**7. Conclusion**

In summary, while the goal for ECMO anticoagulation is to prevent clinically significant bleeding and clotting, the morbidity and mortality for these complications remain high for pediatric patients. Unfractionated heparin continues to be the most commonly used anticoagulant for ECMO patients in spite of its many disadvantages including altered pharmacokinetics in children and difficulty in lab monitoring. While there is a large variation between lab monitoring of heparin among ECMO centers, combination testing with anti-factor Xa and/or aPTT with viscoelastic tests is potentially superior. DTIs such as bivalirudin and argatroban remain promising alternatives to heparin, but prospective studies are needed to confirm their safety and efficacy.
