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Sethi SK, Chakraborty R, Joshi H, Raina R. Renal Replacement Therapy in Pediatric Acute Kidney Injury. Indian J Pediatr 2020; 87:608-617. [PMID: 31925716 DOI: 10.1007/s12098-019-03150-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/27/2019] [Indexed: 01/19/2023]
Abstract
Acute kidney injury (AKI) is common in critically ill children and affects nearly 30-40% of patients admitted to the pediatric intensive care unit (ICU). Even with technological advances in critical care and dialysis, there is a high mortality rate of 66.8% to 90% in ICU patients. Renal replacement therapy (RRT) is often performed to treat patients with AKI. However, for optimal RRT treatment, it is crucial to consider the indications, modes of access, and prescription of each RRT method. Therefore, this review aims to discuss the various modalities of RRT in pediatric patients, which include peritoneal dialysis (PD), hemodialysis (HD), continuous RRT (CRRT), and sustained low-efficiency dialysis (SLED).
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Affiliation(s)
- Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Ronith Chakraborty
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA
| | - Hirva Joshi
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA. .,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
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He Y, He H, Liu D, Long Y, Su L, Cheng W. Fondaparinux in a critically Ill patient with heparin-induced thrombocytopenia: A case report. Medicine (Baltimore) 2018; 97:e12236. [PMID: 30212955 PMCID: PMC6156017 DOI: 10.1097/md.0000000000012236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Fondaparinux, as a factor Xa-inhibitor, is used off label to manage heparin-induced thrombocytopenia (HIT), but little experience with HIT patients has been reported in the literature. Moreover, the use of fondaparinux for full anticoagulation in critically ill patients with HIT and renal insufficiency is limited. PATIENT CONCERNS A trauma patient, who had received low molecular weight heparin (LMWH) and heparin to treat venous thromboembolism, developed thrombocytopenia and multiple organ dysfunction in the intensive care unit (ICU). Also, her deep venous thromboembolism (DVT) continued to progress. DIAGNOSIS The final diagnosis was HIT. INTERVENTIONS Fondaparinux was temporarily used for anticoagulation treatment of DVT for 7 days when another anticoagulant (argatroban) was unavailable. Although the patient had kidney dysfunction, a full therapeutic dose of 7.5 mg fondaparinux was administered every morning through subcutaneous injection for consecutive 7 days. OUTCOMES The patient's thrombocytopenia and thrombosis were successfully treated without bleeding complications during therapeutic fondaparinux administration. LESSONS This is the first case reporting the successful use of fondaparinux for full anticoagulation for DVT in a critically ill patient with HIT and renal insufficiency. Our experience suggests that fondaparinux might be an alternative for anticoagulation treatment in patients with HIT and kidney dysfunction if another anticoagulant (argatroban) is unavailable.
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Bui VC, Nguyen TH. The Role of Single-Molecule Force Spectroscopy in Unraveling Typical and Autoimmune Heparin-induced Thrombocytopenia. Int J Mol Sci 2018; 19:E1054. [PMID: 29614814 PMCID: PMC5979551 DOI: 10.3390/ijms19041054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/26/2018] [Accepted: 03/31/2018] [Indexed: 02/07/2023] Open
Abstract
For the last two decades, heparins have been widely used as anticoagulants. Besides numerous advantages, up to 5% patients with heparin administration suffer from a major adverse drug effect known as heparin-induced thrombocytopenia (HIT). This typical HIT can result in deep vein thrombosis, pulmonary embolism, occlusion of a limb artery, acute myocardial infarct, stroke, and a systemic reaction or skin necrosis. The basis of HIT may lead to clinical insights. Recent studies using single-molecule force spectroscopy (SMFS)-based atomic force microscopy revealed detailed binding mechanisms of the interactions between platelet factor 4 (PF4) and heparins of different lengths in typical HIT. Especially, SMFS results allowed identifying a new mechanism of the autoimmune HIT caused by a subset of human-derived antibodies in patients without heparin exposure. The findings proved that not only heparin but also a subset of antibodies induce thrombocytopenia. In this review, the role of SMFS in unraveling a major adverse drug effect and insights into molecular mechanisms inducing thrombocytopenia by both heparins and antibodies will be discussed.
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Affiliation(s)
- Van-Chien Bui
- Institute for Immunology and Transfusion Medicine, University Medicine of Greifswald, 17475 Greifswald, Germany.
| | - Thi-Huong Nguyen
- Institute for Immunology and Transfusion Medicine, University Medicine of Greifswald, 17475 Greifswald, Germany.
- ZIK HIKE-Center for Innovation Competence, Humoral Immune Reactions in Cardiovascular, 17489 Greifswald, Germany.
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Schaarschmidt BM, Boos J, Buchbender C, Kröpil P, Kröpil F, Lanzman RS, Fürst G, Knoefel WT, Antoch G, Thomas C. Heparin-bonded stent graft treatment for major visceral arterial injury after upper abdominal surgery. Eur Radiol 2018; 28:3221-3227. [PMID: 29480342 DOI: 10.1007/s00330-017-5288-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/13/2017] [Accepted: 12/22/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE To analyse technical success, complications, and short- and intermediate-term outcomes after heparin-bonded stent graft implantation for the treatment of major abdominal vessel injury after upper abdominal surgery. METHODS This retrospective, IRB-approved analysis included 29 consecutive patients (female: n = 6, male: n = 23, mean age 65.9 ± 11.2 years). All patients underwent angiography and attempted heparin-bonded stent-graft implantation because of a major visceral arterial injury after upper abdominal surgery. Electronic clinical records, angiographic reports and imaging datasets were reviewed to assess technical success and complications. Telephone interviews were performed to obtain follow-up information and to estimate short- (> 30 days) and intermediate-term (> 90 days) outcomes. RESULTS Successful stent graft placement was achieved in 82.8% (24/29). Peri-interventional complications were observed in 20.7% (6/29) and delayed, angiography-associated complications were observed in 34.5% (10/29) of the patients. Symptomatic re-bleeding occurred in 24.1% (7/29). Short-term survival (> 30 days) was 72.4% (21/29). Intermediate survival (> 90 days) was 37.9% (11/29). CONCLUSION Treatment of major vascular injuries with heparin-bonded stent grafts is feasible with a high technical success rate. However, survival depends on the underlying surgical condition, making interdisciplinary patient management mandatory. KEY POINTS • Stent graft implantation is challenging, but has a high technical success rate. • Complications are frequent but surgical conversion is rarely necessary. • Survival depends on the underlying surgical condition causing the vascular injury. • Interdisciplinary management is crucial for the survival of these patients.
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Affiliation(s)
- Benedikt Michael Schaarschmidt
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany.
| | - Johannes Boos
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Christian Buchbender
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Patric Kröpil
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Feride Kröpil
- Department of General, Viszeral and Pediatric Surgery, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Rotem Shlomo Lanzman
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Guenter Fürst
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of General, Viszeral and Pediatric Surgery, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
| | - Christoph Thomas
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, 40225, Dusseldorf, Germany
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Nagler M, Bakchoul T. Clinical and laboratory tests for the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost 2017; 116:823-834. [DOI: 10.1160/th16-03-0240] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 08/16/2016] [Indexed: 12/27/2022]
Abstract
SummaryA rapid diagnostic work-up is required in patients with suspected heparin-induced thrombocytopenia (HIT). However, diagnosis of HIT is challenging due to a number of practical issues and methodological limitations. Many laboratory tests and a few clinical scoring systems are available but the individual characteristics and the diagnostic accuracy of these are hard to appraise. The 4Ts score is a well evaluated clinical assessment tool with the potential to rule out HIT in many patients. Still, it requires experience and is subject to a relevant inter-observer variability. Immunoassays such as enzyme-linked immunosorbent assays or recently developed rapid assays are able to exclude HIT in a number of patients. But, accuracy of immunoassays differs depending on type of assay, threshold, antibody specificity and even manufacturer. Due to a comparatively low positive predictive value, HIT cannot be confirmed by immunoassays alone. In addition, only some of them are immediately accessible, particularly in small laboratories. While functional assays such as the serotonin release assay (SRA) and the heparin-induced platelet activation assay (HIPA) are considered as gold standard for diagnosis of HIT, they require a highly specialised laboratory. In addition, some of them are not adequately evaluated. In clinical practice, we recommend an integrated diagnostic approach combining not only clinical assessment (the 4Ts score) but immunoassays and functional assays as well. We propose a clear diagnostic algorithm supporting clinical decision-making. Furthermore, we provide an overview of all current laboratory techniques for HIT and discuss diagnostic pathways and strategies to reduce diagnostic errors, and future perspectives.
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6
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Selleng S, Selleng K. Heparin-induced thrombocytopenia in cardiac surgery and critically ill patients. Thromb Haemost 2017; 116:843-851. [DOI: 10.1160/th16-03-0230] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/16/2016] [Indexed: 11/05/2022]
Abstract
SummaryThrombocytopenia as well as anti-platelet factor 4/heparin (PF4/H) antibodies are common in cardiac surgery patients and those treated in the intensive care unit. In contrast, heparin-induced thrombocytopenia (HIT) is uncommon in these populations (∼1 % and ∼0.5 %, respectively). A stepwise approach where testing for anti-PF4/H antibodies is performed only in patients with typical clinical symptoms of HIT improves diagnostic specificity of the laboratory assays without losing sensitivity, thereby helping to avoid overdiagnosis and resulting HIT overtreatment. Short-term re-exposure to heparin, especially given intraoperatively for cardiovascular surgery, is a reasonable therapeutic option in patients with a history of HIT who subsequently test negative for HIT antibodies. Organ failure(s), enhanced bleeding risks, and other characteristics require special considerations regarding non-heparin anticoagulation: Argatroban is the alternative anticoagulant with pharmacokinetics independent of renal function, but it has a prolonged half-life in case of impaired liver function. For bivalirudin, protocols during cardiopulmonary bypass surgery are established, and it is suitable for patients with liver insufficiency. A major issue of direct thrombin inhibitors are false high activated partial thromboplastin time values in patients with comorbidities affecting prothrombin, which can result in systematic underdosing of the drugs. This is not the case for danaparoid and fondaparinux, which can be monitored by anti-factor Xa assays, but have long half-lives and no suitable antidote. This review includes also information on management of on- and off-pump cardiac surgery, ventricular assist devices, percutaneous interventions, continuous renal replacement therapy, and extracorporeal membrane oxygenation in patients with HIT.
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7
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Ratzlaff RA, Ripoll JG, Kassab LL, Diaz-Gomez JL. Acute oxygenator failure: a new presentation of heparin-induced thrombocytopenia in a patient undergoing venovenous extracorporeal membrane oxygenation support. BMJ Case Rep 2016; 2016:bcr-2016-218179. [PMID: 27986695 DOI: 10.1136/bcr-2016-218179] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A 58-year-old man with medical history of thrombocytopenia was admitted to an outside hospital for a 6-day history of worsening dyspnoea requiring mechanical ventilator support. He was transferred to our institution for extracorporeal membrane oxygenation (ECMO) given his refractory hypoxaemia. On arrival, H1N1 influenza virus was confirmed and all measures to improve oxygenation were ineffective. Thus, the decision was made to start venovenous (VV)-ECMO. Although a low baseline platelet count was recognised (60-70×109/L), a sudden further decrease occurred (30×109/L) and platelet transfusion was initiated. A substantial increase in the pressure across the ECMO oxygenator was identified, and the diagnosis of type II heparin-induced thrombocytopenia was suspected and confirmed. Heparin was discontinued, the oxygenator was exchanged and argatroban was used for anticoagulation. After 28 days on VV-ECMO support, the decision was made to withdraw organ support in conjunction with the patient and family wishes.
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Affiliation(s)
- Robert A Ratzlaff
- Department of Critical Care Medicine, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
| | - Juan G Ripoll
- Department of Critical Care Medicine, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
| | - Lena L Kassab
- Department of Critical Care Medicine, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Anesthesiology and Neurosurgery, Mayo Clinic's Campus in Florida, Jacksonville, Florida, USA
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Gray A, Wallis DE, Hursting MJ, Katz E, Lewis BE. Argatroban Therapy for Heparin-Induced Thrombocytopenia in Acutely Ill Patients. Clin Appl Thromb Hemost 2016; 13:353-61. [PMID: 17911186 DOI: 10.1177/1076029607303617] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic, immune-mediated adverse reaction to heparin therapy. To evaluate clinical outcomes and effects of argatroban therapy in acutely ill HIT patients. Retrospective analysis. Hospital in-patient. Acutely ill patients with clinically diagnosed HIT from previous multicenter, historically controlled studies of argatroban therapy in HIT. Argatroban, adjusted to maintain activated partial thromboplastin times 1.5 to 3 times baseline, or historical control therapy (ie, no direct thrombin inhibition). We identified 488 patients who received argatroban (N = 390; mean dose of 1.9 µg/kg/min for a mean 6 days) or historical control therapy (N = 98) for HIT. The primary all-cause composite endpoint of death, amputation, or new thrombosis within 37 days occurred in 133 (34.1%) argatroban-treated patients and 38 (38.8%) controls ( P = .41). Argatroban, versus control, significantly reduced the primary thrombosis-related composite endpoint of death because of thrombosis, amputation secondary to ischemic complications of HIT, or new thrombosis (17.7% vs 30.6%, P = .007). Significant reductions also occurred in new thrombosis and death because of thrombosis. Major bleeding was similar between groups (7.7% vs 8.2%; P = .84). Adverse outcomes were more likely to occur in patients who were initially diagnosed with HIT and thrombosis, had undergone cardiac surgery, were not white, or had more severe thrombocytopenia. In acutely ill HIT patients, argatroban, versus historical control, provides effective antithrombotic therapy without increasing major bleeding. Patients with more severe thrombocytopenia or HIT-related thrombosis on HIT diagnosis have a poorer prognosis, emphasizing the importance of prompt recognition/ treatment of HIT in acutely ill patients.
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Affiliation(s)
- Anthony Gray
- Department of Pulmonary Medicine, Lahey Clinic, Burlington, Massachusetts 01805, USA.
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9
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Scully M, Gates C, Neave L. How we manage patients with heparin induced thrombocytopenia. Br J Haematol 2016; 174:9-15. [PMID: 27097741 DOI: 10.1111/bjh.14102] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Heparin induced thrombocytopenia (HIT) remains a rare, but significant, condition related to mortality and morbidity. The incidence has decreased with reduced use of unfractionated heparin, with the exception of cardiac surgery. Due to the high risk of thrombosis, a switch to a non-heparin anticoagulant is required, until platelet counts normalize. Within the acute setting, argatroban, fondaparinux and direct acting oral anticoagulants (DOACS) are therapeutic options. In patients with HIT-associated thrombosis or who require long-term anticoagulation, warfarin remains the preference, but DOACs are attractive alternatives.
