Coagulation and Bleeding Management in Pediatric Extracorporeal Membrane Oxygenation: Clinical Scenarios and Review

Abstract

Extracorporeal membrane oxygenation (ECMO) is a life-saving procedure that requires careful coagulation management. Indications for ECMO continue to expand, leading to more complicated patients treated by ECMO teams. At our pediatric institution, we utilize a Coagulation Team to guide anticoagulation, transfusion and hemostasis management in an effort to avoid the all-to-common complications of bleeding and thrombosis. This team formulates a coagulation plan in conjunction with a multidisciplinary ECMO team after careful review of all available laboratory data as well as the patient's clinical status. Here, we present our general strategies for ECMO management in various clinical scenarios and a review of the literature pertaining to coagulation management in the pediatric ECMO setting.

Antithrombin use during pediatric cardiac extracorporeal membrane oxygenation admission: insights from a national database

“…Well-described monitoring protocols and interventions exists and even coagulation teams have been assembled. 26 Our data reinforce the need for a large multicenter effort, including resources from organizations like the extracorporeal life support organization, to truly delineate the role of antithrombin replacement in pediatric ECMO by performing prospective studies, specifically incorporating data demonstrating the association for different antithrombin levels and clinical outcomes. Achieving this may help improve resource utilization by identifying subsets of ECMO patients who may or may not be benefiting from antithrombin replacement.…”

“…24 Some institutions replace antithrombin when activity levels fall to under 50-80% and dose antithrombin to increase the activity level to 100-125%. 9,[24][25][26][27] Other studies only monitor the antithrombin activity level and target heparin rate. [28][29][30] To maintain an optimal heparin drip rate (15 U/kg/ hr), one study calculated that the antithrombin activity level threshold should be kept >42%, and in a separate study where there were no major differences between groups, a group that did not receive antithrombin reported average antithrombin activity levels at 42%.…”

“…24 Some institutions replace antithrombin when activity levels fall to under 50-80% and dose antithrombin to increase the activity level to 100-125%. 9,24–27 Other studies only monitor the antithrombin activity level and target heparin rate. 28–30…”

Pediatric Fibrinogen PART II—Overview of Indications for Fibrinogen Use in Critically Ill Children

“…It is advised that fibrinogen levels are regular monitored ( 108 , 110 , 111 ), however no RCTs have been performed in this patient cohort looking at fibrinogen thresholds and supplementation and hence there is no consensus on the desired fibrinogen levels needed ( 110 ). There is variable practice with respect to fibrinogen supplementation in this cohort.…”

“…The ELSO guidelines, advise for transfusions of plasma or cryoprecipitate to maintain fibrinogen levels >150 mgd/L in neonates ( 112 ) and 250–300 mg/dL in children ( 111 , 112 ). Whilst other centers report targeting fibrinogen levels >100–150 mg/dL in neonates ( 108 ) and fibrinogen levels >200 mg/dL in children ( 110 ).…”