In this episode, I’ll discuss an article about using bivalirudin for anticoagulation during ECMO.
In recent years some ECMO centers have decided to use bivalirudin over heparin to maintain systemic anticoagulation during ECMO as the literature to support this practice has grown. One center that made this switch in 2017 has recently published a retrospective cohort study describing the before and after results of the transition in the journal Critical Care Medicine.
The post-transition group comprised 275 patients, 70% of which received bivalirudin and 30% received heparin. This was compared to a pre-transition cohort of 126 patients, 2% of which received bivalirudin and 98% received heparin.
Drug cost and laboratory test cost were normalized to the duration of ECMO and reported as dollars per ECMO day. The bivalirudin group had a significantly reduced use of antithrombin at just 12.4% vs 30% in the pre-transition heparin group. In addition, the bivalirudin group had almost 1 fewer anticoagulation test ordered per ECMO day. Furthermore, antithrombin assay costs were reduced by 90% to go along with the significant reduction in antithrombin drug costs.
Finally, unadjusted survival at 28 days was significantly higher in the post-transition group at 74.9% vs 64.3% pre-transition.
The authors concluded:
Antithrombin assays and supplementation compromise a significant proportion of heparin-based anticoagulation costs in ECMO patients and is substantially reduced when a bivalirudin-based anticoagulation strategy is deployed. A favorable association exists between the aggregate cost of administration of bivalirudin compared with heparin-based systemic anticoagulation in adults supported on ECMO driven by reductions in antithrombin activity assessments and the cost of antithrombin replacement.
Although this is a retrospective and single-center study, it does add to the strength of the available evidence in support of using bivalirudin to provide systemic anticoagulation to ECMO patients.
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