"Safety of ECMO Cannulation: Organization and Standardized Training Matters"

We appreciate the insightful remarks by Sin et al regarding our systematic review and meta-analysis on extracorporeal membrane oxygenation (ECMO) cannulation by intensivists. Their comments highlight important considerations for contextualizing our findings. Our analysis confirmed that intensivist-performed cannulation is generally safe and feasible when supported by structured training, credentialing, and immediate surgical backup for complications such as vascular injury. Venovenous cannulation was associated with relatively low complication rates, whereas venoarterial cannulation carried higher risks, underscoring the need for additional caution. Importantly, extracorporeal cardiopulmonary resuscitation (ECPR) is characterized by substantially higher complication rates, likely driven by technical and environmental challenges rather than operator specialty. Equipment selection, including the use of smaller arterial cannulas in venoarterial ECMO, may further reduce vascular complications, though survival remains adversely affected when such complications occur. Beyond operator expertise, institutional infrastructure, standardized training, adherence to protocols, and availability of surgical support are pivotal to ensuring safe practice. We concur that future development of standardized guidelines addressing intensivist-led cannulation, including preparation for high-risk scenarios such as ECPR, will be essential to optimize outcomes.