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Jesudas R, Takemoto CM. Where have all the platelets gone? HIT, DIC, or something else? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:43-50. [PMID: 38066886 PMCID: PMC10727081 DOI: 10.1182/hematology.2023000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Thrombocytopenia in ill children is common; accurately diagnosing the underlying etiology is challenging and essential for appropriate management. Triggers for accelerated consumption of platelets are numerous; common downstream mechanisms of clearance include platelet trapping in microvascular thrombi, phagocytosis, and platelet activation. Thrombocytopenia with microangiopathic hemolytic anemia (MAHA) is frequently due to disseminated intravascular coagulation. Thrombotic microangiopathy (TMA) is a subgroup of MAHA. Specific TMA syndromes include thrombotic thrombocytopenic purpura, complement-mediated TMA (CM-TMA), and Shiga toxin-mediated hemolytic uremic syndrome. Isolated thrombocytopenia is characteristic of immune thrombocytopenia; however, concomitant cytopenias are frequent in critically ill patients, making the diagnosis difficult. Immune thrombocytopenia with large vessel thrombosis is a feature of heparin-induced thrombocytopenia and antiphospholipid antibody syndrome. In addition, thrombocytopenia is common with macrophage activation, which is characteristic of hemophagocytic lymphohistiocytosis. While thrombocytopenia in ill patients can be driven by hypoproliferative processes such as myelosuppression and/or bone marrow failure, this review will focus on consumptive thrombocytopenia due to immune and nonimmune causes.
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Alhanshani AA. Heparin Induced Thrombocytopenia - Pathophysiology, Diagnosis and Treatment: A Narrative Review. Int J Gen Med 2023; 16:3947-3953. [PMID: 37667778 PMCID: PMC10475297 DOI: 10.2147/ijgm.s420327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening, immune-mediated complication following heparin exposure and is considered to be the most severe adverse reaction to heparin treatment that is not associated with bleeding. Development of autoantibodies against platelet factor 4 (PF4) - heparin complex constitutes the basis of the pathophysiological changes in patients suffering from HIT, which then binds to the surface of platelets and monocytes, thus provoking their activation and subsequent aggregation, ultimately leading to the formation of thrombosis. Formation of arterial and venous thrombosis is aggravated by the simultaneous activation of platelets and monocytes with a substantial mortality rate. The incidence of HIT is reported to be significantly lower in pediatric patients compared with adults. Diagnosis of HIT in pediatric population remains a clinical entity supplemented by laboratory evaluation. The positive predictive value of laboratory evaluation is further elevated by the use of scoring systems and predictive models used for hastening the diagnosis of HIT. Use of alternative anticoagulants like direct thrombin inhibitors and factor Xa inhibitors form the mainstay of treatment in cases of HIT, however, more prospective studies would be required in the pediatric population to delineate definitive guidelines for proper management of patients in this age-group. This article delivers diagnostic and treatment approach in case of patients with HIT, wherein the pathophysiology, clinical manifestations, diagnostic approach and the management of patients with HIT has been described.
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Affiliation(s)
- Ahmad A Alhanshani
- Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
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Valdes CA, Sharaf OM, Bleiweis MS, Jacobs JP, Mumtaz M, Sharaf RM, Jeng EI, Peek GJ. Heparin-based versus bivalirudin-based anticoagulation in pediatric extracorporeal membrane oxygenation: A systematic review. Front Med (Lausanne) 2023; 10:1137134. [PMID: 36999064 PMCID: PMC10043325 DOI: 10.3389/fmed.2023.1137134] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
IntroductionOptimal anticoagulation therapy is essential for the prevention of thrombotic and hemorrhagic complications in pediatric patients supported with extracorporeal membrane oxygenation (ECMO). Recent data have demonstrated bivalirudin has the potential to surpass and replace heparin as the anticoagulant of choice.MethodsWe conducted a systematic review comparing the outcomes of heparin-based versus bivalirudin-based anticoagulation in pediatric patients supported on ECMO to identify the preferred anticoagulant to minimize bleeding events, thrombotic complications, and associated mortality. We referenced the PubMed, Cochrane Library, and Embase databases. These databases were searched from inception through October 2022. Our initial search identified 422 studies. All records were screened by two independent reviewers using the Covidence software for adherence to our inclusion criteria, and seven retrospective cohort studies were identified as appropriate for inclusion.ResultsIn total, 196 pediatric patients were anticoagulated with heparin and 117 were anticoagulated with bivalirudin while on ECMO. Across the included studies, it was found that for patients treated with bivalirudin, trends were noted toward lower rates of bleeding, transfusion requirements, and thrombosis with no difference in mortality. Overall costs associated with bivalirudin therapy were lower. Time to therapeutic anticoagulation varied between studies though institutions had different anticoagulation targets.ConclusionBivalirudin may be a safe, cost-effective alternative to heparin in achieving anticoagulation in pediatric ECMO patients. Prospective multicenter studies and randomized control trials with standard anticoagulation targets are needed to accurately compare outcomes associated with heparin versus bivalirudin in pediatric ECMO patients.
