Titulo:
Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura
.
Sumario:
El uso de ECMO se ha extendido rápidamente en la población pediátrica y ha permitido alcanzar altas tasas de supervivencia en enfermedades graves y refractarias. Su objetivo es el soporte respiratorio y/o cardiaco hasta la resolución de la enfermedad en curso. Sin embargo, a pesar de los avances aún existe una importante carga de morbimortalidad dada por la presencia de complicaciones hemostáticas. Este desequilibrio de la coagulación es un proceso complejo que involucra factores relacionados con la nueva interfaz sangre-biomaterial generadora de cambios en la cascada de coagulación, proteínas y células, además de factores propios de la edad y de las patologías críticas de estos pacientes. La anticoagulación constituye parte esencial del ma... Ver más
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Revista Colombiana de Hematología y Oncología - 2022
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ASOCIACION COLOMBIANA DE HEMATOLOGIA Y ONCOLOGIA |
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Colombia |
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Revista Colombiana de Hematología y Oncología |
| title |
Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura |
| spellingShingle |
Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura Carrasco De Los Rios, Monica Zúñiga Contreras, Pamela Oxigenación por membrana extracorpórea pediatría anticoagulantes bivalirudina Extracorporeal membrane oxygenation pediatrics anticoagulants bivalirudin |
| title_short |
Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura |
| title_full |
Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura |
| title_fullStr |
Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura |
| title_full_unstemmed |
Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura |
| title_sort |
anticoagulación en pacientes pediátricos con ecmo: una revisión de la literatura |
| title_eng |
Anticoagulation in pediatric ECMO patients: a review of the literature |
| description |
El uso de ECMO se ha extendido rápidamente en la población pediátrica y ha permitido alcanzar altas tasas de supervivencia en enfermedades graves y refractarias. Su objetivo es el soporte respiratorio y/o cardiaco hasta la resolución de la enfermedad en curso. Sin embargo, a pesar de los avances aún existe una importante carga de morbimortalidad dada por la presencia de complicaciones hemostáticas. Este desequilibrio de la coagulación es un proceso complejo que involucra factores relacionados con la nueva interfaz sangre-biomaterial generadora de cambios en la cascada de coagulación, proteínas y células, además de factores propios de la edad y de las patologías críticas de estos pacientes. La anticoagulación constituye parte esencial del manejo y se convierte en un reto lograr el balance del riesgo de trombosis y hemorragia. La heparina no fraccionada ha sido el anticoagulante de mayor uso, sin embargo, su dosificación varía ampliamente y es ajustada a alcanzar el efecto clínico y rangos objetivos en ensayos de monitorización sin una recomendación única para población pediátrica en ECMO y aún con una frecuencia importante de complicaciones hemostáticas. Se plantea el uso de inhibidores directos de la trombina considerados buenos candidatos por tener un mejor perfil de seguridad, sin embargo, no existen estudios prospectivos que permitan estandarizar recomendaciones para su uso. La elección del anticoagulante y las pruebas de monitorización son variadas y dependen de la experiencia de uso y su disponibilidad. Este artículo pretende revisar la evidencia disponible respecto al uso de la anticoagulación para ECMO en población pediátrica.
|
| description_eng |
The use of ECMO has spread rapidly in the pediatric population and has led to high survival rates in severe and refractory diseases. Its objective is respiratory and/or cardiac support until resolution of the ongoing disease. However, despite advances, there is still a significant morbidity and mortality burden due to the presence of hemostatic complications. This coagulation imbalance is a complex process involving factors related to the new blood-biomaterial interface that generates changes in the coagulation cascade, proteins, and cells, as well as factors related to age and the critical pathologies of these patients. Anticoagulation is an essential part of management and it becomes a challenge to balance the risk of thrombosis and bleeding. Unfractionated heparin has been the most widely used anticoagulant, however, its dosage varies widely and is adjusted to achieve clinical effect and objective ranges in monitoring trials without a single recommendation for the pediatric population in ECMO and even with a significant frequency of hemostatic complications. The use of direct thrombin inhibitors considered good candidates because they have a better safety profile, however, there aren’t prospective studies that allow standardizing recommendations for their use. The choice of anticoagulant and monitoring tests are varied and depend on the experience of use and its availability. This article aims to review the available evidence regarding the use of anticoagulation for ECMO in the pediatric population.
