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Therapeutic Dosing of Unfractionated Heparin in ECMO – Adult - Inpatient

Therapeutic Dosing of Unfractionated Heparin in ECMO – Adult - Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Hematology and Coagulation


1
Therapeutic Dosing of Unfractionated Heparin in ECMO –
Adult – Inpatient – Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY .............................................................................................................. 2 
SCOPE ......................................................................................................................................... 5 
METHODOLOGY ......................................................................................................................... 5 
DEFINITIONS: .............................................................................................................................. 6 
INTRODUCTION .......................................................................................................................... 7 
RECOMMENDATIONS ................................................................................................................ 8 
UW HEALTH IMPLEMENTATION ............................................................................................. 12 
REFERENCES ........................................................................................................................... 12 
APPENDIX A .............................................................................................................................. 12 
CPG Contact for Content:
Name: Anne E. Rose, PharmD
Phone Number: 263-9738
Email Address: arose@uwhealth.org
CPG Contact for Changes:
Name: Philip J Trapskin, PharmD, BCPS
Phone Number: 263-1328
Email Address: ptrapskin@uwhealth.org
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2
Guideline Author(s):
Chris Viesselmann, PharmD; Anne Rose, PharmD
Coordinating Team Members:
James Maloney, MD
Shahab Akhter, MD
Takushi Kohmoto, MD
Suzanne Hoffman, MT, ASCP – Anticoag Lab
Margaret Murray, RN, MSN, FAHA, CCNS, CSC, CCRN
Teresa Darcy, MD
Tom Steffens
Review Individuals/Bodies:
Inpatient Anticoagulation Committee
Pharmacy and Therapeutics Committee
Committee Approvals/Dates:
Inpatient Anticoagulation Committee: June 2015
Pharmacy and Therapeutics Committee: July 2015
Release Date:
July 2015
Next Review Date:
June 2017
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3
Executive Summary
Guideline Overview
This clinical practice guideline is intended to provide a standardized process for the initiation,
maintenance, and monitoring of intravenous unfractionated heparin used for patients
undergoing extracorporeal membrane oxygenation (ECMO). Practices considered include
guidance on initial and maintenance monitoring of heparin infusions and initial and maintenance
heparin dose adjustments.
Key Practice Recommendations
1. Initial UFH bolus and infusion starting rate should be based on actual body weight
2. The heparin concentration should be based on the patient’s actual body weight at the time
of initiation of the infusion
Table 2. Initial Dosing of ECMO UFH infusion
Patient Status
Bolus Dose
(units/kg)
Maximum Bolus
(units)
Initial Infusion
(units/kg/hr)
High Bleed Risk None N/A 20
Standard Bleed Risk 100 10,000 40
3. Upon initiation of the UFH infusion, ACT levels should be checked every hour for the first 6
hours, or until the first anti-Xa level is resulted
Table 3. Titration of ECMO UFH infusion by ACT
ACT (seconds) Bolus/Hold Infusion Rate Change
< 180 Consider bolus 20 units/kg ↑ by 2 units/kg/hr
180 – 220 None
NO CHANGE;
Therapeutic Range
221 – 250 None ↓ by 2 units/kg/hr
> 250 Hold infusion until ACT < 250 ↓ by 3 units/kg/hr
4. Suggested laboratory monitoring for the ECMO UFH infusion
Table 4. Suggested laboratory monitoring schedule for ECMO
Condition ACT Anti-Xa
Initiation Q1H After 6 hours
Stable PRN Q6H
Bleeding or
Clotting
Q1H or PRN Q6H or PRN
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4
5. Nomograms for adjusting the ECMO UFH infusion
Table 5. Standard bleed risk ECMO UFH titration nomogram by anti-Xa (Target 0.3 – 0.7)
Heparin Level by
Anti-Xa (IU/mL)
Bolus/Hold Infusion Rate Change
< 0.1 Contact MD for bolus (40 units/kg) ↑ by 3 units/kg/hr
0.10 – 0.19 Contact MD for bolus (20 units/kg) ↑ by 2 units/kg/hr
