Mechanisms and etiologies of thrombocytopenia in the intensive care unit: impact of extensive investigations

Abstract

Background: Thrombocytopenia is common in the intensive care unit. Potential mechanisms and etiologies behind this phenomenon are multiple and often entangled. We assessed the effect of a systematic approach, using routinely available tests, on the proportion of patients in whom the mechanism (primary objective) and etiology (secondary objective) of thrombocytopenia in a mixed intensive care unit (ICU) could be identified. Methods: Before-and-after study of all patients with thrombocytopenia was used. 'Before' group had no intervention. New standard operating procedures for thrombocytopenia management were introduced. In the 'After' group, bone marrow aspiration; determination of fibrinogen dosage, prothrombin time, factor V, D-dimers; assay of fibrin monomers, ferritin, triglycerides, lactic acid dehydrogenase, aspartate transaminase, alanine aminotransferase, vitamin B 12 , folates, reticulocytes, haptoglobin, and bilirubin were performed. Results: In the Before group (n = 20), the mechanism (central, peripheral, or mixed) was identified in 10 % versus 83% in After group (n = 23) (p < 0.001) (48% peripheral, 35% mixed). Before intervention, ≥1 etiology was identified in 15% versus 95.7% in the After group (p < 0.001). Conclusions: Systematic and extensive investigation using routine tests highlights the mechanisms and etiology of thrombocytopenia in most cases.

Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China

“…For example, chronic liver disease reduces platelet production due to bone marrow suppression and forms autoantibodies that lead to increased platelet destruction [13]. In addition, a patient may have two or more conditions that cause thrombocytopenia, making an accurate diagnosis more challenging [14,15].…”

Post‐transfusion platelet responses in critically ill cancer patients with hypoproliferative thrombocytopenia

“…Besides, thrombocytopenia may be associated to an increased risk of bleeding in critically ill patients in association with other risk factors such as endothelial and epithelial alterations, the use of anticoagulants and antiplatelet agents and the frequent requirement for invasive procedures. [1][2][3][4][5][6][7] As a consequence, a number of critically ill patients are liable to receive platelet transfusions in order to prevent or to treat bleeding. In the absence of relevant interventional studies in the field, indications of platelet transfusions still remain largely empirical, based on observational cohorts or derived from interventional studies carried out in different clinical settings.…”

Bleeding and thrombosis in intensive care patients with thrombocytopenia—Protocol for a topical systematic review

“…Thrombocytopenia is a common condition in critically ill patients and in the intensive care unit (ICU). Depending on the definition, the incidence of thrombocytopenia among ICU patients ranges from 13% to 44%, and it is associated with increased duration of stay in the ICU, rates of bleeding, transfusion requirements and mortality …”

“…The aetiology of thrombocytopenia is often multifactorial, but can in general be divided into central causes with impaired production and/or dysfunction of the bone marrow, and peripheral causes with increased turnover following platelet destruction (immune or non‐immune), increased sequestration in the spleen or pharmaceutically induced thrombocytopenia and haemodilution . Typically, thrombocytopenia is a consequence of underlying disease, in ICU patients frequently sepsis, where platelet aggregation and adhesion to leucocytes and endothelial cells results in a decrease in circulating platelets …”