Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
Semin Thromb Hemost. 2018 Feb;44(1):20-29. doi: 10.1055/s-0037-1606179. Epub 2017 Sep 12.
Extracorporeal membrane oxygenation (ECMO) has been used for >40 years to support lung and heart failure; however, bleeding and thrombosis remain serious complications. The known etiologies of bleeding include heparin effect or overdose, coagulopathy, thrombocytopenia, platelet dysfunction, acquired von Willebrand syndrome, and hyperfibrinolysis. Bleeding sites may include cannula insertion sites, recent surgical incisions, vascular access sites, lung, gastrointestinal tract, mouth, nose, thoracic cavity, abdominal cavity, and brain. Massive bleeding in the brain, the most feared bleeding complication, can be rapidly fatal because it occurs in a rigid closed space, is difficult to drain, and cannot be stopped with direct pressure to the bleeding site. Pulmonary hemorrhage may cause irreversible lung damage. Management should be swift and precise to prevent fatal bleeding. In contrast, etiologies of thrombosis include high fibrinogen and factor VIII levels, heparin resistance, and platelet activation. Achieving the optimal anticoagulation balance to prevent bleeding and thrombosis in ECMO patients is extremely complex. Experts in hemostasis should be a part of an institutional ECMO team and continuously available for immediate management.
体外膜肺氧合（ECMO）已经使用了 40 多年来支持肺和心脏衰竭；然而，出血和血栓仍然是严重的并发症。已知的出血原因包括肝素作用或过量、凝血功能障碍、血小板减少症、血小板功能障碍、获得性血管性血友病综合征和纤维蛋白溶解亢进。出血部位可能包括插管插入部位、最近的手术切口、血管通路部位、肺、胃肠道、口腔、鼻子、胸腔、腹腔和大脑。大脑的大量出血是最可怕的出血并发症，因为它发生在一个刚性的封闭空间，难以引流，不能通过直接按压出血部位来止血，因此可能会迅速致命。肺出血可能导致不可逆转的肺损伤。管理应该迅速而精确，以防止致命性出血。相比之下，血栓形成的原因包括纤维蛋白原和因子 VIII 水平升高、肝素抵抗和血小板激活。在 ECMO 患者中实现预防出血和血栓形成的最佳抗凝平衡极其复杂。止血专家应成为机构 ECMO 团队的一部分，并随时可供立即管理。
