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Thrombocytopenia and ThromboprophylaxisThromboprophylaxis With Thrombocytopenia: A Difficult Combination? FREE TO VIEW

Jecko Thachil, MD
Author and Funding Information

From the Department of Haematology, Manchester Royal Infirmary.

Correspondence to: Jecko Thachil, MD, Department of Haematology, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, England; e-mail: jecko.thachil@cmft.nhs.uk


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(6):1979. doi:10.1378/chest.13-1808
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To the Editor:

In a large, multicenter study of thrombocytopenia in critically ill patients in a recent issue of CHEST (October 2013), Williamson et al1 compared unfractionated heparin and low-molecular-weight heparin for thromboprophylaxis. The authors excluded patients who had moderate to severe thrombocytopenia in these cases. This is unfortunate because we lack a similar study in patients where thromboprophylaxis is administered despite thrombocytopenia, at least not severe (< 30 × 109/L).

Physicians often are reluctant to give anticoagulants to patients with thrombocytopenia because of fear of bleeding, but many protocols and guidelines recommend this approach. However, this practice does not have any evidence base. It is not uncommon for a coagulation specialist to accept a platelet count as low as 30 × 109/L (even 20 × 109/L) for thromboprophylaxis, reasoning that bleeding in patients in intensive care is not from isolated thrombocytopenia but from other related factors, such as endothelial dysfunction, which causes vascular leakage.

Significantly lower ADAMTS13 activity (corresponding with increased platelet aggregation) was observed in patients with severe sepsis in intensive care.2 Additionally, in the most serious complication of disseminated intravascular coagulation in these patients, platelet aggregation as demonstrated by low levels of ADAMTS13 enzyme was observed.3 It is relevant to note that platelet aggregation is a common feature of many diseases prevalent in an intensive care population that would predispose patients to thrombosis rather than to bleeding, and thromboprophylaxis is more likely to be helpful. Of interest, the authors identified severe illness, prior surgery, use of inotropes or vasopressors, and renal replacement therapy, all of which are inherently prothrombotic states where thromboprophylaxis would have been more appropriate than excluded.

In summary, thrombocytopenia in patients requiring intensive care may not be a contraindication for thromboprophylaxis in most cases. Indeed, a severe degree of thrombocytopenia may actually signify higher thrombotic risk from platelet aggregation rather than bleeding risk.

References

Williamson DR, Albert M, Heels-Ansdell D, et al. Thrombocytopenia in critically ill patients receiving thromboprophylaxis: frequency, risk factors, and outcomes. Chest. 2013;144(4):1207-1215. [CrossRef] [PubMed]
 
Ono T, Mimuro J, Madoiwa S, et al. Severe secondary deficiency of von Willebrand factor-cleaving protease (ADAMTS13) in patients with sepsis-induced disseminated intravascular coagulation: its correlation with development of renal failure. Blood. 2006;107(2):528-534. [CrossRef] [PubMed]
 
Martin K, Borgel D, Lerolle N, et al. Decreased ADAMTS-13 (a disintegrin-like and metalloprotease with thrombospondin type 1 repeats) is associated with a poor prognosis in sepsis-induced organ failure. Crit Care Med. 2007;35(10):2375-2382. [CrossRef] [PubMed]
 

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References

Williamson DR, Albert M, Heels-Ansdell D, et al. Thrombocytopenia in critically ill patients receiving thromboprophylaxis: frequency, risk factors, and outcomes. Chest. 2013;144(4):1207-1215. [CrossRef] [PubMed]
 
Ono T, Mimuro J, Madoiwa S, et al. Severe secondary deficiency of von Willebrand factor-cleaving protease (ADAMTS13) in patients with sepsis-induced disseminated intravascular coagulation: its correlation with development of renal failure. Blood. 2006;107(2):528-534. [CrossRef] [PubMed]
 
Martin K, Borgel D, Lerolle N, et al. Decreased ADAMTS-13 (a disintegrin-like and metalloprotease with thrombospondin type 1 repeats) is associated with a poor prognosis in sepsis-induced organ failure. Crit Care Med. 2007;35(10):2375-2382. [CrossRef] [PubMed]
 
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