Thrombocytopenia In Intensive Care Unit Research Articles

Thrombocytopenia and platelet transfusions in ICU patients: an international inception cohort study (PLOT-ICU)

PurposeThrombocytopenia (platelet count < 150 × 109/L) is common in intensive care unit (ICU) patients and is likely associated with worse outcomes. In this study we present international contemporary data on thrombocytopenia in ICU patients.MethodsWe conducted a prospective cohort study in adult ICU patients in 52 ICUs across 10 countries. We assessed frequencies of thrombocytopenia, use of platelet transfusions and clinical outcomes including mortality. We evaluated pre-selected potential risk factors for the development of thrombocytopenia during ICU stay and associations between thrombocytopenia at ICU admission and 90-day mortality using pre-specified logistic regression analyses.ResultsWe analysed 1166 ICU patients; the median age was 63 years and 39.5% were female. Overall, 43.2% (95% confidence interval (CI) 40.4–46.1) had thrombocytopenia; 23.4% (20–26) had thrombocytopenia at ICU admission, and 19.8% (17.6–22.2) developed thrombocytopenia during their ICU stay. Non-AIDS-, non-cancer-related immune deficiency, liver failure, male sex, septic shock, and bleeding at ICU admission were associated with the development of thrombocytopenia during ICU stay. Among patients with thrombocytopenia, 22.6% received platelet transfusion(s), and 64.3% of in-ICU transfusions were prophylactic. Patients with thrombocytopenia had higher occurrences of bleeding and death, fewer days alive without the use of life-support, and fewer days alive and out of hospital. Thrombocytopenia at ICU admission was associated with 90-day mortality (adjusted odds ratio 1.7; 95% CI 1.19–2.42).ConclusionThrombocytopenia occurred in 43% of critically ill patients and was associated with worse outcomes including increased mortality. Platelet transfusions were given to 23% of patients with thrombocytopenia and most were prophylactic.

Development and Validation Nomogram for Predicting the Survival of Patients with Thrombocytopenia in Intensive Care Units.

The number of patients with thrombocytopenia (TCP) is relatively high in intensive care units (ICUs). It is therefore necessary to evaluate the prognostic risk of such patients. This study investigated the risk factors affecting the survival of patients with TCP in the ICU. Using the findings of this investigation, we developed and validated a risk prediction model. We evaluated patients admitted to the ICU who presented with TCP. We used LASSO regression to identify important clinical indicators. Based on these indicators, we developed a prediction model complete with a nomogram for the development cohort set. We then evaluated the mode's accuracy using a receiver operating characteristic (ROC) curve, calibration curves, and decision curve analysis (DCA) in a validation cohort. A total of 141 cases of ICU TCP were included in the sample, of which 47 involved death of the patient. Clinical results were as follows: N (HR 0.91, 95% CI 0.86-0.97, P=0.003); TBIL (HR 1.98, 95% CI 1.02-1.99, P=0.048); APACHE II (HR 1.94, 95% CI 1.39, 2.48, P=0.045); WPRN (HR 6.22, 95% CI 2.86-13.53, P<0.001); WTOST (HR 0.56, 95% CI 0.21-1.46, P<0.001); and DMV [HR1.87, 95% CI 1.12-2.33]. The prediction model yielded an area under the curve (AUC) of 0.918 (95% CI 0.863-0.974) in the development cohort and 0.926 (95% CI 0.849-0.994) in the validation cohort. Application of the nomogram in the validation cohort gave good discrimination (C-index 0.853, 95% CI 0.810-0.922) and good calibration. DCA indicated that the nomogram was clinically useful. The individualized nomogram developed through our analysis demonstrated effective prognostic prediction for patients with TCP in ICUs. Use of this prediction metric may reduce TCP-related morbidity and mortality in ICUs.

Platelet transfusions and thrombocytopenia in intensive care units: Protocol for an international inception cohort study (PLOT‐ICU)