|
| author |
Carrasco De Los Rios, Monica Zúñiga Contreras, Pamela |
| author_facet |
Carrasco De Los Rios, Monica Zúñiga Contreras, Pamela |
| topicspa_str_mv |
Oxigenación por membrana extracorpórea pediatría anticoagulantes bivalirudina |
| topic |
Oxigenación por membrana extracorpórea pediatría anticoagulantes bivalirudina Extracorporeal membrane oxygenation pediatrics anticoagulants bivalirudin |
| topic_facet |
Oxigenación por membrana extracorpórea pediatría anticoagulantes bivalirudina Extracorporeal membrane oxygenation pediatrics anticoagulants bivalirudin |
| citationvolume |
9 |
| citationissue |
1 |
| citationedition |
Núm. 1 , Año 2022 : Enero-junio |
| publisher |
Asociación Colombiana de Hematología y Oncología (ACHO) |
| ispartofjournal |
Revista Colombiana de Hematología y Oncología |
| source |
https://revista.acho.info/index.php/acho/article/view/401 |
| language |
spa |
| format |
Article |
| rights |
https://creativecommons.org/licenses/by-nc-nd/4.0 Revista Colombiana de Hematología y Oncología - 2022 Esta obra está bajo una licencia internacional Creative Commons Atribución-NoComercial-SinDerivadas 4.0. info:eu-repo/semantics/openAccess http://purl.org/coar/access_right/c_abf2 |
| references |
Barton R, Ignjatovic V, Monagle P. Anticoagulation during ECMO in neonatal and paediatric patients. Thromb Res. [Internet] 2019;173:172-7. Disponible en: https://doi.org/10.1016/j.thromres.2018.05.009 2. Valencia E, Nasr VG. Updates in Pediatric Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth. [Internet] 2020;34(5):1309-23. Disponible en: https://doi.org/10.1053/j.jvca.2019.09.006 3. Drop JGF, Wildschut ED, Gunput STG, de Hoog M, van Ommen CH. Challenges in Maintaining the Hemostatic Balance in Children Undergoing Extracorporeal Membrane Oxygenation: A Systematic Literature Review. Front Pediatr. [Internet] 2020;8:612467. Disponible en: https://doi.org/10.3389/fped.2020.612467 4. Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, et al. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med. [Internet] 2021;8:671241. Disponible en: https://doi.org/10.3389/fcvm.2021.671241 5. Chlebowski MM, Baltagi S, Carlson M, Levy JH, Spinella PC. Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO. Crit Care. [Internet] 2020;24(1):19. Disponible en: https://doi.org/10.1186/s13054-020-2726-9 6. Koster A, Ljajikj E, Faraoni D. Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation. Ann Cardiothorac Surg. [Internet] 2019. p. 129-36. Disponible en: https://doi.org/10.21037/acs.2018.07.03 7. Ryerson LM, Lequier LL. Anticoagulation Management and Monitoring during Pediatric Extracorporeal Life Support: A Review of Current Issues. Front Pediatr. [Internet] 2016;4:67. Disponible en: https://doi.org/10.3389/fped.2016.00067 8. Franchini M, Mannucci PM. Acquired von Willebrand syndrome: focused for hematologists. Haematologica. [Internet] 2020;105(8):2032-7. Disponible en: https://doi.org/10.3324/haematol.2020.255117 9. Hardart GE, Fackler JC. Predictors of intracranial hemorrhage during neonatal extracorporeal membrane oxygenation. J Pediatr. [Internet] 1999;134(2):156-9. Disponible en: https://doi.org/10.1016/S0022-3476(99)70408-7 10. Dalton HJ, Reeder R, Garcia-Filion P, Holubkov R, Berg RA, Zuppa A, et al. Factors Associated with Bleeding and Thrombosis in Children Receiving Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med. [Internet] 2017;196(6):762-71. Disponible en: https://doi.org/10.1164/rccm.201609-1945OC 11. Sell LL, Cullen ML, Whittlesey GC, Yedlin ST, Philippart AI, Bedard MP, et al. Hemorrhagic complications during extracorporeal membrane oxygenation: prevention and treatment. J Pediatr Surg. [Internet] 1986;21(12):1087-91. Disponible en: https://doi.org/10.1016/0022-3468(86)90015-1 12. Penk JS, Reddy S, Polito A, Cisco MJ, Allan CK, Bembea MM, et al. Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 1. Pediatr Crit Care Med. [Internet] 2019;20(11):1027-33. Disponible en: https://doi.org/10.1097/PCC.0000000000002054 13. Fuentes A, Casado C, Mayordomo A, García R, Solís D, Ramírez B. Protocolo de anticoagulación para ECMO infantil. Revista Española de perfusión. [Internet] 2019;67. Disponible en: https://dialnet.unirioja.es/servlet/articulo?codigo=7272351 14. Wong TE, Delaney M, Gernsheimer T, Matthews DC, Brogan TV, Mazor R, et al. Antithrombin concentrates use in children on extracorporeal membrane oxygenation: a retrospective cohort study. Pediatr Crit Care Med. [Internet] 2015;16(3):264-9. Disponible en: https://doi.org/10.1097/PCC.0000000000000322 15. Panigada M, Cucino A, Spinelli E, Occhipinti G, Panarello G, Novembrino C, et al. A Randomized Controlled Trial of Antithrombin Supplementation During Extracorporeal Membrane Oxygenation. Crit Care Med. [Internet] 2020;48(11):1636-44. Disponible en: https://doi.org/10.1097/CCM.0000000000004590 16. Jones AJ, O'Mara KL, Kelly BJ, Samraj RS. The Impact of Antithrombin III Use in Achieving Anticoagulant Goals in Pediatric Patients. J Pediatr Pharmacol Ther. [Internet] 2017;22(5):320-5. Disponible en: https://doi.org/10.5863/1551-6776-22.5.320 17. Hamzah M, Jarden AM, Ezetendu C, Stewart R. Evaluation of Bivalirudin As an Alternative to Heparin for Systemic Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. [Internet] 2020;21(9):827-34. Disponible en: https://doi.org/10.1097/PCC.0000000000002384 18. Sanfilippo F, Asmussen S, Maybauer DM, Santonocito C, Fraser JF, Erdoes G, et al. Bivalirudin for Alternative Anticoagulation in Extracorporeal Membrane Oxygenation: A Systematic Review. J Intensive Care Med. [Internet] 2017;32(5):312-9. Disponible en: https://doi.org/10.1177/0885066616656333 19. Linkins LA, Dans AL, Moores LK, Bona R, Davidson BL, Schulman S, et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. [Internet] 2012;141(2 Suppl):e495S-e530S. Disponible en: https://doi.org/10.1378/chest.11-2303 20. Seelhammer TG, Bohman JK, Schulte PJ, Hanson AC, Aganga DO. Comparison of Bivalirudin Versus Heparin for Maintenance Systemic Anticoagulation During Adult and Pediatric Extracorporeal Membrane Oxygenation. Crit Care Med. [Internet] 2021;49(9):1481-92. Disponible en: https://doi.org/10.1097/CCM.0000000000005033 21. Li DH, Sun MW, Zhang JC, Zhang C, Deng L, Jiang H. Is bivalirudin an alternative anticoagulant for extracorporeal membrane oxygenation (ECMO) patients? A systematic review and meta-analysis. Thromb Res. [Internet] 2022;210:53-62. Disponible en: https://doi.org/10.1016/j.thromres.2021.12.024 22. Nagle EL, Dager WE, Duby JJ, Roberts AJ, Kenny LE, Murthy MS, et al. Bivalirudin in pediatric patients maintained on extracorporeal life support. Pediatr Crit Care Med. [Internet] 2013;14(4):e182-8. Disponible en: https://doi.org/10.1097/PCC.0b013e31827200b6 23. Kaushik S, Derespina KR, Chandhoke S, Shah DD, Cohen T, Shlomovich M, et al. Use of bivalirudin for anticoagulation in pediatric extracorporeal membrane oxygenation (ECMO). Perfusion. [Internet] 2021:2676591211034314. Disponible en: https://doi.org/10.1177/02676591211034314 24. Szymanski MW, Hafzalah M. Extracorporeal Membrane Oxygenation Anticoagulation. