Journal of Critical Care
Volume 25, Issue 2 , Pages 287-293 , June 2010

The 4Ts scoring system for heparin-induced thrombocytopenia in medical-surgical intensive care unit patients

  • Mark Andrew Crowther, MD, MSc

      Affiliations

    • Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario Canada
    • Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario Canada
    • Corresponding Author InformationCorresponding author. St. Joseph's Hospital, Hamilton, Ontario, Canada L8N 4A6. Tel.: +1 905 521 6024; fax: + 1 905 540 6568.
    • ,
  • Deborah J. Cook, MD, MSc

      Affiliations

    • Department of Medicine, McMaster University, Hamilton, Ontario Canada
    • ,
  • Martin Albert, MD

      Affiliations

    • Pharmacy Department (DW) and Department of Medicine (MA,YS,SL), Université de Montréal, Montréal, Quebec, Canada
    • ,
  • David Williamson, MD

      Affiliations

    • Pharmacy Department (DW) and Department of Medicine (MA,YS,SL), Université de Montréal, Montréal, Quebec, Canada
    • ,
  • Maureen Meade, MD, MSc

      Affiliations

    • Department of Medicine, McMaster University, Hamilton, Ontario Canada
    • Department of Clinical Epidemiology and Biostatisitics, McMaster University, Hamilton, Ontario Canada
    • ,
  • John Granton, MD

      Affiliations

    • Department of Medicine, University of Toronto, Toronto, Canada
    • ,
  • Yoanna Skrobik, MD

      Affiliations

    • Pharmacy Department (DW) and Department of Medicine (MA,YS,SL), Université de Montréal, Montréal, Quebec, Canada
    • ,
  • Stephan Langevin, MD

      Affiliations

    • Department of Medicine, Laval University, Quebec, Canada
    • ,
  • Sangeeta Mehta, MD

      Affiliations

    • Department of Medicine, University of Toronto, Toronto, Canada
    • ,
  • Paul Hebert, MD

      Affiliations

    • Department of Medicine, University of Ottawa, Ottawa, Ontario Canada
    • ,
  • Gordon H. Guyatt, MD

      Affiliations

    • Department of Medicine, McMaster University, Hamilton, Ontario Canada
    • Department of Clinical Epidemiology and Biostatisitics, McMaster University, Hamilton, Ontario Canada
    • ,
  • William Geerts, MD

      Affiliations

    • Department of Medicine, University of Toronto, Toronto, Canada
    • ,
  • Christian Rabbat, MD

      Affiliations

    • Department of Medicine, McMaster University, Hamilton, Ontario Canada
    • ,
  • James Douketis, MD

      Affiliations

    • Department of Medicine, McMaster University, Hamilton, Ontario Canada
    • ,
  • Nicole Zytaruk, RN

      Affiliations

    • Department of Medicine, McMaster University, Hamilton, Ontario Canada
    • ,
  • Joanne Sheppard

      Affiliations

    • Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario Canada
    • ,
  • Andreas Greinacher, MD

      Affiliations

    • Department of Immunology and Transfusion Medicine, Ernst-Moritz-Arndt-University-Greifswald, Greifswald, Germany
    • ,
  • Theodore E. Warkentin, MD

      Affiliations

    • Department of Medicine, McMaster University, Hamilton, Ontario Canada
    • Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario Canada
    • ,
  • For the Canadian Critical Care Trials Group

