Hemostasis in neonatal ECMO
Research article published in Frontiers in pediatrics (2022)
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Peer-reviewed clinical and outcomes research relevant to medicinal leech therapy and its biology. Indexed in PubMed and verified against the NCBI record.
Why This Matters for Hirudotherapy
This review describes how contact activation of blood by the non-endothelial ECMO surface drives a systemic inflammatory and procoagulant state, making coagulation problems a leading source of morbidity and mortality in neonatal ECMO, and notes that unfractionated heparin remains the worldwide standard while direct thrombin inhibitors have more recently been introduced and no ideal monitoring algorithm yet exists. Its relevance to hirudotherapy lies in the drug-discovery story: the medicinal-leech secretome is the natural source of hirudin, the prototype direct thrombin inhibitor whose synthetic descendants are the class the authors cite as newer alternatives to heparin in this hard-to-anticoagulate setting. As a narrative review focused on neonatal ECMO monitoring, it summarizes others' work and current uncertainty rather than presenting new comparative data, and it does not evaluate leech therapy or any specific leech-derived agent in this population.
Citation
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