We suggest achieving an anti-Xa level of 0.3-0.5 U/mL during anticoagulation with UFH for anticoagulation during ECMO.
We suggest AT monitoring in patients with thrombosis; however, current data does not support routine AT repletion.
We recommend to switch anticoagulation to direct thrombin inhibitors for patients with HIT or suspected HIT requiring ECMO support. Heparin alternatives could be considered in other clinical settings where heparin therapy fails to achieve desired anticoagulation e.g., owing to heparin resistance.
If argatroban is used, we recommend using institutionalized protocols for dosing and monitoring of argatroban.
We suggest achieving an aPTT of 2–2.5 times above the normal level. This may require lower doses when used for patients on ECMO. We recommend that clinicians be aware of the risk of underdosing due to aPTT confounding, especially when treating patients with HIT.
We suggest using aPTT-based monitoring of argatroban. Specific drug level testing is suggested if available in case of aPTT confounding.
If bivalirudin is used, we recommend using institutionalized protocols for dosing and monitoring bivalirudin.
We suggest starting bivalirudin at an infusion rate of 0.02–0.05 μg/kg/min to achieve an aPTT of 1.5–2 times above the normal level.
We suggest using aPTT-based monitoring of bivalirudin. Chromogenic anti-IIa testing and diluted TT can be an alternative if an institution has established a protocol for dosing and monitoring using these tests.
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Anticoagulation in Adult Patients Supported with Extracorporeal Membrane Oxygenation
International Society on Thrombosis and Haemostasis
December 20, 2022
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
Adult patients supported with extracorporeal membrane oxygenation
Male, Female, Adult, Older adult