Acute Pulmonary Embolism in the Critical Care Unit: Is it different ?

Kenneth V. Leeper Jr. MD Associate Professor of Medicine Division of Pulmonary, Allergy and Critical Care Medicine Emory School of Medicine Atlanta, Georgia

Acute Pulmonary Embolism in the Critical Care Unit: Is it different ?
Case Presentation The incidence of VTE in MICU patients Clinical Clues of VTE in MICU Patients Treatment of VTE in Critically – Ill Patients Impact of current prophylaxis on the prevention of DVT in MICU patients

Acute Pulmonary Embolism in the Critical Care Unit: Is it different ?
Case Presentation The Risk Factor and Incidence of VTE in MICU patients Clinical Clues of VTE in MICU Patients Impact of current prophylaxis on the prevention of DVT in MICU patients

VTE in the ICU – Case Study 58-y-o AAM presented to the MICU with a RML and RLL pneumonia Patient required 100% non-rebreather to maintain O2 saturation > 90% PMH: History of right lower extremity DVT after a long car drive 8 years PTA No medications. no allergies .

10 bands) CXR: RML/RLL pneumonia Initial Rx: ceftriaxone / azithromycin DVT prophylaxis: UFH 5.7 °C. 2/6 SEM. T 38.VTE in the ICU – Case Study Physical exam Weight 112 kg. egophony right posterior chest. BP 142/78 mm Hg. RR 36.000 SC q 8 h .600 (84 PMNs. rest of exam unremarkable O2 sat 91% on 100% NRM Labs: WBC 15.

VTE in the ICU – Case Study MICU course Patient required face mask ventilation with BiPAP for 48 hours then weaned to 50% Venturi mask Day 4: persistent fever with episode of hypotension that responded to fluid therapy Day 5: persistent fever. LE Dopplers obtained: right proximal LE DVT → Rx with weight-based UFH Evening of day 5: episode of hypotension requiring fluids and brief vasopressor therapy → spiral CT scan of the chest obtained . WBC normalizing.

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VTE in the ICU – Case Study
Spiral CT scan of the chest – large bilateral PE Both troponin and BNP elevated Cardiology fellow performed echocardiogram: Severe RV enlargement with RV wall motion abnormalities Management options?

Acute Pulmonary Embolism in the Critical Care Unit: Is it different ?
Case Presentation The Risk Factor and Incidence of VTE in MICU patients Diagnosis of VTE in MICU Patients Impact of current prophylaxis on the prevention of DVT in MICU patients

The Challenge of VTE in Critically Ill Patients
Critically ill patients commonly develop DVT Rate varies from 22 – 60% depending on patient characteristics Methods of prophylaxis are not universal In high-risk groups more effective prophylaxis regimens are needed

Moser KM. burns Sepsis Malignancy and treatment Pharmacologic interventions: sedation. Estrogens . spinal cord injury Increasing age Heart / respiratory failure An autopsy study revealed that 20% of patients who died in the ICU Previous VTE Pregnancy / puerperium had evidence of PE. paralysis Sepsis Mechanical ventilation Immobilization / bed rest. JAMA 1981.Clinical Risk Factors for VTE in Critically Ill Patients Factors before ICU admission Additional factors acquired in ICU Recent surgery Central venous lines Trauma. stroke.

Prevalence of of DVT Among Patients in the MICU Ultrasound in 100 patients admitted to MICU for > 48 hours Incidence of DVT – 33% 61% received DVT prophylaxis Patients with DVT – more likely to have a history prior VTE Hospital MR – 36% w/ DVT vs. et al. JAMA. . 1995. 24% w/o DVT (P = 0.274:335-7.028) Hirsch DR.

all above the knee 18/21 – asymptomatic No differences in age. FEV1. or dyspnea Physical exam not helpful to detect DVT Schonhofer B. Respiration. 1998. ABG. . Kohler D.VTE on Presentation to the ICU Prospective study of 196 COPD patients admitted to a respiratory ICU Ultrasound on day of admission 21/196 (11%) – had DVT.65:175-7.

128.1 Darze ES.2576 .4%) DVT Thromboprophylaxis: 12/18 (66.VTE in Decompensated CHF patients requiring CCU admission 198 patients admitted with severe decompensated CHF over 31 month period 18/198 – acute PE / 8 of 18 (44.al.9 OR 9. VTE OR 26.2580 .7 OR 9. Chest 2005.7%) vs 126/180 (70%) NS Independent risk factors associates with PE Cancer RV abn Prev.et.

al.DVT in medical-surgical critically ill patients: prevalence. incidence and risk factors. Care Med. 2005 33:1565-71 Prospective cohort study closed university affiliated ICU Consecutive patients enrolled. excluded trauma. orthopedic surgery. Crit. Cook D et. pregnancy and life support withdrawn Bilateral LE US within 48 hrs of admission and twice weekly and if DVT was suspected Thromboprophylaxis was protocol directed and universal .