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Affiliation(s)
- Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK
| | - Carolyn Gates
- Thrombosis and Anticoagulant Pharmacist, University College London Hospital, London, UK
| | - Lucy Neave
- Specialist Registrar, Department of Haematology, UCLH, London, UK
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10
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Lu BY, Kudlowitz D, Gardner LB. Clinical and laboratory characteristics associated with a high optical density anti-platelet factor 4 ELISA test. J Blood Med 2015; 6:277-83. [PMID: 26640392 PMCID: PMC4657791 DOI: 10.2147/jbm.s90179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Diagnosing heparin-induced thrombocytopenia, a potentially catastrophic immune-mediated disorder, continues to pose significant challenges for clinicians, as both clinical and laboratory tools lack specificity. There is mounting evidence supporting a positive correlation between definitive heparin-induced thrombocytopenia and optical density (OD) positivity from the widely available anti-platelet factor 4 enzyme-linked immunosorbent assays (PF4 ELISAs). However, the clinical features distinguishing these patients remain poorly understood. PATIENTS AND METHODS To better characterize this group, we conducted a case-controlled, retrospective chart review of patients from two large, urban academic institutions who underwent a PF4 ELISA at a central laboratory. Associations between OD and 18 clinical characteristics were calculated using the Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. RESULTS In total, 184 negative patients (OD <0.7), and 121 positive patients (OD >0.7), including 74 low-positive patients (0.7< OD <1.4) and 47 high-positive patients (OD >1.4) were identified. Several clinical variables were significantly different in the negative group compared with the positive group, including hospital day (P<0.001), previous admission within the past 3 months (P<0.001), and the presence of a new thrombus (P=0.003). However, many of these variables were not different between the negative and low-positive group, and were only distinct between the negative and high-positive group. When the low-positive and high-positive groups were compared, only the 4T score was significantly different (P=0.003). CONCLUSION These data indicate that those with OD >1.4 form a distinct clinical group and support the clinical utility of the 4T score.
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Affiliation(s)
- Benjamin Y Lu
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - David Kudlowitz
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - Lawrence B Gardner
- Department of Medicine, NYU School of Medicine, New York, NY, USA ; Department of Biochemistry and Molecular Pharmacology, NYU School of Medicine, New York, NY, USA ; The Perlmutter Cancer Center, NYU Langone Medical Center, NYU School of Medicine, New York, NY, USA
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11
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Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood 2015; 127:546-57. [PMID: 26518436 DOI: 10.1182/blood-2015-07-661215] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/27/2015] [Indexed: 01/20/2023] Open
Abstract
Immunoassays are essential in the workup of patients with suspected heparin-induced thrombocytopenia. However, the diagnostic accuracy is uncertain with regard to different classes of assays, antibody specificities, thresholds, test variations, and manufacturers. We aimed to assess diagnostic accuracy measures of available immunoassays and to explore sources of heterogeneity. We performed comprehensive literature searches and applied strict inclusion criteria. Finally, 49 publications comprising 128 test evaluations in 15 199 patients were included in the analysis. Methodological quality according to the revised tool for quality assessment of diagnostic accuracy studies was moderate. Diagnostic accuracy measures were calculated with the unified model (comprising a bivariate random-effects model and a hierarchical summary receiver operating characteristics model). Important differences were observed between classes of immunoassays, type of antibody specificity, thresholds, application of confirmation step, and manufacturers. Combination of high sensitivity (>95%) and high specificity (>90%) was found in 5 tests only: polyspecific enzyme-linked immunosorbent assay (ELISA) with intermediate threshold (Genetic Testing Institute, Asserachrom), particle gel immunoassay, lateral flow immunoassay, polyspecific chemiluminescent immunoassay (CLIA) with a high threshold, and immunoglobulin G (IgG)-specific CLIA with low threshold. Borderline results (sensitivity, 99.6%; specificity, 89.9%) were observed for IgG-specific Genetic Testing Institute-ELISA with low threshold. Diagnostic accuracy appears to be inadequate in tests with high thresholds (ELISA; IgG-specific CLIA), combination of IgG specificity and intermediate thresholds (ELISA, CLIA), high-dose heparin confirmation step (ELISA), and particle immunofiltration assay. When making treatment decisions, clinicians should be a aware of diagnostic characteristics of the tests used and it is recommended they estimate posttest probabilities according to likelihood ratios as well as pretest probabilities using clinical scoring tools.
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Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. J Crit Care 2015; 30:1190-4. [PMID: 26363901 DOI: 10.1016/j.jcrc.2015.07.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/14/2015] [Accepted: 07/28/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE Patients receiving extracorporeal membrane oxygenation (ECMO) are at risk for thrombocytopenia including heparin-induced thrombocytopenia (HIT). The purpose of this study was to determine the frequency of suspected HIT in patients receiving ECMO and unfractionated heparin (UFH). MATERIALS AND METHODS We conducted a retrospective review in adult patients on ECMO. Patients were included if they received ECMO for at least 5 days and concomitant UFH. RESULTS There were 119 patients who met inclusion criteria. Twenty-three patients (19%) had a heparin-platelet factor 4 immunoassay performed. Patients with suspected HIT had a significantly lower platelet count within the first 3 days of ECMO, 69×10(9)/L (22-126×10(9)/L) vs 87.5×10(9)/L (63-149×10(9)/L); P=.04. The lowest platelet count on the day of HIT testing was 43×10(9)/L (26-73), representing a 71% reduction from baseline. Twenty patients (87%) had an optical density score less than 0.4, and all patients had a score less than 1.0. A functional assay was performed in 7 patients (30%), with only 1 patient having laboratory-confirmed HIT. CONCLUSIONS The evaluation of HIT occurred in a small percentage of patients, with HIT rarely being detected. Patients who had heparin-platelet factor 4 immunoassay testing exhibited lower platelet counts with a similar duration of ECMO and UFH exposure.
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Cope JM, Bushwitz J, An G, Antigua A, Patel A, Zumberg M. Reply: clinical experience with prophylactic fondaparinux in critically ill patients with moderate to severe renal impairment or renal failure requiring renal replacement therapy. Ann Pharmacother 2015; 49:614-5. [PMID: 25870447 DOI: 10.1177/1060028015571658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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14
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Levi M, Sivapalaratnam S. Hemostatic abnormalities in critically ill patients. Intern Emerg Med 2015; 10:287-96. [PMID: 25537442 DOI: 10.1007/s11739-014-1176-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/09/2014] [Indexed: 12/17/2022]
Abstract
Hemostatic abnormalities frequently occur in critically ill patients and may vary from prolonged global clotting tests or isolated thrombocytopenia, to composite defects, such as consumption coagulopathies. There are many reasons for a disturbed coagulation in intensive care patients, and each of these underlying syndromes may require specific therapeutic intervention. Hence, an adequate differential diagnosis and initiation of proper (supportive) therapeutic strategies are critical to decrease morbidity and mortality in critically ill patients with hemostatic abnormalities.
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Affiliation(s)
- Marcel Levi
- Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,
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15
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McMahon CM, Cuker A. The 4Ts test in the critically ill: timing is everything. J Crit Care 2015; 29:468-9. [PMID: 24791660 DOI: 10.1016/j.jcrc.2014.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 03/02/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Christine M McMahon
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Abstract
Thrombocytopenia is commonly seen in laboratory findings, especially in critically ill patients. Although the incidence is rare, drug-induced immune thrombocytopenia (DITP) is a serious complication that is often overlooked as a cause of thrombocytopenia. Over the last century, extensive research and data collection have been done in an attempt to better characterize DITP. Heparin-induced thrombocytopenia is the most common DITP and has distinct pathogenesis, diagnosis, and treatment options. However, other offending medications are less well known and have triggered many questions and constant search for answers. This review will discuss both drug-induced immune-mediated and nonimmune-mediated thrombocytopenias, with a focus on immune-mediated processes. Thrombocytopenia caused by chemotherapy will not be discussed in this article.
