Case report: Use of subcutaneous Fondaparinux in a COVID 19 patient with heparin-induced thrombocytopenia during venous-venous ECMO

Objective: During ECMO because of heparin-based anti-coagulation some patients (0.5-5%) may develop heparin-induced thrombocytopenia (HIT) with drastic decrease of platelet count and severe thromboembolic complications. The first therapeutic intervention in HIT patients is immediate heparin discontinuation and replacement with direct thrombin inhibitors such as Bivalirudin Methods: we describe a patient with ARDS from SARSCoV2 and HIT who underwent vv-ECMO with subcutaneous administration of Fondaparinux, a synthetic and selective factor Xa inhibitor, as anti-coagulant treatment Results: A 67 years old patient, suffering from diabetes and grade 3 obesity (BMI>42), was admitted to ICU for severe dyspnea and hypoxia;COVID-19 nasopharyngeal swab resulted positive. He was intubated on day 9 for rapid worsening of the respiratory condition. Antithrombotic prophylaxis (enoxaparin 6000 UI/die) was started at admission. After one month a dramatic decrease of platelet count occurred. HIT was diagnosed by positive determination of anti-PF4 antibodies and administration of fondaparinux 5 mg/day subcutaneously was started. Due to further worsening of hypoxia (P/F 180 and normocapnia). Nor thrombotic neither bleeding complications occurred during ECMO. Unfortunately the patient died 47 days after admission for a multi-drug resistant K. pneumoniae septic shock Conclusions: The use of Fondaparinux could may represent an effective alternative to anticoagulation management in ECMO inof HIT patients with HITduring ECMO support.