Anticoagulation Management during Extracorporeal Membrane Oxygenation—A Mini-Review

Abstract

Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.

Pleiotropic Effects of Heparin and its Monitoring in the Clinical Practice

“…10,43,44 However, UFH is the preferred anticoagulant of choice for patients undergoing cardiac surgery, patients supported by ECMO, and critically unwell patients in the intensive care units requiring anticoagulation due to shorter half-life, independence from renal function, and reversibility by protamine sulfate. 10,45,46 Several large studies demonstrated that there were no significant differences in the safety and efficacy of LMWH compared to UFH in treatment of venous thromboembolism. 47,48 Two meta-analyses reported that LMWHs are safer and more effective than UFH.…”

“…10 43 44 However, UFH is the preferred anticoagulant of choice for patients undergoing cardiac surgery, patients supported by ECMO, and critically unwell patients in the intensive care units requiring anticoagulation due to shorter half-life, independence from renal function, and reversibility by protamine sulfate. 10 45 46…”

Update on Anticoagulation Strategies in Patients with ECMO—A Narrative Review

“…According to the current literature, several pharmacological agents can be used as anticoagulants in patients with ECMO. These are: unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), fondaparinux, and direct thrombin inhibitors [ 11 , 12 ]. Nevertheless, more than choosing the right agent, another challenge is finding and deciding on the appropriate target and the most suitable testing method.…”