Background-Venovenous extracorporeal membrane oxygenation (ECMO) is increasingly being used for acute respiratory distress syndrome and as a bridge to lung transplantation. After initiation of venovenous ECMO, systemic anticoagulation therapy is traditionally administered and can cause bleeding diathesis. Here, we investigated whether venovenous ECMO can be administered without continuous systemic anticoagulation administration for patients with acute respiratory distress syndrome.Methods-This is a retrospective review of an institutional ECMO database. We included consecutive patients from January 2015 through February 2019. Overall, 38 patients received low levels of continuous systemic anticoagulation (AC + ) whereas the subsequent 36 patients received standard venous thromboprophylaxis (AC −). Published Extracorporeal Life Support Organization guidelines were used for the definition of outcomes and complications.Results-Overall, survival was not different between the two groups (P = .58). However, patients in the AC + group had higher rates of gastrointestinal bleeding (28.9%, vs AC− group 5.6%; P < .001). The events per patient-day of gastrointestinal bleeding was 0.00025 in the AC− group and 0.00064 in the AC+ group (P < .001). In addition, oxygenator dysfunction was increased in the AC + group (28.9% and 0.00067 events per patient-day, vs AC− 11.1% and 0.00062 events per patient-day; P = .02). Furthermore, the AC+ group received more transfusions: packed red blood cells, AC+ group 94.7% vs AC− group 55.5% (P < .001); fresh frozen plasma, AC+ 60.5% vs AC − 16.6% (P = .001); and platelets, AC+ 84.2% vs AC− 27.7% (P < .001). There was no circuit thrombosis in either groups throughout the duration of ECMO support.Conclusions-Our results suggest that venovenous ECMO can be safely administered without continuous systemic anticoagulation therapy. This approach may be associated with reduced bleeding diathesis and need for blood transfusions.

Background Veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) support is increasingly used in the management of COVID‐19‐related acute respiratory distress syndrome (ARDS). However, the clinical decision‐making to initiate V‐V ECMO for severe COVID‐19 still remains unclear. In order to determine the optimal timing and patient selection, we investigated the outcomes of both COVID‐19 and non‐COVID‐19 patients undergoing V‐V ECMO support. Methods Overall, 138 patients were included in this study. Patients were stratified into two cohorts: those with COVID‐19 and non‐COVID‐19 ARDS. Results The survival in patients with COVID‐19 was statistically similar to non‐COVID‐19 patients ( p = .16). However, the COVID‐19 group demonstrated higher rates of bleeding ( p = .03) and thrombotic complications ( p < .001). The duration of V‐V ECMO support was longer in COVID‐19 patients compared to non‐COVID‐19 patients (29.0 ± 27.5 vs 15.9 ± 19.6 days, p < .01). Most notably, in contrast to the non‐COVID‐19 group, we found that COVID‐19 patients who had been on a ventilator for longer than 7 days prior to ECMO had 100% mortality without a lung transplant. Conclusions These findings suggest that COVID‐19‐associated ARDS was not associated with a higher post‐ECMO mortality than non‐COVID‐19‐associated ARDS patients, despite longer duration of extracorporeal support. Early initiation of V‐V ECMO is important for improved ECMO outcomes in COVID‐19 ARDS patients. Since late initiation of ECMO was associated with extremely high mortality related to lack of pulmonary recovery, it should be used judiciously or as a bridge to lung transplantation.

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