Bivalirudin in pediatric patients maintained on extracorporeal life support
Research article published in Pediatric critical care medicine (2013)
Abstract
OBJECTIVE: Anticoagulation with heparin is standard of care for patients maintained on extracorporeal life support. Very limited evidence exists for the use of alternative anticoagulants during extracorporeal life support. Patients with heparin-induced thrombocytopenia, heparin resistance, and evidence of significant thrombosis while on heparin may be candidates for alternative anticoagulation. The objective of this analysis is to present evidence for the use of bivalirudin during extracorporeal life support in pediatric patients. DESIGN: Case series. SETTING: University of California, Davis Medical Center. PATIENTS: Twelve critically ill, pediatric patients receiving bivalirudin for anticoagulation during extracorporeal life support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twelve patients meeting entry criteria received bivalirudin during the study period. The median patient age was 8 days (range, 1 d to 6 yr). Eight patients were neonates. Eight patients were male. Nine patients were supported with venoarterial extracorporeal life support. Median duration of extracorporeal life support was 226 hours (range, 111-913) and median time on bivalirudin was 92 hours (range, 60-230). Bivalirudin bolus doses were administered to select patients without bleeding complications. The maintenance dose that corresponded with initial target activated partial thromboplastin time ranged from 0.045 to 0.48 mg/kg/hr with a median rate of 0.16 mg/kg/hr. The median dose for days 1, 3, and 5 was 0.135, 0.175, and 0.267 mg/kg/hr, respectively. The correlation (r2) between dose adjustment and activated partial thromboplastin time response was 0.264. CONCLUSIONS: This is the largest case series describing the use of a direct thrombin inhibitor in pediatric extracorporeal life support patients. The maintenance dose range reflected considerable inter-patient variability. There was an observed increase in dose requirements with time. Bivalirudin, with close monitoring, is a potential option for pediatric patients on extracorporeal life support who have developed heparin-induced thrombocytopenia, heparin resistance, or significant thrombosis while on heparin.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Bivalirudin in pediatric patients maintained on extracorporeal life support.
Why This Matters for Hirudotherapy
This case series—described by the authors as the largest for a direct thrombin inhibitor in pediatric extracorporeal life support—reports 12 critically ill pediatric patients who received bivalirudin for anticoagulation. The study provides dosing observations including a maintenance dose range with considerable inter-patient variability, a weak correlation between dose adjustment and aPTT response, and an observed increase in dose requirements over time. The abstract makes no mention of hirudin, leeches, or any relationship to hirudotherapy, so no defensible ASH connection can be drawn. As a case series without a control group, it cannot support direct comparative efficacy claims, and findings are limited to a specific vulnerable pediatric population.
Citation
Bivalirudin in pediatric patients maintained on extracorporeal life support
Nagle EL et al. · Pediatric critical care medicine, 2013
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