Abstract Background Extracorporeal membrane oxygenation (ECMO) has historically excluded patients with severe neurologic injury, Intracranial bleeding, extensive burns, coagulopathy, septic shock, or refractory cardiac arrest due to perceived futility and hemorrhagic or ethical risks. Evolving multidisciplinary governance, refined hemostatic management, innovative and adaptive ECMO support strategies necessitate re-evaluating these long-standing contraindications. Methods This prospective, single-center case series (2024-2025) describes 10 patients supported with ECMO despite traditional absolute/relative contraindications. All cases underwent expedited review by a formal ECMO Alert Triage using a structured algorithm by ECMO Steering Committee that prioritized reversibility, neurologic trajectory, and ethical feasibility. Data included indication, configuration, cannulation constraints, anticoagulation adaptations, predefined exit strategies, and short-term outcomes. Results Ten patients (mean age 42 ± 15 years) were supported for traumatic lung injury (n = 2), intracranial injury post-transplant (n = 2), coagulopathy (n = 1), extensive burns with bacteremia (n = 1), septic shock with refractory hypoxemia (n = 1), prolonged cardiac arrest 60 minutes (n = 2) and central Airway Obstruction due to maliganncy. ECMO modalities included VA (n = 4), VV (n = 5), and hybrid (n = 1). Several required customized cannulation or anticoagulation modifications. All achieved hemodynamic and respiratory stabilization within 12-24hrs (100%); 8 (80%) were successfully decannulated, and 6 (60%) survived to discharge with favorable neurologic or functional recovery. Representative cases illustrate adaptations such as alternate cannulation positioning under cervical immobilization, tunneled VV-ECMO in burns with bacteremia, and emergent VA-ECMO during transport for refractory arrest. Conclusions With structured multidisciplinary oversight, tailored technical approaches, and ethically grounded exit planning, ECMO can yield meaningful survival in patients previously deemed ineligible. These findings support reframing several “absolute” contraindications as conditional, contingent upon reversibility and governance-driven risk mitigation. Implementation of standardized decision algorithms may responsibly broaden ECMO eligibility while preserving patient safety and ethical integrity. This abstract is funded by: none
Rasul et al. (Fri,) studied this question.