Systematic review and meta-analysis of the clinical effectiveness of point-of-care testing for anticoagulation management during ECMO

STUDY OBJECTIVE: Viscoelastic point-of-care (POC) tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients on ECMO. We evaluated the clinical effectiveness of point-of-care (POC) testing for anticoagulation management in patients on extracorporeal membrane oxygenation (ECMO). DESIGN: Systematic review and meta-analysis. Eligible studies evaluating the use of thromboelastography- or thromboelastometry-guided algorithms, anti-factor Xa and platelet function testing were selected after screening the literature from July 1975 to January 2020. SETTING: Patients on ECMO support. PATIENTS: Anticoagulation management on ECMO patients. INTERVENTIONS: Rotational thromboelastometry, thromboelastography, alone or combined with platelet function testing. Trials monitoring the anticoagulation effects during ECMO using an anti-factor Xa assay were included in the systematic review. MEASUREMENTS: The primary outcomes were bleeding events, surgical revisions, thrombosis events and ECMO circuit change/failure. Secondary outcomes were blood-product transfusions, cerebrovascular accidents, mortality on ECMO, ECMO duration, intensive care unit and hospital discharge rates, and in-hospital mortality. MAIN RESULTS: Thirty-one trials enrolling 1684 participants were included in the systematic review. Four trials enrolling 547 subjects were included in the meta-analysis. The use of a POC testing device resulted in improved detection of surgical bleeding (RR: 0.68, 95% CI 0.49 to 0.94, I2 = 0%; χ2 test for heterogeneity, P = 0.02). The use of POC-guided algorithms did not affect bleeding (RR:0.78, 95% CI 0.58 to 1.04, I2 = 47%; χ2 test for heterogeneity, P = 0.09), thrombosis events (RR:1.35, 95% CI 0.86 to 2.12, I2 = 37%; χ2 test for heterogeneity, P = 0.19), or ECMO circuit/change (RR:0.90, 95% CI 0.48 to 1.71, I2 = 28%; χ2 test for heterogeneity, P = 0.75). CONCLUSION: Routine use of POC tests did not improve the main clinical outcomes beyond suggesting a diagnosis of surgical bleeding in ECMO patients.

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A systematic review of 31 ECMO anticoagulation trials (1684 patients) included a meta-analysis of 4 trials (547 patients); point-of-care testing improved detection of surgical bleeding (RR 0.68) but did not significantly reduce bleeding, thrombosis events, or ECMO circuit change or failure.

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