Objective:

To explore the use of nafamostat mesylate (NM) for regional anticoagulation in a VV-ECMO patient following intracerebral hemorrhage (ICH) and to assess the impact of infusion site on coagulation outcomes.

Approach:

• Patient Background: A 41-year-old male with a history of hypertension, diabetes, and chronic kidney disease underwent emergency hematoma evacuation for a right basal ganglia hemorrhage and later developed severe ARDS requiring VV-ECMO.
• Anticoagulation Strategy: Initially, heparin was used with a target aPTT of 35-45, but due to suspected rebleeding, anticoagulation was switched to an anticoagulant-free strategy, leading to significant thrombosis.
• Nafamostat Administration: Nafamostat was initiated at 10 mg/h; however, initial infusion at the conventional post-pump site failed to achieve effective regional anticoagulation.
• Infusion Site Optimization: Relocating the NM infusion to the pre-pump position established a significant circuit-to-systemic aPTT gradient, enabling effective anticoagulation while minimizing bleeding risk.

Key Findings:

• Nafamostat mesylate can be effectively used for regional anticoagulation in VV-ECMO patients post-ICH.
• Infusion site significantly impacts coagulation outcomes, with pre-pump infusion yielding better results.

Interpretation:

The findings suggest that optimizing the infusion site for NM may enhance its efficacy in achieving regional anticoagulation in VV-ECMO.

Limitations:

• The study is based on a single patient case, limiting generalizability.
• Further research is needed to validate the findings in a larger cohort.

Conclusion:

This case study provides insights into the management of anticoagulation in high-bleeding-risk patients on ECMO.