Sanfilippo Filippo, Asmussen Sven, Maybauer Dirk M, Santonocito Cristina, Fraser John F, Erdoes Gabor, Maybauer Marc O
1 Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy.
2 School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
J Intensive Care Med. 2017 Jun;32(5):312-319. doi: 10.1177/0885066616656333. Epub 2016 Jun 29.
Extracorporeal membrane oxygenation (ECMO) offers therapeutic options in refractory respiratory and/or cardiac failure. Systemic anticoagulation with heparin is routinely administered. However, in patients with heparin-induced thrombocytopenia or heparin resistance, the direct thrombin inhibitor bivalirudin is a valid option and has been increasingly used for ECMO anticoagulation. We aimed at evaluating its safety and its optimal dosing for ECMO.
Systematic web-based literature search of PubMed and EMBASE performed via National Health Service Library Evidence and manually, updated until January 30, 2016.
The search revealed 8 publications relevant to the topic (5 case reports). In total, 58 patients (24 pediatrics) were reported (18 received heparin as control groups). Bivalirudin was used with or without loading dose, followed by infusion at different ranges (lowest 0.1-0.2 mg/kg/h without loading dose; highest 0.5 mg/kg/h after loading dose). The strategies for monitoring anticoagulation and optimal targets were dissimilar (activated partial thromboplastin time 45-60 seconds to 42-88 seconds; activated clotting time 180-200 seconds to 200-220 seconds; thromboelastography in 1 study).
Bivalirudin loading dose was not always used; infusion range and anticoagulation targets were different. In this systematic review, we discuss the reasons for this variability. Larger studies are needed to establish the optimal approach with the use of bivalirudin for ECMO.
体外膜肺氧合（ECMO）为难治性呼吸和/或心力衰竭提供了治疗选择。常规使用肝素进行全身抗凝。然而，对于肝素诱导的血小板减少症或肝素抵抗患者，直接凝血酶抑制剂比伐卢定是一种有效的选择，并且越来越多地用于ECMO抗凝。我们旨在评估其安全性以及ECMO的最佳给药剂量。
通过英国国家医疗服务体系图书馆证据平台对PubMed和EMBASE进行基于网络的系统文献检索，并手动检索，更新至2016年1月30日。
检索发现8篇与该主题相关的出版物（5篇病例报告）。总共报告了58例患者（24例儿科患者）（18例接受肝素作为对照组）。比伐卢定使用时有无负荷剂量，随后以不同范围输注（无负荷剂量时最低0.1 - 0.2 mg/kg/h；负荷剂量后最高0.5 mg/kg/h）。监测抗凝的策略和最佳目标各不相同（活化部分凝血活酶时间为45 - 60秒至42 - 88秒；活化凝血时间为180 - 200秒至200 - 220秒；1项研究中使用血栓弹力图）。
并非总是使用比伐卢定负荷剂量；输注范围和抗凝目标各不相同。在本系统评价中，我们讨论了这种变异性的原因。需要开展更大规模的研究来确定使用比伐卢定进行ECMO的最佳方法。