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Cohen O, Lange K, Budnik I, Tamarin I, Brutman-Barazani T, Barg AA, Rosenberg N, Lubetsky A, Kenet G, Levy-Mendelovich S. Application of a clinical decision rule and laboratory assays in pediatrics: Adult heparin-induced thrombocytopenia. Pediatr Blood Cancer 2022; 69:e29929. [PMID: 35997577 DOI: 10.1002/pbc.29929] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/18/2022] [Accepted: 07/24/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is rare among pediatric patients. The diagnosis of HIT depends upon clinical decision tools to assess its pretest probability, supported by laboratory evidence of anti-platelet factor 4 (anti-PF4)/heparin antibodies. AIMS To compare the use of the 4Ts score clinical decision tool, clinical characteristics, and laboratory findings between pediatric and adult patients with suspected HIT. METHODS We compiled all pediatric patients in our center for whom HIT testing was performed during the years 2015-2021. These were compared with a cohort of consecutive adult patients. Laboratory diagnosis of HIT was performed with particle gel immunoassay (PaGIA) as screening test and confirmed by an automated latex-enhanced immunoturbidimetric assay (LIA) and/or by functional flow cytometry assay (FCA). RESULTS The cohort included 34 children (under 18 years) and 105 adults. Adults mostly received heparins for thromboembolism prophylaxis and treatment (72.4%, n = 76), and were more frequently treated with low-molecular-weight heparin (LMWH). Children were mostly exposed during cardiopulmonary bypass and extracorporeal membrane oxygenation (ECMO, 61.8%, n = 21), and were more frequently treated with unfractionated heparin (UFH). Compared with adults, children had significantly higher 4Ts scores. Nevertheless, adults had a slightly higher rate of a positive diagnosis of HIT. Six out of 16 adults with confirmed HIT presented with thrombosis (37.5%), whereas all three pediatric patients with HIT presented with thrombosis (p = .087). CONCLUSIONS 4Ts scores are higher in children compared with adult patients for whom laboratory tests for HIT were obtained. A potentially higher incidence of thrombosis in children with HIT may be attributable to the severity of underlying illness.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Kfir Lange
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ivan Budnik
- Department of Pathophysiology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ilia Tamarin
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Dworman Automated-Mega Laboratory, Sheba Medical Center, Tel HaShomer, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Arie Barg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nurit Rosenberg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Lubetsky
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Talpiot Medical Leadership Program, Sheba Medical Center, Tel HaShomer, Israel
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Chok R, Turley E, Bruce A. Screening and diagnosis of heparin-induced thrombocytopenia in the pediatric population: A tertiary centre experience. Thromb Res 2021; 207:1-6. [PMID: 34482163 DOI: 10.1016/j.thromres.2021.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/31/2021] [Accepted: 08/19/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is a life-threatening side effect of heparin necessitating immediate heparin discontinuation. A missed diagnosis of HIT carries significant morbidity and mortality, while overdiagnosis may result in unnecessary and potentially harmful use of alternative anticoagulants in the pediatric population. We aimed to determine the proportion of HIT screening tests at our pediatric tertiary care centre ultimately leading to a diagnosis of HIT by functional assay (either lumi-aggregometry or serotonin-release assay). We hypothesized that the frequency of HIT at our centre would be lower than that reported in the literature. MATERIALS AND METHODS We conducted a retrospective review including children aged 0 to 18 years who had HIT testing performed at our centre between 2010 and 2018 (N = 189; 51% female). A screening enzyme immunoassay, if positive, is followed by a functional assay which must be positive to establish the diagnosis of HIT. Data were analyzed to establish trends in demographic and clinical features of patients with a positive HIT screening test. Our primary outcome was the rate of HIT confirmed by functional testing amongst children screened for HIT from 2010 to 2018. RESULTS AND CONCLUSIONS There were 233 screening tests performed on 189 distinct patients. Only one patient (0.4%) received a diagnosis of HIT based on functional assay. This patient was a 16-year-old female later found to have a JAK2 mutation. The false positive rate of the enzyme immunoassay was 9.4% (N = 22). There were no positive enzyme immunoassay tests in the neonatal age group (N = 49). These results reinforce that HIT is rare in children.
