Use of a novel anticoagulation strategy during ECMO in a pediatric population: single-center experience

We describe a novel anticoagulation strategy with continuous intravenous antithrombin infusion and intermittent heparin infusion in pediatric population during extracorporeal membrane oxygenation (ECMO). From November 2004 through February 2006, 11 patients required ECMO for postcardiotomy cardiorespiratory failure. The mean duration of support time was 112 hours (range 68-192 hours). Since April 2005, we modified our anticoagulation protocol in the last six patients. Continuous antithrombin infusion was started immediately after surgery based on the lab result. The antithrombin level was maintained >100% using the following formula: 100 (target value) - (Antithrombin value on lab test) x weight in 4 hours. Antithrombin value was checked at 4-hour intervals. Heparin infusion was started when the antithrombin value was > 100% and remained stable for more than 12 hours and the amount of bleeding was < 2 ml/kg for more than 3 consecutive hours; then heparin infusion was started at 2 UI/kg/h via the oxygenator (target ACT was not < 150 seconds). Three patients in the first group died. Eight patients were weaned and discharged; the third, fourth, and fifth required surgical revision for bleeding. One experienced minor neurologic sequelae. Neither surgical revision nor thromboembolic complications occurred in the new anticoagulation group. A novel anticoagulation strategy utilizing continuous intravenous antithrombin and intermittent heparin infusion reduced significantly surgical revision for bleeding in the first 48 hours. This has translated into excellent overall outcomes.