23: ANTICOAGULATION DURING PEDIATRIC ECMO: EVALUATION OF EFFICACY AND COST

Abstract

Introduction: ECMO typically requires systemic anticoagulation to prevent thrombosis. While unfractionated heparin (UFH) has been traditionally used, direct thrombin inhibitor (DTI) use in pediatric ECMO has increased. However, drug cost for bivalirudin has been reported as potentially prohibitive for some centers. We aimed to evaluate efficacy and cost-effectiveness of these 2 anticoagulants at a single institution. Methods: Retrospective review of pediatric patients requiring ECMO at a tertiary center was conducted from June 2020-June 2022, with initiation of ECMO anticoagulation consultation (EAC). Results: Forty-four patients required ECMO for 47 runs (45 VA, 2 VV), with 40% (19.47) being neonatal ECMO. Median weight was 4 kg (2.4-131 kg). DTIs were used in 34% (16/47) as primary anticoagulant and an additional 21% (10/47) transitioned from UFH to DTI due to inadequate anticoagulation or development of circuit thrombosis. Most common DTI was bivalirudin (23/26). UFH was used in 49% (23/47) with 43% conversion to DTI on mean ECMO day 5. Mean duration of ECMO was 262 hours (48-1200 hours) on DTI and 133 hours (31-412) on UFH. For bivalirudin, mean time to therapeutic range PTT was 5 hours. Mean peak dose of bivalirudin was 1.39 mg/kg/hr. For UFH, mean time to therapeutic range anti-Xa was 9 hours. Mean UFH therapeutic dose was 27 units/kg/hr. Mean daily cost for 5 kg and 25 kg patient on UFH and antithrombin (AT) per institutional practice (to maintain normal AT activity) was $1262, with 64% drug costs (almost all due to AT) and 36% lab cost. Mean daily cost for 5 kg and 25 kg patient on bivalirudin was $235 and $382, respectively with majority of cost related to labs. 13% (6/47) of runs required circuit component changes or thrombectomy, 83% of clots occurring on therapeutic UFH. Survival to ECMO decannulation was 72%. Conclusions: DTI use in pediatric ECMO was efficacious for prolonged runs, directed by EAC, with rapid time to therapeutic range and decreased thrombotic complications, as well as being cost-effective While drug cost for UFH alone is inexpensive, laboratory cost for anti-Xa was more expensive than PTT and if antithrombin is administered the cost significantly increases, for drug and monitoring of activity.