IntroductionThrombocytopenia is frequent in intensive care unit (ICU) patients and has been associated with worse outcome. Platelet transfusions are often used in the management of ICU patients with severe thrombocytopenia. However, the reported frequencies of thrombocytopenia and platelet transfusion practices in the ICU vary considerably. Therefore, we aim to provide contemporary epidemiological data on thrombocytopenia and platelet transfusion practices in the ICU.MethodsWe will conduct an international inception cohort, including at least 1000 acutely admitted adult ICU patients. Routinely available data will be collected at baseline (ICU admission), and daily during ICU stay up to a maximum of 90 days. The primary outcome will be the number of patients with thrombocytopenia (a recorded platelet count < 150 × 109/L) at baseline and/or during ICU stay. Secondary outcomes include mortality, days alive and out of hospital, days alive without life‐support, the number of patients with at least one bleeding episode, at least one thromboembolic event and at least one platelet transfusion in the ICU, the number of platelet transfusions and the indications for transfusion. The primary and secondary outcomes will be presented descriptively. In addition, we will assess risk factors for developing thrombocytopenia during ICU stay and the association between thrombocytopenia at baseline and 90‐day mortality using logistic regression analyses.ConclusionThe outlined international PLOT‐ICU cohort study will provide contemporary epidemiological data on the burden and clinical significance of thrombocytopenia in adult ICU patients and describe the current platelet transfusion practice.

Thrombocytopenia in 737 adult intensive care unit patients: A real-world study of associated factors, drugs, platelet transfusion, and clinical outcome

Objective:We aimed to identify and represent factors associated with thrombocytopenia in intensive care unit, especially the pathogens and drugs related to severe and extremely thrombocytopenia. Then, we aim to compare the mortality of platelet transfusion and non-transfusion in patients with different degrees of thrombocytopenia.Methods:We identified all thrombocytopenic patients in intensive care unit by using platelet-specific values and then extracted electronic health records from our Hospital Information System. Data were statistically analyzed with t test, chi-square test, and logistic regression.Results:We found that infections (32.7%) were the most frequent cause associated with thrombocytopenia, followed by sepsis shock (3.93%) and blood loss (2.99%). Meanwhile, antifungals (p = 0.002) and bacterial infection (p = 0.037) were associated with severe and extremely severe thrombocytopenia. Finally, we found that the mortality of platelet transfusion and non-transfusion in patients was statistically significant for patients with platelet counts between 30 and 49/nL (χ2 = 9.719, p = 0.002).Conclusion:Infection and sepsis emerged as two primary factors associated with thrombocytopenia in intensive care unit. Meanwhile, antifungals and bacterial infection were associated with platelet counts less than 49/nL. Finally, platelet transfusion may be associated with reduced mortality in patients with platelet counts between 30 and 49/nL.

Thrombocytopenia in Intensive care units

Emergency Medicine Specialists (EMS) are supposed to helping/keeping certain patients alive. Although the Intensive Care Unit (ICU) personnel's priority is just saving life of ICU's patients but their approaches are not always in advantage of treated patients [1-5]. Prevalent thrombocytopenia (on ICU admission) occurred in 8.3% to 67.6% of patients; incident thrombocytopenia (developing during the course of the ICU stay) occurred in 13.0% to 44.1% of patients. High illness severity, sepsis, and organ dysfunction often correlated with thrombocytopenia.

Thrombocytopenia in Intensive Care Unit.

How to cite this article: Aluru N, Samavedam S. Thrombocytopenia in Intensive Care Unit. Indian J Crit Care Med 2019;23(Suppl 3):S185–S188.

Limited Impact of Clinician Education on Reducing Inappropriate PF4 Testing for Heparin-Induced Thrombocytopenia

IntroductionStudies have shown that medical centers are faced with a major challenge in making an accurate diagnosis of heparin -induced thrombocytopenia (HIT). Some centers have decreased overdiagnosis with the implementation of anticoagulation stewardship programs, collaboration between pharmacy and hospital laboratory, and mandating clinicians to calculate the 4T score prior to testing. A high frequency of PF4-ELISA testing in patients with low 4T scores has been observed in multiple medical centers, including our institution. Education of ordering clinicians has been suggested to reduce inappropriate testing.In this study, we determined current trends of PF4-ELISA testing in our institution after the introduction of a HIT program that included ongoing education, feedback, and continuous clinical audit of PF4-ELISA utilization.MethodsA HIT Program was developed over a 6-year period. This program consisted of: i) providing department-wide lectures to residents, fellows, and attendings on HIT testing and management including 4T score calculation; ii) providing individual feedback from the Anticoagulation and Bleeding Management service to the ordering clinician when a false positive PF4-ELISA test was ordered inappropriately; iii) providing interactive lectures based on real life case scenarios to internal medicine residents on calculating 4T scores.To assess the impact of the education provided on PF4-ELISA testing trends, we conducted a prospective cohort review of all adult patients (age≥18) who had a PF4-ELISA ordered over a 3-month period (the last quarter of the academic year, March - June 2018) at our academic medical center (an 800-bed hospital). The Hematology Quality Improvement (QI) fellow and attending received a list of all PF4-ELISA tests ordered from the laboratory technician daily. All PF4-ELISA tests requested prior to 12pm are resulted on the same day in the afternoon. 4T scores were independently assessed prior to the results being available to avoid bias. Testing trends, 4T scores, ordering services, and documentation of 4T scores by ordering clinicians were assessed.Results72 PF4-ELISA tests were ordered during the study period. Prospectively calculated 4T scores by investigators revealed 60 low-risk (83.3%), 9 intermediate-risk (12.5%), and 3 high-risk (4.16%). 1 patient had a positive serotonin-release assay (SRA); optical density (O.D.) of the PF4-ELISA was 2.499 and 4T score revealed intermediate risk. The 4T score was documented by the ordering team in only 7 cases; 5 of these revealed discordant calculation between the ordering clinician and the Hematology QI team. All documented 4T scores were by Internal Medicine services. In all discordant cases, ordering clinicians' scores were higher than scores calculated by the Hematology QI team. The majority of PF4-ELISA testing was ordered by the intensive care units (ICUs) (n=32, 44.44%), followed by medical (n=20, 27.77%) and surgical teams (n=20, 27.77%)ConclusionOur study revealed that calculation of 4T scores remains poor and is not universally applied, suggesting that clinician education alone is insufficient. We also observed divergent 4T scores with the ordering clinician calculating a higher 4T score compared to the Hematology QI team. As such, introducing mandatory 4T score calculation prior to PF4-ELISA testing may not be helpful as ordering clinicians can bypass the restriction through inaccurate 4T score calculation.The majority of PF4-ELISA testing was performed in the ICU setting. This is concerning as studies have shown that thrombocytopenia is a common laboratory finding in up to 50% of ICU patients. This seems to suggest the difficulties that ordering clinicians have in distinguishing the multiple causes of thrombocytopenia in ICU patients.Further study is required to assess if initiating an automatic non-malignant hematology consult for each PF4 testing would be an effective addition to our continued attempts to decrease inappropriate testing for HIT. DisclosuresNo relevant conflicts of interest to declare.

Incidence and risk factors for thrombocytopenia in the intensive care units of a tertiary hospital in northern India

Background. In Western countries, incidence of thrombocytopenia in intensive care units (ICUs) has been found to be 13 - 44%. We chose to study the incidence, risk factors and transfusion requirements of thrombocytopenia in tertiary care ICUs in northern India. Objective. To study the incidence and risk factors of thrombocytopenia in a mixed ICU. Methods. This prospective observational 6-month cohort study was conducted in two 22-bedded medical-surgical ICUs. Patients aged 18 years or older with an ICU stay of at least 2 days were included. Results. Thrombocytopenia (<150 000/dL) occurred in 190 (38%) of the 500 patients studied. Thrombocytopenia was present on admission in 41 (8%) patients. Of the remaining patients, 149 (32%) developed new-onset thrombocytopenia (NOT) – thrombocytopenia developing in patients with platelet count more than 150 000/U on admission – during ICU stay. Incidence and prevalence were 30% and 38%, respectively. ICU mortality was 13%. Thrombocytopenia was commonly associated with sepsis, disseminated intravascular coagulation, heparin and certain antibiotics. Cause could not be established in 10 patients. Underlying coronary artery disease and sepsis correlated with thrombocytopenia. Mortality was higher in patients with NOT (15.4 v. 8.7%, p=0.003). Compared with non-thrombocytopenic patients, patients with NOT required more blood product transfusions (57.7 v. 38.4%, p=0.000) and mechanical ventilation (23.5 v. 13.5%, p=0.008). No difference was observed in length of hospital stay and bleeding risk between the two groups. Conclusion. We found incidence and prevalence of thrombocytopenia in the ICU comparable with internationally reported figures. NOT was associated with higher mortality and morbidity and may be considered as a marker of disease severity.

Mechanisms and etiologies of thrombocytopenia in the intensive care unit: impact of extensive investigations.

