**6.5 Initial management: Anticoagulation**

Most ECMO centers have their own institutional protocols for ECMO anticoagulation, usually an amalgam of center experience, ELSO guidelines, and published literature. We suggest utilizing an anticoagulation expert when setting up such a protocol, and recommend reviewing institutional practices regularly with the goal of keeping up-to-date with the literature.

Anticoagulation in this patient population starts with the cannulation procedure. A bolus of unfractionated heparin (typically 50–100 units per kg) is given directly to the patient prior to cannula placement. Afterwards, an unfractionated heparin infusion is started, usually 28–30 units/kg/hr. in neonates and infants, and 20 units/ kg/hr. in larger children. Of note, neonates may need higher doses of unfractionated heparin secondary to naturally lower antithrombin III (ATIII) plasma concentrations. Less heparin may be required in patients who have a coagulopathy.

Anticoagulation monitoring differs between centers [29, 30]. Labs can include partial thromboplastin time (PTT), anti-Xa, and thromboelastography (TEG). ATIII levels may be monitored dependent on the clinical situation. Platelets, fibrinogen, and plasma free hemoglobin are adjunct values that can be monitored, and can help with management of a circuit's anticoagulation. The patient's coagulable state must be taken into consideration, and this may alter dosing and target lab values. **Table 3** lists the most common parameters used in monitoring anticoagulation.

Some centers report the use of direct thrombin inhibitors, such as bivalirudin, as an alternative to unfractionated heparin infusions [31]. Direct thrombin inhibitors (DTI) have the advantage of not requiring ATIII for action and can inhibit clotbound thrombin. However, DTIs do not act on the contact pathway, which may be an issue in low-flow parts of a circuit (such as a bridge or a pigtail for lab draws). DTIs are titrated to a PTT of 1.5–2 times normal, and so it is important to establish a baseline value prior to use.

#### **6.6 Special consideration: left heart decompression**

Patients managed with ECMO, more so in the setting of cardiac disease or ECPR, can develop myocardial dysfunction and left heart failure [32]. In ECMO patients who develop poor left heart function, the team must work to offload the heart [33]. This is necessary to prevent complications such as worsening cardiac function or pulmonary edema [34].

Management of ECMO-related LV distension should start with exclusion of poor cannula positioning and eliminating mechanical issues with the ECMO circuit [35]. Pump function should be adjusted to maintain appropriate flows. LV distension can be secondary to volume overload, and so volume status should be addressed accordingly. In case of poor cardiac muscle function, inotropes to improve contractility and vasodilators to decrease LV afterload can be utilized.

If offloading the left heart cannot be achieved medically, and cardiac output remains compromised, the institution of an interventional approach may be required. Several interventional decompression strategies have been described and are listed in **Table 4**. Evidence-based guidelines are lacking with regards of absolute indications, timing of intervention, and management method. The following is a non-comprehensive list of indications from the literature:


#### **6.7 ECPR program**

Several authors have discussed the essential components of an ECMO program, which are needed before ECPR can be offered as a treatment option [21, 47]. With

**133**

situations or hardship.

**Table 4.**

**7. Complications**

concerns that need to be addressed.

*Extracorporeal Cardiopulmonary Resuscitation DOI: http://dx.doi.org/10.5772/intechopen.83658*

Activated Partial Thromboplastin

Time (aPTT)

*Monitoring anticoagulation.*

**Table 3.**

ECPR, time is of the essence. In order to successfully offer ECPR, a well-established protocol needs to be in-place and needs to be followed each time. There are several reported characteristics of a successful ECPR program, independent of the quality and capability of the ECMO team. An ideal team should be able to respond to situations in a consistent manner while maintaining that quality despite negative

Percutaneous trans-septal LA decompression Aiyagari et al. [38], O'Byrne et al. [39]

Static over-the-wire balloon dilation Baruteau et al. [42], Eastaugh et al. [40]

Direct surgical LA or LV venting Guirgis et al. [45], Sandrio et al. [46]

**Strategy Reference** Intra-aortic balloon pump Aso et al. [36] Pulmonary artery vent Fouilloux et al. [37]

**Lab parameter Description Goals**

Activated Clotting Time (ACT) Assesses whole blood clotting Normal: 80–160 sec

Anti-Xa level Assesses clotting activity ECMO target:

Thromboelastography (TEG) Assessment of whole blood clotting, fibrinolysis and platelet activity

ECMO target: 180–240 seconds

target: 1.5x normal

0.35–0.70 units/ml

Assesses the intrinsic pathway Normal: 30–40 sec ECMO

Trans-septal LA decompression with BAS and LA vent insertion Eastaugh et al. [40] Transaortic vent Hong et al. [41]

