Coagulation Management in Patients Requiring Extracorporeal Membrane Oxygenation Support: a Comprehensive Narrative Review

Background and Objective: Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy to support respiratory or cardiorespiratory function in critically ill patients when conventional treatments fail. The exposure of the patient's blood components to the foreign surface of the ECMO extracorporeal circuit activates the inflammatory and coagulation cascades. Systemic anticoagulation is generally required to prevent thrombotic complications, assuming an increased risk of patient bleeding. Despite the increased biocompatibility of novel ECMO devices, the variety of anticoagulation drugs, and the different anticoagulation monitoring tools, there is no gold -standard hemostasis management in patients with extracorporeal life support (ECLS). We aimed to describe the underlying physiology as a rationale for the need for anticoagulation in ECMO. To describe the different alternatives for anticoagulation management, bleeding prevention, and the specific management of anticoagulation in different subgroups of patients, including coronavirus disease 2019 (COVID-19) patients. Methods: We conducted a comprehensive literature search in the main databases, including Cochrane Database, PubMed, Google Scholar, CINAHL, and Scopus databases, with no start date until December 1 st , 2023. We reviewed articles written in English and Spanish. Key Content and Findings: Evolving evidence has been changing the current practices on anticoagulation in ECMO, and novel alternatives are available to decrease the bleeding risk in high -risk patients and for the management of bleeding complications. Conclusions: Anticoagulation practices in ECMO are ubiquitous though variable among different geographic areas. However, as clinical experience in ECMO patients increases, best practices can be reproduced among different settings to improve patient management and patient outcomes. Some challenges remain regarding the best anticoagulation strategy in specific groups of patients.