Extracorporeal membrane oxygenation without systemic anticoagulation: a case-series in challenging conditions

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) use in patients with active bleedings or traumatic injuries may be challenging because of the risk of refractory haemorrhage related to systemic anticoagulation (SA). Technological advancements, especially heparin coated circuits, allowed ECMO application with a mild or no anticoagulation regimen in some circumstances. We herein report a limited case-series of ECMO application without anticoagulation.Methods: ECMO without SA was established in 6 patients. Four of them received veno-arterial mode. Full heparin antagonization with protamine was provided in 3 post-cardiotomy cases. Tip-to-tip heparin-coated ECMO circuit was used in 4 patients, whereas heparin-coated tubing and no heparin-coated cannulas were applied for the remaining subjects.Results: Mean duration of support and pump flow were 10±4 hours and 3.0±0.7 litres respectively. No ECMO related complication or oxygenator failure occurred, nor was clotting of the circuit observed at inspection. All patients were weaned from ECMO and half of them survived and were discharged.Conclusions: Short ECMO duration without anticoagulation was feasible and provided effective cardiopulmonary support in patients with active bleeding or high hemorrhagic risk. Further investigations are needed to evaluate its benefits or limitations for a protracted time, in a wider range of clinical conditions and in larger patient populations.

Low vs standardized dose anticoagulation regimens for extracorporeal membrane oxygenation: A meta-analysis

“…In terms of these complications, including surgical site bleeding and pulmonary, intracranial or gastrointestinal hemorrhage, are inextricably linked to a higher risk of mortality and other complications (e.g., infection, transfusion-related complications, and multiple organ failure) [ 25 , 27 , 28 ]. Notably, a growing number of ECMO centers who have had to run patients with low doses or no heparin for a variety of reasons (e.g., recent cardiopulmonary bypass, trauma, and head and other organ injury associated with bleeding) [ 29 – 32 ]. Moreover, ECMO with LA or without heparin has been reported in lung transplantation [ 33 , 34 ].…”

“…However, with the progress of science and technology and the continuous expansion of the scope of application of ECMO, such as some patients with trauma, heparin-induced thrombocytopenia (HIT) and bleeding tendency, the concept of LA has been constantly produced, and at the same time, there was no increase in thrombotic events [ 33 , 36 ]. A series of case reports have reported encouraging results in LA [ 10 – 13 , 30 – 32 ]. Subsequently, Wood KL et al reported that the absence of routine systemic anticoagulation for patients supported by VA ECMO was not associated with pump failure, oxygenator failure or thrombotic complications [ 16 ].…”

Use of venovenous extracorporeal membrane oxygenation for resection of a large paratracheal mass causing critical tracheal stenosis: A case report

“…Preoperative planning includes a discussion with anesthesia and ECMO teams for standby during endotracheal intubation or elective placement of VV‐ECMO for total ventilatory/oxygenation support before safe endotracheal intubation, as presented in this case. Heparin‐coated VV‐ECMO circuits may mitigate the need for systemic heparinization, which can facilitate surgery with minimal blood loss 4 . Indications for VV‐ECMO include acute respiratory distress syndrome (ARDS), lung rest (e.g., pulmonary contusion), lung transplantation or hyperinflation (i.e., status asthmatics) or hemorrhage, and congenital diaphragmatic hernia 1 .…”

Evaluating the evidence for angiotensin II for the treatment of vasoplegia in critically ill cardiothoracic surgery patients

“…36 VA ECMO without anticoagulation has been reported, but the circumstances are often unique and secondary to bleeding concerns. 37 Due to the use of systemic anticoagulation in ECMO support, these patients may be protected against thrombotic complications potentially associated with Ang-2. This question remains unanswered and warrants further investigation.…”