Evaluation of Bivalirudin As an Alternative to Heparin for Systemic Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation
Research article published in Pediatric critical care medicine (2020)
Abstract
OBJECTIVES: Heparin is the universal anticoagulant for patients receiving extracorporeal membrane oxygenation support. However, heparin has many disadvantages, especially in young children, who develop heparin resistance. Recently our center has used bivalirudin, a direct thrombin inhibitor, for systemic anticoagulation in pediatric extracorporeal life support. Bivalirudin binds directly to thrombin with no need for antithrombin III and it inhibits both circulating and clot-bound thrombin. In this study, we sought to evaluate our experience with bivalirudin in pediatric extracorporeal life support. DESIGN: Retrospective chart review study of patients receiving extracorporeal membrane oxygenation support between October 2014 and May 2018. SETTING: Tertiary, academic PICU. PATIENTS: Sixteen patients receiving heparin and 16 patients receiving bivalirudin on extracorporeal life support were included in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients in the bivalirudin group had a median age of 31 months versus 59 months in the heparin group (p = 0.41). Recovery and extracorporeal membrane oxygenation decannulation were similar in both groups (56% in the heparin group and 62% in the bivalirudin group; p = 0.62). Time to reach goal therapeutic anticoagulation level was shorter in the bivalirudin group (11 vs 29 hr; p = 0.01). Bleeding events were fewer in the bivalirudin group, and there was no difference in the rate of thrombotic events between the two groups. Comprehensive cost analysis that includes anticoagulant, laboratories, and antithrombin III cost, showed that heparin anticoagulation therapy total cost was significantly higher than bivalirudin (1,184 dollars per day in heparin group vs 494 dollars per day in bivalirudin group; p = 0.03). Bivalirudin dose required to maintain target anticoagulation will increase over time, and this is associated with an increase in creatinine clearance and an increase in fibrinogen serum levels. CONCLUSIONS: This study showed that the use of bivalirudin in pediatric extracorporeal membrane oxygenation support is feasible, safe, reliable, and cost-effective in comparison to heparin. Further prospective randomized clinical trials are necessary to confirm our observations.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Evaluation of Bivalirudin As an Alternative to Heparin for Systemic Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation.
Why This Matters for Hirudotherapy
This retrospective chart review compared 16 pediatric ECMO patients receiving bivalirudin to 16 receiving heparin at a tertiary academic PICU. The bivalirudin group reached therapeutic anticoagulation faster (11 vs 29 hr; p=0.01), had fewer bleeding events with no difference in thrombotic events, and had significantly lower total anticoagulation cost ($494/day vs $1,184/day; p=0.03). The abstract describes bivalirudin as a direct thrombin inhibitor that binds thrombin without antithrombin III but does not mention hirudin, leeches, or any leech-derived product, so no defensible connection to ASH's hirudotherapy domain can be drawn from this source. The authors call for prospective randomized clinical trials to confirm their observations.
Citation
Evaluation of Bivalirudin As an Alternative to Heparin for Systemic Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation
Hamzah M et al. · Pediatric critical care medicine, 2020
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