Cho Joseph H, Parilla Megan, Treml Angela, Wool Geoffrey D
Department of Pathology, The University of Chicago, Chicago, Illinois.
BloodCenter of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin.
J Clin Apher. 2019 Feb;34(1):64-72. doi: 10.1002/jca.21671. Epub 2018 Nov 8.
Current management of heparin-induced thrombocytopenia (HIT) involves prompt discontinuation of all heparin products and concomitant initiation of a direct thrombin or anti-Xa inhibitor for anticoagulation. In the setting of HIT complicated by an urgent need for cardiopulmonary bypass (CPB), the safety and the efficacy of short-term heparin-based anticoagulation after therapeutic plasma exchange (TPE) have been previously demonstrated. Patients with HIT requiring TPE are frequently on extracorporeal circuits (either CPB, extracorporeal membrane oxygenation [ECMO] or external ventricular assist devices [VADs]). Performing TPE in parallel with these circuits involves additional consideration for circuit size, anticoagulant/citrate management, as well as flow rates, and risk of air embolus. We report a case of a patient with HIT on external biventricular assist device (BiVAD) requiring urgent CPB who experienced thrombotic and hemolytic complications related to anticoagulation management around apheresis line placement for TPE. We also present results from a national survey of academic apheresis services regarding specific practices in managing patients with HIT on extracorporeal circuits who require TPE. In addition, we demonstrate the utility of TPE in patients with HIT on extracorporeal circuits and the risks of this procedure and the need to develop practice guidelines.
目前肝素诱导的血小板减少症（HIT）的管理包括立即停用所有肝素产品，并同时启动直接凝血酶抑制剂或抗Xa抑制剂进行抗凝。在HIT并发急需体外循环（CPB）的情况下，治疗性血浆置换（TPE）后短期基于肝素的抗凝的安全性和有效性此前已得到证实。需要TPE的HIT患者经常使用体外循环设备（CPB、体外膜肺氧合[ECMO]或体外心室辅助装置[VADs]）。在这些循环设备并行进行TPE需要额外考虑循环设备尺寸、抗凝剂/柠檬酸盐管理、流速以及空气栓塞风险。我们报告了一例使用体外双心室辅助装置（BiVAD）的HIT患者，该患者需要紧急CPB，在为TPE放置单采血浆术管路时，经历了与抗凝管理相关的血栓形成和溶血并发症。我们还展示了一项针对学术性单采血浆术服务机构的全国性调查结果，该调查涉及管理需要TPE的体外循环设备上的HIT患者的具体做法。此外，我们证明了TPE在体外循环设备上的HIT患者中的实用性、该操作的风险以及制定实践指南的必要性。
