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Published on: January 17, 2025
Anticoagulation Monitoring and Targets: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation
Caroline Ozment1, Peta M A Alexander2,3, Wayne Chandler4
1Division of Critical Care Medicine, Department of Pediatrics, Duke University and Duke University Health System, Durham, NC.
Insights
Optimal anticoagulation monitoring during pediatric extracorporeal membrane oxygenation (ECMO) lacks sufficient evidence. This study derived recommendations and consensus statements for anticoagulation monitoring and targets in pediatric ECMO.
Area of Science:
- Pediatric critical care medicine
- Hematology
- Cardiovascular surgery
Background:
- Anticoagulation management is critical for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO).
- Current evidence guiding anticoagulation monitoring and target levels in this population is limited.
- Establishing consensus-based guidelines is essential for optimizing patient outcomes.
Purpose of the Study:
- To develop evidence-based recommendations and expert consensus statements for anticoagulation monitoring and target levels in pediatric ECMO.
- To address the significant gaps in the literature regarding pediatric ECMO anticoagulation.
- To provide practical resources for clinicians at the bedside.
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 employed over two years to build consensus (>80% agreement).
- Risk of bias and evidence quality were assessed using established tools (QIPS, Cochrane RoB, GRADE).
Main Results:
- One weak recommendation, two consensus statements, and three good practice statements were developed.
- High expert agreement (>80%) was achieved for all derived statements.
- Clinical resources for bedside anticoagulation monitoring in pediatric ECMO were generated.
Conclusions:
- There is insufficient high-quality evidence to establish optimal anticoagulation monitoring protocols for pediatric ECMO.
- The derived recommendations and consensus statements offer guidance in the absence of robust data.
- Significant research gaps remain, highlighting the need for further investigation into pediatric ECMO anticoagulation.
Objectives:
To derive systematic-review informed, modified Delphi consensus regarding anticoagulation monitoring assays and target levels in pediatric extracorporeal membrane oxygenation (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:
Anticoagulation monitoring of pediatric patients on ECMO.
Data Extraction:
Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Evidence tables were constructed using a standardized data extraction form.
Data Synthesis:
Risk of bias was assessed using the Quality in Prognosis Studies tool or the revised Cochrane risk of bias for randomized trials, as appropriate and 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 for clinical recommendations focused on anticoagulation monitoring and targets, using a web-based modified Delphi process to build consensus (defined as > 80% agreement). One weak recommendation, two consensus statements, and three good practice statements were developed and, in all, agreement greater than 80% was reached. We also derived some resources for anticoagulation monitoring for ECMO clinician use at the bedside.
Conclusions:
There is insufficient evidence to formulate optimal anticoagulation monitoring during pediatric ECMO, but we propose one recommendation, two consensus and three good practice statements. Overall, the available pediatric evidence is poor and significant gaps exist in the literature.
