Flow 4.0 L, FdO₂ 0.8, sweep still 1.5 L.
Open console - VAintro6 min
Shock on low support numbers
Refractory cardiogenic shock on VA-ECMO. RPM 2200, flow 2.2 L, MAP 52, lactate 6.5.
Open console - VVintro6 min
Ready to step down?
VV-ECMO day 10. FiO₂ 0.4, PEEP 10, SpO₂ 95% on FdO₂ 0.3 and low sweep. Team asks about a structured wean trial.
Open console - VVintermediate7 min
High FdO₂, still blue
VV-ECMO day 1. FdO₂ 1.0, RPM 3800, flow 4.2 L. SpO₂ stuck ~84%. Pre-oxygenator SvO₂ reads 88%. ΔP modest.
Open console - VVintermediate6 min
The circuit is chattering
VV-ECMO after aggressive diuresis. Flow falling at fixed RPM. Pven deeply negative. Tubing chatters.
Open console - VVintermediate7 min
Gradient climbing, flow slipping
Hours into VV-ECMO. Same RPM, lower flow. ΔP alarming. Membrane looks mottled.
Open console - VAintermediate7 min
Blue head, pink legs
Femoral VA-ECMO. Native output recovering. Legs well saturated; right-hand SpO₂ 78%. Membrane looks fine.
Open console - VAintermediate7 min
Pulse pressure vanishing
VA-ECMO with rising support. Pulse pressure 6 mmHg, high CVP, climbing lactate. AV barely opens on prior echo.
Open console - VAintermediate6 min
Cool, mottled foot
VA-ECMO day 2, femoral arterial cannula. Foot cooler, weak Doppler. Systemic MAP is acceptable.
Open console - VAintermediate7 min
Dark urine, rising free hemoglobin
VA-ECMO. Tea-colored urine, pfHb up, high negative Pven, high RPM.
Open console - VVintermediate6 min
Oozing everywhere, ACT sky-high
Day 3 VV-ECMO. Cannula sites and NG bleeding. ACT 320, Hb falling, MAP soft. Circuit flowing well.
Open console - VVintermediate6 min
Post-membrane numbers disappoint
VV-ECMO with FdO₂ 1.0. Patient SpO₂ low-80s. You check post-membrane PaO₂ — it is only 90 mmHg. ΔP mildly up.
Open console - VAintermediate6 min
Hypertensive, tight LV on support
VA-ECMO. MAP 105 on residual pressors, pulse pressure tight, lungs wetter, CVP high. Flow already solid.
Open console - VVintermediate7 min
Day 8 fevers, cultures pending
VV-ECMO day 8. New fevers, rising vasopressor need, falling SVR. Gases previously stable.
Open console - Avalonintermediate7 min
Avalon in, sats still look fem-fem
31-Fr Avalon Elite via the right IJ. RPM 3600, flow 3.9 L, FdO₂ 1.0. SpO₂ 83%. Pre-oxy SvO₂ 91%. No imaging since insertion. The return mark is rotated posteriorly.
Open console - Avalonintermediate6 min
Avalon after the sit-up
Avalon day 3, overnight sats 94%. After sitting for PT the circuit chatters, Pven −92, flow fell at the same RPM, and the abdomen is tense. Pre-oxy SvO₂ climbed.
Open console - V-AVintermediate6 min
Someone cranked the gate overnight
V-AV for Harlequin, balanced last night. Overnight the venous-return clamp was tightened hard. Qven 0.3 L, Qart 4.2 L. Right-hand sat is sliding, the venous limb looks dark and sluggish.
Open console - Avalonintermediate6 min
Avalon: spinning past the jet
31-Fr Avalon, jet confirmed on the TV this morning. Overnight someone chased a sat of 92% with RPM 4300. Flow 4.7 L, pre-oxy SvO₂ 86%, Pven −78, pfHb 28, circuit starting to chatter. Patient sat is 84%.
Open console - VAadvanced7 min
Console screaming — flow collapsing
VA-ECMO. Abrupt air-detect alarm. Flow plummets, MAP falls. You have seconds.
Open console - VVadvanced8 min
Night call: was fine an hour ago
VV-ECMO overnight. SpO₂ falling despite high RPM and FdO₂ 1.0. Patient febrile and agitated. Hb drifted down.
Open console - VAadvanced6 min
Pump head silent
Sudden zero flow on VA-ECMO. Console error, pump not spinning. Backup equipment is in the room.
Open console - VAadvanced8 min
Equalizing pressures after cannulation
VA-ECMO shortly after initiation. Rising CVP, falling flow, narrow PP. Fluids only briefly help.
Open console - VVadvanced8 min
VV flow fine, right heart struggling
ARDS on VV-ECMO with decent gases. Rising CVP, oliguria, echo yesterday showed RV strain.
Open console - VAadvanced6 min
Cannula out — bed is red
VA-ECMO. During a turn, arterial cannula dislodges. Massive bleeding, air risk, no effective flow.
Open console - VAadvanced8 min
Two problems at once
Femoral VA-ECMO. Upper body desatting as native output returns, and the cannulated foot is cool. MAP OK.
Open console - V-AVadvanced8 min
V-AV: the Y stole the artery
Fem-fem VA for cardiogenic shock, then Harlequin as the heart recovered. Team spliced a RIJ venous return (V-AV). Right-hand sat is 93% now, but MAP is 52 and falling. Total pump flow 4.6 L. No clamp on the Y. Bedside Doppler: Qven 3.5 L, Qart 1.1 L.
Open console - V-VAadvanced8 min
V-VA: the artery is the high-resistance limb
VV-ECMO for ARDS. Overnight the RV failed — MAP 48, rising lactate, echo D-sign. An arterial return was Y'd off the post-membrane tubing (V-VA). Total flow 4.3 L, but almost all of it still returns to the RA. The new 17-Fr arterial cannula barely registers.
Open console - VAadvanced8 min
Harlequin: splice the Y, then clamp it
Fem-fem VA, native output returning. Right-hand sat 76%, legs pink. The RIJ is prepped for a venous-return splice (V-AV). No Hoffman clamp is on the table yet. MAP 76 on modest pressor.
Open console - VVadvanced8 min
V-VA: the heart just joined the problem
VV-ECMO day 4 for viral ARDS. Overnight the RV dilated — MAP 46, lactate 4.6, D-sign, cool mottled knees. The arterial sheath is in. You can Y an arterial return onto this circuit (V-VA). The existing 21-Fr IJ return will steal everything if you do not clamp it.
Open console