Use of bivalirudin for anticoagulation in pediatric extracorporeal membrane oxygenation (ECMO)

Abstract

This study describes the use of bivalirudin in children on extracorporeal membrane oxygenation (ECMO). Pediatric patients receiving bivalirudin were compared to patients receiving heparin as the anticoagulant on ECMO. Data was collected for children under 18 years of age supported by ECMO from January 2016 to December 2019. Data collected included demographics, diagnosis, ECMO indication, type, and duration, indication for bivalirudin use, dose range, activated partial thromboplastin time (aPTT) levels, minor and major bleeding, hemolysis, and mortality. Forty pediatric patients received ECMO; eight received bivalirudin primarily for anticoagulation. The median age was 4 months (IQR 0.5, 92) in the heparin cohort, 0.6 months (IQR 0.0, 80.0) in the primary bivalirudin cohort. The indication for ECMO was respiratory in 5 patients (18%) in the heparin group versus 6 (75%) in the primary bivalirudin group, cardiac in 18 (67%) in heparin versus 1 (12.5%) in primary bivalirudin, and extracorporeal-cardiopulmonary resuscitation (E-CPR) in 4 (15%) in heparin versus 1 (12.5%) in primary bivalirudin. Bivalirudin was the initial anticoagulant for eight patients (66.6%) while three (25%) were switched due to concern for heparin-induced thrombocytopenia (HIT) and one (8%) for heparin resistance. The median time to achieve therapeutic aPTT was 14.5 hours compared to 12 hours in the heparin group. Sixty-five percent of aPTT values in the bivalirudin and 44% of values in the heparin group were in the therapeutic range in the first 7 days. Patients with primary bivalirudin use had significantly lower dose requirement at 12 (p = 0.003), 36 (p = 0.007), and 48 (p = 0.0002) hours compared to patients with secondary use of bivalirudin. One patient (12.5%) had major bleeding, and two patients (25%) required circuit change in the primary bivalirudin cohort. Bivalirudin may provide stable and successful anticoagulation in children. Further large, multicenter studies are needed to confirm these findings.

Is bivalirudin an alternative anticoagulant for extracorporeal membrane oxygenation (ECMO) patients? A systematic review and meta-analysis

“…No articles on the subject were found in CNKI. After screening and evaluation, ten articles [12][13][14][15][16][17][18][19][20][21] were finally included for qualitative synthesis, and nine articles [12][13][14][15][16][17][19][20][21] were included in the meta-analysis because one reference [18] met the inclusion criteria but the data of outcome presented could not be pooled in a meta-analysis. The literature retrieval and screening processes are shown in Fig.…”

“…All data generated or analyzed during this study are included in this published article (shown in Reference [9][10][11][12][13][14][15][16][17][18]).…”

Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis

“…In total 17 studies published from years 2011 to 2022 and one unpublished study were included in this metaanalysis [9][10][11][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63]. All studies had a retrospective study design and only one study was multi-center.…”

The Changing Landscape of Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation: Use of the Direct Thrombin Inhibitors

“…There is also no consensus on whether a loading dose should be used or not. In studies comparing the 2 strategies, the difference in time to achieving therapeutic levels was only 4 h ( 27 ). Further studies are required to determine the safety and risk for bleeding with bolus dosing.…”