The best method to monitor anticoagulation during extracorporeal membrane oxygenation (ECMO) is unknown. We conducted a prospective observational study in a tertiary pediatric intensive care unit. Anti-factor Xa (anti-FXa), antithrombin (AT), and factor VIII activity (FVIII) were measured in blood samples collected at 6, 12, and every 24h of ECMO. We enrolled 34 children who underwent 35 ECMO runs from April 2008–September 2010. ACT and heparin doses were higher, whereas anti-FXa levels were lower in neonates compared to infants/children. Median anti-FXa was 0.4 IU/mL, median AT was 60%, and median FVIII was 67%. Heparin infusion rate, anti-FXa, and AT increased, FVIII was stable, and ACT decreased with each day on ECMO. ACT had poor agreement with anti-FXa (42%). AT was inversely correlated with ACT (r=−0.33), even after adjusting for heparin dose, and positively correlated with anti-FXa (r=0.57). This study emphasizes the age differences as well as the variability over days of coagulation monitoring assays during ECMO. ACT is poorly correlated with anti-FXa and AT modifies the relationship between ACT and heparin dose, indicating that results should be interpreted with caution when managing anticoagulation on ECMO. Additional studies are warranted to determine optimal ECMO anticoagulation monitoring.

Contemporary studies of long-term outcomes in children supported on extracorporeal membrane oxygenation (ECMO) in the United States are limited. We enrolled 99 ECMO patients between July 2010 and June 2015 in a two-center prospective observational study that included neurologic and neuropsychologic evaluation at 6 and 12 months, using standardized outcome measures. Pre-ECMO, 20 (20%) had a pre-existing neurologic diagnosis, 40 (40%) had cardiac arrest, and 10 of 47 (21%) children with neuroimaging had acute abnormal findings. Of 50 children eligible for follow-up at 6 or 12 months, 40 (80%) returned for at least one visit. At the follow-up visit of longest interval from ECMO, the median Vineland Adaptive Behavior Scales-II (VABS-II) score was 91 (interquartile range [IQR], 81–98), the median Pediatric Stroke Outcome Measure (PSOM) score was 1 (IQR, 0–2), and the median Mullen Scales of Early Learning composite score was 85 (IQR, 72–96). Presence of new neuroimaging abnormalities during ECMO or within 6 weeks post-ECMO was associated with VABS-II score <85 or death within 12 months after ECMO. The Pediatric Cerebral Performance Category at hospital discharge showed a strong relationship with unfavorable VABS-II and PSOM scores at 6 or 12 months after ECMO. In this study, we report a higher prevalence of pre-ECMO neurologic conditions than previously described. In survivors to hospital discharge, median scores for adaptive behavior and cognitive, neurologic, and quality of life assessments were all below the general population means, but most deficits would be considered minor within each of the domains tested.