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Affiliation(s)
- Rozalyn Chok
- Department of Pediatrics, University of Alberta, 11405-87th Avenue, Edmonton, Alberta T6G 1C9, Canada.
| | - Elona Turley
- Department of Laboratory Medicine and Pathology, Division of Hematological Pathology, University of Alberta Hospital and University of Alberta, 4B1. 19 Walter Mackenzie Centre, 8440-112 Street, Edmonton, Alberta T6G 2B7, Canada.
| | - Aisha Bruce
- Department of Pediatrics, Division of Hematology/Oncology, Stollery Children's Hospital and University of Alberta, 11405-87th Avenue, Edmonton, Alberta T6G 1C9, Canada.
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Park YS. Thrombosis and severe acute respiratory syndrome coronavirus 2 vaccines: vaccine-induced immune thrombotic thrombocytopenia. Clin Exp Pediatr 2021; 64:400-405. [PMID: 34237213 PMCID: PMC8342878 DOI: 10.3345/cep.2021.00717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/21/2021] [Indexed: 01/19/2023] Open
Abstract
The development of vaccines against severe acute respiratory syndrome coronavirus 2, which features high mortality and morbidity rates, has progressed at an unprecedented rate, and vaccines are currently in use worldwide. Thrombotic events after vaccination are accompanied by thrombocytopenia, and this issue was recently termed vaccine-induced immune thrombotic thrombocytopenia. This manuscript describes recently published guidelines and other related issues and demonstrates characteristic cases.
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Affiliation(s)
- Young Shil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
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7
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Avila L, Amiri N, Yenson P, Khan S, Zavareh ZT, Chan AKC, Williams S, Brandão LR. Heparin-Induced Thrombocytopenia in a Pediatric Population: Implications for Clinical Probability Scores and Testing. J Pediatr 2020; 226:167-172.e2. [PMID: 32640269 DOI: 10.1016/j.jpeds.2020.06.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the applicability of the 4Ts score and the Heparin-Induced Thrombocytopenia (HIT) Expert Probability (HEP) score in children with suspected HIT and to estimate the number of children potentially at risk of HIT. STUDY DESIGN We retrospectively estimated 4Ts and HEP scores in a cohort of 50 children referred for laboratory screening with enzyme immunoassay. In addition, minor modifications were introduced to the 4Ts score (modified 4Ts score) to adapt it for use in the pediatric setting. All patients with positive enzyme immunoassays were tested with serotonin release assay. We also extracted the number of patients started on heparins in a similar period of time. RESULTS The median age at the time of testing was 4 years (25th-75th percentile, 8.7 months to 13.5 years); 78% of patients had low and 22% had intermediate risk pretest probability scores using the original 4Ts score; 86% had low risk and 14% had intermediate risk scores using the modified 4Ts score; 54% of children had a HEP score of ≥2. Six patients (12%) had a positive (≥0.40 optical density units) enzyme immunoassay, but none had a positive serotonin release assay. Based on anticoagulation dose, there were 1-2 new daily potentially high-risk exposures to heparinoids at our institution. CONCLUSIONS The modified 4Ts and original 4Ts scores may be more adequate than the HEP score to determine HIT pretest probability in children. Despite the number of patients potentially at risk, HIT is rare in pediatrics.
