LAUSR

Abstract In its severe manifestation, COVID-19 compromises oxygenation in a manner that is refractory to maximal conventional support and requires escalation to extracorporeal membrane oxygenation (ECMO). Maintaining ECMO support for extended durations requires a delicately balanced anticoagulation strategy to maintain circuit viability by preventing thrombus deposition, while avoiding excessive anticoagulation yielding hemorrhage; a task that is complicated in COVID-19 secondary to an inherent hypercoagulable state. Bivalirudin, a member of the direct thrombin inhibitor drug class, offers potential advantages during ECMO including to its ability to exert its effect by directly attaching to and inhibiting freely circulating and fibrin-bound thrombin. Herein, we report the successful use of an anticoagulation strategy employing the off-label use of a continuous infusion of bivalirudin in a case of severe hypoxemic and hypercarbic respiratory failure caused by COVID-19 requiring VV-ECMO. Importantly, therapeutic anticoagulation intensity was rapidly achieved with stable pharmacokinetics and there was no need for any circuit interventions throughout the patient's 27 day ECMO course. In COVID-19, bivalirudin offers a potential option for maintaining systemic anticoagulation during ECMO in a manner that may mitigate the pro-thrombotic nature of the underlying pathophysiologic state.