Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiac or respiratory failure. Complications associated with ECMO include bleeding, thrombosis, and coagulopathy. Overt disseminated intravascular coagulation (DIC) in ECMO patients is a rare but severe complication, yet its presentation, timing, and outcomes remain poorly portrayed in the literature. We present a case series of three patients who developed overt DIC while receiving veno-arterial (V-A ECMO) or veno-venous (V-V ECMO) at a tertiary academic medical center between 2023 and 2025. Overt DIC was diagnosed using the International Society on Thrombosis and Haemostasis (ISTH) scoring system, with scores ≥ 5 considered diagnostic. All patients met the ISTH criteria for overt DIC during ECMO support upon case review. Laboratory findings demonstrated severe thrombocytopenia, prolonged prothrombin time (PT)/international normalized ratio (INR), and hypofibrinogenemia. Despite supportive management, including blood product replacement, targeted anticoagulation adjustments, and correction of underlying triggers, overall, 2 out of 3 patients in the series died during their index hospital admissions. Overt DIC during ECMO is a life-threatening complication associated with risk of bleeding and poor prognosis. These cases emphasize the importance of vigilance for early indicators of impending DIC, including thrombus formation within the ECMO oxygenator or circuit. Once identified, a timely oxygenator exchange may improve circuit performance and oxygenation, potentially limiting further activation of the coagulation cascade. Urgent decannulation should be considered when extracorporeal support is no longer essential for survival. In conclusion, these cases highlight the importance of early recognition and multidisciplinary management of ECMO-associated DIC and support the need for further research to develop strong evidence-based strategies for prevention and treatment.