Megan Zielke, BCCCP, PharmD
Penn Presbyterian Medical Center
Philadelphia, Pennsylvania
Disclosure information not submitted.
Gretchen Redline, PharmD, BCCCP, BCPS
Clinical Pharmacist
Hospital of the U. of Pennsylvania, United States
Disclosure information not submitted.
Raymond Lamore, III, BCCCP, PharmD
Clinical Pharmacy Specialist, Critical Care
Penn Presbyterian Medical Center
Philadelphia, Pennsylvania
Disclosure information not submitted.
Vanessa Prendergast, PharmD, BCPS
Clinical Pharmacy Specialist, Critical Care
Penn Presbyterian Medical Center, United States
Disclosure information not submitted.
Lauren Schmidt, PharmD, BCCCP
Clinical Pharmacy Specialist, Critical Care
Penn Presbyterian Medical Center
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
.jpg "Jacob Gutsche, MD, FCCM photo")
Jacob Gutsche, MD, FCCM
Associate Professor of Anesthesiology and Critical Care
Hospital of The University of Pennsylvania
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Asad Usman, MD, MPH
Assistant Professor of Anesthesiology and Critical Care
University of Pennsylvania, United States
Disclosure information not submitted.
Title: Characterization of Bivalirudin Use in COVID-19 Extracorporeal Membrane Oxygenation Patients
INRODUCTION: The Extracorporeal Life Support Organization (ELSO) recommends that patients requiring extracorporeal membrane oxygenation (ECMO) receive systemic anticoagulation to mitigate the thrombotic potential of the extracorporeal device. Within the ECMO population, our health system’s traditional anticoagulant is unfractionated heparin (UFH); however, due to several intracranial hemorrhages observed in COVID-19 positive patients, bivalirudin was utilized as the primary anticoagulant for this population. Herein, we characterize the use of bivalirudin and related clinical outcomes in the COVID-19 ECMO patient population.
Methods: This retrospective cohort study included patients with COVID-19 requiring ECMO who received bivalirudin for anticoagulation from April 1, 2020 to April 19, 2021. The primary outcome was to characterize bivalirudin use, including dosing strategies and aPTT goals. Secondary outcomes evaluated the incidence of thrombotic and bleeding events as defined by ELSO.
Results: Forty-two extracorporeal circuits were included in this evaluation, of which 37 (88.1%) were VV-ECMO with a median duration of 34 [11.5-50] days. The cohort was mostly white (43.3%), males (80%) aged 49+9 years. Patients were anticoagulated a median of 84% [59.2-94.1] of the time while on ECMO. There were nine unique aPTT targets identified; the most common being 40-50 (53.3%) and 50-60 (30.7%) seconds. The median percent time within aPTT target was 75.9% [60.5-85.9]. The median bivalirudin starting dose was 0.037 [0.025-0.065] mg/kg/hr; however, the median dose at the target aPTT was 0.06 [0.036-0.095] mg/kg/hr. The median time to aPTT target was 8.1 [3.0-25.4] hours. The most common clotting event was deep vein thrombosis (DVT) (29; 53.7%); of which 11 were associated with intravenous or ECMO access. There were 21 circuit thromboses requiring exchange and 28 bleeding events as defined by ELSO criteria.
Conclusions: This review highlights the multifaceted balance between clotting and bleeding in patients with COVID-19 requiring ECMO. Following evaluation of this data, our institution created a bivalirudin dosing guideline aimed at standardizing anticoagulation strategies in this population. Future steps include a post-implementation assessment of the dosing guideline.