Creating an Evidence-Based Anticoagulation ECMO Protocol Using Simple Data Analysis to Drive Changes throughout the Process

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has advanced over the years, but anticoagulation is still the cornerstone for complicity where centers that have the most success have a better idea of how to balance clotting and bleeding. Coagulation studies are still ambiguous with meaning and results. Clotting and bleeding remain at the highest complication rate in ECMO. An evidence-based protocol standardizes practice but data analysis is needed to determine effectiveness and minimization of complications. This abstract outlines how to create an evidence-based protocol using simple data analysis to show improvement with clotting and bleeding rates. METHODS: A literature review was conducted along with an inquiry of other centers to share their protocol. Retrospectively, we analyzed coagulation results immediately prior to ECMO initiation, which included PT, PTT, INR, Fibrinogen, Platelet count, Hgb/Hct., ATIII, and Anti-Xa labs. We also collected the first 24 hours of ECMO support labs to compare pre and post ECMO initiation. The role of ACTs were minimized but not eliminated as Anti-Xa was brought to the forefront of heparin infusion management. We continued to use ACTs for their advantage of very accessible bedside lab results but made heparin titrations mostly using Anti-Xa and other coagulation studies. The amount of blood product administration was also noted along with bleeding and clotting events. Circuit and component changeout rates were created. We analyzed 4 years’ of patient data for review and comparison. We presented this data to members of our ECMO leadership team, then, collectively agreed on revisions of our existing protocol. Education was conducted with all entities involved and a monitoring system was developed to ensure the new protocol was followed. Patients were reviewed in our monthly ECMO leadership meeting and any ambiguity or issues were discussed with changes made along the way. RESULTS: We analyzed 53 patients in our NICU and 56 patients in our Cardiac ICU. All patients were less than 5kg in weight. 91% of our NICU patients had a platelet count of less than 100,000 and 79% in our Cardiac ICU after ECMO initiation. 53% of our NICU patients had a fibrinogen less than 150,000 and 46% in our Cardiac ICU after ECMO initiation. With this data, we included the immediate administration of platelets to our protocol. With our goal to reduce blood products, we felt the need to administer plasma or cryoprecipitate as needed given the patient’s fibrinogen level prior to ECMO initiation or patient condition of bleeding. Approximately, a 46% reduction of fibrinogen was noted after ECMO initiation. To note, our circuit volume is approximately 250mls for patients <10kg of weight. We also noted that our component/circuit change out rate prior to our new protocol implementation was 53% and 56% in 2016 and 2017 respectively and decreased to 26% in 2018 and then to 16% in 2019. It is important to note that our initial heparin infusion dose was increased at the end of 2018 and the beginning of 2019. Within the first year of the implementation of our protocol, we also saw a decrease in blood product administration; PRBC administration was decreased by 17%, Platelet administration by 44%, and plasma by 41%. CONCLUSION: Creating an evidence-based ECMO anticoagulation protocol is feasible but data analysis is required to determine the effectiveness of the protocol. Simple data analysis can direct changes and determine success. It is also necessary to maintain and continue simple data analysis moving forward to ensure complications remain low with the continual changes of protocols.