Anticoagulation and hemostasis in the extracorporeal membrane oxygenation patient

PURPOSE OF REVIEW: To provide an updated overview of hemostatic disturbances and anticoagulation management during extracorporeal membrane oxygenation (ECMO), emphasizing the mechanisms underlying the dual risk of bleeding and thrombosis, current therapeutic strategies, and future perspectives. RECENT FINDINGS: Bleeding and thrombotic events remain the most frequent and life-threatening complications of ECMO, occurring in up to 50% of patients. Advances in mechanistic understanding have highlighted the roles of platelet activation and dysfunction, acquired von Willebrand syndrome, fibrinolytic imbalance, and hemolysis-induced endothelial injury. While unfractionated heparin remains the mainstay of anticoagulation, direct thrombin inhibitors such as bivalirudin have emerged as potential alternatives with comparable safety and efficacy. Viscoelastic testing, platelet function assays, and anti-Xa monitoring are increasingly integrated into clinical practice to refine anticoagulation titration. SUMMARY: Hemostatic disturbances during ECMO reflect a complex interplay between patient severity, circuit-related shear stress, and systemic anticoagulation. Understanding these mechanisms is key to preventing both bleeding and thrombosis. Standardization of monitoring and the development of personalized, physiology-based anticoagulation protocols, supported by emerging technologies and more biocompatible circuits, represent the next step toward improving outcomes in ECMO-supported patients.