Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation

Glick, D.R.; Dzierba, Amy; Abrams, Darryl; Muir, Justin; Eisenberger, Andrew; Diuguid, David L.; Abel, Erik; Agerstrand, Cara; Bacchetta, Matthew; Brodie, Daniel

doi:10.1016/j.jcrc.2015.07.030

Cited by 59 publications

(55 citation statements)

References 21 publications

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“…We counted the number of medications given that could potentially cause thrombocytopenia (see Supplementary Methods), but we did not include heparin because all subjects received heparin. We evaluated subjects for heparin-induced thrombocytopenia (HIT) when it was suspected (see Supplementary Methods) [23-25]. Comorbid conditions were quantified with the Charlson Index [26].…”

Section: Methodsmentioning

confidence: 99%

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

et al. 2016

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Purpose The association between extracorporeal membrane oxygenation (ECMO) use and the development of thrombocytopenia is widely presumed yet weakly demonstrated. We hypothesized that longer duration of ECMO support would be independently associated with worsened thrombocytopenia. Methods We performed a single-center retrospective cohort study of 100 adults who received ECMO for acute respiratory failure. We used generalized estimating equations to test the association between days on ECMO and daily percentage of platelets compared to the first post-cannulation platelet count. We constructed a multivariable logistic regression model with backwards stepwise elimination to identify clinical predictors of severe thrombocytopenia (≤ 50,000/μL) while on ECMO. Results Days on ECMO was not associated with a decrease in platelet count in the unadjusted analysis (β: -0.85, 95% CI: -2.05 to 0.36), nor after controlling for days hospitalized prior to ECMO, APACHE II score, platelet transfusions, and potential thrombocytopenia-inducing medications (β: -0.85, 95% CI: -1.9 to 0.22). Twenty-two subjects (22%) developed severe thrombocytopenia. The APACHE II score and platelet count at the time of cannulation predicted the development of severe thrombocytopenia. The odds of developing severe thrombocytopenia increased 35% for every 5-point increase in APACHE II score (OR 1.35, 95% CI: 0.94 to 1.94), and increased 35% for every 25,000/μL platelets below a mean at cannulation of 188,000/μL (OR 1.35, 95% CI: 1.10 to 1.64). Conclusions Duration of ECMO is not associated with the development of thrombocytopenia. The severity of critical illness and platelet count at the time of cannulation predict the development of severe thrombocytopenia while receiving ECMO for respiratory failure. Future studies should validate these findings, especially in cohorts with more venoarterial ECMO patients, and should characterize the association between thrombocytopenia and bleeding events while on ECMO.

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Section: Methodsmentioning

confidence: 99%

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

et al. 2016

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“…There were 6.698 V-A ECMO patients, of whom 459 were post-cardiotomy. In 6 studies, authors did not report about the ECMO setting (post-cardiotomy, post-acute myocardial infarction, or other aetiologies) [8,16,25,26,28,39]. V-V ECMO was present in 477 patients.…”

Section: Study Descriptionmentioning

confidence: 99%

“…• Platelet dysfunction Seven studies assessed the platelet function in ECMO patients [7,16,27,28,33,35,38]. Platelet aggregation tests were performed in 5 studies, showing a substantial reduction in platelet function [7,16,27,30,38].…”

Section: • Thrombocytopeniamentioning

confidence: 99%

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

et al. 2020

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Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.

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“…Likewise, a prospective study including 581 patients who developed postoperative thrombocytopenia after cardiopulmonary bypass further revealed the low incidence of laboratory-confirmed HIT (0.5%) 25. Only one retrospective study including 119 patients has estimated the incidence (19%) of this condition in patients under ECMO support;12 laboratory confirmation was provided in only one patient 12. Additional studies in this condition include few case reports 13–15 26.…”

Section: Discussionmentioning

confidence: 99%

“…To date, the incidence of HIT in patients undergoing ECMO support is estimated to be lower than 1% 12. Only a few cases have been reported in the literature of HIT in patients under ECMO support 13–15.…”

Section: Introductionmentioning

confidence: 99%

Acute oxygenator failure: a new presentation of heparin-induced thrombocytopenia in a patient undergoing venovenous extracorporeal membrane oxygenation support

et al. 2016

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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 (60-70×10/L), a sudden further decrease occurred (30×10/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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Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation

Cited by 59 publications

References 21 publications

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

Acute oxygenator failure: a new presentation of heparin-induced thrombocytopenia in a patient undergoing venovenous extracorporeal membrane oxygenation support

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