Heparin-Induced Thrombocytopenia in Medical Surgical Critical Illness

被引：46

作者：

Warkentin, Theodore E. ^{[1
]}

Sheppard, Jo-Ann I. ^{[1
]}

Heels-Ansdell, Diane ^{[2
]}

Marshall, John C. ^{[4
,5
]}

McIntyre, Lauralyn ^{[7
,8
]}

Rocha, Marcelo G. ^{[13
]}

Mehta, Sangeeta ^{[5
,6
]}

Davies, Andrew R. ^{[17
]}

Bersten, Andrew D. ^{[18
,19
]}

Crozier, Tim M. ^{[14
]}

Ernest, David ^{[15
,16
]}

Vlahakis, Nicholas E. ^{[20
]}

Hall, Richard I. ^{[9
,10
]}

Wood, Gordon G. ^{[11
]}

Poirier, Germain ^{[12
]}

Crowther, Mark A. ^{[3
]}

Cook, Deborah J. ^{[3
]}

机构：

[1] McMaster Univ, Dept Pathol & Mol Med, Hamilton, ON, Canada

[2] McMaster Univ, Dept Clin Epidemiol & Biostat, Hamilton, ON, Canada

[3] St Josephs Healthcare, Hamilton, ON, Canada

[4] St Michaels Hosp, Toronto, ON M5B 1W8, Canada

[5] Univ Toronto, Toronto, ON, Canada

[6] Mt Sinai Hosp, Toronto, ON M5G 1X5, Canada

[7] Ottawa Hosp Gen Campus, Ottawa, ON, Canada

[8] Univ Ottawa, Ottawa, ON, Canada

[9] Capital Hlth Queen Elizabeth II Hlth Sci Ctr, Halifax, NS, Canada

[10] Dalhousie Univ, Halifax, NS, Canada

[11] Vancouver Isl Hlth Author, Victoria, BC, Canada

[12] Charles LeMoyne Hosp, Longueuil, PQ, Canada

[13] Pavilhao Pereira Filho, Santa Casa Porto Alegre, Brazil

[14] Monash Med Ctr, Melbourne, Vic, Australia

[15] Box Hill Hosp, Melbourne, Vic, Australia

[16] Monash Univ, Melbourne, Vic 3004, Australia

[17] Alfred Hosp, Melbourne, Vic, Australia

[18] Flinders Med Ctr, Adelaide, SA, Australia

[19] Flinders Univ S Australia, Adelaide, SA 5001, Australia

[20] Mayo Clin, Rochester, MN USA

来源：

CHEST | 2013年 / 144卷 / 03期

基金：

加拿大健康研究院;

关键词：

MOLECULAR-WEIGHT HEPARIN; UNFRACTIONATED HEPARIN; RISK; FREQUENCY; THROMBOPROPHYLAXIS; FEATURES;

D O I：

10.1378/chest.13-0057

中图分类号：

R4 [临床医学];

学科分类号：

1002 ; 100602 ;

摘要：

Background: In a recent multicenter randomized trial comparing unfractionated heparin (UFH) with low-molecular-weight heparin (dalteparin) for thromboprophylaxis in 3,746 critically ill patients, 17 patients (0.5%) developed heparin-induced thrombocytopenia (HIT) based on serotonin-release assay-positive (SRA+) status. A trend to a lower frequency of HIT with dalteparin vs UFH was observed in the intention-to-treat analysis (five vs 12 patients, P = .14), which was statistically significant (three vs 12 patients, P = .046) in a prespecified per-protocol analysis that excluded patients with DVT at study entry. We sought to characterize HIT outcomes and to determine how dalteparin thromboprophylaxis may reduce HIT frequency in patients in the ICU. Methods: In 17 patients with HIT, we analyzed platelet counts and thrombotic events in relation to the study drug and other open-label heparin, to determine whether the study drug plausibly explained seroconversion to SRA+ status and/or breakthrough of thrombocytopenia/thrombosis. We also compared antibody frequencies (dalteparin vs UFH) in 409 patients serologically investigated for HIT. Results: HIT-associated thrombosis occurred in 10 of 17 patients (58.8%) (8: 1: 1 venous: arterial: both). Dalteparin was associated with fewer study drug-attributable HIT-related events (P = .020), including less seroconversion (P = .058) and less breakthrough of thrombocytopenia/thrombosis (P = .032). Antiplatelet factor 4/heparin IgG antibodies by enzyme-linked immunosorbent assay were less frequent among patients receiving dalteparin vs UFH (13.5% vs 27.3%, P<.001). One patient with HIT-associated DVT died after UFH bolus (anaphylactoid reaction), whereas platelet counts recovered in two others with HIT-associated VTE despite continuation of therapeuticdose UFH. Conclusions: The lower risk of HIT in patients in the ICU receiving dalteparin appears related to both decreased antibody formation and decreased clinical breakthrough of HIT among patients forming antibodies.

引用

页码：848 / 858

页数：11

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