PB0304 - Bivalirudin Anticoagulation for an Infant with Heparin Resistance on ECMO

Background: Extracorporeal membrane oxygenation (ECMO) has become a key strategy for the rescue treatment of critically ill children. Bleeding and thrombotic events during ECMO are common, morbid, and potentially lethal. Therefore, how to balance the coagulation state is the key to ECMO management.

Aims: In this report, we present an unusual case of Bivalirudin Anticoagulation management for an Infant with Heparin Resistance on ECMO.

Methods: We retrospectively analyzed the diagnosis and treatment process of infant ECMO patient with heparin resistance

Results: We encountered an unreliable heparin monitoring in an infant on ECMO, which considered as heparin resistance. Subsequently, we switched the anticoagulant from heparin to bivalirudin and managed by using multiple laboratory tests including ACT and APTT. However, the standardized management of bivalirudin administration in infant ECMO patients with heparin resistance has not been clearly elucidated due to limited data. The phenomenon of inconsistent monitoring results between ACT and APTT occurred later. To help the clinic to adjust the anticoagulation dose accurately, we adopted additional tests such as thrombin-antithrombin complex (TAT) and Fibrin / Fibrinogen Degradation Products (FDP) and applied comparison of thrombela stogram (TEG)-ACT and bedside non-anticoagulated ACT, then recommended clinicians to use APTT combined with TAT, successfully maintained the clinical efficacy and safety of bivalirudin anticoagulation therapy during ECMO.

Conclusion(s): Due to special physiological characteristics of newborns, the changes of hemostasis are quite different. Accurate anticoagulation monitoring is the key point and aporia. In this case, the laboratory clinician closely communicated with the doctors and follow up according to the changes of indicators. After the occurrence of heparin resistance, by conducted multi-disciplinary consultation and literature and guidelines review, we choosed bivalirudin, an unconventional anticoagulant drug. A set of personalized coagulation monitoring scheme was jointly summarized by laboratory clinicians, then flexible analyzed, and finally achieved the success of coagulation management.