Point-of-care coagulation management algorithms during ECMO support: are we there yet?

Haemorrhagic and thromboembolic events are common and the main cause for morbidity and mortality in patients treated with extracorporeal membrane oxygenation (ECMO). Monitoring of an adequate anticoagulation is, therefore, essential in patients during ECMO therapy. This review aims to describe the current evidence and emerging data relating to anticoagulation therapy and point-of-care (POC) coagulation monitoring in ECMO patients. Central laboratory-based coagulation testing including activated partial thromboplastin time (aPTT), international normalized ratio (INR) of the prothrombin time (PT), and activated clotting time (ACT) is most commonly used for coagulation monitoring. Several lines of coagulation monitoring devices have been explored for POC assessment of anticoagulation and/or haemostasis during ECMO. POC-type ACT, aPTT and PT have a shorter turn-around time, but they might exhibit a relevant bias in agreement with laboratory-based coagulation tests, and sensitivity and specificity for intervention are variable compared with laboratory- based tests. Whole-blood viscoelastic coagulation tests including ROTEM® and TEG® and platelet function testing have been increasingly used for monitoring haemostasis in ECMO patients. However, no single laboratory-based or POC coagulation test can reliably predict the emergence of haemorrhagic or thrombotic events. Further, treatment algorithms based on POC testing are scarce for ECMO patients. Larger prospective studies are necessary to evaluate the usefulness of POC coagulation monitors or a combination of them in potentially improving anticoagulation and decreasing haemorrhagic and thromboembolic complications.