title: Bivalirudin in pediatric patients maintained on extracorporeal life support.
abstract: OBJECTIVE
  Anticoagulation with heparin is standard of care for patients maintained on extracorporeal life support. Very limited evidence exists for the use of alternative anticoagulants during extracorporeal life support. Patients with heparin-induced thrombocytopenia, heparin resistance, and evidence of significant thrombosis while on heparin may be candidates for alternative anticoagulation. The objective of this analysis is to present evidence for the use of bivalirudin during extracorporeal life support in pediatric patients.
  
  
  METHODS
  Case series.
  
  
  METHODS
  University of California, Davis Medical Center.
  
  
  METHODS
  Twelve critically ill, pediatric patients receiving bivalirudin for anticoagulation during extracorporeal life support.
  
  
  METHODS
  None.
  
  
  RESULTS
  Twelve patients meeting entry criteria received bivalirudin during the study period. The median patient age was 8 days (range, 1 d to 6 yr). Eight patients were neonates. Eight patients were male. Nine patients were supported with venoarterial extracorporeal life support. Median duration of extracorporeal life support was 226 hours (range, 111-913) and median time on bivalirudin was 92 hours (range, 60-230). Bivalirudin bolus doses were administered to select patients without bleeding complications. The maintenance dose that corresponded with initial target activated partial thromboplastin time ranged from 0.045 to 0.48 mg/kg/hr with a median rate of 0.16 mg/kg/hr. The median dose for days 1, 3, and 5 was 0.135, 0.175, and 0.267 mg/kg/hr, respectively. The correlation (r2) between dose adjustment and activated partial thromboplastin time response was 0.264.
  
  
  CONCLUSIONS
  This is the largest case series describing the use of a direct thrombin inhibitor in pediatric extracorporeal life support patients. The maintenance dose range reflected considerable inter-patient variability. There was an observed increase in dose requirements with time. Bivalirudin, with close monitoring, is a potential option for pediatric patients on extracorporeal life support who have developed heparin-induced thrombocytopenia, heparin resistance, or significant thrombosis while on heparin.
authors: University of California, Davis Medical Center, Sacramento, CA, USA.
authors: Erin L
authors: EL
authors: Nagle
authors: William E
authors: WE
authors: Dager
authors: Jeremiah J
authors: JJ
authors: Duby
authors: A Josh
authors: AJ
authors: Roberts
authors: Laura E
authors: LE
authors: Kenny
authors: Manasa S
authors: MS
authors: Murthy
authors: Robert K
authors: RK
authors: Pretzlaff
mesh_terms: D000991:Antithrombins / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D016903:Drug Monitoring; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006629:Hirudins / Q000008:administration & dosage*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008020:Life Support Care / Q000379:methods*; D008297:Male; D010314:Partial Thromboplastin Time; D010446:Peptide Fragments / Q000008:administration & dosage*; D011994:Recombinant Proteins / Q000008:administration & dosage; D012189:Retrospective Studies; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors
chemical_list: D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; C074619:bivalirudin