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Heparin-induced thrombocytopenia in the critical care setting: Diagnosis and managementˆ

Napolitano, Lena M. MD, FACS, FCCP, FCCM; Warkentin, Theodore E. MD, BSc[Med], FRCP(C); AlMahameed, Amjad MD, MPH; Nasraway, Stanley A. MD, FCCM

doi: 10.1097/01.CCM.0000248723.18068.90
Continuing Medical Education Article

Background: Thrombocytopenia is a common occurrence in critical illness, reported in up to 41% of patients. Systematic evaluation of thrombocytopenia in critical care is essential to accurate identification and management of the cause. Although sepsis and hemodilution are more common etiologies of thrombocytopenia in critical illness, heparin-induced thrombocytopenia (HIT) is one potential etiology that warrants consideration.

Objective: This review will summarize the pathogenesis and clinical consequences of HIT, describe the diagnostic process, and review currently available treatment options.

Data Source: MEDLINE/PubMed search of all relevant primary and review articles.

Data Synthesis and Conclusions: HIT is a clinicopathologic syndrome characterized by thrombocytopenia (≥50% from baseline) that typically occurs between days 5 and 14 after initiation of heparin. This temporal profile suggests a possible diagnosis of HIT, which can be supported (or refuted) with a strong positive (or negative) laboratory test for HIT antibodies. When considering the diagnosis of HIT, critical care professionals should monitor platelet counts in patients who are at risk for HIT and carefully evaluate for, a) temporal features of the thrombocytopenia in relation to heparin exposure; b) severity of thrombocytopenia; c) clinical evidence for thrombosis; and d) alternative etiologies of thrombocytopenia. Due to its prothrombotic nature, early recognition of HIT and prompt substitution of heparin with a direct thrombin inhibitor (e.g., argatroban or lepirudin) or the heparinoid danaparoid (where available) reduces the risk of thromboembolic events, some of which may be life-threatening.

Professor of Surgery, Division Chief, Acute Care Surgery, Trauma, Burn, Critical Care, Emergency Surgery, Associate Chair of Surgery for Critical Care, Department of Surgery, Director, Surgical Critical Care, University of Michigan Health System, Ann Arbor, MI (LMN); Professor, Hamilton Health Sciences, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada (TEW); Clinical Fellow, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (AA); Professor, Surgery, Medicine and Anesthesia, Tufts University School of Medicine, Tufts-New England Medical Center, Boston, MA (SAN).

© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins