Thrombosis and coagulopathy in COVID-19 patients requiring extracorporeal membrane oxygenation

The coronavirus disease 2019 (COVID-19) pandemic has challenged intensivists caring for patients with severe respiratory disease, associated multi-organ dysfunction and high mortality. Extracorporeal membrane oxygenation (ECMO) has been used to manage patients with COVID 19-associated severe respiratory or cardiac failure with mortality in excess of 50%. A significant feature of this disease appears to be an excess of thrombosis and there have been reports of an incidence of more than 30% of intensive care unit (ICU) admissions. The etiology of thrombosis in this setting may be closely linked with the hyper-inflammatory response of the immune system when exposed to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In addition, there is early development of a disseminated intravascular coagulation (DIC)-like picture in a subset of patients, the management of which is made more complicated if providing systemic anticoagulation to prevent thrombosis and maintain the extracorporeal circuit. The purpose of this editorial is to briefly discuss COVID19-associated procoagulant and anticoagulant states in the context of ECMO support.