Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review

Abstract

The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.

ROTEM and Bivalirudin: The Confounding Challenges Ahead

“…However, due to the short half-life time, the major disadvantages may have less importance. [9] e use of viscoelastic hemostatic assays is recommended for the guidance of coagulation factors and blood product substitution in patients with hemorrhagic diathesis, usually once a day in the case of ECMO patients. [10,11] Recent observations showed that the hypercoagulable state, as assessed by viscoelastic methods, may predict the risk of thrombotic adverse events.…”

ECMO in Cardiogenic Shock: Time Course of Blood Biomarkers and Associated Mortality

“…Even if these two extracorporeal modalities are closely related and share several similarities, there are important distinctions that should be considered (e.g., duration of support, anticoagulation approach, use of protamine sulphate, temperature management, hemodilution, acute critical illness, potential multiple-organ dysfunction syndrome, etc. ), which may further lead to different inflammatory responses [ 14 , 26 ].…”

“…Multiple studies tried to identify predictors and risk factors for adverse events and mortality during ECMO support; however, inconsistent results indicate a need for further research [ 2 , 3 , 4 , 5 , 6 , 7 ]. It is well-established that hemorrhage has a strong impact on mortality [ 8 , 9 ], but studies failed to identify unique risk factors for bleeding [ 10 , 11 , 12 , 13 , 14 , 15 ]. Recent studies showed that patients with thrombosis had lower mortality, questioning therapeutic anticoagulation during ECMO support [ 12 ].…”

Blood-pH Optical Measurement: A Model to Compensate for the Effects of Temperature

“…Blood tests employed 2 L of bovine blood with the addition of citrate-phosphate-dextrose solution with adenine (CPD-A), an anticoagulant that is often used also in clinical ECC procedures [33].…”