Anticoagulation Strategies in Critically Ill Patients With SARS-CoV-2 Infection: The Role of Direct Thrombin Inhibitors

Pieri, Marina; Quaggiotti, Luisa; Fominskiy, Evgeny; Landoni, Giovanni; Calabrò, Maria Grazia; Ajello, Silvia; Bonizzoni, Matteo Aldo; Scandroglio, Anna Mara

doi:10.1053/j.jvca.2022.03.004

Cited by 4 publications

(9 citation statements)

References 39 publications

(44 reference statements)

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“…However, some clinical outcomes are different between studies. The mortality reported by Pieri et al in the bivalirudin group was 57% [ 40 ], whereas we report 27.6%. This large difference may be explained by the higher need for ECMO and major bleeding complications and transfusions, which we have not recorded.…”

Section: Discussioncontrasting

confidence: 83%

“…Beyond the higher quality (randomized vs. observational) design, our two groups are homogeneous providing stronger evidence. Our cohorts of patients are similar for severity (i.e., SAPS-II score) to the bivalirudin group of the study by Pieri et al [ 40 ]. However, some clinical outcomes are different between studies.…”

Section: Discussionmentioning

confidence: 88%

“…An observational study by Pieri et al enrolled 129 patients, 46 receiving a prophylactic dose of heparin, 60 therapeutic heparin and 23 a full dose of bivalirudin [ 40 ]. When compared to therapeutic doses of heparin, the bivalirudin group was characterized by a longer ICU length of stay and higher number of major bleeding episodes and need for red blood cell transfusions.…”

Section: Discussionmentioning

confidence: 99%

“…No difference was recorded with respect to ICU mortality. Noteworthy, patients receiving bivalirudin were more severe, as demonstrated by a higher SAPS-II score (60 vs. 39) and a higher need for ECMO (65%) [ 40 ]. Beyond the higher quality (randomized vs. observational) design, our two groups are homogeneous providing stronger evidence.…”

Section: Discussionmentioning

confidence: 99%

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Bivalirudin vs. Enoxaparin in Intubated COVID-19 Patients: A Pilot Multicenter Randomized Controlled Trial

Garofalo

Cammarota²,

Neri³

et al. 2022

JCM

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(1) Background: In COVID-19 patients, the occurrence of thromboembolic complications contributes to disease progression and mortality. In patients at increased risk for thrombotic complications, therapeutic enoxaparin should be considered. However, critically ill COVID-19 patients could develop resistance to enoxaparin. Bivalirudin, a thrombin inhibitor, may be an alternative. This pilot multicenter randomized controlled trial aims to ascertain if bivalirudin may reduce the time spent under invasive mechanical ventilation, as compared to enoxaparin. (2) Methods: Intubated COVID-19 patients at risk for thrombo-embolic complications were randomized to receive therapeutic doses of enoxaparin or bivalirudin. We ascertained the time spent under invasive mechanical ventilation during the first 28 days from Intensive Care Unit (ICU) admission. A standardized weaning protocol was implemented in all centers. In addition, we assessed the occurrence of thromboembolic complications, the number of patients requiring percutaneous tracheostomy, the gas exchange, the reintubation rate, the ICU length of stay, the ICU and 28-days mortalities. (3) Results: We enrolled 58 consecutive patients. Bivalirudin did not reduce the time spent under invasive mechanical ventilation as compared to enoxaparin (12 [8; 13] vs. 13 [10; 15] days, respectively; p = 0.078). Thrombotic (p = 0.056) and embolic (p = 0.423) complications, need for tracheostomy (p = 0.423) or reintubation (p = 0.999), the ICU length of stay (p = 0.076) and mortality (p = 0.777) were also similar between treatments. Patients randomized to bivalirudin showed a higher oxygenation at day 7 and 15 after randomization, when compared to enoxaparin group. (4) Conclusions: In intubated COVID-19 patients at increased risk for thromboembolic complications, bivalirudin did not reduce the time spent under invasive mechanical ventilation, nor improved any other clinical outcomes.

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Section: Discussioncontrasting

confidence: 83%

Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Bivalirudin vs. Enoxaparin in Intubated COVID-19 Patients: A Pilot Multicenter Randomized Controlled Trial

Garofalo

Cammarota²,

Neri³

et al. 2022

JCM

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“…[ 11 , 21 ] In another study comparing bivalirudin and heparin in critically ill patients with severe COVID-19, bivalirudin displayed similar rates of hospital mortality and thromboembolic complications. [ 22 ]…”

Section: Discussionmentioning

confidence: 99%

Anticoagulation strategy with bivalirudin plus aspirin combination during extracorporeal membrane oxygenation for COVID-19-associated acute respiratory distress syndrome

Oğuş,

Altınay,

Hançer

et al. 2024

Turk Gogus Kalp Dama

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Background: In this study, we present our experience in treating patients receiving extracorporeal membrane oxygenation for novel coronavirus disease-2019 (COVID-19)-associated acute respiratory distress syndrome using a combined anticoagulant and antiaggregant treatment with intravenous infusion of bivalirudin and aspirin. Methods: Between April 1st, 2020 and January 31st, 2022, a total of 52 adult patients (32 males, 20 females; mean age: 44.5±11.5 years; range, 21 to 71 years) who received extracorporeal membrane oxygenation due to COVID-19-associated acute respiratory distress syndrome and whose anticoagulant treatment consisted of bivalirudin plus aspirin were retrospectively analyzed. During the first 10 days of extracorporeal membrane oxygenation, bivalirudin dosing, activated partial thromboplastin time, and activated clotting time, as well as major bleeding events and patient and/or ECMO-circuit thromboses were recorded. Results: The mean bivalirudin dose per day ranged from 0.03 to 0.04 mg/kg/h, with a mean overall dose of 0.036 mg/kg/h. The mean activated partial thromboplastin time was 49.1±6.9 sec throughout 10 days of the application. The percentage of time in the target range for activated partial thromboplastin time was 58.9±20.1% within 10 days of application, compared to 33.1±31.1% for the first 24 h. The mean daily activated clotting time was below the target range within the first three days, but it was consistently within the target range after Day 3. During the first 10 days of the application, no mortality occurred. Major bleeding occurred in 11 patients (21.1%) and circuit thrombosis occurred in three patients (5.8%). Conclusion: In patients receiving extracorporeal membrane oxygenation for COVID-19-associated acute respiratory distress syndrome, an hourly bivalirudin dose of 0.03 to 0.04 mg/kg/h throughout the first 10 days of application was associated with the targeted anticoagulation profile of 45 to 60 sec. The combination was associated with a comparable rate of major bleeding, but a lower rate of circuit-thrombosis compared to the literature reports.

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Bivalirudin

2022

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Anticoagulation Strategies in Critically Ill Patients With SARS-CoV-2 Infection: The Role of Direct Thrombin Inhibitors

Cited by 4 publications

References 39 publications

Bivalirudin vs. Enoxaparin in Intubated COVID-19 Patients: A Pilot Multicenter Randomized Controlled Trial

Bivalirudin vs. Enoxaparin in Intubated COVID-19 Patients: A Pilot Multicenter Randomized Controlled Trial

Anticoagulation strategy with bivalirudin plus aspirin combination during extracorporeal membrane oxygenation for COVID-19-associated acute respiratory distress syndrome

Bivalirudin

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