Maintaining blood flow in the extracorporeal circuit: haemostasis and anticoagulation

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Abstract
To review the methods and developments in maintaining extracorporeal circuits in critically ill patients. The review includes details of the pathophysiological processes of haemostasis and coagulation in critically ill patients, methods of maintaining blood flow in the extracorporeal circuit and methods of monitoring anticoagulation agents used. Information is relevant to the management of critically ill patients requiring extracorporeal renal and respiratory support and cardiopulmonary bypass. Heparin is the mainstay of anticoagulation for the extracorporeal circuit although the complex abnormalities of the coagulation system in critically ill patients are associated with a considerable risk of bleeding. Alternative therapeutic agents and physical strategies (prostacyclin, low molecular weight heparin, sodium citrate, regional anticoagulation, heparin bonding and attention to circuit design) may reduce the risk of bleeding but expense and difficulty in monitoring are disadvantages.