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Review
. 2021 Apr;37(Suppl 2):241-247.
doi: 10.1007/s12055-021-01176-3. Epub 2021 Mar 23.

Anticoagulation in ECMO patients: an overview

Gaurav Kumar  1 , Ashish Maskey  2
Affiliations
Review

Anticoagulation in ECMO patients: an overview

Gaurav Kumar et al. Indian J Thorac Cardiovasc Surg. 2021 Apr.

Abstract

Extracorporeal membrane oxygenation (ECMO) is a form of cardiorespiratory support, and is being increasingly used to support refractory heart and respiratory failure. It involves draining blood from the vascular system, which is then circulated outside the body by a mechanical pump and then later reinfused back into the circulation. The blood that is circulated outside the body comes in contact with a large surface area of non-endothelial biosurface. This exposure leads to a pro-thrombotic state, and hence anticoagulation is required. Unfractionated heparin is the most commonly used anticoagulation in most ECMO centers, but it does require close monitoring. Despite the advances made, hemostasis remains a challenge for physicians who manage patients on ECMO.

Keywords: Anticoagulation; Extracorporeal life support; Extracorporeal membrane oxygenation.

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Conflict of interest statement

Conflict of interestThe authors declare no competing interests.

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Editorial Comments: Anti-coagulation on ECMO is a challenging subject as no ideal anti-coagulant without side-effects is available. However, for the practical management of patients on ECMO, ELSO has recommended to keep Heparin infusion usually between 20 to 40 international units/kg/hour as continuous infusion keeping ACT ( Activated Clotting Time) between 180-200 seconds. Most units give Heparin 75 units/kg as stat dose at the time of cannulation and follow it up with continuous infusion once the ACT levels start falling to 300 seconds. ACT was chosen as it is available as a point of care test that can be done bedside. It has been our practice to aim for ACTs 160-180 while on veno venous ECMO and 180- 200 while on VA ECMO. In exceptional situations, the infusion rate of Heparin can fluctuate. Examples include states of Disseminated intra-vascular coagulation, pre-surgery and post-surgery, possible deficiency of Anti thrombin 3, Heparin induced thrombocytopenia etc. Additional investigations like Factor Xa levels, thrombo-elastogram will be needed if the requirement of Heparin is disproportionate to the measured levels of ACT. As the half life of Heparin tends to last for 6 hours, Heparin infusion should be stopped for atleast 6 hours or longer prior to an intended surgical procedure. Heparin infusion can be restarted once there is cessation of active bleeding in post surgical state. As long as the ECMO flows remain high, the risk of clotting can be kept low, even without heparinization for few hours to days. Elevated pre-oxygenator pressures and increasing delta pressure are some of the indications for clot accumulation in the membrane oxygenator. The life of the oxygenator will be decided by keeping all the available evidence, including the fall in post-oxygenator blood gas oxygenation. Usually, Heparin reversal medications are not used while on ECMO. Fresh frozen plasma and Cryo precipitate, platelet transfusions can be used as per the need to stop bleeding. In exceptional circumstances of torrential non-surgical bleeding, Novo seven has been used with the understanding it can result in widespread clotting. The above recommendations are made as best practice guidelines with the understanding that clots/bleeds can't be eliminated completely.Reference:
    1. https://www.elso.org/portals/0/files/elsoanticoagulationguideline8-2014-...

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