Original Article
Extracorporeal Membrane Oxygenation—Hemostatic Complications

https://doi.org/10.1016/j.tmrv.2014.12.001Get rights and content

Abstract

The use of extracorporeal membrane oxygenation (ECMO) support for cardiac and respiratory failure has increased in recent years. Improvements in ECMO oxygenator and pump technologies have aided this increase in utilization. Additionally, reports of successful outcomes in supporting patients with respiratory failure during the 2009 H1N1 pandemic and reports of ECMO during cardiopulmonary resuscitation have led to increased uptake of ECMO. Patients requiring ECMO are a heterogenous group of critically ill patients with cardiac and respiratory failure. Bleeding and thrombotic complications remain a leading cause of morbidity and mortality in patients on ECMO. In this review, we describe the mechanisms and management of hemostatic, thrombotic and hemolytic complications during ECMO support.

Section snippets

Mode of ECMO Support

The mode of ECMO is defined by the location of the access and return cannulae. ECMO involves accessing deoxygenated venous blood from the systemic circulation, pressurizing it using a pump, passing it through a membrane oxygenator and then returning it to either the venous side of the circulation (the right atrium) in venovenous ECMO (VV ECMO or respiratory ECMO), or to the arterial circulation (typically the aorta) in venoarterial ECMO (VA ECMO or cardiac ECMO). Pumpless arteriovenous

Thrombosis

Thrombosis is one of the most common and feared complications of ECMO support [19], [17], [25]. The true incidence of thromboembolic complications of ECMO is unknown, and autopsy studies would suggest that clinical evaluation underestimates its occurrence [18].

In the most recent annual ELSO report, clots were reported to occur in the oxygenator in nearly 13% of patients. Additional clots in other parts of the circuit were more common in patients on ECMO for cardiac support than those on for

Strategies for Anticoagulation

The aim of pharmacologic anticoagulation is to counterbalance the effects of exposure to the nonendothelial surface of the ECMO circuit. Ideally, this would inhibit activation of platelets, coagulation, and inflammatory pathways without increasing the risk of bleeding. Critically ill patients requiring ECMO may have additional indications for anticoagulation in the context of their underlying disease that must also be considered. Unfortunately, the ideal pharmacologic anticoagulant agent

Surgery in Patients on ECMO Support

Patients receiving ECMO frequently require surgery, for example, cardiac or thoracic surgery, associated with a high risk of bleeding. Many surgeons can be naturally reticent about operating on a group of patients with such a high risk of bleeding [116]. However, with modern tip-to-tip heparin-bonded circuits, it is possible to run ECMO without any anticoagulation for prolonged lengths of time, and excessive bleeding even in the setting of surgery or massive trauma does not have to be a given

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    Conflict of interest statement: None.

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