Extracorporeal membrane oxygenation (ECMO) is a method of life support to 
maintain cardiopulmonary function. Its use as a medical application has 
increased since its inception to treat multiple conditions including acute 
respiratory distress syndrome, myocardial ischemia, cardiomyopathy, and septic 
shock. While complications including neurological and renal injury occur in 
patients on ECMO, bleeding and coagulopathy are most common. ECMO is associated 
with an inflammatory response promoting a hypercoagulable state, requiring 
anticoagulation to avoid thromboembolism originating in the nonendothelial 
surfaced circuit. However, excessive anticoagulation may result in bleeding 
complications including intracerebral hemorrhage. Monitoring anticoagulation for 
ECMO has its origins in cardiopulmonary bypass for cardiac surgery; however, 
there is no ideal level of anticoagulation, no standardized method to monitor 
anticoagulation, nor are all centers standardized on what is used for 
anticoagulation. Multiple blood products are used in an effort to decrease 
bleeding in the setting of anticoagulation, often in the setting of recent 
surgery, and this leads to significant increases in cost for patients on ECMO 
and transfusion-related complications. In this review article, we discuss the 
evolution of the various modalities of ECMO, indications, contraindications, and 
complications. Furthermore, we review the different strategies for 
anticoagulation and treatment of coagulopathy while on ECMO. Finally, we discuss 
the cost of ECMO and associated blood product transfusion.