ObjectivesTo describe a single center’s experience with the primary use of venovenous cannulation for supporting pediatric acute respiratory failure patients with extracorporeal membrane oxygenation (ECMO).DesignRetrospective chart review of all patients receiving extracorporeal life support at a single institution.SettingPediatric intensive care unit at a tertiary care children’s hospital.PatientsEighty-two patients between the ages of 2 wks and 18 yrs with severe acute respiratory failure.InterventionsECMO for acute respiratory failure.Measurements and Main ResultsFrom January 1991 until April 2002, 82 pediatric patients with acute respiratory failure were cannulated for ECMO support. Median duration of ventilation before ECMO was 5 days (range, 1–17 days). Sixty-eight of these patients (82%) initially were placed on venovenous ECMO. Fourteen patients were initiated and remained on venoarterial support, including six in whom venovenous cannulae could not be placed. One patient was converted from venovenous to venoarterial support due to inadequate oxygenation. Venoarterial patients had significantly greater alveolar-arterial oxygen gradients and lower Pao2/Fio2ratios than venovenous patients (p< .03). Fifty-five of 81 venovenous patients received additional drainage cannulae (46 of 55 with an internal jugular cephalad catheter). Thirty-five percent of venovenous patients and 36% of venoarterial patients required at least one vasopressor infusion at time of cannulation (p= nonsignificant); vasopressor dependence decreased over the course of ECMO in both groups. Median duration on venovenous ECMO for acute hypoxemic respiratory failure was 218 hrs (range, 24–921). Venovenous ECMO survivors remained cannulated for significantly shorter time than nonsurvivors did (median, 212 vs. 350 hrs;p= .04). Sixty-three of 82 ECMO (77%) patients survived to discharge—56 of 68 venovenous ECMO (81%) and nine of 14 venoarterial ECMO (64%).ConclusionsVenovenous ECMO can effectively provide adequate oxygenation for pediatric patients with severe acute respiratory failure receiving ECMO support. Additional cannulae placed at the initiation of venovenous ECMO could be beneficial in achieving flow rates necessary for adequate oxygenation and lung rest.