Predictive value of scoring tools in determining heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation

Perfusion ◽  
2019 ◽  
Vol 35 (5) ◽  
pp. 378-383 ◽  
Author(s):  
Jaclyn Sullivan ◽  
Erica Bak ◽  
Mary Jane Sullivan ◽  
Payal K. Gurnani
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Predictive Value ◽  
Medical Center ◽  
High Sensitivity ◽  
Serotonin Release ◽  
Heparin Induced Thrombocytopenia ◽  
Membrane Oxygenation ◽  
Observational Cohort ◽  
Post Cardiopulmonary Bypass ◽  
Scoring Tools

There are currently no scoring tools validated for use in predicting heparin-induced thrombocytopenia in patients receiving extracorporeal membrane oxygenation. This study aims to determine the predictive value of the Warkentin 4T score, Lilo-Le Louet score, and the heparin-induced thrombocytopenia expert probability score in detecting heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation. This was a single center, retrospective, observational cohort study of patients at Rush University Medical Center. Heparin-induced thrombocytopenia–positive patients were defined as those with an optical density greater than or equal to 0.4, consistent with a positive anti-platelet 4 heparin antibody. Out of 39 patients on extracorporeal membrane oxygenation with suspected heparin-induced thrombocytopenia, six (15.4%) were found to be anti-platelet 4–positive. A heparin-induced thrombocytopenia diagnosis was confirmed by serotonin-release assay in two patients (5.1%). The 4T, heparin-induced thrombocytopenia expert probability, and Lilo-Le Louet scoring tools all demonstrated a low positive predictive value (21.4%, 16.7%, and 6.7%, respectively), with the 4T and heparin-induced thrombocytopenia expert probability scores demonstrating the highest specificity (66.7% and 84.8%, respectively) and lowest sensitivity (50% and 16.7%, respectively). The Lilo-Le Louet score had high sensitivity (100%) and low specificity (12.5%) in post-cardiopulmonary bypass patients. Based on the findings of this study, all three scoring tools have limited utility for predicting heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation.

scholarly journals The Clinical Utility of the Heparin Neutralization Assay in the Diagnosis of Heparin-Induced Thrombocytopenia

2017 ◽  
Vol 24 (5) ◽  
pp. 749-754 ◽  
Author(s):  
Gang Zheng ◽  
Michael B. Streiff ◽  
Clifford M. Takemoto ◽  
Jennifer Bynum ◽  
Elise Gelwan ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Predictive Value ◽  
Clinical Utility ◽  
Predictive Accuracy ◽  
High Sensitivity ◽  
Neutralization Assay ◽  
Serotonin Release ◽  
Enzyme Linked Immunosorbent Assay ◽  
Heparin Induced Thrombocytopenia ◽  
Heparin Neutralization

Heparin-induced thrombocytopenia (HIT) remains diagnostically challenging. Immunoassays including PF4/heparin enzyme-linked immunosorbent assay (ELISA) have high sensitivity but low specificity. Whether the heparin neutralization assay (HNA) improves the diagnostic accuracy of the PF4/heparin ELISA for HIT is uncertain. In this study, to assess its clinical utility and evaluate whether it improves the diagnostic accuracy for HIT, we implemented HNA in conjunction with PF4/heparin ELISA over a 1-year period. A total of 1194 patient samples were submitted to the laboratory for testing from December 2015 to November 2016. Heparin neutralization assay alone is a poor predictor for HIT, but it has high negative predictive value (NPV): Cases with %inhibition <70% are always negative for serotonin release assay. It improves the diagnostic positive predictive value (PPV) of ELISA without compromising sensitivity: ELISA optical density (OD) ≥1.4 alone has a sensitivity of 88% (14/16) and a PPV of 61% (14/23); with HNA %inhibition ≥70%, the sensitivity remains 88% (14/16) and PPV is 82% (14/17). 4Ts score correlates with ELISA OD and predicts HIT; the predictive accuracy of 4Ts score is further improved by HNA. Interestingly, HNA %inhibition of <70% correlates with low 4Ts scores. Based on its high NPV, HNA has the potential to facilitate more timely and accurate HIT diagnosis.

scholarly journals Comparison of Two Different ELISA Methods for Heparin-Induced Thrombocytopenia (HIT) Screening on an Automated ELISA Platform

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4935-4935
Author(s):  
Tatsiana Mardovina ◽  
John G Chromczak ◽  
Paul W Riley
Keyword(s):  
Predictive Value ◽  
False Negative ◽  
High Sensitivity ◽  
Clinical Findings ◽  
Serotonin Release ◽  
Laboratory Evaluation ◽  
Platelet Factor ◽  
Heparin Induced Thrombocytopenia ◽  
Negative Results ◽  
4T Score

