Coagulopathy and anticoagulation management in adult ECPR patients

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a lifesaving strategy for refractory cardiac arrest, restoring systemic perfusion when conventional cardiopulmonary resuscitation fails. However, ECPR profoundly disrupts haemostasis, driven by the combined effects of whole-body ischaemia-reperfusion injury, systemic inflammation, endothelial activation, platelet dysfunction, and blood contact with extracorporeal surfaces. Together, these processes create a highly dynamic and unstable thromboinflammatory milieu, marked by the simultaneous risk of thrombosis and life-threatening bleeding. Systemic anticoagulation is required to maintain circuit patency and prevent thromboembolic complications, yet optimal strategies remain uncertain. Haemostasis during ECPR is highly dynamic, shaped by the underlying aetiology of cardiac arrest, patient-specific characteristics, and circuit-related factors. This complexity underscores the limitations of fixed anticoagulation targets and the need for individualized, context-sensitive management guided by continuous clinical and laboratory assessment. Despite the increasing global adoption of ECPR, high-quality evidence to guide anticoagulation practices remains scarce. Current strategies are largely extrapolated from other extracorporeal life support populations, contributing to substantial inter-centre variability. This review synthesizes the available evidence on coagulopathy and anticoagulation in adult patients receiving ECPR and discusses emerging approaches to monitoring and anticoagulation management.