Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation.

John C Lin,Allan Doctor,Ryan M Colvin,Lauren M Barron,Mark Shepard,Adam M Vogel,Philip C Spinella,Nicole O'Connor,Ahmed S Said,Sirine A Baltagi,Avihu Z Gazit,Mary Mehegan,Michael Wallendorf

doi:10.3389/fcvm.2021.637106

Abstract

Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO).Design: Single-center, observational pre- and post-implementation cohort study.Setting: Academic pediatric hospital.Patients: Patients in the PICU, CICU, and NICU receiving ECMO support.Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline.Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications.Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg.Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.

Highlights

Extracorporeal membrane oxygenation (ECMO) is a vital, life-sustaining therapy for the management of patients with refractory respiratory or cardiac failure
Activated partial thromboplastin time, antifactor Xa levels, antithrombin III (AT-III) activity, fibrinogen levels, thromboelastography (TEG) with and without heparinase, and platelet mapping have been used in varying combinations with or without activated clotting time (ACT) to guide anticoagulation and transfusion management [7,8,9,10,11,12]
The pre- and post-implementation groups were well matched with respect to demographics and primary indication for ECMO (Table 2)

Summary

Introduction

Extracorporeal membrane oxygenation (ECMO) is a vital, life-sustaining therapy for the management of patients with refractory respiratory or cardiac failure. Resulting bleeding and thrombotic complications are a major consequence of ECMO therapy and carry significant mortality and morbidity [2, 3]. In the absence of an evidence-based approach to anticoagulation and transfusion management, wide clinical variability exists among ECMO centers [4]. Widely used to monitor systemic anticoagulation, ACT correlates poorly with both heparin pharmacokinetics and pharmacodynamics [7,8,9]. Activated partial thromboplastin time (aPTT), antifactor Xa levels, antithrombin III (AT-III) activity, fibrinogen levels, thromboelastography (TEG) with and without heparinase, and platelet mapping have been used in varying combinations with or without ACT to guide anticoagulation and transfusion management [7,8,9,10,11,12]. ECMO centers use institution-specific testing to guide anticoagulation and transfusion management without direct evidence of this approach on outcomes [4]

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