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an adverse complication of unfractionated and low molecular weight heparin caused by antibodies recognizing platelet factor 4-heparin (PF4/hep) complexes leading to platelet activation. The diagnosis of HIT is based on the combination of the clinical picture, using the 4T score along with screening and confirmatory methods to detect platelet activating anti‐PF4/H antibodies. OBJECTIVES: Performance was evaluated for two enzyme linked immunosorbent assays (ELISAs), 1) Asserachrom HPIA , Diagnostica Stago Inc., Parsippany, NJ, USA and 2) LIFECODES PF4 Enhanced, Immucor, Inc., Norcross, GA, USA for screening-based detection of PF4/hep antibodies. METHODS: ELISA assays were run per manufacturer recommendations and adapted for automation on a Dynex DS2 automated ELISA platform. Performance characteristics of the two immunoassays were assessed, including sensitivity, specificity, concordance with serotonin release assay (SRA), positive predictive value (PPV) and negative predictive value (NPV). 21 samples were used in the study. Results: Both assays, Asserachrom HPIA and LIFECODES PF4 Enhanced demonstrated 100% sensitivity and NPV, confirming both assays' reliability to detect and rule out HIT (see table). The diagnostic specificity was significantly higher for Asserachrom HPIA vs. LIFECODES PF4 Enhanced (77.8% vs 31.6%). Asserachrom HPIA showed fewer false positive results, with PPV of 42.9% for Asserachrom HPIA vs. 13.3% for LIFECODES PF4 Enhanced. No false negative results were found for either assay. Asserachrom HPIA demonstrated 81.0% concordance with SRA, vs. 38.1% for LIFECODES PF4 Enhanced. CONCLUSIONS: HIT is a life-threatening disorder, with diagnosis depending on clinical findings using the 4T score along with laboratory evaluation. Combining the 4T score with PF4/hep antibody screening increases the accuracy of excluding HIT. Our observations indicate Asserachrom HPIA provides results with high sensitivity and specificity, minimizing false positivess, allowing use of alternative anticoagulants more selectively in at risk patients, to potentially improve patient management while minimizing costs. Disclosures Mardovina: Diagnostica Stago, Inc.: Employment. Chromczak:Diagnostica Stago, Inc.: Employment. Riley:Diagnostica Stago, Inc.: Employment.

scholarly journals Heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation and the role of a heparin-bonded circuit

Perfusion ◽  
2019 ◽  
Vol 34 (7) ◽  
pp. 584-589 ◽  
Author(s):  
Dirk Pabst ◽  
Jacqueline B Boone ◽  
Behzad Soleimani ◽  
Christoph E Brehm
Keyword(s):  
Overall Survival ◽  
Platelet Count ◽  
Retrospective Study ◽  
Extracorporeal Membrane Oxygenation ◽  
Serotonin Release ◽  
Single Center ◽  
Heparin Induced Thrombocytopenia ◽  
Membrane Oxygenation ◽  
Release Assay

Background: In patients supported with extracorporeal membrane oxygenation, and who develop heparin-induced thrombocytopenia, there is no clear evidence to support changing to a non-heparin-coated extracorporeal membrane oxygenation circuit. Our goal was to evaluate clinical outcomes of patients who were continued on heparin-bonded circuits despite diagnosed heparin-induced thrombocytopenia. Methods: We completed a single-center retrospective study of all patients who underwent extracorporeal membrane oxygenation support from July 2008 to July 2017 and were tested heparin-induced thrombocytopenia positive while on extracorporeal membrane oxygenation support. After diagnosis of heparin-induced thrombocytopenia, mean platelet count (k/µL) was measured on consecutive days for 14 days. Results: Out of 455 patients, 14 (3.1%) had a diagnosis of heparin-induced thrombocytopenia by serotonin release assay and systemic heparin treatment was discontinued in every case. In total, 11 of the heparin-induced thrombocytopenia patients (78.6%) survived to discharge. The overall survival of all 455 extracorporeal membrane oxygenation patients was 54.1%. Platelets counts after discontinuation of systemic heparin in the heparin-induced thrombocytopenia patients increased from a mean of 59.8 k/µL at time of heparin-induced thrombocytopenia diagnosis to a mean of 280.2 k/µL at 14 days after discontinuation of heparin despite continuation of the heparin-bonded circuit. Platelet count increased in heparin-induced thrombocytopenia patients on extracorporeal membrane oxygenation support after discontinuation of systemic heparin even if maintained on the heparin-bonded circuit. Conclusion: Discontinuation of systemic heparin but continuation of heparin-coated extracorporeal membrane oxygenation circuits appeared to be an appropriate response for our extracorporeal membrane oxygenation–supported patients who developed heparin-induced thrombocytopenia. Survival in this group was not significantly different to those patients on extracorporeal membrane oxygenation without heparin-induced thrombocytopenia. Larger studies should evaluate the safety of heparin-bonded extracorporeal membrane oxygenation systems in heparin-induced thrombocytopenia patients.

