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Abstract
Management of anticoagulation in patients undergoing extracorporeal membrane oxygenation [ECMO] is controversial despite more than 50 years of ECMO experience. According to the most recent Extracorporeal Life Support Organization [ELSO] guidelines from 2021, there are currently no standardized protocols for anticoagulation agents or monitoring. ELSO currently lists heparin as the most commonly used primary anticoagulant for pediatric and adult ECMO, but they also state many centers have switched to using direct thrombin inhibitors [DTIs] as their primary anticoagulant. The goal of this project was to survey currently licensed and practicing perfusionists in the United States [U.S.] to determine current practices of anticoagulation during ECMO. In addition to determining the most common primary anticoagulant and anticoagulation test used, the survey aimed to glean insights into individual perfusionist preference regarding ECMO anticoagulation.
After the research project was approved by the Milwaukee School of Engineering Institutional Review Board [IRB], responses were collected from November 2023 through January 2024. A recruitment letter explaining the goals of the investigation and survey as well as a link to the survey was posted on a variety of perfusion platforms including Perfusion.com and the Women in Perfusion Facebook group. The survey link was also distributed to perfusionists at Aurora St. Luke’s Medical Center, Froedtert Hospital, and Children’s Hospital of Wisconsin. Multiple perfusionists from the same institution were allowed to participate in order to focus on individual beliefs. Questions were modeled after two recent surveys focused on anticoagulation practices in ECMO, one an international adult survey by Esper et al. from 2017 and the other a 2022 U.S. pediatric survey by Frazier et al.
Similar to the results from other surveys conducted in 2017 and 2022, this survey found the majority of respondents [73%] use heparin as their center’s primary ECMO anticoagulant and activated partial thromboplastin time [aPTT] as the predominant monitoring test. When asked about individual preference, the majority of respondents [36%] selected heparin as their preferred anticoagulant on ECMO while 27% selected bivalirudin. Almost one third [32%] did not prefer one anticoagulant over another. In this survey, 24% of respondents indicated bivalirudin as their center’s primary ECMO anticoagulant, which is a significant increase from just 2% and 8% from the 2017 and 2022 surveys, respectively. These percentages indicate there may be a downward shift in the use of heparin as the primary ECMO anticoagulant and an increase in bivalirudin usage. Continued research and implementation of DTIs is necessary before ECMO anticoagulation practices can be standardized.