Use of argatroban for extracorporeal life support in patients with nonheparin-induced thrombocytopenia

Abstract

Unfractionated heparin (UFH) is currently the standard anticoagulant used in extracorporeal life support (ECLS). However, severe thrombocytopenia occurs frequently during ECLS use and it may be difficult to determine whether this represents heparin-induced thrombocytopenia (HIT) or not. In this case, UFH cannot be continued. Because a confirmatory laboratory test requires time, argatroban is empirically used if HIT is suspected. However, many patients are not found to have HIT. In non-HIT patients, the effectiveness and safety of argatroban are unclear. Thus, we investigated whether argatroban was safe and useful in patients who were suspected of having HIT and were started on argatroban, but were ultimately found to have non-HIT. We retrospectively reviewed all patients on ECLS who received the anticoagulant argatroban as an alternative to UFH between January 2014 and July 2015. The pretest clinical score (4Ts) was calculated, and a score greater than 4 was considered an indication for argatroban. The target-activated clotting time or activated partial thromboplastin time was 1.5 times the patient's upper normal value. Of 191 patients on ECLS during the study period, 10 (5.2%) were treated with argatroban infusion. No patients were found to have antiplatelet factor 4/heparin antibodies. The average maintenance dose of argatroban was 0.1 μg/kg/min. Platelet counts increased significantly following argatroban administration ( P = .02). There were no anticoagulation-related complications such as bleeding or thrombosis. Our results suggest that argatroban is a safe alternative to UFH for patients with non-HIT on ECLS. Argatroban may have a more significant platelet-preserving effect than UFH, regardless of whether HIT is present.

Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review

“…Eight studies used aPTT [18][19][20][21][22][23][24][25] one study used ACT [26] and two studies used both parameters [27,28]. No information was available on the utilized monitoring parameter in two studies [29,30] Reports without control group [20][21][22][23][26][27][28][29][30] were not evaluated. Four retrospective observational studies [18,19,24,25] were assessed for risk of bias.…”

Clinical Pearls of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

“…This direct mechanism of action renders antithrombin levels irrelevant, resulting in more predictable pharmacokinetics and better efficacy. Argatroban may have a more significant platelet-preserving effect than unfractionated heparin, regardless of whether HIT is present 81). Argatroban administered during ECMO is reported to be administered significantly less (0.1–0.2 mcg/kg/min) than the recommended dose for HIT (2 mcg/kg/min) 81)82)…”

Predictive value of scoring tools in determining heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation

“…9 This highlights the need for prompt and appropriate management for patients with high suspicion for HIT which has led to recent publications of single center experiences and protocols for use of DTIs in suspected HIT. 13,14 These retrospective cohort reviews suggest that bivalirudin and argatroban are safe alternatives for HIT in ECMO. However, a 2017 systematic review highlights high variability in bivaliruidin protocols and significant differences among doses utilized in ECMO.…”