While extracorporeal membrane oxygenation (ECMO) case volume continues to increase [1, 2], management of patients receiving ECMO remains technically challenging [2, 3]. Iatrogenic injury is a potential contributor to complications and poor outcomes [4–7]. Drainage insufficiency, wherein limited pump preload leads to reduced circuit blood flow, is ubiquitous, yet there is no consensus regarding treatment. We propose a physiology-based algorithmic approach to the management of drainage insufficiency.