Standard Heparin Anticoagulation

Standard unfractionated heparin will be used for routine

anticoagulation for all children on ECMO

1. Heparin dose at cannulation = 75u/kg (on surgeons instructions)

2. Standard Heparin concentration of 1ml/hr = 25u/kg/hr (1250
units Heparin x wt in 50ml 0.9% saline)
3. Start infusion of 25 u/kg/hr when ACT < 300
4. Alter heparin infusion rate in increments of 5 u/kg/hr
(0.2ml/hr increment or decrement) if change in anticoagulation
needed. Do not bolus(even if platelets are being given etc)
5. Do not alter heparin on single ACT values
6. ACTs have wide variability in individual patients and do not
guarantee an anticoagulant state.
7. Primarily use Anti-Xa level to guide heparin dosage This is
specific for measuring Heparin effect on anticoagulation cascade
8. Hourly ACT monitoring remains useful as approximate safety
margin whilst awaiting AntiXa levels. Only act on ACTs if three
repeated samples, 30 minutes apart remain abnormal
(acceptable range between 180 to 250 seconds)
9. DO NOT STOP HEPARIN: Get Consultant opinion

1.
2.
3.
4.

Heparin levels (Anti-Xa) Target: 0.4 to 1.0 u/ml

Reason for using Anti-Xa levels on ECMO

Heparin has a high affinity for antithrombin in blood

Heparin binds to antithrombin, which activates factor X to Xa
Heparin-Antithrombin complex binds thrombin
This stops free thrombin from activating fibrinogen
Clots formation is thus reduced (fibrin inhibited)
Anti-Xa assay specifically determines the anticoagulant activity of
unfractionated heparin by measuring the ability of heparin-bound
Antithrombin (AT) to inhibit a single enzyme, Factor Xa
The lab test takes an hour or two to perform and is labour intensive
The sample also needs to go on ice to inactivate platelets

Heparin levels should be done after 6hrs on ECMO and at least once
per shift or following any major changes in patient/circuit bleeding or
thrombosis

Ensure sample is labelled Unfractionated heparin on ECMO

when sent to haematology lab

Target Anti-Xa level range in 0.4 to 1.0 u/ml

Levels should be obtained once per shift
Measure ACT hourly as approx bedside guide to clotting
If >50ug/kg/hr heparin is needed then check antithrombin level

Decreasing heparin to target Anti-Xa value

1.
2.
3.
4.
5.

Reduce by 5u/kg/hr until target Anti-Xa reached.

Measure ACT every 30-60 min as approximate guide
Obtain Anti-Xa level 4 to 6 hrs after change in Heparin dose.
If urgent obtain anti-Xa level after 2 hrs of Heparin change
Discuss with Consultant if heparin rate < 20 u/kg/hr before any
further reductions in heparin rate made

Increasing heparin to target Anti-Xa value

6. Increase by 5u/kg/hr until target Anti-Xa reached.
7. Measure ACT every 30-60 min as approximate guide
8. Obtain Anti-Xa level 4 to 6 hrs after change in Heparin dose.
9. If urgent obtain anti-Xa level after 2 hrs of Heparin change
10. Discuss with Consultant if heparin rate > 35 u/kg/hr before any
further increments in heparin rate made. Ensure Antithrombin
levels adequate
Interpret Anti-Xa levels and ACT's in conjunction with other
parameters (Plts, Hb, Fibrinogen and degree of bleeding).
Standard Anti-Xa target

0.4 to 1.0 u/ml

Bleeding (reduce heparin)

0.4 to 0.6 u/ml

Major Bleeding

add Tranexamic acid

Microdose heparin

0.3 to 0.5 u/ml

Start on Heparin 25 u/kg/hr

Anti-Xa guided
Anticoagulation

(1ml/hr = 25u/kg/hr)
6 hrs

 heparin by 5 u/kg/hr

30u/kg/hr
6 hrs

<0.4 u/ml

Target Anti-Xa

 heparin by 5 u/kg/hr

>1 u/ml

0.4 and 1.0

6 hrs : Xa level remains >1 u/ml

remains <0.4 u/ml

Monitor ACTs hourly to ensure within safety range

 heparin by 5 u/kg/hr

35u/kg/hr + FFP
6 hrs

remains <0.4 u/ml

40u/kg/hr + discuss
with consultant
Ensure ATIII till >80% predicted for age
(FFP or concentrated ATIII in needed)

 heparin 5u/kg/hr every 6hrs to

max 60 u/kg/hr

Discuss with Consultant

Acceptable safety range = ACT 180 to 250 sec

Do not change heparin if ACTs within this range
If ACT outside range (sample 1) repeat after 30 minutes
(sample 2) & troubleshoot potential causes.
If sample 2 remains abnormal then repeat again after
further 30 minutes (sample 3)

 heparin by 5 u/kg/hr

20u/kg/hr

If all 3 samples are outside range then obtain urgent

Anti-Xa and adjust heparin dose accordingly
If likely delay in Anti-Xa results then discuss interim
action plan with consultant

 heparin by 5 u/kg/hr

15u/kg/hr (Xa level in 2hrs)

6 hrs : Xa level remains >1 u/ml

Discuss with Consultant

 heparin by 5 u/kg/hr

10u/kg/hr (Xa level in 2hrs)

(Risk of circuit clotting +++)
Reducing heparin to 10u/kg/hr or
stopping heparin should be extremely
rare event in non-responsive life
threatening bleeding

Bleeding Protocol
Local bleeding from cannulae sites
1.
2.
3.
4.

Inspect cannulae sites

Try topical coagulants (thrombostat)
Pack cannulae sites carefully
If bleeding persists (or >1ml/kg/hr) notify surgeon

Generalised bleeding (>4 ml/kg/hr)

Step 1

Optimise clotting: Hb > 10, Plt >150,

INR < 1.5, Fibrinogen >2,

ACT 180-250
AntiXa 0.4 to1.0u/ml

Step 2

Target lower AntiXa level (reduce

heparin)

ACT 180-250
AntiXa <0.4. to 0.6 u/ml

Step 3

Tranexamic Acid Load 4 mg/kg 30

minutes IV, infusion of 1 mg/kg/hr

ACT 180-250
AntiXa <0.4. to 0.6 u/ml

Step 4

Consider surgical bleed: contact

surgeons

ACT 180-250
AntiXa <0.4. to 0.6 u/ml

Step 5

Microdose Heparin10u/kg/hr
(Consultant decision only)

ACT >160*
AntiXa 0.3 to 0.5u/ml

Step 6

Consider stopping heparin (Consultant

decision only)

Ignore ACT
AntiXa 0.2 to 0.4u/ml

*Poor correlation between ACT and clotting. target AntiXa levels as

priority even if ACTs outside of suggested reference range
Discuss any bleeding problems with ECMO lead (step 2 to Microdose
heparin) and stopping heparin to be made only by ECMO leads as
circuit may clot without anticoagulation
Ensure spare circuit available if needed

Do not act on single ACT readings. Interpret in conjunction

with Anti-Xa level. Get opinion from ECMO lead