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2022, StatPearls Publishing LLC.; 2022. 25. Ranucci M, Ballotta A, Kandil H, Isgrò G, Carlucci C, Baryshnikova E, et al. Bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation. Crit Care. [Internet] 2011;15(6):R275. Disponible en: https://doi.org/10.1186/cc10556 26. Penk JS, Reddy S, Polito A, Cisco MJ, Allan CK, Bembea M, et al. Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 2. Pediatr Crit Care Med. [Internet] 2019;20(11):1034-9. Disponible en: https://doi.org/10.1097/PCC.0000000000002104 27. Panigada M, G EI, Brioni M, Panarello G, Protti A, Grasselli G, et al. Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: a safety and feasibility pilot study. Ann Intensive Care. [Internet] 2018;8(1):7. Disponible en: https://doi.org/10.1186/s13613-017-0352-8 28. Willems A, Roeleveld PP, Labarinas S, Cyrus JW, Muszynski JA, Nellis ME, et al. Anti-Xa versus time-guided anticoagulation strategies in extracorporeal membrane oxygenation: a systematic review and meta-analysis. Perfusion. [Internet] 2021;36(5):501-12. Disponible en: https://doi.org/10.1177/0267659120952982 |
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Anticoagulación en pacientes pediátricos con ECMO: una revisión de la literatura Anticoagulation in pediatric ECMO patients: a review of the literature El uso de ECMO se ha extendido rápidamente en la población pediátrica y ha permitido alcanzar altas tasas de supervivencia en enfermedades graves y refractarias. Su objetivo es el soporte respiratorio y/o cardiaco hasta la resolución de la enfermedad en curso. Sin embargo, a pesar de los avances aún existe una importante carga de morbimortalidad dada por la presencia de complicaciones hemostáticas. Este desequilibrio de la coagulación es un proceso complejo que involucra factores relacionados con la nueva interfaz sangre-biomaterial generadora de cambios en la cascada de coagulación, proteínas y células, además de factores propios de la edad y de las patologías críticas de estos pacientes. La anticoagulación constituye parte esencial del manejo y se convierte en un reto lograr el balance del riesgo de trombosis y hemorragia. La heparina no fraccionada ha sido el anticoagulante de mayor uso, sin embargo, su dosificación varía ampliamente y es ajustada a alcanzar el efecto clínico y rangos objetivos en ensayos de monitorización sin una recomendación única para población pediátrica en ECMO y aún con una frecuencia importante de complicaciones hemostáticas. Se plantea el uso de inhibidores directos de la trombina considerados buenos candidatos por tener un mejor perfil de seguridad, sin embargo, no existen estudios prospectivos que permitan estandarizar recomendaciones para su uso. La elección del anticoagulante y las pruebas de monitorización son variadas y dependen de la experiencia de uso y su disponibilidad. Este artículo pretende revisar la evidencia disponible respecto al uso de la anticoagulación para ECMO en población pediátrica. The use of ECMO has spread rapidly in the pediatric population and has led to high survival rates in severe and refractory diseases. Its objective is respiratory and/or cardiac support until resolution of the ongoing disease. However, despite advances, there is still a significant morbidity and mortality burden due to the presence of hemostatic complications. This coagulation imbalance is a complex process involving factors related to the new blood-biomaterial interface that generates changes in the coagulation cascade, proteins, and cells, as well as factors related to age and