Protocols for anticoagulation management in pediatric extracorporeal membrane oxygenation: A comparative retrospective study

IntroductionIn children undergoing Extracorporeal Membrane Oxygenation (ECMO), anticoagulation is given to counterbalance the risk of thrombosis. Several laboratory tests are available to monitor heparin, but the ideal method still needs to be determined.MethodsThis retrospective cohort study included all patients under 18 years on ECMO support between 2010 and 2021. At our institution, the test used to monitor unfractionated heparin changed over time, dividing patients into three periods, using either activated clotting time (ACT) (2010-2014), activated partial thromboplastin time (aPTT) (2014-2018) or anti-Xa (2018-2021). The primary objective was to compare the occurrence of hemorrhagic complications. Secondary objectives included thrombotic complications, neurological complications, and survival.ResultsWe included 118 ECMO runs of which 30 ACT-guided, 40 aPTT-guided, and 48 anti-Xa-guided. No statistically significant differences were found in hemorrhagic complications [respectively 46.7% vs. 52.5% vs. 60.4%; <i>p</i> = 0.48], thrombotic complications (<i>p</i> = 0.15), neurological complications (<i>p</i> = 0.13), or 30-days survival (<i>p</i> = 0.84). Duration of ECMO and length of hospital stay were both the shortest in the anti-Xa-guided group (respectively <i>p</i> = 0.02; <i>p</i> = 0.02). During ECMO, the anti-Xa-guided group received a higher unfractionated heparin dose compared to the aPTT- and ACT-guided group [respectively 839 [651-981] vs. 543 [407-692] vs. 330 [223-489] IU/kg d^-1, <i>p</i> < 0.001].ConclusionIn our study, the test or titration method used to guide heparin-dosing in children on ECMO, was not associated with hemorrhagic complications and death. Of note, the dose of unfractionated heparin was significantly higher in the anti-Xa-guided group. Combined testing may be more effective than a single method, more studies are needed to establish the optimal strategy.