0.2 – 0.29 None ↑ by 1 unit/kg/hr
0.3 – 0.7 None
NO CHANGE;
Therapeutic Range
0.71 – 0.8 None ↓ by 1 unit/kg/hr
0.81 – 1.7 Hold infusion x1 hr ↓ by 2 units/kg/hr
>1.7 Hold infusion x1.5 hr & contact MD ↓ by 3 units/kg/hr
Table 6. High bleed risk ECMO UFH titration nomogram by anti-Xa (Target 0.2 – 0.4)
Heparin Level by
Anti-Xa (IU/mL)
Bolus/Hold Infusion Rate Change
< 0.1 Contact MD for bolus (20 units/kg) ↑ by 2 units/kg/hr
0.1 – 0.19 None ↑ by 1 unit/kg/hr
0.2 – 0.4 None
NO CHANGE;
Therapeutic Range
0.41 – 0.6 None ↓ by 1 unit/kg/hr
0.61 – 1 None ↓ by 2 units/kg/hr
> 1 Hold infusion x 1 hr & contact MD ↓ by 3 units/kg/hr
6. Additional clinical monitoring
Table 7. Suggested clinical monitoring parameters for ECMO
Condition
PT/INR
Fibrinogen
Hemoglobin/
Platelets
AT III TEG
Stable QAM
Q8H for the first
24H, then QAM
If UFH infusion
>60 units/kg/hr
PRN
Bleeding or
Clotting
Treat and redraw
after 4 hr
Treat and redraw
after 1 hr
PRN PRN
7. Use of argatroban for documented or clinically suspected heparin-induced
thrombocytopenia (HIT)
7.1. For recommendations on screening and diagnosis of HIT, as well as monitoring and
adjustment of the argatroban infusion, refer to the UWHC Heparin Induced
Thrombocytopenia – Adult – Inpatient – Clinical Practice Guideline
7.2. Suggested argatroban infusion starting dose: 0.2 mcg/kg/min (actual body weight)
Companion Documents
IP ECMO Heparin Anticoagulant – Supplemental Order Set
Pertinent UW Health Policies & Procedures
UWHC Policy 8.33 High Alert Medication Administration
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5
Scope
Disease/Condition(s):
Hospitalized adult patients receiving intravenous unfractionated heparin intended for therapeutic
anticoagulation while undergoing extracorporeal membrane oxygenation (ECMO).
Clinical Specialty:
Cardiothoracic Surgery, Critical Care
Intended Users:
Physicians, Registered Nurses, Pharmacists, Perfusionists, ECMO Specialists, Advanced
Practice Providers
CPG objective(s):
This clinical practice guideline is intended to provide a standardized process for the initiation,
maintenance, and monitoring of intravenous unfractionated heparin used for therapeutic
anticoagulation in patients undergoing ECMO.
Target Population:
The recommendations within this guideline would apply to adult patients receiving intravenous
unfractionated heparin infusions for therapeutic anticoagulation in ECMO with the intent to titrate
to a therapeutic goal.
Interventions and Practices Considered:
The clinical interventions and practices recommended in this guideline are intended for patients
receiving therapeutic intravenous unfractionated heparin while on ECMO. Practices considered
include guidance on initial and maintenance monitoring of heparin infusions, and initial and
maintenance heparin dose adjustments.
Major Outcomes Considered:
The major outcomes considered in this guideline are for the safe and effective dosing of IV
unfractionated heparin through the use of standardized dosing and monitoring nomograms and
documentation. Efficacy is measured by achieving a therapeutic goal within 24 hours of
initiation, and safety is measured by bleeding (major and minor) and thrombotic outcomes.
Guideline Metrics:
The Anticoagulation Stewardship Program periodically completes a review of our intravenous
heparin infusion administrations. This review is done to assess adherence to the dosing and
monitoring nomograms, assess time to achieving therapeutic ranges, evaluate critical values,
and assess bleeding and thrombotic outcomes. Patient Safety Net events (PSNs) related to
heparin infusions are reviewed throughout the year.
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6
Methodology
Methods Used to Collect/Select the Evidence:
The UWHC Guidelines for Therapeutic Dosing of Unfractionated Heparin in ECMO for adult
inpatients was created after a literature search using MEDLINE and Cochrane databases, and
an evaluation of referenced literature. Searches were extended to reviews and studies
conducted in humans and published in English. Reference lists of relevant studies were also
reviewed.
Rating Scheme for the Strength of the Evidence:
A modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
developed by the American Heart Association and American College of Cardiology has been
used to assess the Quality and Strength of the Evidence in this Clinical Practice Guideline
(Appendix A).
1

