Heparin Induced Thrombocytopenia for the Perioperative and Critical Care Clinician

Moreno-Duarte, Ingrid; Ghadimi, Kamrouz

doi:10.1007/s40140-020-00405-6

Cited by 5 publications

(4 citation statements)

References 116 publications

(190 reference statements)

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“…The predominant mechanism of type 2 HIT is immune‐mediated and occurs 5–14 days after heparin exposure [ 1 , 2 , 5 ]. It largely depends on the activation of the heparin/platelet factor 4 (PF4) antigen complex.…”

Section: Discussionmentioning

confidence: 99%

Plasma exchange and intravenous immunoglobulin for the peri‐operative management of type 2 heparin‐induced thrombocytopaenia in a patient requiring urgent surgery for critical limb ischaemia

Perera,

Taylor,

Bera

et al. 2024

Anaesthesia Reports

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SummaryWe report the case of a 61‐year‐old female who developed heparin‐induced thrombocytopaenia following treatment of a submassive pulmonary embolism, and who then required an above knee amputation for critical limb ischaemia. Heparin‐induced thrombocytopaenia is a rare, immune‐mediated complication associated with an in‐hospital mortality rate of 10%. It is more common in surgical patients, with patients undergoing orthopaedic surgery more likely to develop it than patients undergoing cardiac surgery, but heparin‐dependent immunoglobulin G antibodies are more likely to be formed in the latter. Peri‐operative management remains a challenge. Ideally, it is preferable to wait for the platelet count to improve; but in certain cases, surgery cannot be delayed. Heparin‐induced thrombocytopaenia is usually managed with direct thrombin inhibitors, such as argatroban and bivalirudin. Newer therapeutic modalities, such as plasmapheresis and intravenous immunoglobulin, as used in this case, can rapidly remove antibodies, but the certainty of evidence is low. Our case adds to the literature regarding the use of these modalities and highlights the multidisciplinary team approach required to manage such complex cases.

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Section: Discussionmentioning

confidence: 99%

Plasma exchange and intravenous immunoglobulin for the peri‐operative management of type 2 heparin‐induced thrombocytopaenia in a patient requiring urgent surgery for critical limb ischaemia

Perera,

Taylor,

Bera

et al. 2024

Anaesthesia Reports

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“…Often it is not possible to highlight one particular reason. Thus, aetiology is frequently considered multifactorial [ 68 , 69 , 70 ].…”

Section: Low-molecular-weight Heparins and Fondaparinuxmentioning

confidence: 99%

Update on Anticoagulation Strategies in Patients with ECMO—A Narrative Review

Šoltés,

Skribuckij,

Říha

et al. 2023

JCM

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The use of extracorporeal membrane oxygenation (ECMO) has recently increased exponentially. ECMO has become the preferred mode of organ support in refractory respiratory or circulatory failure. The fragile balance of haemostasis physiology is massively altered by the patient’s critical condition and specifically the aetiology of the underlying disease. Furthermore, an application of ECMO conveys another disturbance of haemostasis due to blood-circuit interaction and the presence of an oxygenator. The purpose of this review is to summarise current knowledge on the anticoagulation management in patients undergoing ECMO therapy. The unfractionated heparin modality with monitoring of activated partial thromboplastin tests is considered to be a gold standard for anticoagulation in this specific subgroup of intensive care patients. However, alternative modalities with other agents are comprehensively discussed. Furthermore, other ways of monitoring can represent the actual state of coagulation in a more complex fashion, such as thromboelastometric/graphic methods, and might become more frequent. In conclusion, the coagulation system of patients with ECMO is altered by multiple variables, and there is a significant lack of evidence in this area. Therefore, a highly individualised approach is the best solution today.

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“…As such, clinicians caring for those undergoing ECMO must remain vigilant in their monitoring of these patients. Severe thrombocytopenia exemplifies one common complication of ECMO and occurs in up to 50% of subjects needing this intervention [ 2 , 3 ]. The list of possible causes of thrombocytopenia in ECMO is extensive.…”

Section: Introductionmentioning

confidence: 99%

“…HIT results from immunologic-mediated platelet destruction that develops due to exposure to heparin. Despite the ensuing thrombocytopenia, HIT can result in catastrophic venous and/or arterial thromboses [2][3][4]. The prevalence of HIT in ECMO ranges from 0.5 to 5.0%, depending on the population evaluated [4,5].…”

Section: Introductionmentioning

confidence: 99%

Heparin-induced thrombocytopenia in extra-corporeal membrane oxygenation: epidemiology, outcomes, and diagnostic challenges

Zaaqoq

Brammer

Chan

et al. 2021

J Thromb Thrombolysis

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To describe the prevalence of heparin-induced thrombocytopenia (HIT) in patients on extracorporeal membrane oxygenation (ECMO) and to explore ways to improve the diagnostic accuracy of the HIT enzyme-linked immunosorbent assay (ELISA). Retrospective review of all patients needing ECMO between September 2011 and September 2020 who underwent evaluation for HIT while on ECMO. The diagnosis of HIT required a confirmatory serotonin release assay (SRA). Various break points for the optical density (OD) that defines a positive HIT ELISA were examined to estimate their utility as screening tests for HIT. Patient outcomes served as a secondary endpoint. Among 417 ECMO patients, 162 (38.8%) had a HIT ELISA. Of these, 114 (70.4%) had a subsequent SRA. Although the HIT ELISA was positive at an OD ≥ 0.4 in 1/3 rd of subjects, only 15 subjects met criteria for HIT by SRA. Hence, the prevalence of HIT equaled 3.6%. At an OD ≥ 0.4 the ELISA had both poor specificity (71.7%) and accuracy (74.6%). Changing the definition of the ELISA to an OD ≥ 1.2 improved both specificity and accuracy with only a limited impact on sensitivity. Nearly 60% of those with HIT developing during ECMO died. HIT is infrequent in persons requiring ECMO. However, HIT remains associated with substantial mortality. The HIT ELISA as currently implemented performs poorly as a screening test and likely results in the unnecessary overuse of alternatives to unfractionated heparin. Altering the definition of a positive OD improves the HIT ELISA’s accuracy.

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Heparin Induced Thrombocytopenia for the Perioperative and Critical Care Clinician

Cited by 5 publications

References 116 publications

Plasma exchange and intravenous immunoglobulin for the peri‐operative management of type 2 heparin‐induced thrombocytopaenia in a patient requiring urgent surgery for critical limb ischaemia

Plasma exchange and intravenous immunoglobulin for the peri‐operative management of type 2 heparin‐induced thrombocytopaenia in a patient requiring urgent surgery for critical limb ischaemia

Update on Anticoagulation Strategies in Patients with ECMO—A Narrative Review

Heparin-induced thrombocytopenia in extra-corporeal membrane oxygenation: epidemiology, outcomes, and diagnostic challenges

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