Bridging the Evidence Gap: A Call to Action for Anticoagulation Research in Pediatric Burned Patients on Extracorporeal Membrane Oxygenation.

Although early extracorporeal membrane oxygenation (ECMO) improves respiratory complications in unburned populations, it remains a rarely utilized rescue therapy in pediatric burn care, averaging just 3 to 6 cases annually worldwide despite a promising 53-62% survival rate. This underutilization stems from a profound therapeutic paradox: the high bleeding risks and need for coagulation inherent to burn wounds with necessary surgical debridement directly conflict with the systemic anticoagulation required to prevent ECMO circuit thrombosis. Importantly, emerging evidence demonstrates that systemic anticoagulation may not be an absolute requirement for veno-venous ECMO. Despite this, no guidance exists for anticoagulation management specifically in pediatric burned patients. A scoping review spanning three databases identified no studies describing a coagulation strategy developed or validated for this population. Addressing this evidence gap is essential to safely transition ECMO from a late rescue modality to an earlier, evidence-based intervention capable of reducing mortality in this patient population. We therefore call for (1) a multicenter collaboration to aggregate sufficient case volume for meaningful analysis; (2) a prospective collection of serial viscoelastic and conventional coagulation data in pediatric burned patients on ECMO to characterize the temporal evolution of coagulopathy on circuit; and (3) the development and validation of coagulation management protocols tailored to this population. Until such evidence exists, pediatric burned patients will continue to be denied a therapy that offers meaningful survival-not because ECMO does not work-but because we have not yet determined how best to manage coagulation while on circuit.