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Extracorporeal membrane oxygenation (ECMO) is an established part of the treatment algorithm for coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome. An intense inflammatory response may cause an imbalance in the coagulation cascade making both thrombosis and bleeding common and notable features of the clinical management of these patients. Large observational and retrospective studies provide a better understanding of the pathophysiology and management of bleeding and thrombosis in COVID-19 patients requiring ECMO. Clinically significant bleeding, including intracerebral hemorrhage, is an independent predictor of mortality, and thrombosis (particularly pulmonary embolism) is associated with mortality, especially if occurring with right ventricular dysfunction. The incidence of heparin-induced thrombocytopenia is higher than the general patient cohort with acute respiratory distress syndrome or other indications for ECMO. The use of laboratory parameters to predict bleeding or thrombosis has a limited role. In this review, the authors discuss the complex pathophysiology of bleeding and thrombosis observed in patients with COVID-19 during ECMO support, and their effects on outcomes., Competing Interests: Declaration of Competing Interest None., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Keywords: COVID-19; decision making; extracorporeal membrane oxygenation; ventilation EN COVID-19 decision making extracorporeal membrane oxygenation ventilation 997 1001 5 07/17/20 20200801 NES 200801 On 11 March 2020, the World Health Organization (WHO) declared novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a worldwide pandemic. Insights from a trial investigating the use of ECMO for ARDS suggested that patients who were hypercapnic despite maximising lung-protective ventilation were the group of patients with the greatest mortality benefit. However, in-house ECMO cannulation is resource intensive, and delaying the decision until the patient is within the centre itself enables ECMO clinicians to better assess and personalise potentially life-saving interventions short of ECMO. [Extracted from the article]