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Affiliation(s)
- Teresa Kam
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Maurice Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
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Schilder L, Nurmohamed SA, Bosch FH, Purmer IM, den Boer SS, Kleppe CG, Vervloet MG, Beishuizen A, Girbes ARJ, Ter Wee PM, Groeneveld ABJ. Citrate anticoagulation versus systemic heparinisation in continuous venovenous hemofiltration in critically ill patients with acute kidney injury: a multi-center randomized clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:472. [PMID: 25128022 PMCID: PMC4161888 DOI: 10.1186/s13054-014-0472-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 07/23/2014] [Indexed: 11/17/2022]
Abstract
Introduction Because of ongoing controversy, renal and vital outcomes are compared between systemically administered unfractionated heparin and regional anticoagulation with citrate-buffered replacement solution in predilution mode, during continuous venovenous hemofiltration (CVVH) in critically ill patients with acute kidney injury (AKI). Methods In this multi-center randomized controlled trial, patients admitted to the intensive care unit requiring CVVH and meeting inclusion criteria, were randomly assigned to citrate or heparin. Primary endpoints were mortality and renal outcome in intention-to-treat analysis. Secondary endpoints were safety and efficacy. Safety was defined as absence of any adverse event necessitating discontinuation of the assigned anticoagulant. For efficacy, among other parameters, survival times of the first hemofilter were studied. Results Of the 139 patients enrolled, 66 were randomized to citrate and 73 to heparin. Mortality rates at 28 and 90 days did not differ between groups: 22/66 (33%) of citrate-treated patients died versus 25/72 (35%) of heparin-treated patients at 28 days, and 27/65 (42%) of citrate-treated patients died versus 29/69 (42%) of heparin-treated patients at 90 days (P = 1.00 for both). Renal outcome, i.e. independency of renal replacement therapy 28 days after initiation of CVVH in surviving patients, did not differ between groups: 29/43 (67%) in the citrate-treated patients versus 33/47 (70%) in heparin-treated patients (P = 0.82). Heparin was discontinued in 24/73 (33%) of patients whereas citrate was discontinued in 5/66 (8%) of patients (P < 0.001). Filter survival times were superior for citrate (median 46 versus 32 hours, P = 0.02), as were the number of filters used (P = 0.002) and the off time within 72 hours (P = 0.002). The costs during the first 72 hours of prescribed CVVH were lower in citrate-based CVVH. Conclusions Renal outcome and patient mortality were similar for citrate and heparin anticoagulation during CVVH in the critically ill patient with AKI. However, citrate was superior in terms of safety, efficacy and costs. Trial registration Clinicaltrials.gov NCT00209378. Registered 13th September 2005. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0472-6) contains supplementary material, which is available to authorized users.
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Williamson DR, Lesur O, Tétrault JP, Pilon D. Drug-Induced Thrombocytopenia in the Critically Ill. Ann Pharmacother 2014; 48:697-704. [DOI: 10.1177/1060028013519065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background:Drugs are suspected when obvious causes of intensive care unit (ICU)-acquired thrombocytopenia have been excluded. It has been estimated that 10% to 25% of cases may be drug induced. Objectives: The objectives of this study were to evaluate the risk of thrombocytopenia associated with drug classes commonly used in the ICU. Methods: Data concerning patients admitted for more than 48 hours between 1997 and 2011 were extracted from a research-purpose database. Patients with thrombocytopenia within the first 72 hours of admission and with diagnoses or interventions considered strongly associated with thrombocytopenia were excluded. Drug exposures were compared and adjusted for confounders using conditional logistic regression. Results: A total of 238 cases were identified after exclusions. Each case was matched according to sex, age, admission year, and admission unit with 1 control. In univariate analysis, quinolones (odds ratio [OR] = 1.56; 95% CI = 1.01-2.40) and extended spectrum β-lactams (OR = 1.71; 95% CI = 1.00-2.93) were significantly associated with an increased risk of thrombocytopenia. After adjusting for confounders, exposure to quinolones was the only drug class with a statistically significant increase in risk of thrombocytopenia (OR = 1.697; 95% CI = 1.002-2.873; P = 0.049). Conclusion: In this study of ICU-acquired thrombocytopenia, we found no association between the exposures to several antibiotic classes, anticonvulsants, antiplatelet agents, nonsteroidal anti-inflammatory agents, and heparins and thrombocytopenia. As linezolid was not studied, no conclusions can be drawn concerning this agent. The statistically significant association between quinolones and thrombocytopenia warrants further investigation.
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Affiliation(s)
- David R. Williamson
- Université de Sherbrooke, Sherbrooke, Québec, Canada
- Université de Montréal, Québec, Canada
- Hôpital du Sacré-Coeur de Montréal, Québec, Canada
| | - Olivier Lesur
- Université de Sherbrooke, Sherbrooke, Québec, Canada
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Matsumura Y, Nakada TA, Oda S. Relationship between the 4Ts scoring system and the antiplatelet factor 4/heparin antibodies test in critically ill patients. Acute Med Surg 2013; 1:37-44. [PMID: 29930820 DOI: 10.1002/ams2.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/10/2013] [Indexed: 01/06/2023] Open
Abstract
Aim Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction and potentially progresses to fatal thrombosis. The 4Ts scoring system has been reported as a clinical pretest for HIT. However, its usefulness in critically ill patients has not yet been thoroughly examined. Thus, we evaluated the clinical usefulness of the 4Ts score in the diagnosis of HIT in critically ill patients. Methods One hundred and four critically ill patients who were admitted to our intensive care unit and who underwent the antiplatelet factor 4/heparin complex antibodies (PF4/heparin Ab) test with suspected HIT were enrolled in the study. The primary endpoint variable was the 4Ts score. The secondary endpoint variables were laboratory data, length of stay, and mortality, compared between thePF4/heparin Ab positive and negative groups. Results There was no significant difference in the 4Ts scores between the PF4/heparin Ab positive and negative groups. The positive predictive value (HIT patients/4T high score patients) was 15.4% (2/13), the negative predictive value (non-HIT patients/4T low score patients) was 87.5% (42/48), and the false-negative rate for the 4Ts score (4T low score patients/HIT patients) was as high as 54.5% (6/11). The PF4/heparin Ab positive patients had longer stay in intensive care compared to the PF4/heparin Ab negative patients (P = 0.035). Conclusions The present study showed the discrepancy between the 4Ts score and PF4/heparin Ab. When HIT is suspected in critically ill patients, an immediate HIT antibody test and initiation of therapeutic management of HIT are required regardless of the 4Ts score.
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Affiliation(s)
- Yosuke Matsumura
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
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Pearson MA, Nadeau C, Blais N. Correlation of ELISA Optical Density With Clinical Diagnosis of Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2013; 20:349-54. [DOI: 10.1177/1076029613513319] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Enzyme-linked immunosorbent assay (ELISA) for antiplatelet factor 4 (anti-PF4)/heparin antibodies is expressed in terms of optical density (OD). Previous studies have shown correlation between OD and heparin-induced thrombocytopenia (HIT) diagnosis. However, these were mainly laboratory based. Objective: Retrospective correlation of clinical HIT to ELISA OD. Patients/Methods: We conducted a retrospective study involving 104 patients with a positive ELISA for anti-PF4/heparin antibodies between 2008 and May 2012. For each patient, a clinical diagnosis was adjudicated based on different features including “4T scores,” laboratory results, and a 3-month clinical follow-up. Results: In this study, 28.8% of the patients were HIT positive, and 71.2% HIT negative. Patients with positive diagnosis had significantly higher mean OD (2.15 ± 0.76 vs 0.83 ± 0.62). Patients with OD <1.0 only had 3.4% positive diagnosis versus 45.5% for OD 1.0 to 2.0 and 78% for >2.0 units. Conclusion: This study is a clinical confirmation that ELISA OD results are correlated with the probability of a clinical diagnosis of HIT.
