Abstract
Thrombocytopenia commonly occurs in hospitalized patients, particularly critically ill patients. We present an exemplifying case of severe heparin-induced thrombocytopenia (HIT) in an effort to solidify its high priority in the differential diagnosis of thrombocytopenia. A 75-year-old female underwent cardiac surgery with intraaortic balloon pump (IABP) placement. A platelet count drop to 25 × 10(9)/L by the third postoperative day was attributed to the IABP, which was removed. Her thrombocytopenia remained refractory to multiple platelet transfusions over several days. Right hand cyanosis then developed, attributed to a right radial arterial catheter, which was removed. All toes and fingers then showed severe ischemic changes. Ten days after the initial platelet count drop, a critical care specialist new to the treating team suspected HIT. Heparin exposure was stopped and argatroban was initiated. A HIT antibody test was subsequently strongly positive. The patients thrombocytopenia gradually resolved. No additional thromboses occurred during a 27-day intensive care unit stay. This case underscores the need for vigilance in suspecting HIT in patients with thrombocytopenia and recent heparin exposure. To avoid catastrophic outcomes in such patients, heparin should be stopped and alternative anticoagulation should be initiated, at least until HIT is excluded.
Highlights
Thrombocytopenia is a common finding in hospitalized patients, critically ill patients, with readily plausible causes including disseminated intravascular coagulation, dilution from blood transfusions, continuous venovenous hemodialysis (CVVHD), liver disease with hypersplenism, and certain medications
Assays for heparin-induced thrombocytopenia (HIT) include the sensitive (>90%) but less specific (~71%) heparin-platelet factor 4 enzyme-linked immunosorbent assay (ELISA) which is often used as a screening test, and the serotonin release assay which can be performed as a confirmatory test but is not universally available and/or utilized [5]
Despite over 50 years of clinical experience with heparin, awareness of heparin-induced thrombocytopenia is still lacking. We present this case in an effort to solidify HIT's place in the differential diagnosis of thrombocytopenia
Summary
Thrombocytopenia is a common finding in hospitalized patients, critically ill patients, with readily plausible causes including disseminated intravascular coagulation, dilution from blood transfusions, continuous venovenous hemodialysis (CVVHD), liver disease with hypersplenism, and certain medications. The patient's preoperative platelet count of 108 × 109/L fell to 25 × 109/L by the third postoperative day She was transfused with 12 units of random donor platelets and received norepinephrine for blood pressure support. The patient bled from the femoral insertion site and developed further hypotension She underwent surgical repair of the femoral artery, during which she received 18 units of random donor platelets, 8 units of packed red blood cells, and 4 units of fresh frozen plasma.
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