Abstract
The balance between systemic anticoagulation and clotting is challenging. In normal hemostasis, the endothelium regulates the balance between anticoagulant and prothrombotic systems. It becomes particularly more challenging to maintain this physiologic hemostasis when we are faced with extracorporeal life support therapies, where blood is continuously in contact with a foreign extracorporeal circuit surface predisposing a prothrombotic state. The blood-surface interaction during extracorporeal life support therapies requires the use of systemic anticoagulation to decrease the risk of clotting. Unfractionated heparin is the most common anticoagulant agent widely used in this setting. New trends include the use of direct thrombin inhibitor agents for systemic anticoagulation; and surface modifications that aim to overcome the blood-biomaterial surface interaction by modifying the hydrophilicity or hydrophobicity of the polymer surface; and coating the circuit with substances that will mimic the endothelium or anti-thrombotic agents. To improve hemocompatibility in an extracorporeal circuit, replication of the anti-thrombotic and anti-inflammatory properties of the endothelium is ideal. Surface modifications can be classified into three major groups: biomimetic surfaces (heparin, nitric oxide, and direct thrombin inhibitors); biopassive surfaces [phosphorylcholine, albumin, and poly- 2-methoxyethylacrylate]; and endothelialization of blood contacting surface. The focus of this paper will be to review both present and future novel surface modifications that can obviate the need for systemic anticoagulation during extracorporeal life support therapies.
Highlights
The balance between systemic anticoagulation and clotting is challenging
It is becoming very clear that algorithms and new anticoagulants may make a difference in the bleeding and thrombotic complications associated with extracorporeal life support (ECLS), they do not work the same for each patient and as a result the anticoagulation management for each patient must be customized to them using all that is presently available in terms of monitoring, anticoagulants and surface modifications
This review details the present and future work needed to develop an extracorporeal circuit that can function as the endothelium so that systemic anticoagulation can be obviated
Summary
Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada Reviewed by: Miguel Angel Cruz, Baylor College of Medicine, United States Wei Li, Marshall University, United States Specialty section: This article was submitted to Hematology, a section of the journal
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