8 Consequences of DVT Longer ICU stay p=0.00 Longer duration on MV Longer hospitalization p .DVT in medical-surgical critically ill patients: prevalence.5 Prevalence of DVT on admission – 2.0 ESRD – HR 3.7% Incidence over the ICU stay – 9. Crit.al. incidence and risk factors.2 Vasopressor use – HR 2. Care Med.7 Platelet transfusions – HR 3. Cook D et. 2005 33:1565-71 261 patients with APII of 25.6% Independent risk factors for DVT Personal or FH of VTE – HR 4.

Critical Care Medicine. 2002. Iregui M. Sherman G. Prentice D.Deep Vein Thrombosis During Prolonged Mechanical Ventilation Despite Prophylaxis Ibrahim EH. Objective: Determine the prevalence of DVT among patients requiring prolonged mechanical ventilation in the ICU . Kollef M. Shannon W.30:771-4.

6%) developed DVT Ibrahim EH.DVT During Prolonged Mechanical Ventilation Despite Prophylaxis Measurements Total of 110 patients requiring mechanical ventilation for > 7 days were enrolled Prophylaxis against DVT employed in 110 patients (100%) 26 patients (23. . Crit Care Med.30:771-4. et al. 2002.

0. 2002.5 vs. . Crit Care Med. et al.30:771-4.DVT During Prolonged Mechanical Ventilation Despite Prophylaxis 20 15 10 5 0 1 2 3 4 Risk factors for DVT Underlying malignancy Renal failure GI disturbances Duration of CVP line Clinical outcomes PE – more common with DVT (11.0%) No difference in LOS or mortality Percent Week DVT detected Ibrahim EH.

2002.9 73. et al. .8 90 80 70 60 50 40 30 20 10 0 UE-DVT LE-DVT UFH SCD 19.30:771-4. Crit Care Med.1 Percent Ibrahim EH.2 26.DVT During Prolonged Mechanical Ventilation Despite Prophylaxis Incidence and Prevention 80.

4 LE DVT and 2 UE DVTs .VTE events on screening US. 2007 50 admissions to the Emory Pulmonary Service 40/50 had screening US of the lower extremities and upper extremities ( if clinically indicated) 6/40 (15%) . VTE – LTAC Study Group Select LTAC ECLH: July 1 2006 – June 13.Prevalence of VTE in and LTAC Setting: Preliminary Data.

. Crit Care Med. 2005.7.1 . 95% CI 1.Vasopressor Administration May Predispose ICU Patients to DVT Multivariable analysis identified vasopressor administration as an independent risk factor (hazard ratio 2.2) for DVT Days in ICU Patients* Vasopressors DVT *Patients (9 of 261) who recevied vasopressors and developed DVT 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 Days in ICU Cook D et al.22:1565.1571.8.

Abstract Chest 2006 Xpress study – large phase 3B 28 day mortality and the relative incidence of VTE in patients treated with drotrecogin alfa (DAA) with or without heparin Dec 2002 – July 2005 Adult pts with high risk for severe sepsis All pts received DAA Study drugs: heparin 5000Usc q 12 hrs. Levy M. enoxaparin 40mg sc qd and placebo Randomization: 1:1:2 Lower extremity US 4 and 6 days .VTE in Severe Sepsis: Incidence of VTE in Severe sepsis treated with Drotrecogin alfa with or without prophylactic heparin.

1% .0% 0. pts on baseline heparin randomized to placebo VTE incidence – 8.6% 5.VTE in Severe Sepsis: Incidence of VTE in Severe sepsis treated with Drotrecogin alfa with or without prophylactic heparin.7% 7. Abstract Chest 2006 1935 patients were enrolled and received DAA and one of the study drugs 959 placebo 976 Heparins ( 498 UFH/478 LMWH) Incidence of VTE Study period heparins placebo pvalue 0-6 days 4.1% 0. Levy M. age > 75. recent surgery.26 Subgroups with highest incidence of VTE: previous VTE.6 0 – 28 days 5.

