Adult extracorporeal membrane oxygenation: an international survey of transfusion and anticoagulation techniques

Esper, Stephen A.; Welsby, Ian J.; Subramaniam, Kathirvel; Wallisch, William John; Levy, Jerrold H.; Waters, Jonathan H.; Triulzi, Darrell J.; Hayanga, J.W. Awori; Schears, Gregory J.

doi:10.1111/vox.12514

Cited by 103 publications

(101 citation statements)

References 67 publications

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“…ECLS is usually initiated with an intravenous heparin bolus of 50–100 units/kg, followed by a continuous infusion titrated to a specified target . Activated clotting time (ACT) and activated partial thromboplastin time (aPTT) are the most commonly used tests for monitoring the level of anticoagulation; however, anti‐factor Xa activity and thromboelastography/thromboelastometry are often used adjunctively . Some institutions use a combination of tests, such as identifying an ACT goal that correlates with a specific anti‐factor Xa range.…”

Section: Specific Ecls Management Considerationsmentioning

confidence: 99%

Section: Specific Ecls Management Considerationsmentioning

confidence: 99%

“…Restrictive transfusion thresholds that have been adopted for the general critical care population (e.g., hemoglobin less than 7 g/dl) have not been directly compared with more liberal targets during ECLS, but they appear to be associated with acceptable outcomes . Practices surrounding the monitoring and administration of antithrombin III, which is needed for heparin's therapeutic effect and may be deficient during critical illness, are also widely variable across centers …”

Section: Specific Ecls Management Considerationsmentioning

confidence: 99%

“…53 Activated clotting time (ACT) and activated partial thromboplastin time (aPTT) are the most commonly used tests for monitoring the level of anticoagulation; however, anti-factor Xa activity and thromboelastography/thromboelastometry are often used adjunctively. 57 Some institutions use a combination of tests, such as identifying an ACT goal that correlates with a specific anti-factor Xa range. Each test has its inherent advantages and disadvantages including availability, cost, turnaround time, influence from factors other than the effect of heparin, and laboratory interference, as well as varying amounts of data for the use of these tests in this setting ( Table 2).…”

Section: Prophylaxis and Management Of Infectious Complicationsmentioning

confidence: 99%

“…In general, the target for patients receiving ECLS is less aggressive than full therapeutic anticoagulation, unless another indication for anticoagulation exists, and this target can be further individualized based on a patient's perceived or observed bleeding or clotting risk. 57 As a reference, the protocol for the recent EOLIA trial targeted an aPTT of 40-55 seconds or anti-factor Xa activity of 0.2-0.3 unit/ml. 2 Considering the invasive nature of ECLS, the blood trauma that may occur, and the need for routine administration of anticoagulants, bleeding is a frequently reported complication, with cannulation and surgical sites the most common sources, occurring in 10-20% of cases.…”

Section: Prophylaxis and Management Of Infectious Complicationsmentioning

confidence: 99%

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Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support

et al. 2019

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Extracorporeal life support (ECLS) can provide mechanical support for patients with severe life‐threatening cardiac or respiratory failure. ECLS is a complex therapy that has increased in use over several decades owing to advances in technology. In concert with this growth, there is an increased need to understand the complexity of this technology to augment the effectiveness of ECLS and minimize complications such as ventilator‐induced lung injury, bleeding, thrombosis, infections, and inadequate drug dosing. The purpose of this review was to discuss management strategies in adult patients receiving ECLS and provide recommendations on ventilator management, provision of adequate analgesia and sedation, treatment and prevention of infections, and anticoagulation.

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Section: Specific Ecls Management Considerationsmentioning

confidence: 99%

Section: Specific Ecls Management Considerationsmentioning

confidence: 99%

Section: Specific Ecls Management Considerationsmentioning

confidence: 99%

Section: Prophylaxis and Management Of Infectious Complicationsmentioning

confidence: 99%

Section: Prophylaxis and Management Of Infectious Complicationsmentioning

confidence: 99%

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Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support

et al. 2019

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Association of anti‐factor Xa‐guided anticoagulation with hemorrhage during ECMO support: A systematic review and meta‐analysis

Rajsic,

Breitkopf,

Treml

et al. 2024

Clinical Cardiology

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BackgroundThe use of extracorporeal membrane oxygenation (ECMO) is associated with complex hemostatic changes. Systemic anticoagulation is initiated to prevent clotting in the ECMO system, but this comes with an increased risk of bleeding. Evidence on the use of anti‐Xa‐guided monitoring to prevent bleeding during ECMO support is limited. Therefore, we aimed to analyze the association between anti‐factor Xa‐guided anticoagulation and hemorrhage during ECMO.MethodsA systematic review and meta‐analysis was performed (up to August 2023). PROSPERO: CRD42023448888.ResultsTwenty‐six studies comprising 2293 patients were included in the analysis, with six works being part of the meta‐analysis. The mean anti‐Xa values did not show a significant difference between patients with and without hemorrhage (standardized mean difference −0.05; 95% confidence interval [CI]: −0.19; 0.28, p = .69). We found a positive correlation between anti‐Xa levels and unfractionated heparin dose (UFH; pooled estimate of correlation coefficients 0.44; 95% CI: 0.33; 0.55, p < .001). The most frequent complications were any type of hemorrhage (pooled 36%) and thrombosis (33%). Nearly half of the critically ill patients did not survive to hospital discharge (47%).ConclusionsThe most appropriate tool for anticoagulation monitoring in ECMO patients is uncertain. Our analysis did not reveal a significant difference in anti‐Xa levels in patients with and without hemorrhagic events. However, we found a moderate correlation between anti‐Xa and the UFH dose, supporting its utilization in monitoring UFH anticoagulation. Given the limitations of time‐guided monitoring methods, the role of anti‐Xa is promising and further research is warranted.

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Review of anticoagulation considerations in extracorporeal membrane oxygenation support

et al. 2023

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Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno‐arterial (VA) and veno‐venous (VV) ECMO, there are still significant hemocompatibility‐related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA‐ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.

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Adult extracorporeal membrane oxygenation: an international survey of transfusion and anticoagulation techniques

Cited by 103 publications

References 67 publications

Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support

Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support

Association of anti‐factor Xa‐guided anticoagulation with hemorrhage during ECMO support: A systematic review and meta‐analysis

Review of anticoagulation considerations in extracorporeal membrane oxygenation support

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