Why the study?
Anticoagulation monitoring during extracorporeal membrane oxygenation is challenging due to the dual risks of bleeding and thrombotic complications, prompting evaluation of a revised heparin protocol.
Does a revised heparin protocol with lower anti-factor Xa targets reduce bleeding and thrombotic complications in adult patients on ECMO support?
Does a revised heparin protocol with lower anti-factor Xa targets reduce bleeding and thrombotic complications in adult patients on ECMO support?
Lowering the anti-factor Xa target to 0.15-0.5 U/mL with a PTT cutoff of 70 seconds for heparin monitoring in ECMO patients significantly reduces bleeding and thrombotic complications.
May support lower anti-Xa ECMO targets; leaves open need for randomized confirmation.
Objective Anticoagulation monitoring in patients supported on extracorporeal membrane oxygenation is challenging given the risks of both bleeding and thrombotic complications. Based on our early clinical experience, we revised our heparin protocol by reducing our target anti-factor Xa assay from 0.3 to 0.7 U/mL to 0.15 to 0.5 U/mL, while instituting a partial thromboplastin time cutoff of 70 seconds. We evaluated the impact of this change on bleeding/thrombotic complications. Methods A single-center retrospective study of adult patients on extracorporeal membrane oxygenation support was conducted from January 2015 to August 2022. Patients were stratified into groups based on protocol revision: Pre-Revision (2015-2018) or Post-Revision (2019-2022). Our primary end point was the incidence of bleeding/thrombotic complications. Time in therapeutic range was calculated to determine protocol adherence. Poisson regression was performed to correlate time in therapeutic range with the likelihood of complication. Results A total of 302 patients were supported on extracorporeal membrane oxygenation during the study period: 67 Pre-Revision and 235 Post-Revision, median age 57 years. Post-Revision, patients experienced longer extracorporeal membrane oxygenation durations with an increase in the percentage of venovenous extracorporeal membrane oxygenation configurations. The incidence of bleeding complications decreased for all categories, reaching significance for surgical site bleeds (5% vs 14%, P = . 013) and gastrointestinal hemorrhage (2% vs 6%, P = . 049). Likewise, thrombotic complications decreased for all categories except fasciotomy, which was unchanged. Time in therapeutic range for anti-factor Xa assay and partial thromboplastin time were similar across time periods. On Poisson regression, the Post-Revision anti-factor Xa assay range significantly correlated with decreases in bleeding ( P = . 023) and a composite of bleeding/thrombotic complications ( P = . 008). Conclusions A modified heparin monitoring protocol defined by a lower therapeutic anti-factor Xa assay target and a set partial thromboplastin time cutoff correlated with decreases in bleeding/thrombotic complications in patients on extracorporeal membrane oxygenation.
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Dorsey et al. (2024) studied this question.
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