The Dosing and Monitoring of Argatroban for Heparin-Induced Thrombocytopenia during Extracorporeal Membrane Oxygenation: A Word of Caution

Phillips, Michael; Khoury, Ayman; Ashton, Rachel; Cairns, Bruce A.; Charles, Anthony

doi:10.1177/0310057x1404200117

Cited by 30 publications

(26 citation statements)

References 12 publications

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“…Because this dose resulted in severe bleeding, a 10‐fold lower dose of 0.2 mcg/kg/min was used for the eight consecutive patients without significant bleeding. Phillips et al recommended a starting dose of argatroban between 0.1 and 0.2 mcg/kg/min and then titrating the dose based on a combination of aPTT, ACT, and clinical evidence of early thrombi formation. This pharmaco‐therapeutic strategy resulted in sufficient anticoagulation without thrombotic or hemorrhagic complications of argatroban.…”

Section: Treatment Of Hitmentioning

confidence: 99%

Heparin‐induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants

Pollak

2019

Journal of Thrombosis and Haemostasis

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Heparin‐induced thrombocytopenia (HIT) is a life‐threatening prothrombotic, immune‐mediated complication of unfractionated heparin and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5‐10 days after initial heparin exposure, detection of platelet‐activating anti‐platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The risk for HIT correlates with the accumulative dosage of heparin exposure. In ECMO patients receiving continuous infusion of heparin for circuit patency, the risk for HIT is not neglected and must be thought of in the differential diagnosis of the appropriate clinical and laboratory circumstances. The following article reviews the current knowledge in HIT complicating ECMO patients and the alternative anticoagulation options in the presence of HIT.

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Section: Treatment Of Hitmentioning

confidence: 99%

Heparin‐induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants

Pollak

2019

Journal of Thrombosis and Haemostasis

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“…Suspicion of HIT was raised in patients on ECLS by various factors including a decrease in platelet count by >50% (5-9), thrombotic event(s) (6,9,10), change in postoperative status (6), duration of ECLS support >72 hours (11) and intermediate to high 4Ts score (>3) (6,12). The cutoff criterion for HIT suspicion was not always specified or uniform for every institution.…”

Section: Definitionsmentioning

confidence: 99%

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

Choi

Luc

Weber

et al. 2019

Ann. Cardiothorac. Surg.

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Background: Heparin-induced thrombocytopenia (HIT) is a severe antibody-mediated reaction leading to transient prothrombosis. However, its incidence in patients on extracorporeal life support (ECLS) is not well described. The aim of this systematic review was to report the incidence of HIT in patients on ECLS, as well as compare the characteristics and outcomes of HIT in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and veno-venous ECMO (VV-ECMO). Methods: An electronic search was performed to identify all studies in the English literature examining outcomes of patients with HIT on ECLS. All identified articles were systematically assessed using specific inclusion and exclusion criteria. Random effects meta-analysis as well as univariate analysis was performed. Results: Of 309 patients from six retrospective studies undergoing ECLS, 83% were suspected, and 17% were confirmed to have HIT. Due to the sparsity of relevant retrospective data regarding patients with confirmed HIT on ECLS, patient-based data was subsequently collected on 28 patients from case reports and case series. Out of these 28 patients, 53.6% and 46.4% of them underwent VA-ECMO and VV-ECMO, respectively. Patients on VA-ECMO had a lower median platelet count nadir (VA-ECMO: 26.0 vs. VV-ECMO: 45.0 per µL, P=0.012) and were more likely to experience arterial thromboembolism (VA-ECMO: 53.3% vs. VV-ECMO: 0.0%, P=0.007), though there was a trend towards decreased likelihood of experiencing ECLS circuit oxygenator thromboembolism (VA-ECMO: 0.0% vs. VV-ECMO: 30.8%, P=0.075) and thromboembolism necessitating ECLS device or circuit exchange (VA-ECMO: 13.3% vs. VV-ECMO 53.8%, P=0.060). Kaplan-Meier survival plots including time from ECLS initiation reveal no significant differences in survival in patients supported on VA-ECMO as compared to VV-ECMO (P=0.300). Conclusions: Patients who develop HIT on VA-ECMO are more likely to experience more severe thrombocytopenia and arterial thromboembolism than those on VV-ECMO. Further research in this area and development of standardized protocols for the monitoring, diagnosis and management of HIT in patients on ECLS support are warranted.

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“…DTIs such as argatroban and bivalirudin have been used in ECLS patients who develop heparin-induced thrombocytopenia (HIT) and there have been case reports and series using a DTI for non-HIT cases. [57][58][59][60][61][62] In addition, there has been a single circuit sham study that demonstrated decreased clot initiation with argatroban. 63 A single study has been performed on adult and pediatric postcardiotomy ECLS patients and anticoagulation with bivalirudin demonstrated a more stable anticoagulation profile, stable platelet counts, and AT activity measurements, less bleeding, decreased fresh frozen plasma and platelet transfusion, and decreased costs.…”

Section: Alternative Anticoagulantsmentioning

confidence: 99%

Managing the Precarious Hemostatic Balance during Extracorporeal Life Support: Implications for Coagulation Laboratories

Winkler¹

2017

Semin Thromb Hemost

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For the past four decades, extracorporeal life support (ECLS) has been used to treat critically ill adult and pediatric patients with cardiac and/or respiratory failure unresponsive to medical management, and there are increasing numbers of centers performing ECLS for numerous indications worldwide. Despite the progress with advancing technology, hemorrhagic and thrombotic complications occur frequently and are associated with worse outcomes, but the exact cause is often elusive or multifactorial. As a result of the interaction between blood and a nonendothelialized circuit, there is activation of coagulation, fibrinolysis, as well as an increased inflammatory response; thus, anticoagulation of the patient and circuit is necessary. While unfractionated heparin (UFH) remains the mainstay anticoagulant used during ECLS, there is a paucity of published data to develop a universal anticoagulation guideline and centers are forced to create individualized protocols to guide anticoagulation management, frequently while lacking expertise. From an international survey, centers often use a combination of tests to guide management, which in turn can lead to discordant results and confused management. Studies are urgently needed to investigate optimization of current anticoagulation strategies with UFH, as well as use of alternative anticoagulants and nonthrombogenic biomaterials.

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The Dosing and Monitoring of Argatroban for Heparin-Induced Thrombocytopenia during Extracorporeal Membrane Oxygenation: A Word of Caution

Cited by 30 publications

References 12 publications

Heparin‐induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants

Heparin‐induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

Managing the Precarious Hemostatic Balance during Extracorporeal Life Support: Implications for Coagulation Laboratories

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