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Bivalirudin resistance in a patient on veno-venous extracorporeal membrane oxygenation with a therapeutic response to argatroban.
BMJ Case Rep 2020; 13(1)BC

Abstract

A 48-year-old male patient requiring extracorporeal membrane oxygenation (ECMO) support for hypoxaemic respiratory failure failed to achieve therapeutic anticoagulation with bivalirudin after continuous dose escalations, and continued to have recurrent fibrin stranding in the circuit over a 6-day course of treatment. Suspecting bivalirudin resistance, the patient was transitioned to argatroban and achieved a therapeutic response in less than 24 hours. The case describes the challenges of anticoagulation in ECMO supported patients. The interplay between bivalirudin metabolism, renal replacement therapy, and immunological effects leading to a heparin-like-effect, inflammatory mediators, and thrombotic burdens may all impact the clinical effect during bivalirudin therapy. The structural biochemistry of thrombin and bivalirudin likely plays a role in the presented patient's successful response to argatroban. Bivalirudin may fail at achieving therapeutic anticoagulation in patients with genetic thrombin mutations or structural defects that alter the binding pockets at the thrombin exosites.

Authors+Show Affiliations

Anesthesiology, Mayo Clinic Florida, Jacksonville, Florida, USA berlioz.beric@mayo.edu.Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA.Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA.Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31915185

Citation

Berlioz, Beric, et al. "Bivalirudin Resistance in a Patient On Veno-venous Extracorporeal Membrane Oxygenation With a Therapeutic Response to Argatroban." BMJ Case Reports, vol. 13, no. 1, 2020.
Berlioz B, Kaseer HS, Sanghavi DK, et al. Bivalirudin resistance in a patient on veno-venous extracorporeal membrane oxygenation with a therapeutic response to argatroban. BMJ Case Rep. 2020;13(1).
Berlioz, B., Kaseer, H. S., Sanghavi, D. K., & Guru, P. K. (2020). Bivalirudin resistance in a patient on veno-venous extracorporeal membrane oxygenation with a therapeutic response to argatroban. BMJ Case Reports, 13(1), doi:10.1136/bcr-2019-232262.
Berlioz B, et al. Bivalirudin Resistance in a Patient On Veno-venous Extracorporeal Membrane Oxygenation With a Therapeutic Response to Argatroban. BMJ Case Rep. 2020 Jan 7;13(1) PubMed PMID: 31915185.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Bivalirudin resistance in a patient on veno-venous extracorporeal membrane oxygenation with a therapeutic response to argatroban. AU - Berlioz,Beric, AU - Kaseer,Haya S, AU - Sanghavi,Devang K, AU - Guru,Pramod K, Y1 - 2020/01/07/ PY - 2020/1/10/entrez KW - adult intensive care KW - mechanical ventilation KW - pharmacology and therapeutics KW - therapeutic indications KW - venous thromboembolism JF - BMJ case reports JO - BMJ Case Rep VL - 13 IS - 1 N2 - A 48-year-old male patient requiring extracorporeal membrane oxygenation (ECMO) support for hypoxaemic respiratory failure failed to achieve therapeutic anticoagulation with bivalirudin after continuous dose escalations, and continued to have recurrent fibrin stranding in the circuit over a 6-day course of treatment. Suspecting bivalirudin resistance, the patient was transitioned to argatroban and achieved a therapeutic response in less than 24 hours. The case describes the challenges of anticoagulation in ECMO supported patients. The interplay between bivalirudin metabolism, renal replacement therapy, and immunological effects leading to a heparin-like-effect, inflammatory mediators, and thrombotic burdens may all impact the clinical effect during bivalirudin therapy. The structural biochemistry of thrombin and bivalirudin likely plays a role in the presented patient's successful response to argatroban. Bivalirudin may fail at achieving therapeutic anticoagulation in patients with genetic thrombin mutations or structural defects that alter the binding pockets at the thrombin exosites. SN - 1757-790X UR - https://www.unboundmedicine.com/medline/citation/31915185/Bivalirudin_resistance_in_a_patient_on_veno-venous_extracorporeal_membrane_oxygenation_with_a_therapeutic_response_to_argatroban L2 - https://casereports.bmj.com/cgi/pmidlookup?view=long&pmid=31915185 DB - PRIME DP - Unbound Medicine ER -