Anticoagulation in Adult Patients Supported with Extracorporeal Membrane Oxygenation

Publication Date: December 19, 2022
Last Updated: March 14, 2023

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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Recommendation Grading

Disclaimer

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.

Overview

Title

Anticoagulation in Adult Patients Supported with Extracorporeal Membrane Oxygenation

Authoring Organization

International Society on Thrombosis and Haemostasis

Publication Month/Year

December 19, 2022

Last Updated Month/Year

April 1, 2024

Document Type

Consensus

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

Scope

Management

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.

Supplemental Methodology Resources

Data Supplement, Data Supplement