1998:114.Sources of Thrombi: Central Vein Catheter-Related Thrombi in the ICU Prospectively performed duplex scans just before or within 24 hours after removing the IJ or subclavian CVL in ICU patients 208 lines studied Mean duration was 9 ± 5 days Catheter-related clot – 33% of patients Timsit JF.207-13. Chest. et al. .

What is the embolic potential for UEDVT? PE% .

Sources of Thrombi:HIT Diagnosis Suspect if the platelet count drops below 150. HIPA or ELISA) .000/mm3 while patient receiving UFH or LMWH Suspect if the platelet count drops 50% from pre-heparin baseline levels Suspect if new thrombosis while the patient is receiving UFH or LMWH Suspect if heparin resistance develops Confirm with laboratory test (SRA.

130:681-7. .2%) 14 cases occurred in 113 SC UFH-treated patients (12. 2006. Chest.7%) Levine RL.219 heparin-treated patients had VTE 32 of 386 VTE patients also had HIT Among 32 cases of HIT in 386 VTE patients 17 cases occurred in 129 IV UFH-treated patients (13. et al.Incidence of HIT and VTE After Use of UFH and LMWH Literature review: Identify studies using UFH or LMWH for thromboprophylaxis or treatment in which new or recurrent VTE and serologically confirmed HIT 10 studies 386 of 6.4%) 1 case occurred in 144 LMWH-treated patients (0.

Acute Pulmonary Embolism in the Critical Care Unit: Is it different ? Case Presentation The Risk Factor and Incidence of VTE in MICU patients Diagnosis of VTE in MICU Patients Impact of current prophylaxis on the prevention of DVT in MICU patients .

Clinical Symptoms and Signs of VTE in MICU Patients Nonspecific Persistent Fever In MV patients. unexplained increase in minute ventilation ET CO2 measurement In MV patients – Paradoxical hypercarbia .

31: 48-55 . Et.Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict DVT in critically ill medical surgical patients Predicting patients who are harboring asymptomatic DVT or PE is a desirable clinical goal Prospective study of 197 patients in a medsurg ICU 6 commercial D-dimer test and markers of hypercoagulabilty Conclusion: None of the test patients at risk for DVT Crowther MA.al intensive Care Med 2005.

) . Suspect VTE Clinically stable + normal renal function or ESRD: Spiral CT scan of the chest and either CTV or Doppler US the extremities Clinically stable + ongoing renal insufficency: US of the extremities and TTE/TEE Clinically unstable – unable to move off the unit: US of the extremities and TEE ( esp in the MV pt.Which diagnostic tests for VTE evaluation in the ICU patients? Depends upon clinical stability and renal function.

Acute Pulmonary Embolism in the Critical Care Unit: Is it different ? Case Presentation The Risk Factor and Incidence of VTE in MICU patients Diagnosis of VTE in MICU Patients Impact of current prophylaxis on the prevention of DVT in MICU patients .

Chest.126(3 suppl):338S-400S. . most should receive thromboprophylaxis (grade 1A) Low-molecular-weight heparin (LMWH) Low-dose unfractionated heparin (UFH) (q 12 h or q 8 h) ACCP=American College of Chest Physicians Geerts WH et al.ACCP Recommendations 2004 Critical Care Unit Upon admission to a critical care unit. 2004. all patients should be assessed for their risk of DVT/PE Accordingly.

1:95-104 .Initial Prophylaxis Considerations in Critical Care Patients High bleeding risk Mechanical prophylaxis Delay prophylaxis until high bleeding risk resolves Screen for proximal DVT with DUS in high risk patients Usual bleeding risk Low-dose UFH 5.000 U q 8 h LMWH Combine AC and mechanical prophylaxis Geerts W. 2002. J Crit Care. et al.

11% 28 v. n 119 791 223 Type of ICU Patient General ICU Medical ICU Ventilated COPD Medical ICU Med-Surg ICU Method of Detection Control Active Tx UFH 5000 bid UFH 5000 bid Nadroparin 65 U/kg SC q day Enoxapar. 13% 31 v.7.Trials for VTE prophylaxis in the ICU Study/Year Cade 1982 Kapoor 1999abst Fraisse 2000 Goldhaber 2000abst Cook Size. 15% FUT for 14d Placebo DUS on q 3 days Venograph by day 21 DUS on day 3. 300 mg bid Dalteparin 5000 IU/d Results 29 v. 16% NR v NR .10 CUS Placebo Placebo 325 129 UFH 5000 bid UFH 5000 bid 13 v.

Do mechanical prophylaxis devices reduce DVT incidence in ICU patients? Stimulates endogenous fibrinolysis production of plasminogen activator More efficacious in moderate risk postoperative patients Robust data lacking efficacy in medical ICU patients .

00 per day equipment rental Bleeding risk: NONE .INTERMITTENT PNEUMATIC COMPRESSION Indication: contraindication to anticoagulation Evidence: limited Compliance: poor Cost: $56.

al. SCDs + LDUH – 62% reduction in post-surgical PE ( 1.5% vs 4%) * Nonhemorrhagic Stroke – 40 fold reduction risk of DVT** •*Ramos R.al. Chest 1996 •**Kamran SL. Neurology 1998 .551 consecutive cardiac surgical patients.Combination Strategy Randomized trial of 2. Et. et.

1%) Group B – 9 DVTs ( 8.4%) and 2 PEs (2.Role of Mechanical prophylaxis in preventing DVT in high risk populations: Stannard JP.7%) no PEs Group A – 11 large and occulsive clots (11. 261 -266 224 patients with blunt trauma – prospective study investigating VTE Group A (97) – enoxaparin SQ BID starting 24 – 48 hrs after blunt trauma Group B (103) – pulsatile foot pumps at time of admission and delayed enoxaparin Group A – 13 DVTs (13. J Bone and Joint Surgery 2006: 88.9%) p=0.3%) Group B – 3 large and occlussive clots (2.025 .

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Prevention of VTE in the Obese MICU Patient Anti-Xa levels with fixed dose LMWH regimens correlate negatively with BMI in critically ill patients (Priglinger U 2003) Standard prophylactic regimens are twice as likely to fail in orthopedic patients with BMI >32 BMI > 32 VTE rate 32% vs 17% BMI <32 –Samama MM. 1995 Nonrandomized studies in bariatric surgery patients suggest a decrease DVT rates with enoxaparin 40mg sq BID vs 30mg BID – Scholten DJ. 2002 No data to guide adjustments in therapy Options include: Use standard dose Empiric dose adjustments Add mechanical measures .

.MICU Patient with Renal Insufficiency: VTE Prevention Delayed renal clearance of LMWHs and Fondaparinux very problematic Lack of outcomes based data FDA approved enoxaparin 30 mg sq qd for patients with CCL <30 ml/min based on pharmacokinetic data alone Additional options UFU and/or mechanical devices.

5 IU/ml BE CAREFUL: consider empiric reduction of enoxaparin or use mechanical devices alone in elderly with low body weight < 45 kg or marginal creatinine clearane .Elderly Patient in the MICU Mahe et.4 levels >0. monitored anti-Xa levels in 68 consecutive hospitalized elderly patients (mean age 82) receiving enoxaparin 40mg sq qd for prophylaxis Day 2 >50% had levels >0.5IU/ml ( optimal range) Day 8 69.al.

Patients with Prior HIT Treatment of HIT is a thrombin inhibitor bridge to warfarin therapy Optimal future VTE prevention strategies are lacking in this population Avoid UFH and LMWH DTIs are impractical for primary VTE prophylaxis Fondaparinux – indirect anti-Xa inhibitor may be a promising prophylaxis scheme Fondaparinux does not bind platelet factor 4 No apparent in vitro cross reactivity to HIT antibiodies .

Heinz G Critical Care Medicine. Joukhadar C. Berger R. Spitzauer S. Hülsmann M. Pabinger I. Geppert A. Graf S.Prophylactic Anticoagulation With Enoxaparin: Is the Subcutaneous Route Appropriate in the Critically Ill? Priglinger U. Delle Karth G. 2003. 31:1405-409 Objective: Determine anti-Xa activities in critically ill patients and in noncritically ill patients receiving prophylactic doses of subcutaneous enoxaparin .

P = 0. .001 ICU patients (n = 16) General ward (n = 13) Anti-Xa activity (U/mL) 0. P = 0. 31:1405-409. Crit Care Med. 2003.4 0.8 F over time = 39. et al.001 F between groups = 23.6 0.0 0.Prophylactic Anticoagulation With Enoxaparin: Is the SC Route Appropriate in the Critically Ill? 1.2 0 0 3 6 Time (hours) 9 12 Priglinger U.

P = 0.Prophylactic Anticoagulation With Enoxaparin: Is the SC Route Appropriate in the Critically Ill? 1.8 Anti-Xa activity (U/mL) 0.6 0. .5.001 F between groups = 1.2 ICU patients (n = 16) General ward (n = 13) 0 24 48 Time (hours) 72 96 120 Priglinger U. Crit Care Med.4 0.2 0 F over time = 43.2. P = 0.0 0. et al. 31:1405-409. 2003.

