Feasibility of Venovenous Extracorporeal Membrane Oxygenation Without Systemic Anticoagulation

Abstract

Background-Venovenous extracorporeal membrane oxygenation (ECMO) is increasingly being used for acute respiratory distress syndrome and as a bridge to lung transplantation. After initiation of venovenous ECMO, systemic anticoagulation therapy is traditionally administered and can cause bleeding diathesis. Here, we investigated whether venovenous ECMO can be administered without continuous systemic anticoagulation administration for patients with acute respiratory distress syndrome.Methods-This is a retrospective review of an institutional ECMO database. We included consecutive patients from January 2015 through February 2019. Overall, 38 patients received low levels of continuous systemic anticoagulation (AC + ) whereas the subsequent 36 patients received standard venous thromboprophylaxis (AC −). Published Extracorporeal Life Support Organization guidelines were used for the definition of outcomes and complications.Results-Overall, survival was not different between the two groups (P = .58). However, patients in the AC + group had higher rates of gastrointestinal bleeding (28.9%, vs AC− group 5.6%; P < .001). The events per patient-day of gastrointestinal bleeding was 0.00025 in the AC− group and 0.00064 in the AC+ group (P < .001). In addition, oxygenator dysfunction was increased in the AC + group (28.9% and 0.00067 events per patient-day, vs AC− 11.1% and 0.00062 events per patient-day; P = .02). Furthermore, the AC+ group received more transfusions: packed red blood cells, AC+ group 94.7% vs AC− group 55.5% (P < .001); fresh frozen plasma, AC+ 60.5% vs AC − 16.6% (P = .001); and platelets, AC+ 84.2% vs AC− 27.7% (P < .001). There was no circuit thrombosis in either groups throughout the duration of ECMO support.Conclusions-Our results suggest that venovenous ECMO can be safely administered without continuous systemic anticoagulation therapy. This approach may be associated with reduced bleeding diathesis and need for blood transfusions.

Blood transfusion utilization in hospitalized COVID‐19 patients

“…13 Procedures performed on patients such as ECMO may increase blood transfusion needs, although in our hospital avoidance of systemic anticoagulation during ECMO was recently shown to minimize transfusion needs. 21,22 In this preliminary study, we used COVID-19 ward locations as a rapid means to estimate transfusion rates in a large number of patients. This included some patients who were assigned there briefly for clinical suspicion before their tests were negative.…”

SARS-CoV-2 and ECMO: early results and experience

“…We had two intra-cerebral haemorrhage, both leading to death, and 2 cases of gastrointestinal haemorrhage, of which one required endoscopic intervention. We were able to run the ECMO circuit without anticoagulation for longer than a week without any issue in the patients with gastrointestinal and intra-cerebral haemorrhage; this is a recognised strategy in ECMO patients at high risk of bleeding [17].…”

Bleeding, Thromboembolism, and Clinical Outcomes in Venovenous Extracorporeal Membrane Oxygenation

“…Conducting venovenous ECMO without continuous systemic anticoagulation has been proposed ( 9 , 10 ). Although confounded by indication bias, recent observational studies suggest that strategies using only prophylactic doses of anticoagulation appear safe in venovenous ECMO ( 9 , 10 ).…”

“…Conducting venovenous ECMO without continuous systemic anticoagulation has been proposed ( 9 , 10 ). Although confounded by indication bias, recent observational studies suggest that strategies using only prophylactic doses of anticoagulation appear safe in venovenous ECMO ( 9 , 10 ). Further, a recent systematic review suggested that the rates of thromboembolism and circuit thrombosis among patients who did not receive systemic anticoagulation during venovenous ECMO were comparable with the rates reported among patients treated with systemic anticoagulation ( 11 ).…”