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Thromb Haemost 2022; 122(04): 480-491
DOI: 10.1055/a-1508-8230
Review Article

Optimal Tests to Minimise Bleeding and Ischaemic Complications in Patients on Extracorporeal Membrane Oxygenation

Rahim Kanji   *
1   Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
,
Christophe Vandenbriele   *
2   Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
3   Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
,
Deepa R. J. Arachchillage
4   Haematology Department, Royal Brompton Hospital, London, United Kingdom
5   Centre for Haematology, Imperial College Healthcare NHS Trust & Imperial College, London, United Kingdom
,
Susanna Price   **
1   Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
3   Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
,
Diana Adrienne Gorog    **
1   Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
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Abstract

Patients supported with extracorporeal membrane oxygenation (ECMO) experience a very high frequency of bleeding and ischaemic complications, including stroke and systemic embolism. These patients require systemic anticoagulation, mainly with unfractionated heparin (UFH) to prevent clotting of the circuit and reduce the risk of arterial or venous thrombosis. Monitoring of UFH can be very challenging. While most centres routinely monitor the activated clotting time and activated partial thromboplastin time (aPTT) to assess UFH, measurement of anti-factor Xa (anti-Xa) level best correlates with heparin dose, and appears to be predictive of circuit thrombosis, although aPTT may be a better predictor of bleeding. Although monitoring of prothrombin time, platelet count and fibrinogen is routinely undertaken to assess haemostasis, there is no clear guidance available regarding the optimal test.

Additional tests, including antithrombin level and thromboelastography, can be used for risk stratification of patients to try and predict the risks of thrombosis and bleeding. Each has their specific role, strengths and limitations. Increased thrombin generation may have a role in predicting thrombosis. Acquired von Willebrand syndrome is frequent with ECMO, contributing to bleeding risk and can be detected by assessing the von Willebrand factor activity-to-antigen ratio, while the platelet function analyser can be used in urgent situations to detect this, with a high negative predictive value. Tests of platelet aggregation can aid in the prediction of bleeding.

To personalise management, a selection of complementary tests to collectively assess heparin-effect, coagulation, platelet function and platelet aggregation is proposed, to optimise clinical outcomes in these high-risk patients.

Keywords

mechanical circulatory support - thrombosis - bleeding - heparin - anticoagulation

** Joint senior authors.


Author Contributions

D.A.G. and S.P. are responsible for the paper conception and design. C.V. and R.K. performed the literature search and data analysis and prepared the first draft. D.R.J.A. provided the haemostasis management algorithm. D.A.G., C.V., D.R.J.A. and S.P. all critically reviewed and revised the manuscript. All authors have approved the final version of the manuscript.




Publication History

Received: 29 January 2021

Accepted: 12 May 2021

Accepted Manuscript online:
13 May 2021

Article published online:
21 June 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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