(1274) Quality Improvement Initiative for Utilization of TEG Data to Manage Neonatal ECMO Anticoagulation

Introduction: Developmental hemostasis suggests age related physiologic changes in the coagulation system as it matures from fetal life to adulthood. Published data demonstrate that routinely used anticoagulation measures in neonatal and pediatric extracorporeal membrane oxygenation (ECMO), including anti-Xa, aPTT, and ACT levels, poorly correlate and are not associated with clinically relevant hematologic complications. New research suggests that viscoelastic tests, such as thromboelastography (TEG), provide real-time assessment of clot formation and lysis. Clinically, TEG appears to be a rapid and accurate assessment of coagulation in neonates and infants, which could be essential in preventing complications in patients on ECMO.

Methods: Using standard QI (Quality Improvement) methodology, we aimed to increase the frequency of routinely obtained TEG data, in addition to standard anticoagulation labs, for neonatal ECMO patients by 50% in the first 6 months after modifying our existing protocol. We completed a retrospective chart review of baseline anticoagulation markers, including TEG, for neonates on ECMO or on heparin for other reasons, from 2015-2022. We surveyed our multidisciplinary PICU (Pediatric Intensive Care Unit) and ECMO teams to assess perceptions of our institution's ECMO anticoagulation protocol, comfort with titrating heparin infusions based on TEG data, and understanding of TEG interpretation.

Results: In the first 10 months, utilization of the modified ECMO anticoagulation protocol was 100% (n=3). Of the 34 pre-implementation survey respondents, most felt it was unclear which anticoagulation lab was used to titrate the heparin infusion during an ECMO run (65%), that we collect too many labs not utilized in daily anticoagulation titration (75%), and are willing to reduce the quantity of labs drawn for monitoring ECMO anticoagulation (85%). The survey identified a desire to utilize TEG data for anticoagulation titration and a need for education to enhance understanding of TEG data.

Conclusions: Modifications to our institution’s ECMO anticoagulation protocol allow for increased analysis of TEG data. We suspect future changes to our protocol and further provider education will reduce excessive blood draws and transfusions due to anticoagulation monitoring in the neonatal ECMO population.