Anticoagulation in Adult Patients Supported with Extracorporeal Membrane Oxygenation
Publication Date: December 20, 2022
Unfractionated Heparin
We recommend the use of intravenous unfractionated heparin for anticoagulation during ECMO support.
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We suggest using anti-Xa assays to monitor UFH anticoagulation for patients on ECMO.
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We suggest achieving an anti-Xa level of 0.3-0.5 U/mL during anticoagulation with UFH for anticoagulation during ECMO.
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Coagulation Tests And Rates Of Bleeding And Thrombotic Events
We suggest AT monitoring in patients with thrombosis; however, current data does not support routine AT repletion.
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Heparin Alternatives: Direct Thrombin Inhibitors
We recommend to switch anticoagulation to direct thrombin inhibitors for patients with HIT or suspected HIT requiring ECMO support. Heparin alternatives could be considered in other clinical settings where heparin therapy fails to achieve desired anticoagulation e.g., owing to heparin resistance.
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Argatroban
If argatroban is used, we recommend using institutionalized protocols for dosing and monitoring of argatroban.
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We suggest achieving an aPTT of 2–2.5 times above the normal level. This may require lower doses when used for patients on ECMO. We recommend that clinicians be aware of the risk of underdosing due to aPTT confounding, especially when treating patients with HIT.
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We suggest using aPTT-based monitoring of argatroban. Specific drug level testing is suggested if available in case of aPTT confounding.
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Bivalirudin
If bivalirudin is used, we recommend using institutionalized protocols for dosing and monitoring bivalirudin.
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We suggest starting bivalirudin at an infusion rate of 0.02–0.05 μg/kg/min to achieve an aPTT of 1.5–2 times above the normal level.
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We suggest using aPTT-based monitoring of bivalirudin. Chromogenic anti-IIa testing and diluted TT can be an alternative if an institution has established a protocol for dosing and monitoring using these tests.
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Ecmo Without Anticoagulation
We suggest against the routine use of no anticoagulation for patients on ECMO.
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The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Title
Anticoagulation in Adult Patients Supported with Extracorporeal Membrane Oxygenation
Authoring Organization
International Society on Thrombosis and Haemostasis
Publication Month/Year
December 20, 2022
Country of Publication
Global
Document Objectives
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
Target Patient Population
Adult patients supported with extracorporeal membrane oxygenation
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Diseases/Conditions (MeSH)
D000925 - Anticoagulants, D015199 - Extracorporeal Membrane Oxygenation
Keywords
anticoagulation, extracorporeal membrane oxygenatio
Source Citation
Helms J, Frere C, Thiele T, Tanaka KA, Neal MD, Steiner ME, Connors JM, Levy JH. Anticoagulation in adult patients supported with extracorporeal membrane oxygenation: guidance from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. J Thromb Haemost. 2023 Feb;21(2):373-396. doi: 10.1016/j.jtha.2022.11.014. Epub 2022 Dec 22. PMID: 36700496.