The primary areas of extracorporeal membrane oxygenation (ECMO) technology with engineering components are: biomaterials, oxygenator design, ECMO physiology and total system design. The evolution of ECMO has been largely empirical, with many innovations introduced directly from clinical experience and observation. Major advances are needed in both materials ans oxygenator design if current hematologic hazards are to be reduced. Optimization of ECMO systems has not been attempted in any systematic way because the basic physiology is not well enough understood to define the rationales for optimum control and management strategies. Once these strategies have been developed and tested, currently available automation technology can be applied to make the ECMO system system simpler and safer for clinical use.