A Survey of Anticoagulation and Transfusion Practices during Extracorporeal Membrane Oxygenation in South West Asian and African Countries

Introduction:The use of extracorporeal membrane oxygenation (ECMO) has increased over the last decade owing to its wider application in different disease conditions in both adult and pediatric population.However, there is a paucity of data, in both adult and pediatric populations, about different aspects of ECMO management, including the anticoagulation practice on ECMO.Objectives: To survey the ECMO Centers in South West Asian and African Countries (SWAAC) to assess how the management of anticoagulation and blood transfusion differs, with the intent of identifying areas for future study, including making standard protocols.Materials and methods: Descriptive, self-reporting, nonrandom, cross-sectional, semistructured (multiple-choice and open-ended questions) voluntary, nonincentivized, international survey of anticoagulation and transfusion practice in institutions catering ECMO service for patients, including both pediatric and adult age-group.Survey was conducted via Google Form circulated among the members of the ECMO Society of India and personal contacts in ECMO centers in SWAAC countries during the period of January to June 2020.The ECMO specialists and intensivists performing pediatric or adult ECMO were requested to respond.The survey consisted of 21 questions related to different domains like demographics, anticoagulation, and transfusion practices.Results: There were 25 responses to the survey.Majority (n = 20) responses were from India, and remaining five were from Middle East Countries.Majority of centers catered ECMO service for both adults and pediatrics (n = 11, 45%), while remaining catered only adult (n = 9, 36%) or pediatric patients alone (n = 5, 20%).Most institutions (n = 18, 72%) cared for 0-20 patients on ECMO annually, while the remaining (n = 7, 28%) cared for 20-50 cases annually.All of the units used unfractionated heparin (UFH) as their primary anticoagulant agent.Routine measurement of anticoagulation used to titrate anticoagulants was activated clotting time (ACT) in most units (n = 18, 72%) followed by activated partial thromboplastin time (aPTT) (n = 5, 20%).During venovenous (VV) ECMO, majority of the centers targeted ACT of 160-180 seconds (n = 15, 60%) and 180-200 seconds (n = 8, 30%).The ACT targets followed on VA ECMO were 160-180 seconds in (n = 12, 48%) followed by 180-200 seconds (n = 8, 32%) and >200 seconds in 12% (n = 3).More than one-third (36%) never used thromboelastography (TEG) test, while half (52%) of the units used it only when a need was felt.Hemoglobin (Hb) (gm/dL) cut-off for packed red blood cell transfusion followed in VV ECMO was 10 in 36%, 9 in 28%, and 8 in 28% of institutions.During venoarterial ECMO (VA ECMO), the hemoglobin (gm/dL) cut-off used was 10 in 40% followed by 9 in 24% and 8 in 36%.Majority of the units (n = 16, 64%) used a cut-off of 50,000 (/L) for giving platelet transfusion.Conclusion: Our survey showed a wide variation in anticoagulation and transfusion practice during ECMO in different units and it emphasizes the need for internationally accepted standard protocols and guidelines.