Hemostatic Management in Extracorporeal Membrane Oxygenation

Abstract

The use of extracorporeal membrane oxygenation (ECMO) for acute cardiac and/or respiratory failure has grown exponentially in the past several decades. Systemic anticoagulation is a fundamental element of caring for ECMO patients. Hemostatic management during ECMO walks a fine line to balance the risk of safe and effective anticoagulant delivery to mitigate thromboembolic complications and minimizing hemorrhagic sequelae. This review discusses the pharmacology, monitoring parameters, and special considerations for anticoagulation in patients requiring ECMO.

Extracorporeal Membrane Oxygenation in Acute Respiratory Failure

“…Despite advances in material and circuit design, including biocompatible surface coatings and improved flow metrics, thromboembolic and hemorrhagic complications still complicate 10–30% of ECMO runs [ 55 ]. The ECMO circuit serves as a classic model of contact-phase activation whereby prolonged contact between the blood with the non-endothelial surfaces of the artificial components activates primary and secondary hemostatic cascades cumulating in the genesis of fibrin deposition and clot deposition [ 56 ]. Consequently, the prolonged maintenance of an ECMO circuit typically necessitates systemic anticoagulants to prevent thrombus formation.…”

“…Considerable controversy remains with regard to optimal anticoagulant intensity, titration strategy (e.g., frequency of laboratory assessment and assay utilized), antithrombin replacement in patients receiving unfractionated heparin [ 65 , 66 ], and the biocompatible surface coating employed advances in durable biocompatible coatings (covalently or ionically bonded heparinoids, phosphorylcholine, poly acrylates) [ 67 ] have facilitated surface coating of most components, including polymethylpentene membrane oxygenators, and allow patients to be maintained on low, or even absent, levels of anticoagulation for prolonged periods with acceptably low rats of complication [ 68 ]. Bleeding complications for ECMO patients are frequent and include cannulation and/or surgical site bleeding, gastrointestinal hemorrhage, cardiac tamponade, pulmonary hemorrhage, and central nervous system bleeds (Table 1 ) [ 56 , 69 ].…”

Plasma Transfusion and Procoagulant Product Administration in Extracorporeal Membrane Oxygenation: A Secondary Analysis of an International Observational Study on Current Practices

“…Of the 205 VV-ECMO patients, 40% of the patients (n = 81) received one or more plasma transfusions (Table 1) during their ECMO runs. Patients received 5 (3)(4)(5)(6)(7)(8) plasma units in total, equivalent to 17 mL/kg of bodyweight. They received 3 units (2-4) per administered day (equivalent to 9 [6][7][8][9][10][11][12][13][14][15][16][17] mL/kg bodyweight).…”

Heparin Versus Bivalirudin for Anticoagulation in Adult Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

“…3,4 Historically, unfractionated heparin has been the predominant anticoagulant used during ECMO because of its widespread availability, low cost, intensivist familiarity, and extensive clinical experience in the setting of cardiopulmonary bypass. 5 Heparin, however, depends on a sufficient supply of antithrombin to exert a pharmacologic effect, has the potential for immunogenic sequestration of platelets with paradoxical thrombosis generation (i.e., heparin-induced thrombocytopenia [HIT]), and interacts with multiple plasma proteins leading to potentially inconsistent dosing reliability. 6 Because of these limitations, bivalirudin, a direct thrombin inhibitor, has been increasingly used for anticoagulation during ECMO due to its rapid onset of action, short halflife, pharmacologic effect independent of a cofactor, low incidence of thrombocytopenia, and reversible thrombin binding that may theoretically result in fewer hemorrhagic sequelae.…”

“…Historically, unfractionated heparin has been the predominant anticoagulant used during ECMO because of its widespread availability, low cost, intensivist familiarity, and extensive clinical experience in the setting of cardiopulmonary bypass. 5 Heparin, however, depends on a sufficient supply of antithrombin to exert a pharmacologic effect, has the potential for immunogenic sequestration of platelets with paradoxical thrombosis generation ( i.e. , heparin-induced thrombocytopenia [HIT]), and interacts with multiple plasma proteins leading to potentially inconsistent dosing reliability.…”