Methods Used to Formulate the Recommendations:
Recommendations were based on strength of evidence and clinical expert consensus.
Definitions
Patient Population
Adults – patients 18 years of age or older
2

Anticipated Bleed Risk Upon UFH Initiation
High Bleed Risk – When the likelihood of clinically significant bleeding outweighs the risk of
thrombotic events as determined by the physician’s clinical assessment of the patient.
Examples of high bleed risk situations include (but are not limited to): recent major surgery,
active bleeding / hemorrhage, or clinical signs of active bleeding as assessed by laboratory
measures.
Standard Bleed Risk – Defined as the absence of a condition that would qualify the patient
as “high bleed risk” as determined by the physician’s clinical assessment of the patient.
Outcome Metrics
Major bleeding
3
includes any clinically significant bleeding with concurrent hemoglobin
decrease of ≥2 g/dL in a 24 hour period, estimated blood loss of ≥20 mL/kg in a 24 hour
period, or packed red cell transfusion requirement of ≥10 mL/kg in a 24 hour period. Major
bleeding also includes any bleeding that is retroperitoneal, pulmonary, involves the central
nervous system, or requires surgical intervention.
Minor bleeding
3
includes an estimated blood loss of ≤20 mL/kg or packed red cell
transfusion requirement of ≤10 mL/kg in a 24 hour period.
Thrombosis
3
, for the purpose of evaluating safety, includes clotting identified within the
ECMO circuit (within the oxygenator, blood pump, or circuit, or any clot that requires
replacement of any one of these components), or venous thromboembolism within the
patient that is diagnosed by imaging (e.g. ultrasound or computed tomography).
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7
Introduction
ECMO allows for the maintenance of cardiopulmonary function in the setting of cardiac and/or
respiratory failure, allowing time for recovery, transplant, or initiation of long-term management.
4

The use of ECMO is highly complex and has the potential for numerous complications, most
notably bleeding and thrombosis. The presence of a nonbiological membrane within the ECMO
circuit creates the potential for significant inflammation and hypercoagulability, normally
necessitating systemic anticoagulation to prevent clogging of the membrane as well as end-
organ damage caused by microemboli.
Anticoagulation is typically achieved with the use of intravenous unfractionated heparin (UFH).
Intravenous UFH has an immediate onset of action but requires monitoring and infusion rate
adjustments in order to achieve a targeted therapeutic range.
5
The following guideline provides
recommendations for how to initiate, dose adjust, and monitor a UFH infusion when used for
ECMO.
While ECMO has been used for decades, there is no consensus on the optimal intensity of
anticoagulation that should be targeted, nor the preferred laboratory method that should be
used for monitoring.
4
The Extracorporeal Life Support Organization (ELSO) has recently
published guidelines for anticoagulation in ECMO, however no definitive recommendations for
dosing and monitoring of UFH were provided in this guideline.
6

