Alexsander Santiago: When Was Your ECMO Anticoagulation Target Last Challenged?
Alexsander Santiago, Health Education Coordinator at Terapia Intensiva em Foco, shared a post on LinkedIn:
”When was your ECMO anticoagulation target last challenged?
RATE gives that question a randomized evidence base.
The Lancet trial enrolled 330 adults across seven Dutch ICUs; 320 were analyzed. It included VV and VA ECMO, excluding patients with a separate vital indication for full-dose anticoagulation.
Three strategies:
- Standard unfractionated heparin: aPTT two to two and a half times the baseline.
- Lower-target unfractionated heparin: aPTT one and a half to two times the baseline.
- Therapeutic subcutaneous low-molecular-weight heparin.
The primary composite combined severe bleeding and severe thromboembolism during ECMO with mortality at six months.
It occurred in 81 percent, 72 percent and 75 percent, respectively.
Both alternatives met noninferiority within the prespecified 7.5-percentage-point margin.
Bleeding was numerically lower; a statistically significant reduction was not demonstrated. RATE, The Lancet, 2026.
My reading: this supports a serious review of anticoagulation defaults, with careful attention to who the evidence applies to.
Noninferiority for a composite does not establish equivalent protection against every component.
Therapeutic LMWH also represents a distinct strategy, making ‘less heparin’ an incomplete description of the trial.
For an ECMO programme, I would bring four questions to the protocol review:
- Which patients match the trial population?
- What justifies the target for this patient today?
- Which findings should trigger reassessment?
- How will we review bleeding, thrombosis and circuit exchanges separately?
A revised target needs explicit exceptions, shared bedside judgment and an audit of what happens after implementation.
The useful institutional change would be to make the reasoning behind each target visible, with reassessment built into routine care.
What would RATE change first in your unit: the default target, patient selection or monitoring?”
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