Anticoagulation in pediatric ECMO patients: a review of the literature

Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura

The use of ECMO has spread rapidly in the pediatric population and has led to high survival rates in severe and refractory diseases. Its objective is respiratory and/or cardiac support until resolution of the ongoing disease. However, despite advances, there is still a significant morbidity and mortality burden due to the presence of hemostatic complications. This coagulation imbalance is a complex process involving factors related to the new blood-biomaterial interface that generates changes in the coagulation cascade, proteins, and cells, as well as factors related to age and the critical pathologies of these patients. Anticoagulation is an essential part of management and it becomes a challenge to balance the risk of thrombosis and bleeding. Unfractionated heparin has been the most widely used anticoagulant, however, its dosage varies widely and is adjusted to achieve clinical effect and objective ranges in monitoring trials without a single recommendation for the pediatric population in ECMO and even with a significant frequency of hemostatic complications. The use of direct thrombin inhibitors considered good candidates because they have a better safety profile, however, there aren’t prospective studies that allow standardizing recommendations for their use. The choice of anticoagulant and monitoring tests are varied and depend on the experience of use and its availability. This article aims to review the available evidence regarding the use of anticoagulation for ECMO in the pediatric population.