Extracorporeal Membrane Oxygenation in the Adult

Abstract

Extracorporeal membrane oxygenation (ECMO) is a method of life support to maintain cardiopulmonary function. Its use as a medical application has increased since its inception to treat multiple conditions including acute respiratory distress syndrome, myocardial ischemia, cardiomyopathy, and septic shock. While complications including neurological and renal injury occur in patients on ECMO, bleeding and coagulopathy are most common. ECMO is associated with an inflammatory response promoting a hypercoagulable state, requiring anticoagulation to avoid thromboembolism originating in the nonendothelial surfaced circuit. However, excessive anticoagulation may result in bleeding complications including intracerebral hemorrhage. Monitoring anticoagulation for ECMO has its origins in cardiopulmonary bypass for cardiac surgery; however, there is no ideal level of anticoagulation, no standardized method to monitor anticoagulation, nor are all centers standardized on what is used for anticoagulation. Multiple blood products are used in an effort to decrease bleeding in the setting of anticoagulation, often in the setting of recent surgery, and this leads to significant increases in cost for patients on ECMO and transfusion-related complications. In this review article, we discuss the evolution of the various modalities of ECMO, indications, contraindications, and complications. Furthermore, we review the different strategies for anticoagulation and treatment of coagulopathy while on ECMO. Finally, we discuss the cost of ECMO and associated blood product transfusion.

The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology

“…This difference in duration requires a different approach to anticoagulation. During CPB, loading doses of unfractionated heparin between 300 and 500 U/kg may be used [39], versus 40–80 U/kg during ECMO [40]. Upon the completion of CPB, protamine sulphate is administered to reverse the effects of heparin, a practice which is avoided during and at the conclusion of ECMO.…”

Extracorporeal Membrane Oxygenation for Hemodynamic Support of Ventricular Tachycardia Ablation

“…16 After CA, in the ICU, unfractionated heparin or bivalirudin was administered targeting an activated partial thromboplastin time value between 45 and 50 seconds. 16 Coagulation profile was monitored every 6 hours or when deemed necessary.…”

Development of zwitterionic sulfobetaine block copolymer conjugation strategies for reduced platelet deposition in respiratory assist devices

“…Balancing required blood anticoagulation while maintaining adequate levels of hemostatic activity is a major challenge that presents with a wide variety of blood contacting medical devices. This issue is particularly challenging in extracorporeal circuits such as respiratory assist devices, which expose patient blood to large surface areas (∼2 m 2 ) of synthetic material . Blood contact with these artificial surfaces results in activation of the coagulation cascade, and platelet deposition onto the foreign surfaces, leading to reduced device performance and emboli formation .…”