Bleeding, Transfusion, and Mortality on Extracorporeal Life Support: ECLS Working Group on Thrombosis and Hemostasis

Abstract

Bleeding and red blood cell transfusion occur frequently during adult extracorporeal life support, but only the amount of red blood cell transfusion is associated with inhospital mortality after controlling for confounding variables.

Hemostasis Management during Adult Extracorporeal Membrane Oxygenation: A Shot in the Dark?

“…3 We previously reported that up to 56% of patients experience at least one significant bleeding event during ECMO and the rate of serious bleeding events is approximately 10 per 100 ECMO days. 4 Our data also suggest that bleeding events and the amount of transfusion on ECMO are associated with decreased survival.Why do ECMO patients bleed and what hemostatic therapies are most effective for treatment? Unfortunately, there are limited data to help answer these questions.…”

“…Our own work showed that over-anticoagulation with unfractionated heparin contributes to bleeding complications during ECMO, as patients with bleeding were more often above their target activated Partial Thromboplastin Time (aPTT). 4 Data from one small observational study suggest that low dose unfractionated heparin with a target Activated Clotting Time ACT of 180-220 seconds is associated with significantly less bleeding than high dose heparin with a target ACT of 180-220 seconds. 5 In this study low dose heparin was not associated with a higher rate of thrombosis or oxygenator changes.…”

Veno-Arterial Extracorporeal Membrane Oxygenation with Conventional Anticoagulation Can Be a Best Solution for Shock Due to Massive PE

“…14) Therefore, thrombolytic therapy should be the first line therapy for patients without any bleeding risk. However, since serious bleeding events are frequently observed in patients with V-A ECMO, 15) additional bleeding caused by thrombolytic therapy can be fatal in patients with a massive PE. Although clinical guidelines recommended percutaneous catheter-directed treatment as an alternative to surgical pulmonary embolectomy for patients whom full dose systemic thrombolysis was contraindicated, 16) we did not perform catheter-directed therapy, because there was the potential risk of severe complications such as periprocedural hemodynamic deterioration, distal embolization, pulmonary artery perforation, lung hemorrhage, and pericardial tamponade.…”

ECMO as a bridge to non-transplant cardiac surgery

“…Serious bleeding complications occur in 40‐68% of patients on VA ECMO support . Bleeding may be surgical from the cannulation site in the groin or subclavian artery, from the sternotomy, or from other surgical sites, for example, inserted chest tubes.…”

“…Bleeding may be surgical from the cannulation site in the groin or subclavian artery, from the sternotomy, or from other surgical sites, for example, inserted chest tubes. Bleeding complications from non‐surgical sites including gastrointestinal tract and central nervous system are not uncommon and often devastating . As patients on VA ECMO are often treated with sedatives, evaluation of the neurological status can be challenging.…”