Change in anticoagulation management to Anti-Xa monitoring during COVID-19 Pandemic to avoid ICH in VV ECMO patients

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.