title: Heparin-induced thrombocytopenia in a pediatric patient receiving extracorporeal membrane oxygenation managed with argatroban.
abstract: BACKGROUND
  Heparin-induced thrombocytopenia (HIT) is rare in the pediatric population, with a majority occurring in the pediatric intensive care unit setting. All cases reported to date have been associated with the use of unfractionated heparin. Because unfractionated heparin is the anticoagulant of choice for extracorporeal membrane oxygenation (ECMO) and other extracorporeal therapies, the development of HIT in these patients can be devastating, making management problematic. We report a case of HIT type II with evidence of small-vessel arterial thrombosis in a 17-month-old boy receiving ECMO and continuous renal replacement therapy successfully treated with argatroban.
  
  
  METHODS
  The patient was a 17-month-old boy with severe hypercapnic and hypoxemic respiratory failure secondary to asthma and mucus plugging that failed conventional and unconventional ventilation. Venovenous ECMO was initiated, and within 24 hrs, there was a precipitous decrease in the platelet count, with the development of cutaneous ischemia involving his lower limbs. Argatroban was started and the child maintained on ECMO and continuous renal replacement therapy, with resolution of the cutaneous ischemia and recovery of the platelet count. Heparin-associated antibodies were positive.
  
  
  CONCLUSIONS
  HIT is rare in the pediatric population. Recognition of HIT is vital because withdrawal of heparin is the first and most important therapy. For patients receiving ECMO or continuous renal replacement therapy who develop HIT, synthetic thrombin inhibitors have been reported as an alternative. However, little information on their use in extracorporeal life support has been published, particularly in the pediatric population.
  
  
  CONCLUSIONS
  This report documents a pediatric case of HIT type II successfully treated with argatroban, allowing continuation of the ECMO and continuous renal replacement therapy therapy, with resolution of the cutaneous ischemia and thrombocytopenia.
authors.affiliation: Extracorporeal Life Support Program, Critical Care Medicine Division, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
authors.forename: L Keith
authors.initials: LK
authors.lastname: Scott
authors.forename: Laurie R
authors.initials: LR
authors.lastname: Grier
authors.forename: Steven A
authors.initials: SA
authors.lastname: Conrad