Anticoagulation Management and Monitoring in ECMO: An International Survey: Communication from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis

The objective of this survey is to assess current practices in anticoagulation management, laboratory monitoring and hematology involvement in extracorporeal membrane oxygenation (ECMO) patients. A cross-sectional international survey distributed between April 2023 to November 2023 to members of Hemostasis and Thrombosis Research Society, International Society on Thrombosis and Haemostasis, and Extracorporeal Life Support Organization (ELSO). Respondents were pediatric and adult physicians involved in the care of ECMO patients. Seventy-two survey responses were included with 83.3% of respondents being from an ELSO Institution. The respondents included both adult (41.7%) and pediatric (34.7%) physicians, as well as those who managed all age groups (23.6%). Approximately 53% reported including hematology as part of the care team. However, the majority reported that the hematologist is involved in complex cases only (72.2%). Respondents reported the routine utilization of an anticoagulation protocol (92%) and transfusion protocol (83%) to guide management decisions during ECMO therapy, however, management practices were variable. Both unfractionated heparin and bivalirudin were reported to be used routinely for anticoagulation at 92.2% and 52.9%, respectively. This survey demonstrated that hematology involvement for ECMO patients is still primarily for complicated cases. In addition, unfractionated heparin continued to be the anticoagulant of choice, with no significant changes in laboratory monitoring. Most centers utilize protocols for management, yet wide variability in ECMO management was again highlighted. Continued prospective and collaborative research efforts are needed to make advancements in treatment and outcomes, and to help streamline the care of this complex patient population. • Management of extracorporeal membrane oxygenation (ECMO) is evolving with the use of bivalirudin. • International survey of physicians to define current practices in pediatric and adult ECMO. • Bivalirudin for use in ECMO was reported as being utilized by 53% of respondents. • Hematology input for complex cases was 72%, but unable to determine if involvement has changed.