2021 ELSO Adult and Pediatric Anticoagulation Guidelines

Abstract

Disclaimer: These guidelines for adult and pediatric anticoagulation for extracorporeal membrane oxygenation are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge and expertise. These guidelines do not take the place of physicians’ and other health professionals’ judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

Bleeding During Veno-Venous ECMO: Prevention and Treatment

“…This was based on experiences from cardiac bypass surgery when patients without therapeutic anticoagulation had a larger waste of fibrinogen and platelet concentrates compared to those who were anticoagulated ( 43 ). Anticoagulation is established with unfractionated heparin (UFH) in the majority of patients ( 44 ). Modern cannulas, pumps, and membranes are coated with heparin or phosphorylcholine ( 45 ).…”

“…Transfusion thresholds, however, are mainly based on experts' opinions and differ between guidelines and recommendations. It is widely accepted that hemoglobin levels below 7–9 g/l should not be tolerated in adult vvECMO resulting in almost 90% of all patients receiving at least one packed red blood cell transfusion (RBC) during vvECMO ( 44 , 52 , 61 ). Treating anemia can improve oxygen delivery and may support coagulation at bleeding sites.…”

“…Several studies, however, demonstrated that a restrictive threshold has acceptable outcomes in single-center cohorts ( 62 ). The recommended threshold to substitute platelet concentrates ranges from 50 to 100 thousand platelets/μl ( 44 ). Platelets are indispensable for primary hemostasis, but on the contrary platelet count does not necessarily correlate with platelet function; therefore, even with a platelet count above the aforementioned threshold, platelet transfusion may be reasonable in bleeding patients.…”

“…This is mainly based on the key points such as prevention of bleeding, minimized anticoagulation, and correction of acquired coagulation disorders. The protocol and the treatment algorithm ( Figure 1 ) at the author's department go far beyond what is recommended in current international guidelines ( 44 ). This is due to the high experience of this center and made possible by the good availability of a coagulation laboratory.…”

Management of Anticoagulation during Extracorporeal Membrane Oxygenation in Children

“…Anticoagulation therapy is much needed to avoid clotting during ECMO support. Unfractionated heparin (UFH) is the anticoagulant of choice during ECMO [ 12 , 13 , 14 ]. Mechanism of action of heparin involves inhibition of thrombin and factor Xa via activation and binding of antithrombin (AT) [ 15 ].…”