• Melissa Lannon, Taylor Duda, Alisha Greer, Mark Hewitt, Arjun Sharma, Amanda Martyniuk, Julian Owen, Faizan Amin, and Sunjay Sharma.
• Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada. Electronic address: melissa.lannon@medportal.ca.
• J Crit Care. 2023 Oct 1; 77: 154319154319.

BackgroundExtracorporeal membrane oxygenation (ECMO) is routinely used in patients with severe respiratory failure and has been increasingly needed during the COVID-19 pandemic. In patients treated with ECMO, significant intracranial hemorrhage (ICH) risk exists due to circuit characteristics, anticoagulation, and disease characteristics. ICH risk may be substantially higher in COVID-19 patients than patients treated with ECMO for other indications.MethodsWe systematically reviewed current literature regarding ICH during ECMO treatment of COVID-19. We utilized Embase, MEDLINE, and Cochrane Library databases. Meta-analysis was performed for included comparative studies. Quality assessment was performed using MINORS criteria.ResultsA total of 54 studies with 4000 ECMO patients were included, all retrospective. Risk of bias was increased via MINORS score primarily due to retrospective designs. ICH was more likely in COVID-19 patients (RR 1.72, 95% CI 1.23, 2.42). Mortality among COVID patients on ECMO with ICH was 64.0%, compared with 41% in patients without ICH (RR1.9, 95% 1.44, 2.51).ConclusionThis study suggests increased hemorrhage rates in COVID-19 patients on ECMO compared to similar controls. Hemorrhage reduction strategies may include atypical anticoagulants, conservative anticoagulation strategies, or biotechnology advances in circuit design and surface coatings.Copyright © 2023 Elsevier Inc. All rights reserved.

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