ECMO without anticoagulation in patients with disease‐related severe thrombocytopenia: Feasible but futile?

Abstract

Severe thrombocytopenia poses a high risk for bleeding thus representing a relative contraindication for anticoagulation and therefore extracorporeal membrane oxygenation (ECMO). We herein report on a series of immunocompromised patients with severe thrombocytopenia undergoing long‐term ECMO without systemic anticoagulation. We retrospectively identified seven adult patients with anticoagulation withdrawal for ≥3 days (range 5–317) during venovenous ECMO therapy due to thrombocytopenia < 50 G/L treated in a university‐affiliated hospital from January 2013 to April 2017. All ECMO systems used were heparin coated. Overall, 530 ECMO days were observed, 404 (76%) of them without systemic anticoagulation. Platelet count during ECMO treatment was 24 G/L (median, range 1‐138), ECMO duration was 35 days (5‐317), and ECMO was run without any anticoagulation for 20 days (5‐317). Altogether, five clotting events were seen leading to oxygenator exchanges. Bleeding was common including one fatal intracerebral hemorrhage. Altogether, 29 platelet concentrates per patient (7‐207) were administered, which correspond to 0.8 per day (0.6‐1.3). One patient survived ICU and hospital. In patients with thrombocytopenia, ECMO can be run without anticoagulation even for considerably long periods of time. Bleeding remains common, while clotting events seem to be rare. However, prognosis of this patient population undergoing ECMO support seems grim.

Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China

“…Therefore, during ECLS, clinicians should comprehensively evaluate coagulation function, choose an appropriate anticoagulation regimen, and make every effort to control influencing factors of thrombocytopenia. In cases of thrombocytopenia during ECLS, clinicians should actively identify the cause and discontinue anticoagulation therapy if needed [83,206].…”

Arteriovenous access in hemodialysis: A multidisciplinary perspective for future solutions

“…[88][89][90] The effect is enhanced using a ligand such as albumin. 90 The same is valid for heparin-coated ECCs and membrane oxygenators 52,91,92 and PTFE grafts. 93 However, the coating is most effective and beneficial if all the inner surfaces of the device are uniformly coated with heparin.…”

“…93 However, the coating is most effective and beneficial if all the inner surfaces of the device are uniformly coated with heparin. 91,92 Besides limiting the clotting, heparin coating may also reduce the complement activation. 52,91,94 The thorough coating of heparin on PTFE can be realized by coupling heparin to a PTFE surface coated with dopamine.…”

Chinese expert consensus on diagnosis and treatment of coagulation dysfunction in COVID-19

“…If ATIII cannot be monitored and a larger dose of unfractionated heparin is given to achieve anticoagulation effect, ATIII deficiency should be considered and fresh frozen plasma can be given. If significant coagulation dysfunction or active bleeding occurs during ECLS, the anticoagulation therapy can be stopped when necessary [64].…”