Zhong Han, Zhu Ming-Li, Yu Yue-Tian, Li Wen, Xing Shun-Peng, Zhao Xian-Yuan, Wang Wei-Jun, Gu Zhi-Chun, Gao Yuan
Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
Department of Critical Care, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
Front Pharmacol. 2020 Sep 11;11:565013. doi: 10.3389/fphar.2020.565013. eCollection 2020.
Extracorporeal membrane oxygenation (ECMO) can provide respiratory and cardiac support to patients in reversible devastated conditions. Heparin is the mainstay for anticoagulation during ECMO. Bivalirudin, a direct thrombin blocker, may represent an effective alternative for patients suffering from heparin-induced thrombocytopenia (HIT). We present the first case of a Chinese patient who experienced HIT and received bivalirudin anticoagulation during ECMO. In addition, we present a systematic review for this topic. We searched PubMed, EMBASE, and Cochrane Library (up to April 20, 2020) for studies that included patients undergoing ECMO, presenting with HIT, requiring bivalirudin treatment, and reporting relevant outcomes. The literature review yielded 15 studies involving 123 patients, amongst whom 58 patients were confirmed or suspected HIT patients, and 76 patients received bivalirudin as an anticoagulant for ECMO. Twelve studies were included for quantitative synthesis, and 46 patients were retrieved. The mean age of these patients was 46 years, and 30 patients were males. The average maintenance rate of bivalirudin was 0.27 ± 0.37 mg/kg/h, in order to maintain a target of activated clotting time (ACT) of 160-220 s. Additionally, bivalirudin doses in patients with continuous renal replacement therapies (CRRT) and patients without CRRT were 0.15 ± 0.06 mg/kg/h vs 0.28 ± 0.36 mg/kg/h, respectively (=0.15). Most of the patients with confirmed HIT improved platelet counts in 3.3 ± 2.8 days after switching to bivalirudin anticoagulation. The patient-level data showed that 29 cases survived, 1 reported major bleeding, and 4 reported thrombotic events. Bivalirudin might be a promising optimal choice for ECMO anticoagulation in patients with HIT. A tailored protocol for management of bivalirudin treatment during ECMO should be developed with caution. Further prospective studies are necessary to standardise the use of bivalirudin.
PROSPERO, identifier CRD42020160907.
体外膜肺氧合（ECMO）可为处于可逆性严重病情的患者提供呼吸和心脏支持。肝素是ECMO期间抗凝的主要药物。比伐芦定，一种直接凝血酶抑制剂，可能是肝素诱导的血小板减少症（HIT）患者的有效替代药物。我们报告了首例在ECMO期间发生HIT并接受比伐芦定抗凝治疗的中国患者。此外，我们对该主题进行了系统评价。我们检索了PubMed、EMBASE和Cochrane图书馆（截至2020年4月20日），以查找纳入接受ECMO、患有HIT、需要比伐芦定治疗并报告相关结果的患者的研究。文献综述产生了15项涉及123例患者的研究，其中58例患者为确诊或疑似HIT患者，76例患者接受比伐芦定作为ECMO的抗凝剂。纳入12项研究进行定量综合分析，共检索到46例患者。这些患者的平均年龄为46岁，男性30例。比伐芦定的平均维持率为0.27±0.37mg/kg/h，以维持活化凝血时间（ACT）目标为160 - 220秒。此外，接受持续肾脏替代治疗（CRRT）的患者和未接受CRRT的患者的比伐芦定剂量分别为0.15±0.06mg/kg/h和0.28±0.36mg/kg/h（P = 0.15）。大多数确诊HIT的患者在改用比伐芦定抗凝治疗后3.3±2.8天血小板计数有所改善。患者层面的数据显示，29例存活，1例报告有大出血，4例报告有血栓形成事件。比伐芦定可能是HIT患者ECMO抗凝的一个有前景的最佳选择。在ECMO期间应谨慎制定比伐芦定治疗管理的定制方案。有必要进行进一步的前瞻性研究以规范比伐芦定的使用。
PROSPERO，标识符CRD42020160907。
