Gupta S, Tiruvoipati R, Green C, Botha J, Tran H. Heparin induced thrombocytopenia in critically ill: Diagnostic dilemmas and management conundrums. World J Crit Care Med 2015; 4(3): 202-212 [PMID: 26261772 DOI: 10.5492/wjccm.v4.i3.202]
Corresponding Author of This Article
Ravindranath Tiruvoipati, Associate Professor, Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Rd, Frankston VIC 3199, Australia. travindranath@hotmail.com
Research Domain of This Article
Critical Care Medicine
Article-Type of This Article
Review
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Crit Care Med. Aug 4, 2015; 4(3): 202-212 Published online Aug 4, 2015. doi: 10.5492/wjccm.v4.i3.202
Heparin induced thrombocytopenia in critically ill: Diagnostic dilemmas and management conundrums
Sachin Gupta, Ravindranath Tiruvoipati, Cameron Green, John Botha, Huy Tran
Sachin Gupta, Ravindranath Tiruvoipati, Cameron Green, John Botha, Department of Intensive Care Medicine, Frankston Hospital, Frankston VIC 3199, Australia
Sachin Gupta, Ravindranath Tiruvoipati, John Botha, School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
Huy Tran, Department of Oncology, Frankston Hospital, Frankston VIC 3199, Australia
Author contributions: Gupta S contributed to conception and design, drafting the manuscript and revising it critically for important intellectual content; Tiruvoipati R, Green C and Botha J contributed to drafting the manuscript and revising it critically for important intellectual content; Tran H contributed to conception and design, drafting the manuscript and revising it critically for important intellectual content, overall supervision; all authors had given final approval of the version to be published.
Conflict-of-interest statement: None of the authors have any conflicts of interests (including but not limited to commercial, personal, political. Intellectual, or religious interests) in relation to this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Ravindranath Tiruvoipati, Associate Professor, Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Rd, Frankston VIC 3199, Australia. travindranath@hotmail.com
Telephone: +61-4-31279347 Fax: +61-3-97847398
Received: October 3, 2014 Peer-review started: October 3, 2014 First decision: December 26, 2014 Revised: February 25, 2015 Accepted: May 11, 2015 Article in press: May 14, 2015 Published online: August 4, 2015 Processing time: 318 Days and 9.1 Hours
Abstract
Thrombocytopenia is often noted in critically ill patients. While there are many reasons for thrombocytopenia, the use of heparin and its derivatives is increasingly noted to be associated with thrombocytopenia. Heparin induced thrombocytopenia syndrome (HITS) is a distinct entity that is characterised by the occurrence of thrombocytopenia in conjunction with thrombotic manifestations after exposure to unfractionated heparin or low molecular weight heparin. HITS is an immunologic disorder mediated by antibodies to heparin-platelet factor 4 (PF4) complex. HITS is an uncommon cause of thrombocytopenia. Reported incidence of HITS in patients exposed to heparin varies from 0.2% to up to 5%. HITS is rare in ICU populations, with estimates varying from 0.39%-0.48%. It is a complex problem which may cause diagnostic dilemmas and management conundrum. The diagnosis of HITS centers around detection of antibodies against PF4-heparin complexes. Immunoassays performed by most pathology laboratories detect the presence of antibodies, but do not reveal whether the antibodies are pathological. Platelet activation assays demonstrate the presence of clinically relevant antibodies, but only a minority of laboratories conduct them. Several anticoagulants are used in management of HITS. In this review we discuss the incidence, pathogenesis, diagnosis and management of HITS.
Core tip: Thrombocytopenia is common in critically ill patients. While there are several causes of thrombocytopenia, heparin induced thrombocytopenia syndrome (HITS) is an uncommon cause often difficult to diagnose and manage. This article summarises the current diagnostic techniques and management options with a focus on critically ill patients with HITS.