scholarly journals Transportation of patients on extracorporeal membrane oxygenation: a tertiary medical center experience and systematic review of the literature

2017 ◽  
Vol 7 (1) ◽  
Author(s):  
Pedro Vitale Mendes ◽  
Cesar de Albuquerque Gallo ◽  
Bruno Adler Maccagnan Pinheiro Besen ◽  
Adriana Sayuri Hirota ◽  
Raquel de Oliveira Nardi ◽  
...  
Keyword(s):  
Systematic Review ◽  
Extracorporeal Membrane Oxygenation ◽  
Medical Center ◽  
Transportation Of Patients ◽  
Review Of The Literature ◽  
Membrane Oxygenation

scholarly journals Predictors of brain infarction in adult patients on extracorporeal membrane oxygenation: an observational cohort study

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Riccardo Iacobelli ◽  
Alexander Fletcher-Sandersjöö ◽  
Caroline Lindblad ◽  
Boris Keselman ◽  
Eric Peter Thelin ◽  
...  
Keyword(s):  
Cohort Study ◽  
Extracorporeal Membrane Oxygenation ◽  
Brain Infarction ◽  
Multivariable Analysis ◽  
Group Analysis ◽  
Observational Cohort Study ◽  
Adult Patients ◽  
Membrane Oxygenation ◽  
Observational Cohort ◽  
Va Ecmo

AbstractNon-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and associated with increased mortality. However, predictors of BI in these patients are poorly understood. The aim of this study was to identify predictors of BI in ECMO-treated adult patients. We conducted an observational cohort study of all adult patients treated with venovenous or venoarterial (VA) ECMO at our center between 2010 and 2018. The primary endpoint was a computed tomography (CT) verified BI. Logistic regression models were employed to identify BI predictors. In total, 275 patients were included, of whom 41 (15%) developed a BI. Pre-ECMO Simplified Acute Physiology Score III, pre-ECMO cardiac arrest, VA ECMO and conversion between ECMO modes were identified as predictors of BI. In the multivariable analysis, VA ECMO demonstrated independent risk association. VA ECMO also remained the independent BI predictor in a sub-group analysis excluding patients who did not undergo a head CT scan during ECMO treatment. The incidence of BI in adult ECMO patients may be higher than previously believed and is independently associated with VA ECMO mode. Larger prospective trials are warranted to validate these findings and ascertain their clinical significance.

Adenosine Infusion Improves Oxygenation in Term Infants With Respiratory Failure

PEDIATRICS ◽  
1996 ◽  
Vol 97 (3) ◽  
pp. 295-300
Author(s):  
G. Ganesh Konduri ◽  
Daisy C. Garcia ◽  
Nadya J. Kazzi ◽  
Seetha Shankaran
Keyword(s):  
Pulmonary Hypertension ◽  
Placebo Group ◽  
Extracorporeal Membrane Oxygenation ◽  
Normal Saline ◽  
Medical Center ◽  
Blood Gases ◽  
Adenosine Infusion ◽  
Term Infants ◽  
Membrane Oxygenation ◽  
Arterial Blood

Objective. Adenosine infusion causes selective pulmonary vasodilation in fetal and neonatal lambs with pulmonary hypertension. We investigated the effects of a continuous infusion of adenosine on oxygenation in term infants with persistent pulmonary hypertension of newborn (PPHN). Design. A randomized, placebo-controlled, masked trial comparing the efficacy of intravenous infusion of adenosine to normal saline infusion over a 24-hour period. Setting. Inborn and outborn level III neonatal intensive care units at a university medical center. Participants. Eighteen term infants with PPHN and arterial postductal Po2 of 60 to 100 Torr on inspired O2 concentration of 100% and optimal hyperventilation (PaCo2 &lt;30 Torr) were enrolled into the study. Study infants were randomly assigned to receive a placebo infusion of normal saline, or adenosine infusion in doses of 25 to 50 µg/kg/min over a 24-hour period. Results. Nine infants each received adenosine or placebo. The two groups did not differ in birth weight, gestational age, or blood gases and ventilator requirements at the time of entry into the study. Four of nine infants in the adenosine group and none of the placebo group had a significant improvement in oxygenation, defined as an increase in postductal PaO2 of ≥20 Torr from preinfusion baseline. The mean PaO2 in the adenosine group increased from 69 ± 19 at baseline to 94 ± 15 during 50 µg/kg/min infusion rate of adenosine and did not change significantly in the placebo group. Arterial blood pressure and heart rate did not change during the study in either group. The need for extracorporeal membrane oxygenation, incidence of bronchopulmonary dysplasia, and mortality were not different in the two groups. Conclusion. Data from this pilot study indicate that adenosine infusion at a dose of 50 µg/kg/min improves PaO2 in infants with PPHN without causing hypotension or tachycardia. Larger trials are needed to determine its effects on mortality and/or need for extracorporeal membrane oxygenation in infants with PPHN.

