Heparin Induced Thrombocytopenia for the Perioperative and Critical Care Clinician
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BLOOD MANAGEMENT (KA TANAKA, SECTION EDITOR)
Heparin Induced Thrombocytopenia for the Perioperative and Critical Care Clinician Ingrid Moreno-Duarte 1 & Kamrouz Ghadimi 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review This review will illustrate the importance of heparin-induced thrombocytopenia in the intraoperative and critical care settings. Recent Findings Heparin-induced thrombocytopenia (HIT) occurs more frequently in surgical patients compared with medical patients due to the inflammatory release of platelet factor 4 and perioperative heparin exposure. Recognition of this disease requires a high index of suspicion. Diagnostic tools and therapeutic strategies have been expanded and refined in recent years. Summary HIT is a condition where antibodies against the heparin/platelet factor 4 complex interact with platelet receptors to promote platelet activation, aggregation, and thrombus formation. Our review will focus on intraoperative and postoperative considerations related to HIT to help the clinician better manage this rare but often devastating hypercoagulable disease process. Keywords Heparin . Thrombocytopenia . Surgery . Limb ischemia . Thrombosis
Introduction Heparin-induced thrombocytopenia (HIT) is a prothrombotic disease where antibodies against the molecular complex of heparin-to-platelet factor 4 (PF4/H) interact with platelet receptors to promote platelet activation, aggregation, and removal from circulation [1, 2•]. PF4 is secreted by platelet granules or displaced from the endothelium. HIT antibodies against the heparin/PF4 complex will trigger downstream thrombin generation and catastrophic thrombus formation. The prevalence of HIT is rare in both medical and surgical patients, and the incidence in most population-based studies ranges between 0.3 and 3.0%. However, the occurrence of HIT in the operating theater or the postoperative critical care setting can be swift and devastating. In this review, we will discuss standard definitions, scoring systems, epidemiology, and pathogenesis that is relevant to the perioperative and critical care environments. For our review, we will be referring to This article is part of the Topical Collection on Blood Management * Kamrouz Ghadimi [email protected] 1
Department of Anesthesiology & Critical Care, Duke University School of Medicine, DUMC Box 3094, Durham, NC 27710, USA
the type 2 variety of HIT, where an immune-mediated disorder emerges typically 4–10 days after heparin exposure to heparin and has life- and limb-threatening thrombotic complications [2•, 3]. There will be a limited focus on the less clinically important type 1, which is a non-immune process that presents within the first 2 days after heparin exposure with correction of thrombocytopenia despite continuation of heparin therapy [3].
Definition and Epidemiology Approximately 20–50% of critically ill patients present with thrombocytopenia in the intensive care unit (ICU), whereby a reduced platelet count below 150,000 platelets p
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