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The Influence of the Extracorporeal Membrane Oxygenation Circuit and Components on Anticoagulation Management: The
Adam S Himebauch1, John R Priest2, Gail M Annich3
1Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Insights
New component technologies in extracorporeal membrane oxygenation (ECMO) outpace anticoagulation research for pediatric ECMO. Experts developed consensus statements and recommendations on managing anticoagulation with different ECMO circuit components.
Area of Science:
- Pediatric critical care medicine
- Cardiopulmonary bypass technology
- Anticoagulation management
Background:
- Extracorporeal membrane oxygenation (ECMO) is a vital life support therapy for critically ill children.
- Management of anticoagulation during pediatric ECMO is complex and influenced by circuit components.
- There is a need for evidence-based guidance on anticoagulation practices in pediatric ECMO.
Purpose of the Study:
- To establish consensus on the influence of ECMO circuit components on anticoagulation practices in pediatric ECMO.
- To provide evidence-based recommendations and good practice statements for anticoagulation management.
- To address the gap between new ECMO technology and clinical anticoagulation research.
Main Methods:
- A systematic literature search was conducted across major databases (PubMed, EMBASE, Cochrane Library) from 1988 to 2021.
- A modified Delphi process involving 48 experts was used to develop consensus statements and recommendations.
- Evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE) system; risk of bias assessed with Quality in Prognosis Studies tool.
Main Results:
- Forty-eight experts convened over two years to formulate recommendations.
- Consensus was achieved through a web-based modified Delphi process with >80% agreement.
- The study presents one good practice statement, two weak recommendations, and two consensus statements regarding ECMO circuit components and anticoagulation.
Conclusions:
- Clinical adoption of novel ECMO component technologies has surpassed dedicated research into associated anticoagulation strategies.
- Future research should prioritize collaborations, translational platforms, and advanced biostatistics to enhance pediatric ECMO patient outcomes.
- Standardized anticoagulation management informed by circuit components is crucial for optimizing pediatric ECMO therapy.
Objectives:
To derive systematic-review informed, modified Delphi consensus regarding the influence of extracorporeal membrane oxygenation (ECMO) circuit components on anticoagulation practices for pediatric ECMO for the Pediatric ECMO Anticoagulation CollaborativE.
Data Sources:
A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021.
Study Selection:
Management of ECMO anticoagulation in the setting of different ECMO circuit components.
Data Extraction:
Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twenty-nine references were used for data extraction and informed recommendations, evidence-based consensus statements, and good practice statements. Evidence tables were constructed using a standardized data extraction form.
Data Synthesis:
Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements or good practice statements for the influence of ECMO circuit and components on anticoagulation management. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One good practice statement, 2 weak recommendations, and 2 consensus statements are presented.
Conclusions:
The incorporation of new component technologies into clinical practice has outpaced clinical investigations of anticoagulation strategies for pediatric ECMO. Future investigations should leverage academic and industrial collaborations, translational platforms, and modern biostatistical methods to improve patient outcomes.
