Newly Published
Editorial  |   January 2020
Anticoagulation and Antithrombin in Veno-venous Extracorporeal Membrane Oxygenation
Author Notes
  • From the Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada.
  • Accepted for publication December 3, 2019.
    Accepted for publication December 3, 2019.×
  • This editorial accompanies the article on p. XXX.
    This editorial accompanies the article on p. XXX.×
  • Correspondence: Address correspondence to Dr. Massicotte: mm41@ualberta.ca
Article Information
Editorial / Coagulation and Transfusion
Editorial   |   January 2020
Anticoagulation and Antithrombin in Veno-venous Extracorporeal Membrane Oxygenation
Anesthesiology Newly Published on January 8, 2020. doi:https://doi.org/10.1097/ALN.0000000000003098
Anesthesiology Newly Published on January 8, 2020. doi:https://doi.org/10.1097/ALN.0000000000003098
Extracorporeal membrane oxygenation is effective therapy for combined respiratory and cardiac failure (veno-arterial extracorporeal membrane oxygenation) or respiratory failure alone (veno-venous extracorporeal membrane oxygenation) providing days and weeks of support. However, extracorporeal membrane oxygenation is also associated with serious sequelae including mortality (overall survival 55%) and morbidity both highly related to hemostatic abnormalities. Morbidity includes major bleeding (50%), intracranial hemorrhage (6%), and thrombosis (12%),1–3  with ischemic stroke being the most feared (12%).1,3  Thrombosis results from activation of in vivo physiologic pathways (hemostasis, fibrinolysis, platelets, complement, and inflammation)4  as a result of blood interaction with the foreign materials within extracorporeal membrane oxygenation circuit components and shear stress caused by the circuit pump. Cellular damage as reflected by elevated plasma-free hemoglobin, circulating microparticles (platelets, endothelial cells), and biomarkers of activation of coagulation, complement, inflammation, and platelets increases the risk of thrombosis. Often, thrombosis in extracorporeal membrane oxygenation components (circuit, oxygenator, and/or pump) necessitates equipment replacement during ongoing therapy to prevent malfunction and thrombus embolization. However, compounding the challenge is increased bleeding risk due to a number of factors including underlying illnesses, decreased levels of von Willebrand factor due to degradation, and unknown optimal anticoagulation strategies, as reflected by variable dosing and laboratory monitoring. Modulation of hemostasis using anticoagulation therapy is necessary to prevent thrombosis, but must do so without increasing bleeding.