Email updates

Keep up to date with the latest news and content from Critical Care and BioMed Central.

Highly Accessed Open Badges Letter

Algorithm-based management of bleeding in patients with extracorporeal membrane oxygenation

David Faraoni1* and Jerrold H Levy2

Author Affiliations

1 Department of Anesthesiology, Queen Fabiola Children's University Hospital, 15 Avenue JJ Crocq, B-1020 Brussels, Belgium

2 Department of Anesthesiology and Intensive Care, Duke University School of Medicine, DUMC 3094, Durham, NC 27710, USA

For all author emails, please log on.

Critical Care 2013, 17:432  doi:10.1186/cc12682

See related research by Repressé et al.,

The electronic version of this article is the complete one and can be found online at:

Published:8 May 2013

© 2013 BioMed Central Ltd


We read with interest the paper published by Repressé and colleagues [1]. Coagulation management is a challenge during extracorporeal membrane oxygenation (ECMO) due to complex hemostatic and inflammatory responses associated with the underlying conditions that include infection, sepsis, surgery, and/or traumatic injury [2]. Repressé and colleagues present the first algorithm-based approach to bleeding in ECMO patients. However, additional perspectives are important to consider.

First, activated partial thromboplastin time or antiactivated factor × monitoring are routinely used to monitor heparin therapy in ECMO patients, despite intraindividual and inter-individual variability [3]. Rotational thromboelastometry (ROTEM®; TEM® International GmbH, Munich, Germany) is also increasingly used in the ICU to rapidly assess the coagulation status, including clotting factors, fibrinogen levels, and whole blood clotting [4]. Moreover, this test also facilitates fibrinolytic pathway evaluation, which cannot be easily explored by routine laboratory tests. We believe ROTEM® could be used to design an algorithm-based approach to bleeding in ECMO patients and follow fibrinogen consumption associated with hyperfibrinolysis, an important cause of bleeding. For this reason, anti-fibrinolytic agents should be considered in the multimodal approach (Figure 1), an important point the authors omitted in their algorithm.

thumbnailFigure 1. Hyperfibrinolysis diagnosed in a bleeding extracorporeal membrane oxygenation patient. (a) Baseline EXTEM, (b) baseline FIBTEM, (c) EXTEM and (d) FIBTEM thromboelastometry tests after the administration of tranexamic acid (TXA; 10 mg/kg) and fibrinogen concentrates (2 g).

Second, adverse events including 32% venous thrombosis and a 2.5% incidence of fatal pulmonary embolism have already been reported in ECMO patients [5]. In another series, Combes and colleagues reported a 10% incidence of femoral vein and 7% incidence vena cava thrombosis [6]. Recombinant activated factor VII is associated with thromboembolic events [7] and should be used with caution until additional data help us evaluate the benefit-to-risk administration in bleeding ECMO patients.


ECMO: extracorporeal membrane oxygenation; ROTEM: rotational thromboelastometry.

Competing interests

The authors declare that they have no competing interests.


  1. Repressé X, Au SM, Brechot N, Trouillet J, Leprince P, Chastre J, Combes A, Luyt CE: Recombinant factor VIIa for uncontrollable bleeding in patients with extracorporeal membrane oxygenation: report on 15 cases and literature review.

    Crit Care 2013, 17:R55. PubMed Abstract | BioMed Central Full Text OpenURL

  2. Peek GJ, Firmin RK: The inflammatory and coagulative response to prolonged extracorporeal membrane oxygenation.

    ASAIO J 1999, 45:250-263. PubMed Abstract | Publisher Full Text OpenURL

  3. Dempfle CE, Elmas E, Link A, Suvajac N, Liebe V, Janes J, Borggrefe M: Endogenous plasma activated protein C levels and the effect of enoxaparin and drotrecogin alfa (activated) on markers of coagulation activation and fibrinolysis in pulmonary embolism.

    Crit Care 2011, 15:R23. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  4. Bischof D: Thrombelastography in the surgical patient.

    Minerva Anestesiol 2010, 76:131-137. PubMed Abstract | Publisher Full Text OpenURL

  5. Rastan AJ, Lachmann N, Walther T, Doll N, Gradistanac T, Gommert JF, Lehmann S, Wittekind C, Mohr FW: Autopsy findings in patients on postcardiotomy extracorporeal membrane oxygenation (ECMO).

    Int J Artif Organs 2006, 29:1121-1131. PubMed Abstract OpenURL

  6. Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL, Leger P, Pavie A, Chastre J: Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock.

    Crit Care Med 2008, 36:1404-1411. PubMed Abstract | Publisher Full Text OpenURL

  7. Levy JH, Faraoni D, Sniecinski RM: Perioperative coagulation management in the intensive care unit.

    Curr Opin Anaesthesiol 2013, 26:65-70. PubMed Abstract | Publisher Full Text OpenURL