2003.Prophylactic Anticoagulation With Enoxaparin: Is the SC Route Appropriate in the Critically Ill? Conclusion: Critically ill patients with normal renal function demonstrated significantly lower anti-Xa levels in response to a single daily dose of subcutaneous enoxaparin when compared with medical patients in the normal ward. Priglinger U. et al. 31:1405-409. . Crit Care Med.

. Leeper. GA. A. Velasquez.H. Emory Healthcare. Atlanta. Hypothesis: Current dosing guidelines for VTE prophylaxis may be inadequate in MICU patients who often have altered pharmacokinetic and pharmacodynamic profiles. K. Shaz. observational study.THE EVALUATION OF VENOUS THROMBOEMBOLISM PROPHYLAXIS THERAPY IN A MEDICAL INTENSIVE CARE UNIT VIA THERAPEUTIC DRUG MONITORING . Heparin and low molecular weight heparins (LMWHs) are pharmacological agents used for prevention of VTE. Introduction : Patients in a medical intensive care unit (MICU) are often at very high risk of developing a venous thromboembolism (VTE). Patel. Anti-Xa levels were drawn at least after 4 doses and 4 hours after subcutaneous administration of medication. D. Pulmonary/Critical Care Medicine. Methods : Patients in the MICU receiving VTE prophylaxis with heparin or LMWH had anti-Xa levels monitored in this prospective.

Weight based dosing of heparin should be considered in future patients. Pulmonary/Critical Care Medicine. Leeper. Future studies should evaluate whether subtherapeutic VTE prophylaxis correlates to a higher incidence of VTE compared to therapeutic dosing. . ICU length of stay and days on the ventilator were longer in patients with non-therapeutic anti-Xa levels. Patel. 50 patients had anti-Xa levels monitored.H. D.THE EVALUATION OF VENOUS THROMBOEMBOLISM PROPHYLAXIS THERAPY IN A MEDICAL INTENSIVE CARE UNIT VIA THERAPEUTIC DRUG MONITORING . Emory Healthcare. Among the 50 patients. Conclusions : Current dosing guidelines of heparin for VTE prophylaxis are inadequate in an MICU setting. The LMWHs may have a better predictability. Atlanta. 12 patients (24%) acheived appropriate anti-Xa levels compared to 38 patients (76%) who were nontherapeutic. K. Results : From March 2007 to August 2007. 8 patients (67%) were receiving LMWH. GA. A. Shaz. Among those in the appropriate range. Velasquez.

1998.827 patients in 3 similar CCUs No special compliance intervention Education provided to physicians Education and mandatory computer order entry 38% 62% 97% Levi et al.114(Suppl):392S. .Strategies to Improve Thromboprophylaxis Comparison of strategies among 1. Chest.

5 mg SQ daily Intermittent compression devices Utilization of prophylaxis is inadequate AND or prophylactic regimens may be inadequate New sources of thrombi – HIT induced thrombosis We can do better !!! .Summary Critically ill patients are at high risk of VTE Low rate of clinical diagnosis Prevalence 10 – 60% Predominant test: ultrasound Prophylaxis UFH 5000 U q 8 h LMWH (enoxaparin 40 mg SC/d) Dalteparin 5000 IU SC daily Fondaparinux 2.

Georgia . Allergy and Critical Care Medicine Emory School of Medicine Atlanta. Leeper Jr.Treatment of VTE in the Critical Care Patients Kenneth V. MD Associate Professor of Medicine Division of Pulmonary.

2002. heparin initially for at least 5 days Overlap with oral anticoagulation for at least 4-5 days Discontinue LMWH/UFH on day 5/6 if INR is therapeutic for 2 consecutive days LMWH preferred over UFH Massive pulmonary embolism/severe iliofemoral thrombosis: LMWH/UFH for approximately 10 days LMWH: dose based on manufacturers’ instructions UFH: adjust to correspond to a plasma heparin level of 0. LMWH/UFH or adjusted-dose s.2-0.28(Suppl 3):3-11.v.3-0.4 IU/mL (amidolytic anti-Xa assay) Grade 2B Grade 1C Grade 1C+ .4 IU/mL (protamine sulfate) or 0. Sem Thromb & Hemost.Summary of Sixth American College of Chest Physicians (ACCP) Guidelines for Antithrombotic Therapy in the Treatment of Venous Thromboembolism Recommendations Grade 1A Guidelines for Treatment i.c. .Turpie AGG et al.