the critical pathologies of these patients. Anticoagulation is an essential part of management and it becomes a challenge to balance the risk of thrombosis and bleeding. Unfractionated heparin has been the most widely used anticoagulant, however, its dosage varies widely and is adjusted to achieve clinical effect and objective ranges in monitoring trials without a single recommendation for the pediatric population in ECMO and even with a significant frequency of hemostatic complications. The use of direct thrombin inhibitors considered good candidates because they have a better safety profile, however, there aren’t prospective studies that allow standardizing recommendations for their use. The choice of anticoagulant and monitoring tests are varied and depend on the experience of use and its availability. This article aims to review the available evidence regarding the use of anticoagulation for ECMO in the pediatric population. Carrasco De Los Rios, Monica Zúñiga Contreras, Pamela Oxigenación por membrana extracorpórea pediatría anticoagulantes bivalirudina Extracorporeal membrane oxygenation pediatrics anticoagulants bivalirudin 9 1 Núm. 1 , Año 2022 : Enero-junio Artículo de revista Journal article 2022-11-01T14:42:14Z 2022-11-01T14:42:14Z 2022-11-01 application/pdf Asociación Colombiana de Hematología y Oncología (ACHO) Revista Colombiana de Hematología y Oncología 2256-2877 2256-2915 https://revista.acho.info/index.php/acho/article/view/401 10.51643/22562915.401 https://doi.org/10.51643/22562915.401 spa https://creativecommons.org/licenses/by-nc-nd/4.0 Revista Colombiana de Hematología y Oncología - 2022 Esta obra está bajo una licencia internacional Creative Commons Atribución-NoComercial-SinDerivadas 4.0. Barton R, Ignjatovic V, Monagle P. Anticoagulation during ECMO in neonatal and paediatric patients. Thromb Res. [Internet] 2019;173:172-7. Disponible en: https://doi.org/10.1016/j.thromres.2018.05.009 2. Valencia E, Nasr VG. Updates in Pediatric Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth. [Internet] 2020;34(5):1309-23. Disponible en: https://doi.org/10.1053/j.jvca.2019.09.006 3. Drop JGF, Wildschut ED, Gunput STG, de Hoog M, van Ommen CH. Challenges in Maintaining the Hemostatic Balance in Children Undergoing Extracorporeal Membrane Oxygenation: A Systematic Literature Review. Front Pediatr. [Internet] 2020;8:612467. Disponible en: https://doi.org/10.3389/fped.2020.612467 4. Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, et al. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med. [Internet] 2021;8:671241. Disponible en: https://doi.org/10.3389/fcvm.2021.671241 5. Chlebowski MM, Baltagi S, Carlson M, Levy JH, Spinella PC. Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO. Crit Care. [Internet] 2020;24(1):19. Disponible en: https://doi.org/10.1186/s13054-020-2726-9 6. Koster A, Ljajikj E, Faraoni D. Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation. Ann Cardiothorac Surg. [Internet] 2019. p. 129-36. Disponible en: https://doi.org/10.21037/acs.2018.07.03 7. Ryerson LM, Lequier LL. Anticoagulation Management and Monitoring during Pediatric Extracorporeal Life Support: A Review of Current Issues. Front Pediatr. [Internet] 2016;4:67. Disponible en: https://doi.org/10.3389/fped.2016.00067 8. Franchini M, Mannucci PM. Acquired von Willebrand syndrome: focused for hematologists. Haematologica. [Internet] 2020;105(8):2032-7. Disponible en: https://doi.org/10.3324/haematol.2020.255117 9. Hardart GE, Fackler JC. Predictors of intracranial hemorrhage during neonatal extracorporeal