Bivalirudin Monitoring Using Dilute Thrombin Time in Pediatric Extracorporeal Membrane Oxygenation: Single-Center, Retrospective Cost Analysis, 2018-2023

OBJECTIVES: The parenteral anticoagulant bivalirudin has favorable safety and efficacy outcomes compared with unfractionated heparin (UFH) in pediatric patients requiring extracorporeal membrane oxygenation (ECMO), and is frequently monitored using the activated partial thromboplastin time (aPTT). Our group has demonstrated that the dilute thrombin time (dTT) provides superior reliability compared with the aPTT for bivalirudin monitoring, but there is a concern about access to using dTT and its cost. We report a comparative cost analysis of monitoring ECMO patients anticoagulated with bivalirudin or UFH. DESIGN: Retrospective analysis of total number of laboratory tests ordered at various time points during ECMO (5, 7, 10, 14, and 21 d) using 2024 institutional list prices for each test. SETTING: Single-center quaternary-care ICUs at Cincinnati Children's Hospital and Medical Center (CCHMC). PATIENTS: Children younger than 18 years supported on ECMO in our ICUs, anticoagulated with UFH (n = 46) or bivalirudin (n = 30) between January 2018 and August 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The total number of tests (complete blood count, prothrombin time, aPTT, fibrinogen, and antithrombin 3) ordered were lower in patients receiving bivalirudin compared with UFH across multiple time points of ECMO. In comparison with UFH, use of bivalirudin was associated with fewer total tests ordered and lower costs at both early and late time points. At CCHMC, dTT can be run at equivalent cost to aPTT. CONCLUSIONS: From 2018 to 2023, use of dTT monitoring for bivalirudin, rather than aPTT monitoring for UFH, during ECMO was associated with decreased laboratory testing and costs and is available on an automated or semi-automated platform. Overall, our data support the use of dTT-monitored bivalirudin during ECMO support, which is cost-efficient and may lead to reduction in total laboratory testing and blood volume sampling.

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