Anticoagulation and Coagulation Management for ECMO

Abstract

Advances in extracorporeal membrane oxygenation (ECMO) management have helped to reduce complications compared with its inception but they remain high. The principal causes of mortality and morbidity are bleeding and thrombosis. The nonbiologic surface of an extracorporeal circuit provokes a massive inflammatory response leading to consumption and activation of procoagulant and anticoagulant components. The vast differences in neonatal and adult anticoagulation and transfusion requirements demands tremendous clinical knowledge to provide the best care. Increased use of thrombelastogram will complement other methods currently being used to improved care. Methods to recognize the level of thrombin formation at the bedside could help reduce neurologic complications. ECMO requires a multidisciplinary team approach to achieve the best outcomes.

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

“…Prolongation of the PTT to 1.5 to 2.5 times the control value and an antiFXa level of 0.3 to 0.7 U/mL have been suggested as suitable targets for anticoagulation of patients on ECMO. 499,500 In addition, the ECMO circuit must be visually inspected for clots on a regular basis. For patients who cannot be weaned from CPB, it is reasonable to forego the loading dose of heparin because the patient should already be suitably anticoagulated and additional heparin may increase the risk of bleeding.…”

Year in Review 2015: Extracorporeal Membrane Oxygenation

“…[21][22][23] To evaluate the bleeding and thrombotic complications, Dalton et al 24 analyzed the ELSO registry data from 8 of the Collaborative Pediatric Critical Care Research Network (CPCCRN) centers for a 7-y period (2005-2011). The study outcome was to describe the bleeding and thrombotic complications and survival to hospital discharge.…”

Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure

“…10 Due to the risk of clot formation with patients on ECMO, anticoagulation is necessary with the goal of preventing thrombosis while avoiding excessive bleeding.…”

“…10 Newer circulatory systems utilizing a heparin bonded tubing, a low pressure oxygenator and centrifugal pump allows for maintenance of anticoagulation on ECMO to be lower without thrombotic complications. VV ECMO may be maintained using heparin bonded tubing without administration of systemic heparin; however, in our experience clot formation in the cannulas and oxygenator is common often necessitating circuit exchange, increased expense and risk for systemic thrombosis or embolism.…”

“…Our practice no longer uses ACT for titration of heparin due to unreliability 10 ; PTT levels are monitored with point of care testing. 10,12 Sources of bleeding while on ECMO are varied and may be related to pre-ECMO procedures, may occur during ECMO cannulation, or as a result of prolonged cannulation, as evidenced by our series of patients.…”