membrane oxygenation. J Pediatr. [Internet] 1999;134(2):156-9. Disponible en: https://doi.org/10.1016/S0022-3476(99)70408-7 10. Dalton HJ, Reeder R, Garcia-Filion P, Holubkov R, Berg RA, Zuppa A, et al. Factors Associated with Bleeding and Thrombosis in Children Receiving Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med. [Internet] 2017;196(6):762-71. Disponible en: https://doi.org/10.1164/rccm.201609-1945OC 11. Sell LL, Cullen ML, Whittlesey GC, Yedlin ST, Philippart AI, Bedard MP, et al. Hemorrhagic complications during extracorporeal membrane oxygenation: prevention and treatment. J Pediatr Surg. [Internet] 1986;21(12):1087-91. Disponible en: https://doi.org/10.1016/0022-3468(86)90015-1 12. Penk JS, Reddy S, Polito A, Cisco MJ, Allan CK, Bembea MM, et al. Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society: Part 1. Pediatr Crit Care Med. [Internet] 2019;20(11):1027-33. Disponible en: https://doi.org/10.1097/PCC.0000000000002054 13. Fuentes A, Casado C, Mayordomo A, García R, Solís D, Ramírez B. Protocolo de anticoagulación para ECMO infantil. Revista Española de perfusión. [Internet] 2019;67. Disponible en: https://dialnet.unirioja.es/servlet/articulo?codigo=7272351 14. Wong TE, Delaney M, Gernsheimer T, Matthews DC, Brogan TV, Mazor R, et al. Antithrombin concentrates use in children on extracorporeal membrane oxygenation: a retrospective cohort study. Pediatr Crit Care Med. [Internet] 2015;16(3):264-9. Disponible en: https://doi.org/10.1097/PCC.0000000000000322 15. Panigada M, Cucino A, Spinelli E, Occhipinti G, Panarello G, Novembrino C, et al. A Randomized Controlled Trial of Antithrombin Supplementation During Extracorporeal Membrane Oxygenation. Crit Care Med. [Internet] 2020;48(11):1636-44. Disponible en: https://doi.org/10.1097/CCM.0000000000004590 16. Jones AJ, O'Mara KL, Kelly BJ, Samraj RS. The Impact of Antithrombin III Use in Achieving Anticoagulant Goals in Pediatric Patients. J Pediatr Pharmacol Ther. [Internet] 2017;22(5):320-5. Disponible en: https://doi.org/10.5863/1551-6776-22.5.320 17. Hamzah M, Jarden AM, Ezetendu C, Stewart R. Evaluation of Bivalirudin As an Alternative to Heparin for Systemic Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. [Internet] 2020;21(9):827-34. Disponible en: https://doi.org/10.1097/PCC.0000000000002384 18. Sanfilippo F, Asmussen S, Maybauer DM, Santonocito C, Fraser JF, Erdoes G, et al. Bivalirudin for Alternative Anticoagulation in Extracorporeal Membrane Oxygenation: A Systematic Review. J Intensive Care Med. [Internet] 2017;32(5):312-9. Disponible en: https://doi.org/10.1177/0885066616656333 19. Linkins LA, Dans AL, Moores LK, Bona R, Davidson BL, Schulman S, et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. [Internet] 2012;141(2 Suppl):e495S-e530S. Disponible en: https://doi.org/10.1378/chest.11-2303 20. Seelhammer TG, Bohman JK, Schulte PJ, Hanson AC, Aganga DO. Comparison of Bivalirudin Versus Heparin for Maintenance Systemic Anticoagulation During Adult and Pediatric Extracorporeal Membrane Oxygenation. Crit Care Med. [Internet] 2021;49(9):1481-92. Disponible en: https://doi.org/10.1097/CCM.0000000000005033 21. Li DH, Sun MW, Zhang JC, Zhang C, Deng L, Jiang H. Is bivalirudin an alternative anticoagulant for extracorporeal membrane oxygenation (ECMO) patients? A systematic review and meta-analysis. Thromb Res. [Internet] 2022;210:53-62. Disponible en: https://doi.org/10.1016/j.thromres.2021.12.024 22. Nagle EL, Dager WE, Duby JJ, Roberts AJ, Kenny LE, Murthy MS, et al. 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