Predictive value of scoring tools in determining heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation

Sullivan, Jaclyn; Bak, Erica; Sullivan, Mary Jane; Gurnani, Payal

doi:10.1177/0267659119881266

Cited by 11 publications

(23 citation statements)

References 20 publications

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“…17 In fact, circuit thrombosis is most commonly unrelated to HIT. 18 The incidence of HIT in ECMO patients ranges from 0.4 to 3.7% and is sometimes overestimated when immune assays available in most centers ( e.g. , enzyme-linked immunosorbent assay–heparin–PF4 antibody testing) are used as the sole means to assess for HIT.…”

Section: Coagulation Managementmentioning

confidence: 99%

“…17 In fact, circuit thrombosis is most commonly unrelated to HIT. 18 The incidence of HIT in ECMO patients ranges from 0.4 to 3.7% and is sometimes overestimated when immune assays available in most centers (e.g., enzyme-linked immunosorbent assay-heparin-PF4 antibody testing) are used as the sole means to assess for HIT. Establishing an HIT diagnosis is difficult in this scenario, with many false-positive results noted on PF-4 enzymelinked immunosorbent assay testing.…”

Section: Choice Of Anticoagulation Agentmentioning

confidence: 99%

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Management of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock

et al. 2021

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Section: Coagulation Managementmentioning

confidence: 99%

“…17 In fact, circuit thrombosis is most commonly unrelated to HIT. 18 The incidence of HIT in ECMO patients ranges from 0.4 to 3.7% and is sometimes overestimated when immune assays available in most centers (e.g., enzyme-linked immunosorbent assay-heparin-PF4 antibody testing) are used as the sole means to assess for HIT. Establishing an HIT diagnosis is difficult in this scenario, with many false-positive results noted on PF-4 enzymelinked immunosorbent assay testing.…”

Section: Choice Of Anticoagulation Agentmentioning

confidence: 99%

Management of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock

et al. 2021

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“…Events of interest that are known to contribute to expected sudden falls in PC were identified by EHR review of all procedures/surgeries occurring during the index hospitalization, including cardiovascular surgery (with or without cardiopulmonary bypass); initiation of extracorporeal membrane oxygenation (ECMO); and placement of an intra-aortic balloon pump (IABP), or left ventricular assist device (LVAD). 17,18 Graphs of PCs from date of hospitalization to day of HIT testing, heparin exposure, and events of interest were generated for each patient. Two reviewers (AP and DL) independently reviewed these graphs to determine the start date of the relevant PC fall that raised suspicion for HIT (start of fall date).…”

Section: Platelet Count Fall Metricmentioning

confidence: 99%

Maximum 24‐hour platelet count fall: Metric for improving the diagnosis of heparin‐induced thrombocytopenia among patients with intermediate probability 4Ts scores

Lefler

Cuker

Linkins

et al. 2020

Journal of Thrombosis and Haemostasis

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Background: Most patients with suspected heparin-induced thrombocytopenia (HIT) and an intermediate probability 4Ts score do not have HIT. We aimed to develop a metric based on the rate of platelet count fall to aid in discriminating HIT status among patients with an intermediate 4Ts score. Methods:We derived a measure of the maximum 24-hour percentage decrease in platelet count (Fall max ) in a cohort of patients with suspected HIT and an intermediate 4Ts score at the University of Pennsylvania. We validated this metric in a prospectively collected cohort of patients with suspected HIT and an intermediate 4Ts score from four hospitals in Hamilton, Ontario.Results: One hundred fifty-eight and 139 patients were included in the analysis from the derivation and validation cohorts, respectively. Fall max was significantly higher in HIT-positive patients in the derivation cohort (49.6% versus 38.6%, P = .009) and validation cohort (43.5% versus 29.3%, P = .027). The area under the receiver operating characteristic curve was 0.68 (95% confidence interval [CI] 0.57-0.78) and 0.71 (0.59-0.83) in the two cohorts, respectively. At Fall max ≥ 30%, sensitivity and specificity were 95.5% and 29.4% in the derivation cohort and 80.0% and 52.7% in the validation cohort.Conclusions: Among patients with suspected HIT and an intermediate 4Ts score, Fall max aided in discriminating HIT-negative from HIT-positive patients. Using a measure that accounts for the rate of platelet count fall may help to avoid unnecessary suspension of heparin and treatment with an alternative anticoagulant in HIT-negative patients with an intermediate probability 4Ts score, though further evaluation is warranted.

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“…HIT represents a unique diagnostic challenge in ECMO. Often utilized clinical scores for defining the pre-test probability of HIT, such as the 4Ts score, have limited sensitivity and specificity in the setting of ECMO [ 6 ]. Moreover, the commonly relied upon serum enzyme-linked immunoassay (ELISA) for platelet antibodies also lacks sensitivity and specificity when the question of HIT arises in a subject supported on ECMO [ 7 ].…”

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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Predictive value of scoring tools in determining heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation

Cited by 11 publications

References 20 publications

Management of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock

Management of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock

Maximum 24‐hour platelet count fall: Metric for improving the diagnosis of heparin‐induced thrombocytopenia among patients with intermediate probability 4Ts scores

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

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