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Affiliation(s)
- Marc-André Pearson
- Department of Hematology-Oncology, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Chantal Nadeau
- Haemostasis Laboratory, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Normand Blais
- Department of Hematology-Transfusion Medicine, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Raschke RA, Curry SC, Warkentin TE, Gerkin RD. Improving Clinical Interpretation of the Anti-Platelet Factor 4/Heparin Enzyme-Linked Immunosorbent Assay for the Diagnosis of Heparin-Induced Thrombocytopenia Through the Use of Receiver Operating Characteristic Analysis, Stratum-Specific Likelihood Ratios, and Bayes Theorem. Chest 2013; 144:1269-1275. [DOI: 10.1378/chest.12-2712] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Warkentin TE, Sheppard JAI, Heels-Ansdell D, Marshall JC, McIntyre L, Rocha MG, Mehta S, Davies AR, Bersten AD, Crozier TM, Ernest D, Vlahakis NE, Hall RI, Wood GG, Poirier G, Crowther MA, Cook DJ. Heparin-Induced Thrombocytopenia in Medical Surgical Critical Illness. Chest 2013; 144:848-858. [DOI: 10.1378/chest.13-0057] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Andrews DM, Cubillos GF, Paulino SK, Seckinger DL, Kett DH. Prospective observational evaluation of the particle immunofiltration anti-platelet factor 4 rapid assay in MICU patients with thrombocytopenia. Crit Care 2013; 17:R143. [PMID: 23876263 PMCID: PMC4056086 DOI: 10.1186/cc12822] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 07/22/2013] [Indexed: 11/10/2022] Open
Abstract
Introduction Heparin-induced thrombocytopenia (HIT) results from antibodies to PF4/heparin complexes and clinical diagnosis is difficult. We evaluated the particle immunofiltration anti-platelet factor 4 (PIFA) rapid assay, in conjunction with a clinical risk score, in the diagnosis of HIT. Methods We performed a prospective observational study in all patients admitted to the medical intensive care unit (MICU) in a large academic medical center. Patients were screened daily for thrombocytopenia defined as either a platelet count that decreased by at least 33% or an absolute platelet count less than 150,000/μL. Patients with suspected HIT underwent PIFA and ELISA testing for anti-PF4/heparin antibodies. Available residual frozen sera were sent to a reference laboratory for serotonin release assay (SRA) testing. Results During the study period, 340 patients were admitted to the MICU, of which 143 patients met criteria for thrombocytopenia. Forty-three patients had no evidence of recent heparin exposure. PIFA and ELISA testing were performed on 100 patients, of which 92 had samples available for SRA analysis. PIFA results were negative in 62, positive in 28 and inconclusive in 2 patients. The 4Ts score showed low to intermediate risk in 57 of the PIFA negative patients. The ELISA results were negative in 86 and positive in 6 patients. SRA testing identified 3 patients with a positive SRA test and 89 patients with a negative result. All patients with a negative PIFA result also had a negative SRA result. In the one patient deemed to have clinical HIT, the pretest probability was high (4Ts score of 6) and the anti-PF4/heparin antibody testing revealed a positive SRA, inconclusive PIFA and a negative ELISA result. Conclusions While thrombocytopenia in our population is common, the prevalence of HIT is low. The combination of a low to intermediate pretest probability with a negative PIFA test can rapidly exclude the presence of platelet activating anti-PF4/heparin antibodies and, therefore, HIT as the cause of the thrombocytopenia. Since a positive PIFA result has a low positive predictive value, a positive PIFA is not diagnostic of HIT and additional evaluation is warranted.
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Trehel-Tursis V, Louvain-Quintard V, Zarrouki Y, Imbert A, Doubine S, Stéphan F. Clinical and biologic features of patients suspected or confirmed to have heparin-induced thrombocytopenia in a cardiothoracic surgical ICU. Chest 2013; 142:837-844. [PMID: 22406956 DOI: 10.1378/chest.11-3074] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The diagnosis of heparin-induced thrombocytopenia (HIT) is problematic in the surgical ICU, as there are multiple potential explanations for thrombocytopenia. We conducted a study to assess the incidence, clinical presentation, and outcome of HIT in a cardiothoracic surgical ICU. METHODS From January 2005 to December 2010, all patients with suspicion of HIT were prospectively identified, and data were collected retrospectively. Detection of anti-PF4/heparin antibodies and functional assays were systematically performed. RESULTS During the study period, 5,949 patients were admitted to the ICU (2,751 after cardiac surgery and 3,198 after thoracic surgery), of whom 101 were suspected to have HIT(1.7% [95% CI, 1.4%-2.0%]). Suspicion of HIT occurred at a median of 5 (4-9) days after ICU admission. Diagnosis was confirmed in 28 of 5,949 patients (0.47% [95% CI, 0.33%-0.68%]).Thrombosis was detected in 14 patients with HIT (50%) and in 12 patients without HIT (16%)( P 5 .0006). After receiver operating characteristic analysis (area under curve 5 0.78 0.06),a 4Ts score ≥ 5 had a sensitivity of 86% and a specificity of 70%. Course of platelet count was similar between the two groups. Six patients (21%) with HIT and 20 (27%) without died( P 5 .77). CONCLUSIONS Even with a prospective platelet monitoring protocol, suspicion for HIT arose in <2% of patients in a cardiothoracic ICU. Most were found to have other causes of thrombocytopenia,with HIT confirmed in 28 of 101 suspected cases (0.47% of all patients in the ICU). The 4Ts score may have value by identifying patients who should have laboratory testing performed.The mortality of patients with HIT was not different from other very ill thrombocytopenic patients in the ICU.
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Affiliation(s)
| | | | | | | | - Sylvie Doubine
- Hemostasis Laboratory, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Heparin-induced thrombocytopenia: general considerations. Clin Appl Thromb Hemost 2013; 19:344-9. [PMID: 23732823 DOI: 10.1177/1076029613491346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024] Open
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Thrombocytopenia in the critically ill: prevalence, incidence, risk factors, and clinical outcomes. Can J Anaesth 2013; 60:641-51. [DOI: 10.1007/s12630-013-9933-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 04/08/2013] [Indexed: 01/17/2023] Open
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Nicolaides A, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, Myers K, Samama M, Fletcher J, Kalodiki E, Bergqvist D, Bonnar J, Caprini JA, Carter C, Conard J, Eklof B, Elalamy I, Gerotziafas G, Geroulakos G, Giannoukas A, Greer I, Griffin M, Kakkos S, Lassen MR, Lowe GDO, Markel A, Prandoni P, Raskob G, Spyropoulos AC, Turpie AG, Walenga JM, Warwick D. Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2013; 19:208-13. [DOI: 10.1177/1076029612474840s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kapadia FN, Ketkar AS, Deshpande AS, Puri VC, Khodaiji SJ. Evaluation of various laboratory assays in detection of heparin-induced thrombocytopenia in an adult general ICU. Int J Lab Hematol 2012; 35:137-43. [DOI: 10.1111/ijlh.12008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 08/08/2012] [Indexed: 11/28/2022]
Affiliation(s)
- F. N. Kapadia
- Department of Intensive Care; P. D. Hinduja National Hospital and Medical Research Centre; Mumbai; India
| | - A. S. Ketkar
- Department of Research; P. D. Hinduja National Hospital and Medical Research Centre; Mumbai; India
| | - A. S. Deshpande
- Department of Laboratory Medicine; P. D. Hinduja National Hospital and Medical Research Centre; Mumbai; India
| | - V. C. Puri
- Department of Laboratory Medicine; P. D. Hinduja National Hospital and Medical Research Centre; Mumbai; India
| | - S. J. Khodaiji
- Department of Laboratory Medicine; P. D. Hinduja National Hospital and Medical Research Centre; Mumbai; India
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Abstract
Thrombocytopenia is common in critically ill patients and increases morbidity and mortality. A diagnosis of heparin-induced thrombocytopenia (HIT) is frequently considered in any ICU patient who develops thrombocytopenia in the context of ongoing heparin exposure. As the usual tests to diagnose HIT are often neither specific nor sensitive enough to be confirmatory, the intensivist must largely rely on clinical judgment in treatment decisions. Patients in the ICU may also develop thrombocytopenia resulting from non-HIT immune mechanisms, nonimmune platelet consumption, and from decreased platelet production due to preexisting disorders or as a result of their critical illness and/or drug therapy.
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Affiliation(s)
- Robert I Parker
- Department of Pediatrics, Stony Brook University School of Medicine, Pediatric Hematology/Oncology, Stony Brook Long Island Children's Hospital, Stony Brook, NY 11794-8111, USA.
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Sakr Y, Haetscher F, Gonsalves MD, Hoffman M, Theis B, Barz D, Reinhart K, Kortgen A. Heparin-induced thrombocytopenia type II in a surgical intensive care unit. J Crit Care 2012; 27:232-41. [DOI: 10.1016/j.jcrc.2011.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 06/19/2011] [Accepted: 06/26/2011] [Indexed: 11/26/2022]
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Wu MY, Hsu YH, Bai CH, Lin YF, Wu CH, Tam KW. Regional citrate versus heparin anticoagulation for continuous renal replacement therapy: a meta-analysis of randomized controlled trials. Am J Kidney Dis 2012; 59:810-8. [PMID: 22226564 DOI: 10.1053/j.ajkd.2011.11.030] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 11/01/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Anticoagulation of the extracorporeal circuit is required in continuous renal replacement therapy (CRRT). Heparin is the classic choice for anticoagulation, although it may increase the risk of bleeding. Regional citrate anticoagulation reduces the risk of bleeding, but may cause hypocalcemia and metabolic disturbances. STUDY DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING & POPULATION Patients admitted to the intensive care unit with acute kidney injury that required CRRT. SELECTION CRITERIA FOR STUDIES RCTs regardless of publication status or language. INTERVENTION Regional citrate versus heparin anticoagulation in CRRT. OUTCOMES The primary outcomes were circuit survival time, the occurrence of major bleeding defined as a site of gross bleeding with a decrease in blood pressure or requiring transfusion of 2 or more units of red blood cells, metabolic alkalosis, hypocalcemia, and thrombocytopenia. The secondary outcome was cost. RESULTS 6 RCTs with 488 patients were identified. Citrate anticoagulation was associated with a significant decrease in bleeding (RR, 0.34; 95% CI, 0.17-0.65). Circuit survival time, the incidence of metabolic alkalosis, and thrombocytopenia showed no significant difference between groups. Hypocalcemia was more common in patients receiving citrate, although no clinical adverse event was reported in the included studies. LIMITATIONS Significant heterogeneity in the primary outcome. CONCLUSION The efficacy of citrate and heparin anticoagulation for CRRT was similar. However, citrate anticoagulation decreased the risk of bleeding with no significant increase in the incidence of metabolic alkalosis. We recommend citrate as an anticoagulation agent in patients who require CRRT but are at high risk of bleeding.
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Affiliation(s)
- Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
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Selby NM, McIntyre CW. Predicting and Managing Complications of Renal Replacement Therapy in the Critically Ill. Blood Purif 2012; 34:171-6. [DOI: 10.1159/000342063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Results of a consensus meeting on the use of argatroban in patients with heparin-induced thrombocytopenia requiring antithrombotic therapy - a European Perspective. Thromb Res 2011; 129:426-33. [PMID: 22178575 DOI: 10.1016/j.thromres.2011.11.041] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 11/22/2011] [Accepted: 11/24/2011] [Indexed: 02/07/2023]
Abstract
Argatroban has been introduced as an alternative parenteral anticoagulant for HIT-patients in several European countries in 2005. In 2009 a panel of experts discussed their clinical experience with argatroban balancing risks and benefits of argatroban treatment in managing the highly procoagulant status of HIT-patients. This article summarizes the main conclusions of this round table discussion. An ongoing issue is the appropriate dosing of argatroban in special patient groups. Therefore, dosing recommendations for different HIT-patient groups (ICU patients; non-ICU patients, paediatric patients, and for patients undergoing renal replacement therapies) are summarized in this consensus statement. Because of the strong correlation between argatroban dosing requirements and scores used to characterize the severity of illness (APACHE; SAPS, SOFA) suitable dosing nomograms are given. This consensus statement contributes to clinically relevant information on the appropriate use and monitoring of argatroban based on the current literature, and provides additional information from clinical experience. As the two other approved drugs for HIT, danaparoid and lepirudin are either currently not available due to manufacturing problems (danaparoid) or will be withdrawn from the market in 2012 (lepirudin), this report should guide physicians who have limited experience with argatroban how to use this drug safely in patients with HIT.
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Levi M, Schultz M, van der Poll T. Coagulation biomarkers in critically ill patients. Crit Care Clin 2011; 27:281-97. [PMID: 21440202 DOI: 10.1016/j.ccc.2010.12.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article discusses coagulation biomarkers in critically ill patients where coagulation abnormalities occur frequently and may have a major impact on the outcome. An adequate explanation for the cause is important, since many underlying disorders may require specific treatment and supportive therapy directed at the underlying condition. Deficiencies in platelets and coagulation factors in bleeding patients or patients at risk for bleeding can be achieved by transfusion of platelet concentrate or plasma products, respectively. Prohemostatic treatment may be beneficial in case of severe bleeding, whereas restoring physiological anticoagulant pathways may be helpful in patients with sepsis and disseminated intravascular coagulation.
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Affiliation(s)
- Marcel Levi
- Department of Vascular Medicine and Internal Medicine, Academic Medical Centre F-4, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Prechel MM, Escalante V, Drenth AF, Walenga JM. A colorimetric, metabolic dye reduction assay detects highly activated platelets: application in the diagnosis of heparin-induced thrombocytopenia. Platelets 2011; 23:69-80. [DOI: 10.3109/09537104.2011.592957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Oudemans-van Straaten HM, Kellum JA, Bellomo R. Clinical review: anticoagulation for continuous renal replacement therapy--heparin or citrate? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:202. [PMID: 21345279 PMCID: PMC3222015 DOI: 10.1186/cc9358] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Heparin is the most commonly prescribed anticoagulant for continuous renal replacement therapy. There is, however, increasing evidence questioning its safety, particularly in the critically ill. Heparin mainly confers its anticoagulant effect by binding to antithrombin. Heparin binds to numerous other proteins and cells as well, however, compromising its efficacy and safety. Owing to antithrombin consumption and degradation, and to the binding of heparin to acute phase proteins, and to apoptotic and necrotic cells, critical illness confers heparin resistance. The nonspecific binding of heparin further leads to an unpredictable interference with inflammation pathways, microcirculation and phagocytotic clearance of dead cells, with possible deleterious consequences for patients with sepsis and systemic inflammation. Regional anticoagulation with citrate does not increase the patient's risk of bleeding. The benefits of citrate further include a longer or similar circuit life, and possibly better patient and kidney survival. This needs to be confirmed in larger randomized controlled multicenter trials. The use of citrate might be associated with less inflammation and has useful bio-energetic implications. Citrate can, however, with inadequate use cause metabolic derangements. Full advantages of citrate can only be realized if its risks are well controlled. These observations suggest a greater role for citrate.
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Khan MM, Noble DW, Watson HG. Heparin-induced thrombocytopenia and the utility of the 4Ts score in the Intensive Care Unit. Br J Haematol 2011; 152:672-4. [PMID: 21255001 DOI: 10.1111/j.1365-2141.2010.08436.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Thrombocytopenia occurs in 15% to 58% of intensive care unit patients. The incidence varies based upon patient population, timing and frequency of platelet monitoring, and definition of thrombocytopenia. Up to 25% of acutely ill patients develop drug-induced thrombocytopenia. When drug-induced thrombocytopenia is suspected, nondrug related causes must be evaluated and excluded. Establishing the diagnosis of drug-induced thrombocytopenia is challenging, as hundreds of medications have been implicated. Medications commonly associated with drug-induced thrombocytopenia include glycoprotein IIb/IIIa inhibitors, cinchona alkaloids, antibiotics, anticonvulsants, and heparin. Once the diagnosis is suspected, clinicians should identify the start date of medications to assess the timeline of development. The likelihood of each medication causing thrombocytopenia must be evaluated. The risk vs. benefit of discontinuing the suspected medication and availability of alternative medications must be assessed. The role of corticosteroids, immune globulin, and plasmapheresis is uncertain. Once the offending agent has been discontinued, the overall prognosis is excellent. In the case of suspected or confirmed heparin-induced thrombocytopenia, an alternative anticoagulant should be initiated. Drug-induced thrombocytopenia should be documented in the medical record and reported according to institutional and national standards. This review focuses on immune-mediated drug-induced thrombocytopenia from medications commonly utilized in the critically ill patient.