Abstract 210: Effects of Indication for Veno-Arterial Extracorporeal Membrane Oxygenation on Predictive Value of Save Score

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Marinos Kosmopoulos ◽  
Jason A Bartos ◽  
Demetris Yannopoulos
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Roc Curve ◽  
Predictive Value ◽  
Prediction Models ◽  
External Validation ◽  
Area Under The Curve ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Membrane Oxygenation ◽  
Survival Estimation ◽  
Va Ecmo

Introduction: Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) has emerged as a prominent tool for management of patients with Inability to Wean Off Cardiopulmonary Bypass (IWOCB), extracorporeal cardiopulmonary resuscitation (eCPR) or refractory cardiogenic shock (RCS). The high mortality that is still associated with these diseases urges for the development of reliable prediction models for mortality after cannulation. Survival After VA ECMO (SAVE) Score consists one of the most widely used prediction tools and the only model with external validation. However, its predictive value is still under debate. Hypothesis: Whether VA ECMO indication affects the predictive value of SAVE Score. Methods: 317 patients treated with VA ECMO in a quaternary center (n= 52 for IWOCB, n=179 for eCPR and n=86 for RCS) were retrospectively assessed for differences in SAVE Score and their primary outcomes. The Receiver Operating Characteristic (ROC) curve for SAVE Score and mortality was calculated separately for each VA ECMO indication. Results: The three groups had significant differences in SAVE Score (p<0.01) without significant differences in mortality (p=0.176). ROC Curve calculation indicated significant differences in predictive value of SAVE Score for survival among its different indications. (Area Under the Curve= 81.69% for IWOCB, 53.79% for eCPR and 69.46% for RCS). Conclusion: VA ECMO indication markedly affects the predictive value of SAVE Score. Prediction of primary outcome in IWOCB patients was reliable. On the contrary, routine application for survival estimation in eCPR patients is not supported from our results.

Incidence of Heparin-Induced Thrombocytopenia in Patients With Newly Implanted Mechanical Circulatory Support Devices

2021 ◽  
pp. 106002802110387
Author(s):  
Long To ◽  
Dana Attar ◽  
Brittany Lines ◽  
Melissa McCarty ◽  
Hassan Nemeh ◽  
...  
Keyword(s):  
Negative Predictive Value ◽  
Predictive Value ◽  
Mechanical Circulatory Support ◽  
Serotonin Release ◽  
Circulatory Support ◽  
Anticoagulation Management ◽  
Heparin Induced Thrombocytopenia ◽  
Mechanical Circulatory Support Devices ◽  
High Negative Predictive Value ◽  
Release Assay

Background: Heparin exposure and device-related thrombocytopenia complicate the diagnosis of heparin-induced thrombocytopenia (HIT) in patients receiving mechanical circulatory support (MCS). To improve anticoagulation management for patients with newly implanted MCS devices, incidence of confirmed HIT needs to be further characterized. Objectives: The purpose of this study is to describe the incidence of HIT and clinical utility of the 4Ts score in patients with newly implanted MCS devices. Methods: This is a retrospective analysis of MCS patients receiving unfractionated heparin from 2014 to 2017. The primary end point was incidence of laboratory-confirmed HIT. Strong positive, likely positive, low probability, and negative HIT categories were established based on heparin-induced platelet antibody (HIPA) and serotonin release assay (SRA). Secondary end points include characterization of platelet trends, argatroban use, incidence of HIT among each of the MCS devices, and utility of 4Ts score. Results: A total of 342 patient encounters met inclusion criteria, of which 68 HIPA tests and 25 SRAs were ordered. The incidence of HIT was 0.88% (3/342) and 4.4% (3/68) in patients with suspected HIT. Of the 68 HIPA tests, 3 (4.4%) were considered strong positive and 3 of the 25 SRAs were positive. Median 4Ts score was 4 [2.5-4] and optical density 0.19 [0.11-0.54]. The positive predictive value for the 4Ts score was 0.15 (CI = 0.03-0.46) and negative predictive value, 0.93 (CI = 0.82-0.98). Conclusion and Relevance: HIT occurs infrequently with newly implanted MCS devices. The 4Ts score appears to have a high negative predictive value for ruling out HIT.

Sign in / Sign up

Export Citation Format

Share Document