132: ANTI THE ANTICOAGULATION IN ECMO? A SURVEY OF PRACTICES IN ADULT ECMO PATIENTS

Abstract

Introduction: Two of the major risks associated with extracorporeal membrane oxygenation (ECMO) are bleeding and thromboembolism. Due to concerns for thrombosis, particularly of the circuit and oxygenator, the Extracorporeal Life Support Organization (ELSO) recommends that ECMO patients be systemically anticoagulated. However, several recent trials have called into question the preferred anticoagulant with direct thrombin inhibitors (DTIs) potentially supplanting unfractionated heparin (UFH) due to their more favorable pharmacokinetic profile and potential superiority. There is also increasing evidence in VV ECMO to suggest lower therapeutic ranges, or even no anticoagulation, are safe and effective strategies. The purpose of this survey was to assess and describe anticoagulation prescribing patterns at adult ECMO centers. Methods: An electronic survey was distributed to respondents through the ELSO newsletter and discussion board. The primary objective was to identify the primary anticoagulant utilized by respondent institutions. Secondary objectives included identifying anticoagulation monitoring methods, rationale for switching from UFH, and VV ECMO anticoagulation practices. Institutional demographics, standard anticoagulant and monitoring method, rationale for switching from UFH, and anticoagulation practices in VV ECMO patients were all assessed. Results: Eighteen centers completed the survey, with 17 of the 18 (94%) being ELSO designated centers. Most respondents (67%) were pharmacists at their respective institutions. UFH was identified as the primary anticoagulant at most centers (78%) with activated partial thromboplastin time (aPTT) (64%) and anti-Xa (21%) being the most common monitoring methods. The main reason for switching from UFH to a DTI was heparin-induced thrombocytopenia (HIT) (93%). There was variability with regards to anticoagulation practices for VV ECMO patients with 44% of centers anticoagulating all patients, 39% anticoagulating depending on patient specific factors, and 17% not anticoagulating at all. Conclusions: While UFH remains the anticoagulant of choice at most centers despite recent evidence, variability still exists with monitoring methods and anticoagulation practices for VV ECMO patients. Further research is necessary to standardize anticoagulation practices.