title: Overtreatment of Heparin-Induced Thrombocytopenia in the Surgical ICU.
abstract: OBJECTIVE
  Recent studies reveal a high occurrence of overdiagnosis of heparin-induced thrombocytopenia in surgical patients with critical illness. The optimal criteria for diagnosis of heparin-induced thrombocytopenia remain unclear, contributing to unnecessary treatment. We reviewed patients who were admitted to surgical ICUs and were suspected of heparin-induced thrombocytopenia to identify how often patients were correctly treated.
  
  
  METHODS
  In this clinical prospective study, data were collected including age, sex, antiplatelet factor 4/heparin enzyme-linked immunosorbent assay, serotonin release assay, and Warkentin 4Ts scores. Heparin-induced thrombocytopenia-positive patients were defined as those with both positive antiplatelet factor 4/heparin enzyme-linked immunosorbent assay (optical density, ≥ 0.40) and positive serotonin release assay results.
  
  
  METHODS
  Urban tertiary medical center.
  
  
  METHODS
  Patients admitted to the surgical and cardiac ICU who were presumed to have heparin-induced thrombocytopenia and underwent antiplatelet factor 4/heparin enzyme-linked immunosorbent assay and serotonin release assay testing between January 1, 2011, and August 1, 2014.
  
  
  METHODS
  None.
  
  
  RESULTS
  A total of 135 patients had 4Ts, antiplatelet factor 4/heparin enzyme-linked immunosorbent assay, and serotonin release assay scores. A total of 11 patients (8.1%) had positive serotonin release assay and 80 patients had positive antiplatelet factor 4/heparin enzyme-linked immunosorbent assay; 10 patients were identified as heparin-induced thrombocytopenia positive. Positive serotonin release assay was noted in nine of 11 patients (81.8%) with antiplatelet factor 4/heparin enzyme-linked immunosorbent assay optical density greater than or equal to 2.0, compared with one of 22 patients (4.5%) with optical density values of 0.85-1.99, and one of 102 patients (1.0%) with optical density values of 0-0.84. Out of 135 patients, 29 patients (21.5%) received treatment with argatroban, lepirudin, or fondaparinux: 10 of 10 heparin-induced thrombocytopenia-positive patients (100%) compared with 19 of 125 heparin-induced thrombocytopenia-negative patients (15%).
  
  
  CONCLUSIONS
  Overtreatment of heparin-induced thrombocytopenia in the surgical ICU continues even with recent increased caution encouraging a higher antiplatelet factor 4/heparin enzyme-linked immunosorbent assay optical density threshold before initiating treatment. More stringent criteria should be used to determine when to order serologic testing and when the results of such testing should prompt a change in anticoagulant treatment. If antiplatelet factor 4/heparin enzyme-linked immunosorbent assay is used to consider immediate treatment, an optical density greater than or equal to 2.0 may be a more appropriate threshold.
authors: 1Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA. 2Division of Coagulation Service, Department of Hematology, Cedars-Sinai Medical Center, Los Angeles, CA. 3Center for Neurosurgical Outcomes Research, Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors: Megan Y
authors: MY
authors: Harada
authors: David M
authors: DM
authors: Hoang
authors: Andrea A
authors: AA
authors: Zaw
authors: Jason S
authors: JS
authors: Murry
authors: Oksana
authors: O
authors: Volod
authors: Beatrice J
authors: BJ
authors: Sun
authors: Miriam
authors: M
authors: Nuño
authors: Russell
authors: R
authors: Mason
authors: Daniel R
authors: DR
authors: Margulies
authors: Eric J
authors: EJ
authors: Ley
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000906:Antibodies / Q000032:analysis; D000925:Anticoagulants / Q000009:adverse effects*; D000991:Antithrombins / Q000627:therapeutic use; D001120:Arginine / Q000031:analogs & derivatives; D004797:Enzyme-Linked Immunosorbent Assay; D005260:Female; D000077425:Fondaparinux; D006493:Heparin / Q000009:adverse effects*; D006629:Hirudins; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D000069342:Medical Overuse / Q000706:statistics & numerical data*; D008875:Middle Aged; D010875:Pipecolic Acids / Q000627:therapeutic use; D010978:Platelet Factor 4 / Q000276:immunology; D011134:Polysaccharides / Q000627:therapeutic use; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000627:therapeutic use; D012701:Serotonin / Q000378:metabolism; D013449:Sulfonamides; D013921:Thrombocytopenia / Q000139:chemically induced* / Q000188:drug therapy*
chemical_list: D000906:Antibodies; D000925:Anticoagulants; D000991:Antithrombins; D006629:Hirudins; D010875:Pipecolic Acids; D011134:Polysaccharides; D011994:Recombinant Proteins; D013449:Sulfonamides; D012701:Serotonin; D010978:Platelet Factor 4; D006493:Heparin; D001120:Arginine; C031942:argatroban; D000077425:Fondaparinux; C083544:lepirudin