Role of argatroban infusion in controlling clot formation in post-cardiac surgical extracorporeal membrane oxygenation in pediatrics: A case series of three patients

Anticoagulation in pediatric patients on extracorporeal membrane oxygenation (ECMO) presents significant challenges. Direct thrombin inhibitors (DTIs), such as argatroban, are increasingly considered when heparin is ineffective or contraindicated. However, guidelines regarding optimal dosing and monitoring remain established. This case series examines three pediatric patients who received argatroban infusion following cardiac surgery. We focus on titration challenges, complications, and outcomes. Patient 1, a 3-month-old girl, required a gradual increase in argatroban to 0.7 mcg/kg/min over 8 days. Patient 2, a 3-year-old boy, transitioned to argatroban due to suspected heparin-induced thrombocytopenia (HIT) and required doses up to 1.43 mcg/kg/min. Patient 3, a 23-month-old boy, reached 2.13 mcg/kg/min over 39 days. While patients were successfully decannulated, complications included arterial thrombosis, circuit thrombosis, and mild intracranial hemorrhage. In our series, effective argatroban doses ranged widely (0.18 to 2.13 mcg/kg/min), highlighting the need for individualized dosing, while optimal monitoring strategies remain to be established; lower doses are recommended for patients with hepatic impairment.