Heparin-induced thrombocytopenia in COVID-19 patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation: two case reports

Abstract

Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is increasingly used in Coronavirus disease-19 patients with the most severe forms of acute respiratory distress syndrome (ARDS). Its use is associated with a significant hemostatic challenge, especially in COVID-19 patients who have been demonstrated to otherwise present a COVID-19-associated coagulopathy. The systematic use of unfractionated heparin therapy to prevent circuit thrombosis is warranted during ECMO support. The clinical presentation and management of heparin-induced thrombocytopenia, which is a rare but life-threatening complication of heparin therapy, has not been described in those patients yet. We report herein two cases of laboratory-confirmed HIT in COVID-19 patients with severe ARDS admitted to our intensive care unit for VV-ECMO support and the successful use of argatroban as an alternative therapy. We also provide a brief literature review of best evidence for managing such patients. The diagnosis and management of HIT is particularly challenging in COVID-19 patients receiving ECMO support. An increased awareness is warranted in those patients who already present a procoagulant state leading to higher rates of thrombotic events which can confuse the issues. Argatroban seems to be an appropriate and safe therapeutic option in COVID-19 patients with HIT while on VV-ECMO. Keywords COVID-19 • Extracorporeal membrane oxygenation • Heparin-induced thrombocytopenia • ArgatrobanPublisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study

“… 10 The high rates of pulmonary embolism on ECMO reflect the hyperthrombogenicity associated with COVID-19. 22 , 23 , 24 , 25 This might suggest the need for a more intense anticoagulation regimen compared with the approach used for non-COVID-19 patients with severe ARDS on ECMO. 11 However, we also report a high rate of haemorrhagic complications and a greater incidence of intracranial bleeding compared with other ECMO cohorts (eg, 2% in the EOLIA trial and 6% in the recent COVID ELSO registry 21 ).…”

Heparin in COVID-19 Patients Is Associated with Reduced In-Hospital Mortality: The Multicenter Italian CORIST Study

“…Paradoxically, HIT is characterized by both thrombocytopenia and a prothrombotic state. Recently, some reports presented the occurrence of HIT in COVID-19 patients [36,37]. However, larger investigations are warranted to confirm this increased incidence of HIT and to understand its physiopathology [36].…”

Should we avoid heparin based anticoagulants in “COVID-19 infection-vaccination related thrombosis”? Insights from the HIT like syndrome observed with infected cases. 

“…Several reports of HIT were reported (a total of 9 reports/series including 18 cases) before the current vaccine rollout; these were reviewed and summarized in table 1 (4)(5)(6)(7)(8)(9)(10)(11)(12). All the reports incriminated heparin in the development of the observed prothrombotic state.…”