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Affiliation(s)
- Laura Avila
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Yenson
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shirin Khan
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; G. Raymond Chang School of Continuing Education, Ryerson University, Toronto, Ontario, Canada
| | - Zahra Tofighi Zavareh
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; G. Raymond Chang School of Continuing Education, Ryerson University, Toronto, Ontario, Canada
| | - Anthony K C Chan
- Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Cohen O, Levy-Mendelovich S, Ageno W. Rivaroxaban for the treatment of venous thromboembolism in pediatric patients. Expert Rev Cardiovasc Ther 2020; 18:733-741. [DOI: 10.1080/14779072.2020.1823218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tisch Cancer Institue, Icahn School of Medicine, Mount Sinai Hospital, NY, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Challenges and Opportunities in the Pharmacological Treatment of Acute Venous Thromboembolism in Children. Paediatr Drugs 2020; 22:385-397. [PMID: 32519267 DOI: 10.1007/s40272-020-00403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is an important but historically under-recognized problem in pediatrics, with an incidence concentrated in hospitalized children. A number of specific VTE diseases with discrete triggers have been described, but the most common pediatric trigger is the presence of central venous access devices. VTE diseases, though heterogenous in etiology, are linked by the common therapeutic strategies shared by their management. Historically, the most commonly used drug therapies have been unfractionated heparin, low-molecular-weight heparins, and vitamin K antagonists, based on extrapolation from adult data rather than any specific pediatric trials. Although these widely used drugs appear safe and effective in expert hands, the historical lack of pediatric data is problematic in view of the recognized significant differences between children and adults with regards to hemostatic physiology, VTE etiology, and drug pharmacokinetics. The increasing adult usage of novel VTE pharmacotherapies such as direct oral anticoagulants (DOACs) has led to considerable interest in exploring the pediatric applications of these newer drugs. This review summarizes the advantages and disadvantages of existing VTE pharmacotherapies and outlines emerging novel pediatric VTE therapies, particularly DOACs, within the context of the current pediatric trial landscape.
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Zhou P, Yin JX, Tao HL, Zhang HW. Pathogenesis and management of heparin-induced thrombocytopenia and thrombosis. Clin Chim Acta 2020; 504:73-80. [DOI: 10.1016/j.cca.2020.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 01/19/2023]
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Abstract
After vascular injury and exposure of subendothelial matrix proteins to the intravascular space, mediators of hemostasis are triggered and allow for clot formation and restoration of vascular integrity. Platelets are the mediators of primary hemostasis, creating a platelet plug and allowing for initial cessation of bleeding. Platelet disorders, qualitative and quantitative, may result in bleeding signs and symptoms, particularly mucocutaneous bleeding such as epistaxis, bruising, petechiae, and heavy menstrual bleeding. Increasing evidence suggests that platelets have functional capabilities beyond hemostasis, but this review focuses solely on platelet hemostatic properties. Herein, normal platelet function as well as the effects of abnormal function and thrombocytopenia are reviewed.
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Affiliation(s)
- Kristina M Haley
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
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13
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Bhat R, Monagle P. Anticoagulation in preterm and term neonates: Why are they special? Thromb Res 2020; 187:113-121. [DOI: 10.1016/j.thromres.2019.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 01/19/2023]
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Kumar P. The General Pediatrician's Guide to Isolated Thrombocytopenia. Pediatr Ann 2020; 49:e27-e35. [PMID: 31930420 DOI: 10.3928/19382359-20191212-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Platelets are an essential component of the hemostatic pathway; therefore, it is important to identify and diagnose patients with low platelet counts. This can be challenging, however, because thrombocytopenia can be relatively common and the differential diagnosis can be broad. Furthermore, because platelets can be affected both in form and function in a variety of medical conditions, platelet abnormalities can be the principal driver in some disorders but only a consequence in others. Critical factors in identifying the etiology of the thrombocytopenia include the severity and acuity of the patient's initial presentation along with the history, physical examination, and laboratory findings, all of which can provide important clues. The accurate diagnosis of thrombocytopenia is crucial for determining the appropriate management. This review highlights the key diagnostic considerations and recommended treatment when isolated thrombocytopenia is encountered in clinical practice. [Pediatr Ann. 2020;49(1):e27-e35.].