Historically, the activated clotting time (ACT) has been used to monitor the level of
anticoagulation by UFH in ECMO due to its ability to be performed rapidly at the bedside using
whole blood.
4
However, this test is subject to significant variability due to influence from factors
in addition to heparin, and has been shown to correlate poorly with the dose of heparin
administered in adult ECMO populations.
7
There is literature to suggest that monitoring UFH
infusions in ECMO with antifactor Xa (anti-Xa) levels may improve time to therapeutic range and
warrant less lab testing, and two small pediatric studies have shown a more positive correlation
with heparin dose in ECMO compared to ACT or activated partial thromboplastin time (aPTT).
8-
10
A recently published single-center study has also shown a correlation between using an anti-
Xa based monitoring protocol and decreased blood product administration, decreased
hemorrhagic events, and decreased frequency of ECMO circuit replacement.
11
See Table 1 for
an overview of the advantages and disadvantages of the ACT, aPTT, and anti-Xa laboratory
tests for monitoring UFH in ECMO.
Table 1 Comparison of laboratory tests for UFH monitoring in ECMO
Advantages Disadvantages
ACT
4

- Rapid result
- Performed at bedside
- Whole blood
- Results vary between devices
- Influenced by many factors
- Poor correlation with UFH dose
7-9
- Not automatically reported in the
UWHC EMR
aPTT
4

- Better correlation with heparin
dose (vs. ACT)
8
- Widely used
10
- Sensitivity can vary based on
several factors
- Results vary between institutions
10
- Longer result time
Anti-Xa
10

- Minimal influence from other
factors
- Better correlation with heparin
dose (vs. aPTT)
8,9
- Less familiarity with test among
clinical staff
- Longer result time
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8
UFH is a high alert medication. An additional double-check is required as specified in Hospital
Administrative Policy 8.33 and must be performed on all boluses, when IV pump programming
is outside of the established IV pump decision support software (Alaris Guardrails®) limits, when
a new bag of heparin is hung, and at each shift change.
Recommendations
UFH intravenous infusions with the intent for use in ECMO must be ordered via the Adult IP
ECMO Heparin Anticoagulant – Supplemental Order Set. Listed in this guideline are
recommendations for monitoring and adjusting the heparin infusion. Separate order sets are
available for standard therapeutic heparin.
1. Baseline monitoring of ECMO UFH infusion
1.1. Collection of baseline PT/INR and ACT prior to initiating the UFH infusion if not already
available is reasonable (Class IIa, Level B)
1.2. Collection of baseline CBC and platelet count prior to initiating the UFH infusion if not
already available is recommended (Class I, Level A)
2. Initiation of UFH in fusion for ECMO
2.1. Initial bolus doses may be reasonable for standard bleed risk patients (Class IIb, Level
C)
2.1.1. Bolus doses are based on actual body weight (Class I, Level B)
2.1.2. Round doses to the nearest 100 units for ease of preparation (Class I, Level C)
Table 2. Initial Dosing of ECMO UFH infusion (Class IIb, Level C)
Patient Status
Bolus Dose
(units/kg)
Maximum Bolus
(units)
Initial Infusion
(units/kg/hr)
High Bleed Risk None N/A 20
Standard Bleed Risk 100 10,000 40
2.2. Initial starting rate should be based on actual body weight (Class I, Level C)
2.3. Use a concentration of UFH for ECMO in adults of 87,500 units in 250 mL D5W
2.4. Upon initiation of the UFH infusion, ACT levels are reasonable to check every hour for
the first 6 hours, or until the first anti-Xa level is resulted (Class IIa, Level C)
2.5. Recommended ACT target range: 180-220 seconds (Class I, Level C)
2.6. UFH infusion rate titration may be considered using the suggested titration nomogram
listed in Table 3 (Class IIb, Level C)
Table 3. Titration of ECMO UFH infusion by ACT (Class IIa, Level C)
ACT (seconds) Bolus/Hold Infusion Rate Change
< 180 Consider bolus 20 units/kg ↑ by 2 units/kg/hr
180 – 220 None
NO CHANGE;
Therapeutic Range
221 – 250 None ↓ by 2 units/kg/hr
> 250 Hold infusion until ACT < 250 ↓ by 3 units/kg/hr
3. Suggested maintenance monitoring and titration of ECMO UFH infusion
3.1. The anti-Xa level is reasonable for maintenance titration of the UFH infusion
11
(Class
IIa, Level B)
3.2. It is reasonable to check anti-Xa 6 hours after initiation and every 6 hours thereafter
11