BackgroundThrombocytopenia is common in the intensive care unit. Potential mechanisms and etiologies behind this phenomenon are multiple and often entangled. We assessed the effect of a systematic approach, using routinely available tests, on the proportion of patients in whom the mechanism (primary objective) and etiology (secondary objective) of thrombocytopenia in a mixed intensive care unit (ICU) could be identified.MethodsBefore-and-after study of all patients with thrombocytopenia was used. ‘Before’ group had no intervention. New standard operating procedures for thrombocytopenia management were introduced. In the ‘After’ group, bone marrow aspiration; determination of fibrinogen dosage, prothrombin time, factor V, D-dimers; assay of fibrin monomers, ferritin, triglycerides, lactic acid dehydrogenase, aspartate transaminase, alanine aminotransferase, vitamin B12, folates, reticulocytes, haptoglobin, and bilirubin were performed.ResultsIn the Before group (n = 20), the mechanism (central, peripheral, or mixed) was identified in 10 % versus 83% in After group (n = 23) (p < 0.001) (48% peripheral, 35% mixed). Before intervention, ≥1 etiology was identified in 15% versus 95.7% in the After group (p < 0.001).ConclusionsSystematic and extensive investigation using routine tests highlights the mechanisms and etiology of thrombocytopenia in most cases.

The Incidence, Causes, and Prognostic Significance of New-Onset Thrombocytopenia in Intensive Care Units: A Prospective Cohort Study in a Korean Hospital

This study was designed to investigate the incidence, causes, and outcomes of new-onset thrombocytopenia (NOT) in Korean intensive care units (ICUs). A prospective cohort study was conducted in medical ICUs of Samsung Medical Center between August 2010 and February 2011. All newly admitted patients were included if they stayed in the ICU for more than 48 hr and did not have thrombocytopenia upon admission. A total of 186 patients were included. NOT developed in 37.1%. Most common cause of NOT was sepsis with disseminated intravascular coagulation (66.7%), followed by drug-induced thrombocytopenia (18.8%), and heparin-induced thrombocytopenia (2.9%). IgG-specific antibody to platelet factor 4/heparin was positive in 2.4% among patients treated with heparin, and thrombosis occurred in two patients. Twenty eight-day mortality was higher in patients that developed NOT compared to those that did not develop NOT (39.1% vs 12%, P < 0.001). NOT increased the odds ratio of 28-day mortality and was an independent risk factor for mortality (OR 3.52; 95% CI 1.32-9.38; P = 0.012). In conclusion, NOT is common and is an independent risk factor for mortality in Korean ICU patients. Therefore, clinicians should make every effort to correct the causes of NOT.

Management of thrombocytopenia in the ICU (pregnancy excluded)

Thrombocytopenia is a very frequent disorder in the intensive care unit. Many etiologies should be searched, and therapeutic approaches differ according to these different causes. However, no guideline exists regarding optimum practices for these situations in critically ill patients. We present recommendations for the management of thrombocytopenia in intensive care unit, excluding pregnancy, developed by an expert group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF), the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP) and of the Haemostasis and Thrombosis Study Group (GEHT) of the French Society of Haematology (SFH). The recommendations cover six fields of application: definition, epidemiology, and prognosis; diagnostic approach; therapeutic aspects; thrombocytopenia and sepsis; iatrogenic thrombocytopenia, with a special focus on heparin-induced thrombocytopenia; and thrombotic microangiopathy.

Thrombocytopenia in intensive care unit: is it related to acquired pneumonia?

One of the most common infections in mechanically ventilated patients in the intensive care unit is acquired pneumonia, which has a considerable mortality and morbidity. Low platelet count is considered one of the most common laboratory abnormal finding in ICU, and in this study we are trying to correlate it with ICU acquired pneumonia (ICUAP). We reviewed the data of 41 mechanically ventilated ICU patients, including the date of ICUAP, platelet count on admission, etiologic factors and pathogens, the nadir value within seven days before and after the date of ICUAP, development of low platelets (platelets

Risk factors of mortality in critically ill patients with thrombocytopenia

Determine predictive factors of intensive care mortality in thrombocytopenic patients. Retrospective study. Data including the last 100 patients hospitalised in intensive care unit during period from March 2002 to January 2003 and having presented, at least one time, a platelet count <150 x 10(9)/l. Comparison between patients was realized according to the definitive issue (death or discharge from intensive care). Incidence of thrombocytopenia was 27%. Mortality rate was 53%. Thrombocytopenia in admission was noted in 44% of the patients. IGS II score (OR = 1.05 and p = 0.014), sepsis (OR = 34.2 and p = 0.002) or hepatic dysfunction cases (OR = 42.5 and p = 0.026) were predictive factors of death in intensive care unit when thrombocytopenia occurred. Our results concerning prognostic value of thrombocytopenia in intensive care unit are partly similar to those of literature with a surmortality associated to thrombocytopenia related to sepsis and hepatic dysfunction.