ECMO in hinterland-feasibility and challenges (case-based narrative review)

Extracorporeal membrane oxygenation (ECMO) is one of the most advanced forms of cardiopulmonary support used for severe respiratory and/or cardiac failure when other conventional treatments are not optimal. However, the practice or use of ECMO remains predominant in tertiary centres due to its resource-intensive nature (human, skill, technical, and financial), thereby limiting access in peripheral and resource-constrained regions. So, this narrative review examines the feasibility and challenges of establishing ECMO services in such settings (described as the hinterland) through three major models: outreach ECMO programmes, hub-and-spoke systems, and tele-ECMO networks. Previous reviews have discussed ECMO organisation, transport, and regionalisation in general. Few have addressed the practical question of which ECMO model a hinterland hospital should choose and when. This review aims to fill that gap by directly comparing three practical models. Using case-based discussions and available literature, the review outlines the common foundational requirements for safe ECMO delivery, including infrastructure, logistics, multidisciplinary teamwork, transport preparedness, ethical governance, and protocol standardisation. It explores the advantages and disadvantages of each model, with a focus on components such as early referral, expert oversight, safe interfacility transfer, and a viable long-term partnership between peripheral and expert ECMO centres to improve patient outcomes. The review discusses ethical and financial aspects of ECMO program. It specifically explores the future role of telemedicine, artificial intelligence, and digital connectivity in expanding ECMO across all areas. To conclude, the review demonstrates that, with proposed models of structured systems and appropriate training, ECMO can be safely extended to unexplored regions while maintaining quality and patient safety.