(Class IIa, Level B)
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9
3.2.1. If the infusion is held for an elevated level and restarted, it is reasonable to check
anti-Xa 6 hours after the infusion was restarted
11
(Class IIa, Level B)
3.2.2. If the infusion is held for a procedure, it is reasonable to restart at the previous
infusion rate and check an anti-Xa 6 hours after the infusion was restarted
11
(Class
IIa, Level B)
3.3. Do NOT titrate the UFH infusion with both anti-Xa levels and ACT or aPTT (Class III,
Level C)
3.4. It can be beneficial to monitor ECMO UFH initiation, stable conditions, and active
bleeding or clotting as shown in Table 4
11
(Class IIa, Level B)
Table 4. Suggested laboratory monitoring schedule for ECMO
11
(Class IIa, Level B)
Condition ACT Anti-Xa
Initiation Q1H After 6 hours
Stable PRN Q6H
Bleeding or
Clotting
Q1H or PRN Q6H or PRN
3.5. It can be effective to target an anti-Xa target range of 0.3-0.7
11
for standard bleed risk
patients. Adjust the UFH infusion rate based on the nomogram in Table 5. (Class IIa,
Level B)
3.6. It can be effective to target an anti-Xa target range of 0.2-0.4 in high bleed risk patients.
Adjust the UFH infusion rate based on the nomogram in Table 6 (Class IIa, Level C)
Table 5. Standard bleed risk ECMO UFH titration nomogram by anti-Xa (Target 0.3 – 0.7)
Heparin Level by
Anti-Xa (IU/mL)
Bolus/Hold Infusion Rate Change
< 0.1 Contact MD for bolus (40 units/kg) ↑ by 3 units/kg/hr
0.10 – 0.19 Contact MD for bolus (20 units/kg) ↑ by 2 units/kg/hr
0.2 – 0.29 None ↑ by 1 unit/kg/hr
0.3 – 0.7 None
NO CHANGE;
Therapeutic Range
0.71 – 0.8 None ↓ by 1 unit/kg/hr
0.81 – 1.7 Hold infusion x1 hr ↓ by 2 units/kg/hr
>1.7 Hold infusion x1.5 hr & contact MD ↓ by 3 units/kg/hr
Table 6. High bleed risk ECMO UFH titration nomogram by anti-Xa (Target 0.2 – 0.4)
Heparin Level by
Anti-Xa (IU/mL)
Bolus/Hold Infusion Rate Change
< 0.1 Contact MD for bolus (20 units/kg) ↑ by 2 units/kg/hr
0.1 – 0.19 None ↑ by 1 unit/kg/hr
0.2 – 0.4 None
NO CHANGE;
Therapeutic Range
0.41 – 0.6 None ↓ by 1 unit/kg/hr
0.61 – 1 None ↓ by 2 units/kg/hr
> 1 Hold infusion x 1 hr & contact MD ↓ by 3 units/kg/hr
4. Additional monitoring (see Table 7)
11
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10
4.1. Hemoglobin/hematocrit and platelets must be followed every 8 hours after initiating
ECMO UFH therapy until UFH these levels are determined to be stable or until UFH is
discontinued. Once stable, the frequency of monitoring may be reduced to every 24
hours. (Class I, Level A)
4.1.1. If blood product replacement is necessary, hemoglobin/hematocrit and platelets
are reasonable to re-draw 1 hour after transfusion completion (Class IIa, Level B)
4.2. PT/INR and fibrinogen may be reasonable to follow daily while receiving ECMO UFH
therapy (Class IIb, Level B)
4.2.1. If blood product replacement is necessary, PT/INR and fibrinogen it may be
reasonable to re-draw 4 hours after completion of transfusion (Class IIa, Level B)
4.3. At least every 8 hours, inspect line/surgical/wound sites for bleeding and check patient
for symptoms indicating bleeding such as hematomas or enlargement of hematoma,
new bruising, or extension of bruising. Contact MD if any signs of bleeding. (Class I,
Level C)
4.4. Antithrombin III (ATIII) activity is reasonable to be drawn only as needed when there is
evidence of or concern for heparin resistance (i.e. rate of infusion >60 units/kg/hr)
11

