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Research Snapshot Theater: Pharmacology, Pediatric I

Practice Variation in Anticoagulation With Direct Thrombin Inhibitors During ECMO

Monday, March 23, 2026
2:30 PM - 3:30 PM Central Time
Location: Connections Central - RST 08

  • Shubhi Kaushik, MD

    Mount Sinai Kravis Children's Hospital

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • DM

    Desiree S. Machado, MD

    Associate Professor
    D'Or Institute for Research and Education(IDOR), Sao Paulo, Brazil, Brazil

    Disclosure information not submitted.

  • AS

    Ahmed Said, MD, PhD

    Assistant Professor of Pediatrics, Division of Critical Care Medicine
    Institute of Informatics, Biostatistics and Data Science, Washington University, St. Louis School of Medicine

    Disclosure information not submitted.

  • MY

    Margaret Yang, MD

    PCCM Fellow
    Icahn School of Medicine at Mount Sinai

    Disclosure information not submitted.

  • SA

    Scott Aydin, MD

    Associate Professor
    Mount Sinai Kravis Children's Hospital

    Disclosure information not submitted.

  • Peta Alexander, MBBS, FRACP, FCICM

    Boston Children's Hospital, Massachusetts

    Disclosure information not submitted.

  • Ryan Barbaro, MD, MS

    University of Michigan Health System

    Disclosure information not submitted.

Introduction: Understanding current practice variability is crucial for informing future trials and optimizing anticoagulation strategies in Extracorporeal Membrane Oxygenation (ECMO). A 2019 survey of ECMO medical directors reported only 6% of pediatric ECMO centers used bivalirudin as a primary anticoagulant. Since then, several single-center reports describe the use of direct thrombin inhibitors (DTIs), particularly bivalirudin, as a primary anticoagulant. To assess current practice variation in the use of direct thrombin inhibitors for anticoagulation management in neonatal and pediatric ECMO across the United States.


Methods: A cross-sectional survey study was conducted in 2024 targeting ECMO medical directors at U.S. centers identified through the Children's Hospital Association and Extracorporeal Life Support Organization registry.


Results: A total of 107 centers were contacted, and 77 responses were received. After removing duplicate and unidentifiable responses, 73 unique center responses were analyzed, yielding a response rate of 68%. Bivalirudin is used in 75% centers (55/73) for anticoagulation, with 49% centers (36/73) using it as the primary anticoagulant. Ninety percent of centers have a written institutional protocol for the use of bivalirudin. Activated partial thromboplastin time is used by the majority of centers for monitoring anticoagulation. Additional tests employed by some centers include activated clotting time, direct thrombin time, kaolin thromboelastography, direct thrombin inhibitor-specific assays, chromogenic anti-IIa assay, and clotting time. For non-bleeding neonates and infants, the most commonly reported starting dose of bivalirudin is between 0.15 and 0.3 mg/kg/hr, while for non-bleeding pediatric patients, the typical starting dose is 0.3 mg/kg/hr. Among surveyed centers using DTIs, only one center reported using bivalirudin for circuit priming, and two centers reported using a bolus dose before initiating infusion. When transitioning off ECMO, 25 centers reported switching to heparin, while 11 centers administered a heparin bolus directly to the circuit.


Conclusions: There is a notable increase in the use of DTIs in ECMO. However, significant practice variation exists across centers.