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Garcés EO, Victorino JA, Thomé FS, Röhsig LM, Dornelles E, Louzada M, Stifft J, de Holanda F, Veronese FV. Enoxaparin versus unfractioned heparin as anticoagulant for continuous venovenous hemodialysis: a randomized open-label trial. Ren Fail 2010; 32:320-7. [PMID: 20370447 DOI: 10.3109/08860221003606281] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM In this study we aimed to compare the efficacy and safety of enoxaparin with unfractioned heparin (UFH) as anticoagulant for continuous venovenous hemodialysis (CVVHD). METHODS An open-label randomized controlled trial was carried out in an intensive care unit (ICU) where 40 patients with acute renal failure (ARF) who needed continuous renal replacement therapy were randomized to receive UFH (n=21) or enoxaparin (n=19). Coagulation parameters were evaluated, and antithrombotic activity of UFH was measured by activated partial thromboplastin time (aPTT) and for enoxaparin by anti-factor Xa activity. Primary outcomes were thrombosis of the extracorporeal circuit and bleeding, classified as major or minor. RESULTS Minor bleeding episodes were observed only in patients anticoagulated with enoxaparin (26 vs. 0%, p=0.018). Comparing patients with or without bleeding after 24 hours of therapy, the level of anticoagulation tended to be higher (anti-factor Xa: 1.62 vs. 1.13 IU/mL, p=0.09) and the platelet count to be lower [107+/-53 vs. 229+/-84 (x10(3)/microL), p=0.09] in patients who bled, but without statistical difference. Filter life span of enoxaparin and UFH groups was similar (43+/-15 vs. 52+/-18 hr, p=0.10), as well as the proportion of circuit clotting. CONCLUSION Weight-unadjusted enoxaparin in patients with ARF in CVVHD was associated with an increased rate of bleeding, a finding that addresses the need to adjust drug dose and to monitor anti-factor Xa activity during dialysis. No benefit to prolong dialysis circuit survival was found with enoxaparin. In patients who do not present contraindication for systemic anticoagulation, UFH remains an effective and low-cost option.
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Affiliation(s)
- Erwin Otero Garcés
- Graduate Program in Medical Sciences: Nephrology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Schaden E, Kozek-Langenecker SA. Direct thrombin inhibitors: pharmacology and application in intensive care medicine. Intensive Care Med 2010; 36:1127-37. [PMID: 20425104 DOI: 10.1007/s00134-010-1888-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 03/24/2010] [Indexed: 01/31/2023]
Abstract
PURPOSE Anticoagulation is part of the daily routine of intensive care physicians. As the possibilities of pharmacological anticoagulation are becoming more numerous and diverse, intensive care physicians have to be familiar with indications, contraindications, dosing, and reversal of many different substances. This paper presents an overview of the substance group of direct thrombin inhibitors (DTI) indicated for alternative anticoagulation in intensive care medicine. METHODS The review is a synopsis of scientific evidence, expert opinion, open forum commentary, and clinical feasibility data. RESULTS AND CONCLUSIONS Due to their antithrombotic potential without direct activation of platelets, DTI could offer potential advantages over heparins and vitamin K antagonists in critically ill patients, especially regarding heparin-induced thrombocytopenia. Because of multiple organ dysfunction, organ failure, and comedications, simple extrapolation of results of medical to critically ill patients is not permissible. The fine line between thrombosis and bleeding in intensive care patients requires cautious dosing and close drug monitoring. Studies dealing with DTI in the intensive care setting are of utmost clinical interest.
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Affiliation(s)
- Eva Schaden
- Department of Anesthesiology, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Guertel 18-20, 1090, Vienna, Austria.
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Crowther MA, Cook DJ, Albert M, Williamson D, Meade M, Granton J, Skrobik Y, Langevin S, Mehta S, Hebert P, Guyatt GH, Geerts W, Rabbat C, Douketis J, Zytaruk N, Sheppard J, Greinacher A, Warkentin TE. The 4Ts scoring system for heparin-induced thrombocytopenia in medical-surgical intensive care unit patients. J Crit Care 2010; 25:287-93. [PMID: 20149589 DOI: 10.1016/j.jcrc.2009.12.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Revised: 12/06/2009] [Accepted: 12/17/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is commonly considered but rarely confirmed in critically ill patients. The 4Ts score (Thrombocytopenia, Timing of thrombocytopenia, Thrombosis, and oTher reason) might identify individual patients at risk of having this disorder. OBJECTIVE The aim of the study was to evaluate the value of the 4Ts HIT score in comparison with the serotonin-release assay (SRA) in critically ill patients. METHODS This study describes the combined results of 3 prospective studies enrolling critically ill patients who were investigated for HIT if platelets fell to less than 50 x 10(9)/L or if platelet counts decreased to less than 50% of the value upon intensive care unit admission. We confirmed HIT by a positive platelet SRA. We assigned a 4Ts score blinded to SRA results to all 50 patients investigated for HIT; those with positive SRA results were scored in duplicate. RESULTS Of 528 patients, 50 (9.5%) were investigated for HIT; 39 (78%) of 50 (64%-88%) of these patients were scored as "low probability" by 4Ts score and none had a positive SRA. Of 49 patients who underwent SRA testing because of thrombocytopenia, only 2 (4.1%; 0.5-14.0) had a positive SRA (1 with a moderate 4Ts score and 1 with a high 4Ts score). Therefore, the overall incidence of HIT confirmed by SRA was 2 (0.4%) of 528 (0.04%-1.4%). CONCLUSIONS Significant thrombocytopenia during heparin administration occurred in 9.5% of critically ill patients, but HIT was confirmed in only 4.1% of those undergoing testing, for an overall incidence of 0.4%. A low 4Ts score occurred in 78% of patients investigated for HIT; none of these patients had a positive SRA. We conclude that HIT is uncommon in critically ill patients and that the 4Ts score is worthy of further evaluation in this patient population.
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Affiliation(s)
- Mark Andrew Crowther
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
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Hall A, Thachil J, Martlew V. Heparin-Induced Thrombocytopenia in the Intensive Care Unit. J Intensive Care Soc 2010. [DOI: 10.1177/175114371001100107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) occurs following an immune reaction to the administration of heparin, which results in increased platelet activation and thrombocytopenia, and lead to arterial and venous thrombosis in untreated cases. It may be considered as an idiosyncratic, drug-induced reaction in which heparin injections result in the formation of complexes with platelet factor 4 (PF4), triggering an antibody-mediated reaction in certain individuals. Low platelet count in this instance is secondary to platelet aggregation and can lead to thrombotic complications by vascular occlusion and other mechanisms. Early recognition of this complication is essential to prevent life- and limb-threatening thrombosis. Therefore, it is important that intensive care physicians who administer heparin in different forms are aware of this potential adverse event and follow a regular plan in monitoring the platelet count while the patient is on heparin. In a patient whose platelet count falls while on heparin, when no other diagnostic possibilities can easily explain it, immediate withdrawal of any form of heparin and commencement of an alternative anticoagulant is necessary until the diagnosis of HIT is confirmed or excluded. At the same time, it is important that over-diagnosis of HIT is not made to avoid unwanted bleeding complications from the alternative anticoagulants. This review outlines the pathophysiology, diagnosis and management of HIT with a focus on the intensive care setting.