(Class IIa, Level B)
4.4.1. It is reasonable to replace ATIII only if there is both a rate of heparin infusion
>60 units/kg/hr AND an ATIII activity <50% (Class IIa, Level B)
4.4.2. A target ATIII activity of 50-100% for replacement is reasonable (Class IIa, Level
C)
4.4.3. There is a lack of evidence in regards to the need to replace ATIII in ECMO
patients receiving UFH, and the need to replace ATIII above a level of 50% is likely
unnecessary
4.4.4. If ATIII replacement is performed, an ATIII activity may be considered 2 hours
after completion of transfusion to determine if ATIII activity is within the 50-100%
target range or if a repeat dose is necessary (Class IIb, Level C)
4.4.5. Following replacement of ATIII, it is reasonable to use ACT levels for titration of
the UFH infusion until the next anti-Xa level is resulted (see Table 3). Titration of
the UFH infusion by anti-Xa should then be resumed (Class IIa, Level B)
4.5. Thromboelastography (TEG) may be considered as needed for bleeding and
thrombotic complications in order to assist clinicians by providing a framework for blood
product replacement in ECMO patients (Class IIb, Level C)
4.5.1. If TEG is ordered in an ECMO patient receiving UFH, both “TEG – Patient not on
Heparin” and “TEG – Patient on Heparin” lab tests should be ordered. TEG should
only be ordered by a provider with the ability to interpret the results
Table 7. Suggested clinical monitoring parameters for ECMO
11
(Class IIa, Level B)
Condition
PT/INR
Fibrinogen
Hemoglobin/
Platelets
AT III TEG
Stable QAM
Q8H for the first
24H, then QAM
If UFH infusion
>60 units/kg/hr
PRN
Bleeding or
Clotting
Treat and redraw
after 4 hr
Treat and redraw
after 1 hr
PRN PRN
5. Use of argatroban in ECMO for heparin-induced thrombocytopenia (HIT)
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11
5.1. Acceptable indications for the use of argatroban in patients receiving ECMO:
5.1.1. High clinical suspicion or documented laboratory evidence for HIT (Class I,
Level A)
5.1.1.1. See the UWHC Heparin Induced Thrombocytopenia – Adult – Inpatient –
Clinical Practice Guideline for recommendations on screening and diagnosis
of HIT
5.1.2. Documented patient history of HIT (Class I, Level A)
5.2. Recommended baseline monitoring of argatroban infusion
5.2.1. Collect baseline PT/INR and aPTT prior to initiating the argatroban infusion if not
already available (Class I, Level C)
5.2.2. Collect baseline CBC and platelet count prior to initiating the argatroban infusion
if not already available (Class I, Level C)
5.3. Initiation of argatroban infusion for ECMO
5.3.1. Bolus doses are not routinely recommended (Class III, Level C)
5.3.2. Initial starting rate should be based on actual body weight (Class IIa, Level C)
5.3.2.1. Suggested starting dose: 0.2 mcg/kg/min
12,13
(Class IIa, Level B)
5.3.2.2. Higher doses may be required with concomitant CVVH therapy (Class IIb,
Level C)
5.4. Suggested maintenance monitoring and titration of argatroban infusion for ECMO
5.4.1. It is reasonable to check aPTT 2 hours after initiation and/or 2 hours after any
rate change (Class IIb, Level C)
5.4.1.1. Once the aPTT is within target range for 2 consecutive measurements, the
aPTT may be reasonable to check every 6 hours (Class IIb, Level C)
5.4.2. If the infusion is held for an elevated level and restarted, it may b e reasonable to
check aPTT 2 hours after the infusion was restarted (Class IIb, Level C)
5.4.3. Do NOT titrate the argatroban infusion with both ACT and aPTT (Class III, Level
C)
5.4.4. Contact the physician responsible for the heparin infusion after each aPTT lab
result for infusion titration orders
5.4.5. Adjust the argatroban infusion rate as indicated using the ordered titration
nomogram (Class I, Level C)
5.4.5.1. See Table 11 from the UWHC Heparin Induced Thrombocytopenia – Adult –
Inpatient – Clinical Practice Guideline for a suggested argatroban dosing
nomogram
5.4.6. A reasonable aPTT therapeutic range is 1.5 – 3 times the baseline aPTT (Class
