Perfusion Strategies for Bivalirudin Anticoagulation: AIIMS Protocol
Anticoagulation strategies for cardiac surgery are witnessing a change with the identification of serious limitations of heparin, including development of resistance in 3 to 13% of patients undergoing cardiac surgery and heparin-induced thrombocytopenia/thrombosis syndrome in 1 to 5.5% of patients. Heparin alternatives have a potential role in these scenarios. Bivalirudin, a reversible direct thrombin inhibitor, has an onset time of 2 to 4 minutes and half-life of 25 minutes, is eliminated mainly by a proteolytic mechanism, does not require antithrombin III for effect, and is nonimmunogenic. The considerations for extracorporeal circulation are peculiar with its use, and this article outlines the aspects of initiating, maintaining, and terminating cardiopulmonary bypass and extracorporeal membrane oxygenation with bivalirudin as the anticoagulant.
The protocol presented herein is followed at the authors' institution and readers may adopt the practical suggestions as per their discretion. The ECMO circuit is improvised to make it less complicated and easy to manage by using fewer connectors, stopcocks, and avoiding potential sites of flow turbulence and blood stasis.
Artikel online veröffentlicht:
01. Juni 2022
© 2022. Official Publication of The Simulation Society (TSS), accredited by International Society of Cardiovascular Ultrasound (ISCU). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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- 1 Kaplan JA, Augoustides JGT, Manecke Jr GR, Maus T, Reich DL. Kaplan's Cardiac Anesthesia: For Cardiac and Noncardiac Surgery. 7th ed.. Philadelphia, PA: Elsevier; 2017
- 2 Dyke CM, Smedira NG, Koster A. et al. A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: the EVOLUTION-ON study. J Thorac Cardiovasc Surg 2006; 131 (03) 533-539
- 3 Erdoes G, Ortmann E, Martinez Lopez De Arroyabe B, Reid C, Koster A. Role of bivalirudin for anticoagulation in adult perioperative cardiothoracic practice. J Cardiothorac Vasc Anesth 2020; 34 (08) 2207-2214
- 4 Goswami D, DiGiusto M, Wadia R. et al. The use of bivalirudin in pediatric cardiac surgery and in the interventional cardiology suite. J Cardiothorac Vasc Anesth 2020; 34 (08) 2215-2223
- 5 Hasija S, Talwar S, Makhija N. et al. Randomized controlled trial of heparin versus bivalirudin anticoagulation in acyanotic children undergoing open heart surgery. J Cardiothorac Vasc Anesth 2018; 32 (06) 2633-2640
- 6 Hasija S, Hote M, Makhija N. et al. Bivalirudin anticoagulation in neonates and infants undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2022 DOI: 10.1053/j.jvca.2022.04.044
- 7 Koster A, Chew D, Gründel M. et al. An assessment of different filter systems for extracorporeal elimination of bivalirudin: an in vitro study. Anesth Analg 2003; 96 (05) 1316-1319
- 8 Sanfilippo F, Asmussen S, Maybauer DM. et al. Bivalirudin for alternative anticoagulation in extracorporeal membrane oxygenation: a systematic review. J Intensive Care Med 2017; 32 (05) 312-319
- 9 Burstein B, Wieruszewski PM, Zhao YJ, Smischney N. Anticoagulation with direct thrombin inhibitors during extracorporeal membrane oxygenation. World J Crit Care Med 2019; 8 (06) 87-98