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants. J Thromb Haemost 2019; 17:1608-1622. [PMID: 31313454 DOI: 10.1111/jth.14575] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/25/2019] [Accepted: 07/11/2019] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening prothrombotic, immune-mediated complication of unfractionated heparin and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The risk for HIT correlates with the accumulative dosage of heparin exposure. In ECMO patients receiving continuous infusion of heparin for circuit patency, the risk for HIT is not neglected and must be thought of in the differential diagnosis of the appropriate clinical and laboratory circumstances. The following article reviews the current knowledge in HIT complicating ECMO patients and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
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Gill M. Platelet Refractoriness in a Pediatric ECMO Patient: A Case Report. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2019; 51:83-87. [PMID: 31239581 PMCID: PMC6586261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 03/20/2019] [Indexed: 06/09/2023]
Abstract
Thrombocytopenia is a life-threatening condition, the severity of which is exacerbated further if the patient requires anticoagulation and is refractory to platelet transfusion. This is the first report of an infant undergoing extracorporeal support with immune-mediated platelet refractoriness. A 19-month-old girl, with a complex cardiac history, required extracorporeal support because of deterioration 8 days post-cardiac surgery. The child suffered from ongoing thrombocytopenia, unresponsive to multiple platelet transfusions. An incremental rise in the platelet count was achieved following transfusion of human leukocyte antigen-matched platelets, although this was unsuccessful with subsequent transfusions of matched platelets. Following 7 days on extracorporeal membrane oxygenation (ECMO), without cardiac improvement and likely poor prognosis, treatment was withdrawn and the patient died. The management of immune-mediated platelet refractoriness, in an anticoagulated patient on ECMO, requires early diagnosis and timely intervention to achieve a good outcome for the child. An understanding of the condition and a multidisciplinary approach to its treatment will assist in effective direction of medical therapy.
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Affiliation(s)
- Martin Gill
- The Heart Centre for Children, The Sydney Children's Hospitals Network, Sydney, Australia
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17
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Doyle AJ, Crowley MP, Hunt BJ. Perioperative management of antithrombotic treatment in children. Paediatr Anaesth 2019; 29:405-413. [PMID: 30848062 DOI: 10.1111/pan.13511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Andrew J Doyle
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Maeve P Crowley
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
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18
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Fibronectin: a “double hit” modulator in HIT? Blood 2019; 133:891-892. [DOI: 10.1182/blood-2019-01-894295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Cuker A, Arepally GM, Chong BH, Cines DB, Greinacher A, Gruel Y, Linkins LA, Rodner SB, Selleng S, Warkentin TE, Wex A, Mustafa RA, Morgan RL, Santesso N. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv 2018; 2:3360-3392. [PMID: 30482768 PMCID: PMC6258919 DOI: 10.1182/bloodadvances.2018024489] [Citation(s) in RCA: 373] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction mediated by platelet-activating antibodies that target complexes of platelet factor 4 and heparin. Patients are at markedly increased risk of thromboembolism. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about diagnosis and management of HIT. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 33 recommendations. The recommendations address screening of asymptomatic patients for HIT, diagnosis and initial management of patients with suspected HIT, treatment of acute HIT, and special situations in patients with acute HIT or a history of HIT, including cardiovascular surgery, percutaneous cardiovascular intervention, renal replacement therapy, and venous thromboembolism prophylaxis. CONCLUSIONS Strong recommendations include use of the 4Ts score rather than a gestalt approach for estimating the pretest probability of HIT and avoidance of HIT laboratory testing and empiric treatment of HIT in patients with a low-probability 4Ts score. Conditional recommendations include the choice among non-heparin anticoagulants (argatroban, bivalirudin, danaparoid, fondaparinux, direct oral anticoagulants) for treatment of acute HIT.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Beng H Chong
- Department of Haematology, University of New South Wales, Sydney, NSW, Australia
| | - Douglas B Cines
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Yves Gruel
- Department of Haematology-Haemostasis, Trousseau Hospital, Tours, France
| | - Lori A Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Sixten Selleng
- Department of Anaesthesiology, University of Greifswald, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
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20
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support in pediatric patients: review of the literature and alternative anticoagulants. Perfusion 2018; 33:7-17. [PMID: 29788841 DOI: 10.1177/0267659118766723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic, immune-mediated complication of unfractionated heparin (UFH) and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The following article reviews the current knowledge in pediatric HIT, especially in ECMO patients, and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- 1 Pediatric Cardiac Intensive Care Unit, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,2 Pediatric Cardiology, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,3 ECMO service, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,4 The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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Jaffray J, Young G. Deep vein thrombosis in pediatric patients. Pediatr Blood Cancer 2018; 65. [PMID: 29115714 DOI: 10.1002/pbc.26881] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 01/19/2023]
Abstract
Due to advances in caring for critically ill children and those with chronic diseases, rates of deep vein thrombosis (DVT) are increasing in children. Risk factors consist of central venous catheters, chronic medical conditions, thrombophilia, and various medications. Compression Doppler ultrasonography is the method most commonly used to diagnose DVT, and patients will usually present with pain and swelling of the affected limb. Anticoagulation via subcutaneous injection is the most common treatment regime for children with DVT, and the new, direct oral anticoagulants are currently under investigation. Prevention techniques are not established, but clinical studies are addressing this need.
