Comparison of two pediatric cases requiring the use of bivalirudin during cardiopulmonary bypass
Bryant ME, Regan WL, Fynn-Thompson F, Hoganson D, Nasr VG, Zaleski K, Faella K, Matte GS (2018) · Perfusion · n=2
Perfil del estudio
- Diseño
- case comparison of two pediatric cardiopulmonary bypass cases (bilateral lung transplant and ventricular assist device implantation) using identical bivalirudin protocol
- Tamaño de la muestra (n)
- 2
- Intervención
- Bivalirudin 1 mg/kg bolus + 50 mg pump prime + 2.5 mg/kg/h infusion titrated to K-ACT >400s during CPB
- Comparador
- Same protocol comparison between BLT and VAD implantation
- Punto final primario
- K-ACT achievement and dose titration requirements during pediatric CPB
- Resultado primario
- BLT case maintained K-ACT >720s despite reducing infusion to 0.5 mg/kg/h; VAD case required infusion increase to 5.0 mg/kg/h for low K-ACTs; both cases successful but highlight dose variability
- Duración del seguimiento
- CPB run duration
- PMID
- 29638202
Hallazgos clave
- 10-fold variability in bivalirudin dose requirements between two pediatric CPB cases
- BLT case over-anticoagulated, VAD case required dose escalation
- Same starting protocol but dramatically different titration needed
- Recommends minimum infusion of 0.5 mg/kg/h
- One-page timeline protocol shared for adoption
Limitaciones
- Only 2 cases - case comparison not generalizable
- Single-center experience
- Heterogeneous clinical scenarios (transplant vs VAD)
- K-ACT not validated against direct bivalirudin levels
- Not applicable to whole-leech hirudotherapy
Implicaciones clínicas
Bryant 2018 documents extreme inter-patient dose variability in pediatric CPB bivalirudin use, motivating individualized monitoring protocols. For ASH, this Boston Children's case comparison illustrates how the synthetic thrombin inhibitor pharmaceutical pathway requires substantial institutional protocolization, distinct from the K040187 device-leech US clinical practice where dose-equivalent considerations are clinically simpler (number and duration of leech sessions).
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