Prospective Exploratory Experience With Bivalirudin Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation
| Autor: | Mary E. Bauman, Kelsey R Balutis, Laurance Lequier, Lee-Ann Nelson, Lindsay M. Ryerson, Donald A. Granoski, M. Patricia Massicotte |
|---|---|
| Rok vydání: | 2020 |
| Předmět: |
medicine.medical_treatment
Activated clotting time Pilot Projects 030204 cardiovascular system & hematology Critical Care and Intensive Care Medicine 03 medical and health sciences Extracorporeal Membrane Oxygenation 0302 clinical medicine Bolus (medicine) Interquartile range medicine Extracorporeal membrane oxygenation Humans Bivalirudin Prospective Studies Child Retrospective Studies medicine.diagnostic_test Heparin business.industry Anticoagulants 030208 emergency & critical care medicine Hirudins medicine.disease Thrombosis Peptide Fragments Recombinant Proteins Anesthesia Pediatrics Perinatology and Child Health business medicine.drug Partial thromboplastin time |
| Zdroj: | Pediatric Critical Care Medicine. 21:975-985 |
| ISSN: | 1529-7535 |
| Popis: | OBJECTIVES Objective of this study was to determine if bivalirudin resulted in less circuit interventions than unfractionated heparin. A secondary objective was to examine associations between bivalirudin dose and partial thromboplastin time, international normalized ratio, and activated clotting time. DESIGN Prospective observational. SETTING Medical-surgical and cardiac PICUs. PATIENTS Neonatal and pediatric extracorporeal membrane oxygenation patients who received bivalirudin anticoagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty extracorporeal membrane oxygenation runs in 18 patients used bivalirudin; 90% were venoarterial. Median (interquartile range) age was 4.5 months (1.6-35 mo). Thirteen patients (72%) had an underlying cardiac diagnosis. Of the 20 runs using bivalirudin, 16 (80%) were initially started on unfractionated heparin and transitioned to bivalirudin due to ongoing circuit thrombosis despite therapeutic anti-Xa levels (n = 13), ongoing circuit thrombosis with unfractionated heparin greater than or equal to 40 U/kg/hr (n = 2), or absence of increase in ACT after bolus of 100 U/kg of unfractionated heparin and escalation of unfractionated heparin infusion (n = 1). Initial bivalirudin dose ranged from 0.2 to 0.5 mg/kg/hr; no bolus doses were used. Median (range) bivalirudin dose was 0.9 mg/kg/hr (0.15-1.6 mg/kg/hr). Median (interquartile range) time on extracorporeal membrane oxygenation was 226.5 hours (150.5-393.0 hr) including 84 hours (47-335 hr) on bivalirudin. Nonparametric results are as follows: the rate of circuit intervention was significantly lower in patients on bivalirudin than on unfractionated heparin (median [interquartile range]: 0 [0-1] and 1 [1-2], respectively; Wilcoxon p = 0.0126). Bivalirudin dose was correlated to PTT (rs = 0.4760; p < 0.0001), INR (rs = 0.6833; p < 0.0001), and ACT (rs = 0.6161; p < 0.0001). Four patients had a significant bleeding complication on bivalirudin. Survival to hospital discharge was 56%. CONCLUSIONS Bivalirudin appears to be a viable option for systemic anticoagulation in pediatric extracorporeal membrane oxygenation patients who have failed unfractionated heparin, but questions remain namely its optimal monitoring strategy. This pilot study supports the need for larger prospective studies of bivalirudin in pediatric extracorporeal membrane oxygenation, particularly focusing on meaningful monitoring variables. |
| Databáze: | OpenAIRE |
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