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Affiliation(s)
- Julie Jaffray
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Guy Young
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
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22
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Abstract
Venous thromboembolism is occurring with increasing frequency in children resulting in the more widespread use of anticoagulation in pediatrics. Antithrombotic drugs in children can be divided into the standard and alternative agents. This review discusses standard and alternative anticoagulants. Because standard anticoagulants have significant limitations, including variable pharmacokinetics, issues with therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects, it is expected that the use of alternative anticoagulants will increase over time. With their improved properties and recent prospective clinical trial data, the current and future use of these agents will likely slowly replace of the standard anticoagulants.
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Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Los Angeles, CA 90027, USA.
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23
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent findings on heparin-induced thrombocytopenia (HIT), a prothrombotic disorder caused by platelet-activating IgG targeting platelet factor 4 (PF4)/polyanion complexes. RECENT FINDINGS HIT can explain unusual clinical events, including adrenal hemorrhages, arterial/intracardiac thrombosis, skin necrosis, anaphylactoid reactions, and disseminated intravascular coagulation. Sometimes, HIT begins/worsens after stopping heparin ('delayed-onset' HIT). Various HIT-mimicking disorders are recognized (e.g., acute disseminated intravascular coagulation/'shock liver' with limb ischemia). HIT has features of both B-cell and T-cell immune responses; uptake of PF4/heparin complexes into macrophages ('macropinocytosis') facilitates the anti-PF4/heparin immune response. Antibody-induced activation of monocytes and platelets via their FcγIIA receptors triggers an intense procoagulant response. Sometimes, HIT antibodies recognize PF4 bound to (platelet-associated) chondroitin sulfate, explaining how HIT might occur without concurrent or recent heparin (delayed-onset HIT, 'spontaneous HIT syndrome'). The molecular structure of HIT antigen(s) has been characterized, providing a rationale for future drug design to avoid HIT and improve its treatment. The poor correlation between partial thromboplastin time and plasma argatroban levels (risking subtherapeutic anticoagulation) and need for intravenous administration of argatroban have led to increasing 'off-label' treatment with fondaparinux or one of the direct oral anticoagulants. SUMMARY Understanding the molecular mechanisms and unusual clinical features of HIT will improve its management.
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Young G, Male C, van Ommen CH. Anticoagulation in children: Making the most of little patients and little evidence. Blood Cells Mol Dis 2017; 67:48-53. [PMID: 28552476 DOI: 10.1016/j.bcmd.2017.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/25/2017] [Accepted: 05/03/2017] [Indexed: 01/19/2023]
Abstract
Thrombotic complications are increasing at a steady and significant rate in children resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the standard agents (heparin, low molecular weight heparin, and vitamin K antagonists) and alternative agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the standard and alternative anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. Clearly, the standard anticoagulants all have significant shortcomings including variable pharmacokinetics, issues with therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The alternative anticoagulants have properties which overcome these shortcomings and prospective clinical trial data are presented supporting the current and future use of these agents in place of the standard anticoagulants.
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Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine.
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - C Heleen van Ommen
- Department of Pediatric Hematology/Oncology, Erasmus MC Sophia's Children's Hospital, Rotterdam, Netherlands
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25
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin. Pathogenic antibodies to PF4/heparin bind and activate cellular FcγRIIA on platelets and monocytes to propagate a hypercoagulable state culminating in life-threatening thrombosis. It is now recognized that anti-PF4/heparin antibodies develop commonly after heparin exposure, but only a subset of sensitized patients progress to life-threatening complications of thrombocytopenia and thrombosis. Recent scientific developments have clarified mechanisms underlying PF4/heparin immunogenicity, disease susceptibility, and clinical manifestations of disease. Insights from clinical and laboratory findings have also been recently harnessed for disease prevention. This review will summarize our current understanding of HIT by reviewing pathogenesis, essential clinical and laboratory features, and management.
