title: Bivalirudin as a bridge for anticoagulation in high risk neurosurgical patients with active DVT or high risk of thrombosis.
abstract: BACKGROUND
  Bivalirudin is an ultrashort acting direct thrombin inhibitor, which has been used in place of heparin in selected settings. We describe our preliminary experience with the use of bivalirudin in patients who required anticoagulation for a deep vein thrombosis, prosthetic heart valve, or hypercoagulable state but were felt to be at high risk for the use of heparin.
  
  
  METHODS
  Eight patients in our neurocritical care unit required anticoagulation but were felt to be poor candidates for heparin either due to heparin-induced thrombocytopenia or due to high risk for intracranial hemorrhage. A standard protocol was utilized for bivalirudin with a loading dose of 0.75 mg/kg followed by a continuous infusion of 0.15 mg/kg hr. Serial aPTT levels were checked on a routine basis to monitor therapeutic effect. The bivalirudin infusion was continued for a period of 2 days to 2 weeks prior to starting coumadin therapy.
  
  
  RESULTS
  These patients were in the early postoperative period (within 48 h) following craniotomy, had suffered a recent large hemispheric infarct with hemorrhagic conversion, or had presented with an acute intracerebral hemorrhage. In this small series of patients, no intracranial hemorrhagic complications were encountered. No patients demonstrated progressive systemic thrombotic issues while on bivalirudin.
  
  
  CONCLUSIONS
  Based on these findings, bivalirudin may represent a reasonable alternative in patients for whom heparin anticoagulation is contraindicated. A larger multicenter trial of bivalirudin in this setting may be appropriate.
authors.affiliation: National Brain Aneurysm Center, Saint Joseph's Hospital, Saint Paul, MN 55102, USA. tmjanjua@healtheast.org
authors.forename: Tariq
authors.initials: T
authors.lastname: Janjua
authors.forename: Eric
authors.initials: E
authors.lastname: Nussbaum
authors.forename: Jodi
authors.initials: J
authors.lastname: Lowary
authors.forename: Virginia
authors.initials: V
authors.lastname: Babbini
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000991:Antithrombins / Q000627:therapeutic use*; D005260:Female; D006350:Heart Valve Prosthesis; D006629:Hirudins; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced / Q000150:complications*; D008297:Male; D008875:Middle Aged; D010446:Peptide Fragments / Q000627:therapeutic use*; D011994:Recombinant Proteins / Q000627:therapeutic use; D012189:Retrospective Studies; D013923:Thromboembolism / Q000150:complications / Q000517:prevention & control*; D019851:Thrombophilia / Q000150:complications / Q000188:drug therapy*; D016896:Treatment Outcome; D020246:Venous Thrombosis / Q000150:complications / Q000188:drug therapy* / Q000517:prevention & control
chemical_list: D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; C074619:bivalirudin