Evaluation of Bivalirudin as the Primary Anticoagulant in Patients Receiving Extracorporeal Membrane Oxygenation for SARS-CoV-2–Associated Acute Respiratory Failure

Abstract

Background Extracorporeal membrane oxygenation (ECMO) is a potential option for the management of severe acute respiratory failure secondary to COVID-19. Conflicting the use of this therapy is the known coagulopathy within COVID-19, leading to an incidence of venous thrombotic events of 25% to 49%. To date, limited guidance is available on optimal anticoagulation strategies in this population. Objective The purpose of this study was to evaluate the utilization of a pharmacist-driven bivalirudin dosing protocol for anticoagulation in the setting of ECMO for COVID-19–associated respiratory failure. Methods This was a single-center retrospective chart review over a 9-month period of patients receiving bivalirudin while on ECMO. All patients with acute respiratory failure requiring ECMO with a positive SARS-CoV-2 polymerase chain reaction were included. Bivalirudin was dosed via aPTT monitoring after a starting dose of 0.2 or 0.3 mg/kg/h. Results There were 33 patients included in this study, all receiving mechanical ventilation. The most common starting dose of bivalirudin was 0.2 mg/kg/h, with an average time to therapeutic range of 20 hours. Compared to previous reports, rates of bleeding were low at 15.1%, and 6.1% of patients developed a new venous thromboembolic event while on ECMO. ECMO survival was 51.5%, with an ICU mortality rate of 48.5%. Conclusion and Relevance In the first published report of its use within this population, bivalirudin was found to be a viable choice for anticoagulation in those patients on ECMO for severe respiratory failure secondary to COVID-19.

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

“…A reduction in the bleeding rate of VV ECMO patients treated with bivalirudin compared to heparin has also been specifically documented in a homogenous population treated with either one or the other anticoagulant [14]. In addition, preliminary evidence exists also on the use of bivalirudin to mitigate the thrombotic risk determined by the peculiar setting of SARS-CoV-2 infection [15,22]. Our data are in line with existing literature, and the fact that we observed comparable survival between patients treated with bivalirudin and heparin further supports the efficacy and safety of the use of direct thrombin inhibitors in such a complex clinical context.…”

The Use of Extracorporeal Membrane Oxygenation in COVID-19: a systematic review

“…Body mass index was situated between 28,9 kg/m 2 [32] and 36 kg/m 2 [33]. The baseline characteristics of the studies are presented in Table 3.…”

Direct Thrombin Inhibition in Extracorporeal Membrane Oxygenation

“…Several recent reports assessed the use of DTIs in this patient population. 4,5 The use of DTIs represents a viable alternative for systemic anticoagulation in ECMO patients when UFH is contraindicated or not effective. This article focuses on the two most widely used DTIs: bivalirudin and argatroban.…”