ABSTRACT
Introduction: At the outset of the COVID-19 pandemic we observed an unacceptably high incidence of intracranial hemorrhage during VV ECMO support for COVID-19 related respiratory failure. The relationship between PTT and Anti-Xa values was explored by pharmacy and facility ECMO leadership, and found COVID patients to have elevated Anti-Xa levels at prescribed PTT levels. Method(s): We retrospectively analyzed data of 38 adult COVID-19 VV ECMO patients at Massachusetts General Hospital from March 18, 2020 to February 1, 2022 for incidence of ICH before and after anticoagulation protocol was changed on May 12th 2020. Result(s): Prior to change in practice, ICH was present in 33% (n = 4) of all COVID+ VV ECMO runs (n = 12). ICH was present in 57% of all deaths (n = 7) during this period. On May 12th 2020, after a pharmacy review, along with regional/international meetings among many ECMO centers MGH initiated a new protocol for COVID-19 positive ECMO patients targeting an Anti-Xa range of 0.15-0.29 with heparin titration. After this change, there were a subsequent 26 VV ECMO runs meeting the criteria for this study. ICH was present in only 3.8 % of patients (n = 1). And was present 6.3% (n = 1) of all deaths (n = 16). Conclusion(s): Anti Xa guided anticoagulation strategy resulted in a 88% decrease in the incidence of ICH in COVID-19 positive VV ECMO patients during the time of this retrospective analysis and proved a safe alternative to PTT guided heparin therapy.