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Affiliation(s)
- Alison Hall
- Specialist Registrar, Department of Anaesthesia and Critical Care, University of Liverpool
| | - Jecko Thachil
- Specialist Registrar, Department of Haematology, University of Liverpool
| | - Vanessa Martlew
- Consultant, Department of Haematology, Royal Liverpool University Hospital
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Levine RL, Hergenroeder GW, Francis JL, Miller CC, Hursting MJ. Heparin–platelet factor 4 antibodies in intensive care patients: an observational seroprevalence study. J Thromb Thrombolysis 2009; 30:142-8. [DOI: 10.1007/s11239-009-0425-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
OBJECTIVE Continuous venovenous hemofiltration (CVVH) is applied in critically ill patients with acute renal failure for renal replacement. Heparins used to prevent circuit clotting may cause bleeding. Regional anticoagulation with citrate reduces bleeding, but has metabolic risks. The aim was to compare the safety and efficacy of the two. DESIGN Randomized, nonblinded, controlled single-center trial. SETTING General intensive care unit of a teaching hospital. PATIENTS Adult critically ill patients needing CVVH for acute renal failure and without an increased bleeding risk. INTERVENTIONS Regional anticoagulation with citrate or systemic anticoagulation with the low-molecular weight heparin nadroparin. MEASUREMENTS AND MAIN RESULTS End points were adverse events necessitating discontinuation of study anticoagulant, transfusion, metabolic and clinical outcomes, and circuit survival. Of the 215 randomized patients, 200 received CVVH per protocol (97 citrate and 103 nadroparin). Adverse events required discontinuation of citrate in two patients (accumulation and clotting) of nadroparin in 20 (bleeding and thrombocytopenia) (p < 0.001). Bleeding occurred in 6 vs. 16 patients (p = 0.08). The median number of red blood cell units transfused per CVVH day was 0.27 (interquartile range, 0.0-0.63) for citrate, 0.36 (interquartile range, 0-0.83) for nadroparin (p = 0.31). Citrate conferred less metabolic alkalosis (p = 0.001) and lower plasma calcium (p < 0.001). Circuit survival was similar. Three-month mortality on intention-to-treat was 48% (citrate) and 63% (nadroparin) (p = 0.03), per protocol 45% and 62% (p = 0.02). Citrate reduced mortality in surgical patients (p = 0.007), sepsis (p = 0.01), higher Sepsis-Related Organ Failure Assessment score (p = 0.006), and lower age (p = 0.009). CONCLUSIONS The efficacy of citrate and nadroparin anticoagulation for CVVH was similar, however, citrate was safer. Unexpectedly, citrate reduced mortality. Less bleeding could only partly explain this benefit, less clotting could not. Post hoc citrate appeared particularly beneficial after surgery, in sepsis and severe multiple organ failure, suggesting interference with inflammation.
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Kerz T, Schinzel H. Anticoagulation in a Neurosurgical Patient with Heparin-Induced Thrombocytopenia Type II with Argatroban and Fondaparinux after Clipping of an Intracranial Aneurysm. Transfus Med Hemother 2009; 36:141-143. [PMID: 20823996 DOI: 10.1159/000205964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 10/24/2008] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND: Therapeutic anticoagulation in patients after a major neurosurgical procedure remains critical because of the risk of a major intracranial bleed. Novel drugs could play a beneficial role in this setting. CASE REPORT: We describe a patient with heparin-induced thrombocytopenia type II and pulmonary embolism who was anticoagulated with argatroban and, later, with fondaparinux. No intracranial bleeding was detected when anticoagulation was performed with argatroban and, later, fondaparinux. CONCLUSION: Both substances could have therapeutic potential in this context.
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Affiliation(s)
- Thomas Kerz
- Department of Neurosurgery, Johannes Gutenberg University Medical School, Mainz, Germany
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Begelman SM, Baghdasarian SB, Singh IM, Militello MA, Hursting MJ, Bartholomew JR. Argatroban anticoagulation in intensive care patients: effects of heart failure and multiple organ system failure. J Intensive Care Med 2009; 23:313-20. [PMID: 18701526 DOI: 10.1177/0885066608321246] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We retrospectively evaluated argatroban dosing patterns, clinical outcomes, and the effects of heart failure and multiple organ system failure on dosing requirements in 65 adult, intensive care patients administered argatroban anticoagulation for clinically suspected heparin-induced thrombocytopenia (n=56) or history of heparin-induced thrombocytopenia (n=9). Argatroban was initiated then titrated to achieve target activated partial thromboplastin times 1.5 to 3 times normal control (ie, 42-84 seconds). Overall, argatroban was initiated at 1.14+/-0.62 microg/kg/min (mean+/-SD) and administered for 11.4+/-9.5 days, with comparable dosing patterns between patients with suspected, versus previous, heparin-induced thrombocytopenia. Sixty-four (98.5%) patients achieved target activated partial thromboplastin times, typically following no or one dose adjustment. Therapeutic doses were lower in patients with, versus without, heart failure (0.58+/-0.28 vs 0.97+/-0.6 microg/kg/min, P= .042) and decreased as the number of failed organ systems increased from 1 to 2 to =3 (1.10+/-0.67 vs 0.87+/-0.47 vs 0.58+/-0.47 microg/kg/min, P= .008). From argatroban initiation until patient discharge or death, 11 (16.9%) patients (3 off argatroban) developed thromboembolic complications; 14 (21.5%) died (11 off argatroban, 7 from multiple organ system failure); and 1 (1.5%) required amputation. Nine patients (13.8%) experienced bleeding, none fatal. This experience suggests that argatroban administered at approximately 1 micro/kg/min provides adequate levels of anticoagulation in many intensive care unit patients with suspected or previous heparin-induced thrombocytopenia. Reduced doses are needed when heart failure or multiple organ system failure is present.
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Affiliation(s)
- Christopher W DiGiovanni
- Brown University Orthopaedic Residency Program, Department of Orthopaedic Surgery, The Warren Alpert School of Medicine at Brown University, 100 Butler Drive, Providence, RI 02906, USA.
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Warkentin TE, Greinacher A, Koster A, Lincoff AM. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:340S-380S. [PMID: 18574270 DOI: 10.1378/chest.08-0677] [Citation(s) in RCA: 536] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This chapter about the recognition, treatment, and prevention of heparin-induced thrombocytopenia (HIT) is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices. Among the key recommendations in this chapter are the following: For patients receiving heparin in whom the clinician considers the risk of HIT to be > 1.0%, we recommend platelet count monitoring over no platelet count monitoring (Grade 1C). For patients who are receiving heparin or have received heparin within the previous 2 weeks, we recommend investigating for a diagnosis of HIT if the platelet count falls by >/= 50%, and/or a thrombotic event occurs, between days 5 and 14 (inclusive) following initiation of heparin, even if the patient is no longer receiving heparin therapy when thrombosis or thrombocytopenia has occurred (Grade 1C). For patients with strongly suspected (or confirmed) HIT, whether or not complicated by thrombosis, we recommend use of an alternative, nonheparin anticoagulant (danaparoid [Grade 1B], lepirudin [Grade 1C], argatroban [Grade 1C], fondaparinux [Grade 2C], or bivalirudin [Grade 2C]) over the further use of unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) therapy or initiation/continuation of vitamin K antagonists (VKAs) [Grade 1B]. The guidelines include specific recommendations for nonheparin anticoagulant dosing that differ from the package inserts. For patients with strongly suspected or confirmed HIT, we recommend against the use of vitamin K antagonist (VKA) [coumarin] therapy until after the platelet count has substantially recovered (usually, to at least 150 x 10(9)/L) over starting VKA therapy at a lower platelet count (Grade 1B); that VKA therapy be started only with low maintenance doses (maximum, 5 mg of warfarin or 6 mg of phenprocoumon) over higher initial doses (Grade 1B); and that the nonheparin anticoagulant (eg, lepirudin, argatroban, danaparoid) be continued until the platelet count has reached a stable plateau, the international normalized ratio (INR) has reached the intended target range, and after a minimum overlap of at least 5 days between nonheparin anticoagulation and VKA therapy rather than a shorter overlap (Grade 1B). For patients receiving VKAs at the time of diagnosis of HIT, we recommend use of vitamin K (10 mg po or 5 to 10 mg IV) [Grade 1C].
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Affiliation(s)
| | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University Greifswald, Greifswald, Germany
| | | | - A Michael Lincoff
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, The Cleveland Clinic Foundation, Cleveland, OH
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