Department of Cardiothoracic Surgery, Children's Hospital of Orange County, Orange, CA 92868, USA.
Artif Organs. 2010 Aug;34(8):667-9. doi: 10.1111/j.1525-1594.2009.00961.x. Epub 2010 May 31.
Infants with heparin-induced thrombocytopenia (HIT) represent a challenging and high-risk group of patients when they require cardiopulmonary bypass (CPB). Bivalirudin offers many potential pharmacologic advantages over other nonheparin anticoagulants for such patients. We describe our protocol for the use of bivalirudin in a 5-month-old infant undergoing stage 2 Norwood for hypoplastic left heart syndrome. The patient was a 5- month-old, 6-kg infant who developed HIT after a bowel resection complicating initial Norwood stage 1. After sternotomy and dissection had been redone, the child received an initial dose of bivalirudin of 1.0 mg/kg and 0.5 mg/kg 5 min later. The CPB circuit was primed with 50 mg/kg bivalirudn/400 cc volume. With the initiation of CPB, a continuous infusion of 2.5 mg/kg bivalirudin was begun. Activated clotting time (ACT) was targeted for over 400 s, with an examination prior to bypass and each 15 min thereafter. Bivalirudin was discontinued with separation from bypass and during modified ultrafiltration (MUF). The ACT was 286 s after the initial 1 mg/kg bolus and 597 s after the second 0.5 mg/kg bolus and initiation of CPB. At a rate of 2.5 mg/kg/min, ACT ranged between 461 and 597 s. At the completion of MUF, the ACT was 316 s. The ACT was 214 s 20 min after MUF. No clots were noted in the CPB circuit, and good hemostasis was achieved within 10 min after MUF was completed. Incision to closure time was 160 min; time from completion of MUF to sternal closure was 30 min. Post-MUF, 60 cc of processed cell saver blood was reinfused, and no clotting factors were required. Chest tube output was 10, 10, 3, and 4 ccs, respectively, at hours 1-4 post operation. Bivalirudin provides effective anticoagulation in infants requiring CPB in the presence of HIT. Bivalirudin's efficacy is effectively monitored by ACT, and, after CPB, its short half-life and ability to be ultrafiltered facilitate the ability to achieve hemostasis in a timely fashion.
患有肝素诱导血小板减少症（HIT）的婴儿在需要体外循环（CPB）时代表着一个具有挑战性和高风险的群体。与其他非肝素抗凝剂相比，比伐卢定在这类患者中具有许多潜在的药理优势。我们描述了我们在一名 5 个月大的婴儿中使用比伐卢定的方案，该婴儿因初始 Norwood 1 期手术中并发的肠切除术后出现 HIT，需要进行二期 Norwood 手术治疗左心发育不全综合征。在重新进行胸骨切开术和解剖后，婴儿接受了初始剂量 1.0mg/kg 的比伐卢定和 5 分钟后 0.5mg/kg 的剂量。CPB 回路用 50mg/kg 的比伐卢定和 400cc 体积预充。在开始 CPB 时，开始以 2.5mg/kg 的剂量输注。目标 ACT 超过 400s，在 CPB 前和此后每 15min 进行检查。CPB 分离时和在改良超滤（MUF）期间停用比伐卢定。初始 1mg/kg 推注后 ACT 为 286s，第二次 0.5mg/kg 推注和 CPB 后 ACT 为 597s。以 2.5mg/kg/min 的速度输注，ACT 范围在 461s 至 597s 之间。MUF 完成后，ACT 为 316s。MUF 完成后 20min 的 ACT 为 214s。CPB 回路中未发现凝块，MUF 完成后 10min 内达到良好止血。切口至关闭时间为 160min；MUF 完成至胸骨关闭时间为 30min。MUF 后，分别输注 60cc 加工的细胞保存血，不需要凝血因子。术后 1-4 小时胸腔引流分别为 10、10、3 和 4cc。在存在 HIT 的情况下，需要 CPB 的婴儿中比伐卢定可提供有效的抗凝作用。ACT 有效监测比伐卢定的疗效，CPB 后，其半衰期短且能够超滤，有助于及时实现止血。
