7, 39, 40, 41, 42, 43, 44, 45
Treat published targets as suggestions rather than validated thresholds. Choose one monitoring test, record which, and start conservatively while cannulation sites are fresh.
Not applicable
DOI 10.1007/s00134-022-06723-z
Anticoagulation agents and monitoring strategies
Narrative state-of-the-art summary. The authors state explicitly that there is no evidence-based consensus guiding anticoagulation agents, monitoring, therapeutic targets, optimal levels, or management of complications and outcomes. No anti-Xa concentration has been shown to improve outcomes.
ELSO database 2010-2017: of 7,579 VV ECMO patients, 40.2% experienced one or more bleeding or thrombotic event, circuit thrombosis the most common at 54.9% of events; of 11,984 VA ECMO patients there were 8,457 events of which 62.1% were bleeding. Suggested monitoring targets: ACT 180-200 seconds; aPTT 40-50 seconds initially then titrated to 60-80 seconds by bleeding and thrombosis risk; anti-Xa 0.3-0.7 IU/mL. Unfractionated heparin is the mainstay (titratable, reversible, duration about 1 hour). ACT correlates poorly with anti-Xa and aPTT; aPTT and anti-Xa frequently discordant. ACT prolonged by hypothermia, platelet number and function, and factor levels; anti-Xa influenced by antithrombin deficiency, hyperlipidaemia and haemolysis. Antithrombin falls during ECMO but no data support improved outcomes from supplementation. Heparin resistance poorly defined, current definitions suggesting over 35,000 units/day. Argatroban half-life 40-50 min with hepatic elimination (preferred DTI in renal failure); bivalirudin half-life 20-30 min, prolonged up to 240 min in renal failure.
Adults on VV and VA ECMO