When the risk of cardiopulmonary arrest during intubation is high, “awake” extracorporeal membrane oxygenation (ECMO) cannulation with sedation and a natural airway may provide hemodynamic stability and gas exchange to mitigate the hazards of intubation. This retrospective case series characterizes patient selection, clinical periprocedural management, and frequency of “awake” pediatric ECMO cannulations in nonintubated patients at a quaternary pediatric hospital. Between 2014 and 2024, 58 patients (7–18 years) with nonpostoperative cardiac indications underwent ECMO support, with six (10%) “awake” venoarterial ECMO cannulations. Of the “awake” cohort median age was 13 years, with pulmonary hypertension, myocarditis, dilated cardiomyopathy with arrhythmia, and severe mitral stenosis diagnoses. Five were emergent or urgent with cannulations performed after interdisciplinary discussions in the cardiac intensive care unit or catheterization lab. Access was via femoral cutdown with one patient requiring additional neck venous access. Postcannulation, five of six patients were intubated, with one later extubated, such that two were managed extubated while supported on ECMO. All survived to hospital discharge, one received a bilateral lung transplant, and none sustained neurological injuries. We describe ECMO cannulation in spontaneously breathing children with varied physiology who were considered at high risk for cardiopulmonary arrest during induction of anesthesia and intubation. Though rare in pediatric practice, this approach is feasible with appropriate preparation and team expertise.