Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.
Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
Int J Artif Organs. 2022 Aug;45(8):688-694. doi: 10.1177/03913988221106225. Epub 2022 Jun 16.
Unfractionated heparin is the most commonly utilized anticoagulant in extracorporeal membrane oxygenation (ECMO) due to clinician familiarity, ease of reversal, and low cost compared to alternative agents. However, heparin's anticoagulant effect can be unpredictable and its use accompanies a risk of heparin induced thrombocytopenia (HIT). Successful use of bivalirudin as an alternative to heparin in non-HIT ECMO patients has previously been described. However, there is a paucity of data regarding its utilization in patients with confirmed HIT on ECMO.
This single-center retrospective chart review at Cleveland Clinic Main Campus included 12 ECMO patients who were managed with bivalirudin for a new diagnosis of HIT. Descriptive statistical analyses were performed utilizing median with interquartile range and number with percent as appropriate.
Of the 12 patients included, median ECMO duration was 328.5 (218.8-502.1) h and venoarterial ECMO was the most common configuration. No patients experienced the primary outcome of in-circuit thrombosis while on bivalirudin. One patient developed a deep vein thrombosis 22.5 h after switching from heparin to bivalirudin. Major bleeding occurred during bivalirudin therapy in 8 (66.7%) patients.
Overall, our study results suggest that bivalirudin is effective for the management of HIT and did not show evidence of in-circuit thrombosis. A high incidence of major bleeding was observed with bivalirudin use within this study. Clinicians should view bivalirudin as an acceptable agent for the treatment of HIT in the ECMO population, but must consider bleeding risk given the lack of effective reversal agents.
由于医生对普通肝素（unfractionated heparin）的熟悉程度、易于逆转以及与其他药物相比成本较低，普通肝素是体外膜肺氧合（extracorporeal membrane oxygenation，ECMO）中最常使用的抗凝剂。然而，肝素的抗凝效果可能难以预测，并且其使用伴随着肝素诱导的血小板减少症（heparin-induced thrombocytopenia，HIT）的风险。之前已经描述了将比伐卢定（bivalirudin）作为肝素的替代药物在非 HIT ECMO 患者中的成功应用。然而，在确诊 HIT 的 ECMO 患者中，关于其使用的数据很少。
克利夫兰诊所主院区的这项单中心回顾性图表审查纳入了 12 名因新诊断的 HIT 而接受比伐卢定治疗的 ECMO 患者。采用中位数（四分位距）和数量（百分比）描述性统计分析。
在纳入的 12 名患者中，ECMO 持续时间中位数为 328.5（218.8-502.1）小时，最常见的配置为静脉-动脉 ECMO。在使用比伐卢定期间，没有患者发生电路内血栓形成这一主要结局。1 名患者在从肝素转换为比伐卢定后 22.5 小时发生深静脉血栓形成。8 名（66.7%）患者在比伐卢定治疗期间发生大出血。
总体而言，我们的研究结果表明，比伐卢定对 HIT 的管理有效，并且没有证据表明电路内血栓形成。在本研究中，观察到比伐卢定使用时大出血的发生率较高。鉴于缺乏有效的逆转剂，临床医生应将比伐卢定视为 ECMO 人群中治疗 HIT 的可接受药物，但必须考虑出血风险。
