Management of Bivalirudin Dosing and Replacement Fluid During Therapeutic Plasma Exchange in Children on Extracorporeal Membrane Oxygenation.

The use of bivalirudin as the primary anticoagulant for children supported on extracorporeal membrane oxygenation (ECMO) is growing. Ideal management of bivalirudin dosing during therapeutic plasma exchange (TPE) on ECMO is unknown. We performed a single-center retrospective study of ECMO patients anticoagulated with bivalirudin who underwent TPE from January 2019 to December 2021. Therapeutic plasma exchange sessions were analyzed individually by bivalirudin dosing strategy (no change [NC] versus increased dose [dose change {DC} bivalirudin group]) and replacement fluid (all fresh-frozen plasma [FFP] versus all albumin or FFP and albumin [FFP/Albumin]). Primary outcomes included bleeding, coagulopathy, and circuit thrombosis within 24 hours of TPE. Secondary outcomes included change in bivalirudin dose and coagulation parameters following TPE. There were 60 unique TPE sessions. Bivalirudin dosing or replacement fluid strategies were not associated with bleeding, coagulopathy, or thrombosis post-TPE. All albumin or fresh frozen plasma and albumin combinations (FFP/Albumin) group had longer post-TPE thromboelastography (TEG) reaction time, clot time, and more acute angle. The FFP/Albumin group had increased post-TPE international normalization ratio (INR) and partial thrombin time (PTT). Therapeutic plasma exchange for children on ECMO and bivalirudin anticoagulation is feasible; however, optimal dosing during TPE requires further investigation. Replacement fluid with FFP/Albumin is associated with more coagulopathic laboratory parameters. Patients may benefit from all FFP fluid replacement strategy. Further investigation is needed to prove generalizability.

Is anticoagulation with bivalirudin comparable to heparin for pediatric extracorporeal life support? Results from a high-volume center.

There is a paucity of data regarding the use of direct thrombin inhibitors such as bivalirudin for children on extracorporeal life support (ECLS). We sought to compare the outcomes of children on ECLS anticoagulated with bivalirudin versus heparin. Patients transitioned from heparin to bivalirudin were treated as a separate group. A single-institution, retrospective review of all consecutive children (neonate to 18 years) placed on ECLS in the cardiac or pediatric intensive care units was performed (June 2018-December 2019). Data collected included demographics, anticoagulation strategy, number of circuit interventions, blood product use on ECLS, survival to decannulation, and survival to discharge. Fifty-four children were placed on ECLS for a total of 56 runs. Demographics and venovenous versus venoarterial ECLS were similar. The bivalirudin group had longer median duration of support compared to the heparin group--11.0 days [IQR 6.2, 23.1] versus 3.3 days [2.1, 6.2], P < .001. Patients switched from heparin to bivalirudin had a similar duration of support (10.3 days [8.3, 18.3]) as those on bilvalirudin alone. However, there was no difference in red blood cell, fresh frozen plasma, or platelet transfusions. There was no difference in the number of circuit interventions, survival to decannulation or discharge. The freedom to first circuit intervention was longer with bivalirudin compared to heparin. Our data suggest that even with longer pediatric ECLS runs on bivalirudin, there were no differences in the outcomes between the heparin and bivalirudin groups, with longer freedom from first circuit intervention with bivalirudin. While this is the largest reported series comparing children on ECLS anticoagulated with heparin versus bivalirudin, larger studies are needed to determine the optimal anticoagulation strategy for this diverse and complicated group of children.