VAP.6C Differential Dx: 1. LE dopplers Positive for DVT right deep femoral Treatment: No contraindications to heparin therapy: Treat with UFU or LMWH .o man with a history of alcoholism admitted to the MICU in respiratory failure secondary to pneumonia.Slow resolution of the pneumonia.56 y. He is on no vasopressors and renal function is normal and on heparin 5000 units sq BID On day 5 his WBC count is normal but temperature is 38. 3 Possible DVT Evaulation: Mini BAL negative. 2.

6-1.5 IU/ml 0.1 IU/ml 1.1 – 0.Therapeutic peak anti-Xa levels with LMWHs for the treatment of VTE Enoxaparin 1mg/kg q 12 hrs Enoxaparin 1.85 – 1.6 IU/ml Chromogenic anti-Xa level assay drawn 4 hours after the subq dose .4 – 1.0 IU/ml 0.0 IU/ml 0.0IU/ml 1.5mg/kg qd Tinzaparin 175 IU/kg qd Dalteparin 100IU/kg q 12 hrs Dalteparin 200 IU/kg qd Prophylaxis 0.0 –1.0-2.

o woman with diabetes and ESRD. On MICU day 4 she developes a sudden onset of dyspnea . The patient is placed on SCDs for DVT prophylaxis. Evaluation: Spiral CT scan of the chest – large right main pulmonary embolism. TEE – Moderate RV dilation with parodoxical septal shift. admitted to the MICU with MRSA bacteriemia.hypoxemia and SPB of 98 mmHg .This is a 62 y. LE dopplers – Right popliteal DVT. Management Hypotension responded to fluid therapy Pharmacologic management and other options UFH infusion UFH infusion and retrieveable filter Thrombolysis Pulmonary embolectomy .

abdominal tenderness and distention. 9th post-op day fever to 39C and hypotension with BP 90/70. Fifth post – op day prophylactic therapy with enoxaparin was started.o man underwent coronary artery bypass surgery complicated by a hemopericardium. requiring pericardial window drainage.51 y. now – 40 X109 cells cells/l . Admission platelet count – 182X109 cells/l post-op day 3.

requiring pericardial window drainage Differential Diagnosis: Sepsis with DIC Management Moved to the ICU Antibiotics and fluids started DIC profile negative Serum cortisol ordered Argatroban started HIT – ELISA for heparin – induced PF 4 antibodies strongly positive CTscan of abdomen – revealed bilateral adrenal necrosis Serum cortisol < 1ug/ml Patient improved – discharged on adrenal replacement and warfarin .51 y.o man underwent coronary artery bypass surgery complicated by a hemopericardium.

51 y. requiring pericardial window drainage: Comment If there is a moderate suspicion of HIT .o man underwent coronary artery bypass surgery complicated by a hemopericardium.treat with DTI Large amount of heparin during bypass was sensitizing along with the LMWH. When heparin was stopped greatest risk period for new thromboembolic complications Adrenal necrosis is a microthrombotic lesion with secondary necrosis and hemorrhage Diagnosis: HIT with acute adrenal crisis .

et al.219 heparin-treated patients had VTE 32 of 386 VTE patients also had HIT Among 32 cases of HIT in 386 VTE patients 17 cases occurred in 129 IV UFH-treated patients (13. 2006. Chest.Incidence of HIT and VTE After Use of UFH and LMWH Literature review: Identify studies using UFH or LMWH for thromboprophylaxis or treatment in which new or recurrent VTE and serologically confirmed HIT 10 studies 386 of 6.7%) Levine RL.130:681-7. .2%) 14 cases occurred in 113 SC UFH-treated patients (12.4%) 1 case occurred in 144 LMWH-treated patients (0.

systemic rx to post IV UFU bolus No apparent Suspected thrombosis not yet proven Possible Platelet count <4 days without recent exposure None Other causes of thrombocytopenia Definite . skin necrosis. Warkentenin and Heddle.Pretest Scoring System for HIT. Curr Hematol Rep 2003 4Ts Thrombocytopenia 2 Points Platelet count >50% and platelet nadir >20 X109/L 1 point Platelet count> 3050% 0 points Platelet count < 30% Timing of platelet count decrease Thrombosis or other sequelae Clear onset between Consistent with days 5 -10 or platelet immunization but dec with one day unclear history New thrombosis.

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