Bivalirudin in pediatric patients maintained on extracorporeal life support

Erin L. Nagle, William E. Dager, Jeremiah J. Duby, A. Josh Roberts, Laura E. Kenny, Manasa S. Murthy, Robert K. Pretzlaff

Research output: Contribution to journalArticle

29 Citations (Scopus)

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.

Original languageEnglish (US)
JournalPediatric Critical Care Medicine
Volume14
Issue number4
DOIs
StatePublished - May 2013

Fingerprint

Extracorporeal Membrane Oxygenation
Pediatrics
Heparin
Partial Thromboplastin Time
bivalirudin
Thrombocytopenia
Thrombosis
Antithrombins
Standard of Care
Critical Illness
Anticoagulants

Keywords

  • Anticoagulation
  • Bivalirudin
  • Extracorporeal life support
  • Extracorporeal membrane oxygenation
  • Heparin
  • Pediatric

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Critical Care and Intensive Care Medicine

Cite this

Nagle, E. L., Dager, W. E., Duby, J. J., Roberts, A. J., Kenny, L. E., Murthy, M. S., & Pretzlaff, R. K. (2013). Bivalirudin in pediatric patients maintained on extracorporeal life support. Pediatric Critical Care Medicine, 14(4). https://doi.org/10.1097/PCC.0b013e31827200b6

Bivalirudin in pediatric patients maintained on extracorporeal life support. / Nagle, Erin L.; Dager, William E.; Duby, Jeremiah J.; Roberts, A. Josh; Kenny, Laura E.; Murthy, Manasa S.; Pretzlaff, Robert K.

In: Pediatric Critical Care Medicine, Vol. 14, No. 4, 05.2013.

Research output: Contribution to journalArticle

Nagle, EL, Dager, WE, Duby, JJ, Roberts, AJ, Kenny, LE, Murthy, MS & Pretzlaff, RK 2013, 'Bivalirudin in pediatric patients maintained on extracorporeal life support', Pediatric Critical Care Medicine, vol. 14, no. 4. https://doi.org/10.1097/PCC.0b013e31827200b6
Nagle, Erin L. ; Dager, William E. ; Duby, Jeremiah J. ; Roberts, A. Josh ; Kenny, Laura E. ; Murthy, Manasa S. ; Pretzlaff, Robert K. / Bivalirudin in pediatric patients maintained on extracorporeal life support. In: Pediatric Critical Care Medicine. 2013 ; Vol. 14, No. 4.
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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.",
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AU - Duby, Jeremiah J.

AU - Roberts, A. Josh

AU - Kenny, Laura E.

AU - Murthy, Manasa S.

AU - Pretzlaff, Robert K.

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N2 - 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.

AB - 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.

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KW - Extracorporeal membrane oxygenation

KW - Heparin

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