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26
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Malec L, Young G. Treatment of Venous Thromboembolism in Pediatric Patients. Front Pediatr 2017; 5:26. [PMID: 28293549 PMCID: PMC5328974 DOI: 10.3389/fped.2017.00026] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 02/01/2017] [Indexed: 01/19/2023] Open
Abstract
Given the increased incidence of venous thromboembolism (VTE) in pediatric patients, which has been associated with increased survival of medically complex patients and increased use of invasive supportive measures, it is important to understand treatment options and unique aspects of anticoagulant use in children. The objective of this mini-review is to outline the goals of treatment, treatment options, and adverse events associated with the use of anticoagulants in pediatric patients with VTE.
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Affiliation(s)
- Lynn Malec
- BloodCenter of Wisconsin, Milwaukee, WI, USA; Medical College of Wisconsin, Milwaukee, WI, USA
| | - Guy Young
- Department of Pediatrics, Division of Hematology, Children's Hospital of Los Angeles , Los Angeles, CA , USA
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27
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Khandelwal S, Arepally GM. Immune pathogenesis of heparin-induced thrombocytopenia. Thromb Haemost 2016; 116:792-798. [PMID: 27465274 DOI: 10.1160/th16-01-0074] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 07/04/2016] [Indexed: 02/06/2023]
Abstract
The immune response to heparin is one of the most common drug-induced allergies, and yet, atypical for a drug hypersensitivity reaction. Whereas most drug-induced allergies are rare, idiosyncratic and life-long, the allergic response to heparin is common, predictable in certain clinical settings and transient. Advances in the last decade with regards to structural characterisation of the PF4/heparin antigenic complex, contributions of innate immunity and development of animal models have provided insights into the distinctive features of the HIT immune response. Recent descriptions of the crystal structure of the PF4/heparin complex, alongside other biophysical studies, have clarified the structural requirements for immunogenicity and heparin-dependency of antibody formation. Studies of interactions of PF4 with bacterial cell walls as well as epidemiologic associations of anti-PF4/heparin antibody formation and infection suggest a role for immune priming and explain the rapid evolution of an isotype-switched immune response in sensitised patients. Murine models have greatly facilitated investigations of cellular basis of the HIT response and identified a major role for T-cells and marginal zone B-cells, but key findings have yet to be validated in human disease. This chapter will summarise recent investigations of the HIT immune response in the context of major pathways of immune activation and identify areas of uncertainty.
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Affiliation(s)
| | - Gowthami M Arepally
- Gowthami Arepally, MD, Division of Hematology, DUMC Box 3486, Rm 356A Alex H. Sands Bldg., Research Drive, Durham, NC 27710, USA, Tel: +1 919 668 3696, Fax: +1 919 684 2420, E-mail:
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28
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Resontoc LPR, Yap HK. Renal vascular thrombosis in the newborn. Pediatr Nephrol 2016; 31:907-15. [PMID: 26173707 DOI: 10.1007/s00467-015-3160-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/02/2015] [Accepted: 06/24/2015] [Indexed: 01/19/2023]
Abstract
Neonatal renal vascular thrombosis is rare but has devastating sequelae. The renal vein is more commonly affected than the renal artery. Most neonates with renal vein thrombosis present with at least one of the three cardinal signs, namely, abdominal mass, macroscopic hematuria and thrombocytopenia, while unilateral renal artery thrombosis presents with transient hypertension. Contrast angiography is the gold standard for diagnosis but because of exposure to radiation and contrast agents, Doppler ultrasound scan is widely used instead. Baseline laboratory tests for platelet count, prothrombin time, activated partial thromboplastin time and fibrinogen concentration are essential before therapy is initiated. Maternal blood is tested for lupus anticoagulant and anticardiolipin antibody. Evaluation for prothrombotic disorders is warranted when thrombosis is clinically significant, recurrent or spontaneous. Management should involve a multidisciplinary team that includes neonatologists, radiologists, pediatric hematologists and nephrologists. In addition to supportive therapy, recent guidelines recommend at least prophylactic heparin therapy in the majority of cases to prevent thrombus extension. Thrombolytic therapy is reserved for bilateral thrombosis compromising kidney function. Long-term sequelae, such as kidney atrophy, systemic hypertension and chronic kidney disease, are common, and follow-up by pediatric nephrologists is recommended for monitoring of kidney function, early detection and management of hypertension and chronic kidney disease.
