Anticoagulation for Extracorporeal Life Support: Direct Thrombin Inhibitors and Heparin

Since its introduction to bedside clinical practice over 40 years ago, extracorporeal life support (ECLS) has been continually changing and improving as a life-saving technology. Extracorporeal life support disrupts the normal finely maintained balance of coagulation and fibrinolysis by exposing large amounts of blood to nonendothelial surfaces. This leads to an inflammatory response with activation of the coagulation cascade and the need for systemic anticoagulation. Unfractionated heparin (UNFH) is currently the standard anticoagulant in ECLS. Alternative anticoagulants have been recently developed with improved safety profiles and reliable monitoring. Within this group of agents are the direct thrombin inhibitors (DTIs) bivalirudin and argatroban. The purpose of this article is to compare these DTIs to the current standard of UNFH anticoagulation during ECLS, to evaluate the current literature surrounding the use of these drugs in ECLS, and finally to propose therapeutic guidelines for their use in ECLS.