Blade balloon septostomy Johnston et al. [43] Atrial stenting Haynes et al. [44]

*Interventional decompression strategies for ECMO-related left heart dysfunction.*

Consistency is maintained by continued training of all members of the team. Ongoing training must be both theoretical and hands-on. Simulation is a unique, effective way to incorporate the necessary training and dispense it to all members of the team in a way that can model real-life situations [48–52]. Leaders of the team must be able to keep up with the most up-to-date literature in ECMO and ECPR. Continued improvement of team performance is also assisted with maintaining quality improvement projects focused on outcomes-based factors related to each institution. On-the-spot debriefing after each event is a good way to identify

ECPR, like all other forms of extracorporeal life support, is associated with a host of mechanical and non-mechanical complications. Frequency and severity

#### *Extracorporeal Cardiopulmonary Resuscitation DOI: http://dx.doi.org/10.5772/intechopen.83658*


#### **Table 3.**

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

**6.6 Special consideration: left heart decompression**

and vasodilators to decrease LV afterload can be utilized.

non-comprehensive list of indications from the literature:

3.Poor left outflow tract ejection/closed aortic valve

4.Refractory pulmonary edema or pulmonary hemorrhage

baseline value prior to use.

function or pulmonary edema [34].

5.Aortic valve regurgitation

6.Elevated LV wall stress

7.LV or RV dysfunction

**6.7 ECPR program**

Anticoagulation monitoring differs between centers [29, 30]. Labs can include partial thromboplastin time (PTT), anti-Xa, and thromboelastography (TEG). ATIII levels may be monitored dependent on the clinical situation. Platelets, fibrinogen, and plasma free hemoglobin are adjunct values that can be monitored, and can help with management of a circuit's anticoagulation. The patient's coagulable state must be taken into consideration, and this may alter dosing and target lab values. **Table 3**

Some centers report the use of direct thrombin inhibitors, such as bivalirudin, as an alternative to unfractionated heparin infusions [31]. Direct thrombin inhibitors (DTI) have the advantage of not requiring ATIII for action and can inhibit clotbound thrombin. However, DTIs do not act on the contact pathway, which may be an issue in low-flow parts of a circuit (such as a bridge or a pigtail for lab draws). DTIs are titrated to a PTT of 1.5–2 times normal, and so it is important to establish a

Patients managed with ECMO, more so in the setting of cardiac disease or ECPR, can develop myocardial dysfunction and left heart failure [32]. In ECMO patients who develop poor left heart function, the team must work to offload the heart [33]. This is necessary to prevent complications such as worsening cardiac

Management of ECMO-related LV distension should start with exclusion of poor cannula positioning and eliminating mechanical issues with the ECMO circuit [35]. Pump function should be adjusted to maintain appropriate flows. LV distension can be secondary to volume overload, and so volume status should be addressed accordingly. In case of poor cardiac muscle function, inotropes to improve contractility

If offloading the left heart cannot be achieved medically, and cardiac output remains compromised, the institution of an interventional approach may be required. Several interventional decompression strategies have been described and are listed in **Table 4**. Evidence-based guidelines are lacking with regards of absolute indications, timing of intervention, and management method. The following is a

1.Elevated LA pressure and LVEDP despite maximal medical management

2.Severe distension of LA or LV (can include LV thrombus in setting of stasis)

Several authors have discussed the essential components of an ECMO program, which are needed before ECPR can be offered as a treatment option [21, 47]. With

lists the most common parameters used in monitoring anticoagulation.

**132**

*Monitoring anticoagulation.*


#### **Table 4.**

*Interventional decompression strategies for ECMO-related left heart dysfunction.*

ECPR, time is of the essence. In order to successfully offer ECPR, a well-established protocol needs to be in-place and needs to be followed each time. There are several reported characteristics of a successful ECPR program, independent of the quality and capability of the ECMO team. An ideal team should be able to respond to situations in a consistent manner while maintaining that quality despite negative situations or hardship.

Consistency is maintained by continued training of all members of the team. Ongoing training must be both theoretical and hands-on. Simulation is a unique, effective way to incorporate the necessary training and dispense it to all members of the team in a way that can model real-life situations [48–52]. Leaders of the team must be able to keep up with the most up-to-date literature in ECMO and ECPR. Continued improvement of team performance is also assisted with maintaining quality improvement projects focused on outcomes-based factors related to each institution. On-the-spot debriefing after each event is a good way to identify concerns that need to be addressed.