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Affiliation(s)
- Lourdes Paula R Resontoc
- Shaw-NKF-NUH Children's Kidney Center, KTP-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Hui-Kim Yap
- Shaw-NKF-NUH Children's Kidney Center, KTP-National University Children's Medical Institute, National University Health System, Singapore, Singapore.
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Tower Block 12 #1E, Kent Ridge Road, Singapore, 119228, Singapore.
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29
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Hehir DA, Easley RB, Byrnes J. Noncardiac Challenges in the Cardiac ICU: Feeding, Growth and Gastrointestinal Complications, Anticoagulation, and Analgesia. World J Pediatr Congenit Heart Surg 2016; 7:199-209. [PMID: 26957404 DOI: 10.1177/2150135115615847] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Outcomes following cardiac intensive care unit (CICU) admission are influenced by many factors including initial cardiac diagnosis, surgical complexity, and burden of critical illness. Additionally, the presence of noncardiac issues may have a significant impact on outcomes and the patient experience during and following an intensive care unit stay. This review focuses on three common noncardiac areas which impact outcomes and patient experience in and beyond the CICU: feeding and growth, pain and analgesia, and anticoagulation. Growth failure and feeding dysfunction are commonly encountered in infants requiring cardiac surgery and have been associated with worse surgical and developmental outcomes. Recent studies most notably in the single ventricle population have demonstrated improved weight gain and outcomes when feeding protocols are implemented. Children undergoing cardiac surgery may experience both acute and chronic pain. Emerging research is investigating the impact of sedatives and analgesics on neurodevelopmental outcomes and quality of life. Improved pain scores and standardized management of pain and withdrawal may improve the patient experience and outcomes. Effective anticoagulation is a critical component of perioperative care but may be complicated by inflammation, multiorgan dysfunction, and patient factors. Advances in monitoring of anticoagulation and emerging therapies are reviewed.
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Affiliation(s)
- David A Hehir
- Nemours Cardiac Center, AI Dupont Hospital for Children, Thomas Jefferson Medical College, Philadelphia, PA, USA
| | - R Blaine Easley
- Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jonathan Byrnes
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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30
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Sampat HN, Brandão LR, Tamburro RF, Kees-Folts D, Dandekar S. HIT or Miss: The Sequential Diagnostic Approach to Heparin-Induced Thrombocytopenia Illustrated in a Child With Acute Post-Streptococcal Glomerulonephritis. Clin Pediatr (Phila) 2016; 55:294-7. [PMID: 25963179 DOI: 10.1177/0009922815586055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Hemal N Sampat
- Penn State Milton S. Hershey Medical Center, Hershey, PA, USA Penn State Hershey Children's Hospital, Hershey, PA, USA
| | | | - Robert F Tamburro
- Penn State Hershey Children's Hospital, Hershey, PA, USA National Institute of Child Health and Human Development, Bethesda, MD, USA
| | | | - Smita Dandekar
- Penn State Hershey Children's Hospital, Hershey, PA, USA
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31
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Abstract
Thrombotic complications are increasing at a steady and significant rate in children, resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the older multitargeted agents (heparin, low-molecular-weight heparin, and warfarin) and the newer targeted agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the multitargeted and targeted anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. The various agents differ in their pharmacokinetics, requirements for therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The targeted anticoagulants have properties that may make them more attractive for use in specific clinical situations. Prospective clinical trial data are presented supporting the current and future use of these agents in children.
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32
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Abstract
Abstract
Thrombotic complications are increasing at a steady and significant rate in children, resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the older multitargeted agents (heparin, low-molecular-weight heparin, and warfarin) and the newer targeted agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the multitargeted and targeted anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. The various agents differ in their pharmacokinetics, requirements for therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The targeted anticoagulants have properties that may make them more attractive for use in specific clinical situations. Prospective clinical trial data are presented supporting the current and future use of these agents in children.
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33
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