IIa, Level C)
5.4.6.1. Since the aPTT is not directly influenced by the effects of argatroban, clinical
evidence of clot formation might be considered addition to laboratory
measures when making argatroban dose adjustments (Class IIb, Level C)
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12
UW Health Implementation
Potential Benefits:
The benefits of implementation of this guideline include providing a standardized approach for
the management and monitoring of UFH in ECMO. While literature support is limited, available
data demonstrates that defined management results in decreased bleeding events, decreased
blood transfusion, and increase in circuit life
11
.
Potential Harms:
While it is anticipated that the overall safety and quality of UFH management will be improved
after guideline implementation there is a risk for acute bleeding. Additionally, patients receiving
ECMO can not only experience bleeding but also have a risk for thrombosis which in some
cases may require the need for circuit exchange.
Implementation Plan/Tools
1. Guideline will be housed on U-Connect, Pediatric ICU and ECMO workspaces and on the
UW Health Anticoagulation Web page.
2. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice newsletter.
3. Nursing education will be completed at the pediatric unit staff meeting
4. Links to this guideline will be updated and/or added in appropriate Health Link or equivalent
tools, including: IP ECMO Heparin Anticoagulant – Supplemental Order Set
Disclaimer
Clinical Practice Guidelines (CPGs) are described to assist clinicians by providing a framework
for the evaluation and treatment of patients. This CPG outlines the preferred approach for most
patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all
patients. It is understood that some patients will not fit the clinical condition contemplated by a
guideline and that a guideline will rarely establish the only appropriate approach to a problem.
References
1. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline
methodology summit report: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. 2013;61(2):213-265.
2. Kliegman R, Stanton B, St. Geme J, Schor N, Behrman R. Nelson Textbook of
Pediatrics, Nineteenth Edition. Philadelphia, PA: Saunders; 2011.
3. ECMO Registry of the Extracorporeal Life Support Organization (ELSO), Ann Arbor,
Michigan, January 2014. www.elso.org.
4. Esper SA, Levy JH, Waters JH, Welsby IJ. Extracorporeal membrane oxygenation in the
adult: a review of anticoagulation monitoring and transfusion. Anesth Analg.
2014;118(4):731-743.
5. Garcia DA, Baglin TP, Weitz JI, Samama MM. Parenteral anticoagulants: Antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e24S-43S.
6. ECMO Registry of the Extracorporeal Life Support Organization (ELSO), Ann Arbor,
Michigan, January 2014. www.elso.org.
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13
7. Atallah S, Liebl M, Fitousis K, Bostan F, Masud F. Evaluation of the activated clotting
time and activated partial thromboplastin time for the monitoring of heparin in adult
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9. Bembea MM, Schwartz JM, Shah N, et al. Anticoagulation monitoring during pediatric
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time for monitoring unfractionated heparin. Pharmacotherapy. 2012;32(6):546-558.
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oxygenation anticoagulation laboratory protocol is associated with decreased blood
product use, decreased hemorrhagic complications, and increased circuit life. Pediatr
Crit Care Med. 2015;16(1):66-74.
12. Beiderlinden M, Treschan TA, Gorlinger K, Peters J. Argatroban anticoagulation in
critically ill patients. Ann Pharmacother. 2007;41(5):749-754.
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org

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Appendix A: Quality of Evidence and Strength of Recommendation Grading Matrix
1

Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org