References 

  1. Crowther MA, Cook DJ, Meade MO, Griffith LE, Guyatt GH, Arnold DM, et al. Thrombocytopenia in medical-surgical critically ill patients: prevalence, incidence, and risk factors. J Crit Care. 2005;20(4):348–353
  2. Warkentin TE, Sheppard JA, Moore JC, Moore KM, Sigouin CS, Kelton JG. Laboratory testing for the antibodies that cause heparin-induced thrombocytopenia: how much class do we need?. J Lab Clin Med. 2005;146(6):341–346
  3. Greinacher A, Juhl D, Strobel U, Wessel A, Lubenow N, Selleng K, et al. Heparin-induced thrombocytopenia: a prospective study on the incidence, platelet-activating capacity and clinical significance of antiplatelet factor 4/heparin antibodies of the IgG, IgM, and IgA classes. J Thromb Haemost. 2007;5(8):1666–1673
  4. Selleng K, Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia in intensive care patients. Crit Care Med. 2007;35(4):1165–1176
  5. Napolitano L, Warkentin TE, Al Mahameed A, Nasraway SA. Heparin-induced thrombocytopenia in the critical care setting:diagnosis and management. Crit Care Med. 2006;34(12):2898–2911
  6. Warkentin TE, Elavathil LJ, Hayward CP, Johnston MA, Russett JI, Kelton JG. The pathogenesis of venous limb gangrene associated with heparin-induced thrombocytopenia. Ann Intern Med. 1997;127(9):804–812
  7. Chan M, Malynn E, Shaz B, Uhl L. Utility of consecutive repeat HIT ELISA testing for heparin-induced thrombocytopenia. Am J Hematol. 2008;83(3):212–217
  8. Warkentin TE, Greinacher A, Koster A, Lincoff AM. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(6 Suppl):340S–380S
  9. Brand PA, Egberts JH, Scholz J, Weiler N, Bein B. Argatroban therapy in patients with hepatic and renal impairment. Eur J Anaesthesiol. 2008;25(4):344–346
  10. Williamson DR, Boulanger I, Tardif M, Albert M, Gregoire G. Argatroban dosing in intensive care patients with acute renal failure and liver dysfunction. Pharmacotherapy. 2004;24(3):409–414
  11. Lobo B, Finch C, Howard A, Minhas S. Fondaparinux for the treatment of patients with acute heparin-induced thrombocytopenia. Thromb Haemost. 2008 Jan;99(1):208–214
  12. Greinacher A, Warkentin TE. The direct thrombin inhibitor hirudin. Thromb Haemost. 2008;99(5):819–829
  13. Lo GK, JUHL D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A. Evaluation of pretest clinical score (4Ts) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost. 2006;4(4):759–765
  14. Cook DJ, Crowther MA, Meade M, Rabbat C, Schiff D, Geerts W, et al. Deep vein thrombosis in medical-surgical ICU patients: prevalence, incidence and risk factors. Crit Care Med. 2005;31(1):48–55
  15. Cook DJ, Rocker G, Meade M, Guyatt G, Geerts W, Anderson D, et al. Prophylaxis of Thromboembolism in Critical Care (PROTECT) Trial: a pilot study. J Crict Care. 2005;20(4):364–372
  16. Cook D, Douketis J, Meade M, Guyatt G, Zytaruk N, Granton J, et al. Venous thromboembolism and bleeding in critically ill patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence, incidence and risk factors. Crit Care. 2008;12(2):R32
  17. Sheridan D, Carter C, Kelton JG. A diagnostic test for heparin-induced thrombocytopenia. Blood. 1986;67(1):27–30
  18. Kelton JG, Sheridan D, Santos A, Smith J, Steeves K, Smith C, et al. Heparin-induced thrombocytopenia: laboratory studies. Blood. 1988;72(3):925–930
  19. Warkentin TE, Hayward CP, Smith CA, Kelly PM, Kelton JG. Determinants of donor platelet variability when testing for heparin-induced thrombocytopenia. J Lab Clin Med. 1992;120:371–379
  20. Warkentin TE, Sheppard JI. Testing for heparin-induced thrombocytopenia (HIT) antibodies. Transfus Med Rev. 2006;[in press]
  21. Warkentin TE, Levine MN, Hirsh J, Horsewood P, Roberts RS, Gent M, et al. Heparin-induced thrombocytopenia in patients treated with low- molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995;332:1330–1335
  22. Horsewood P, Warkentin TE, Hayward CP, Kelton JG. The epitope specificity of heparin-induced thrombocytopenia. Br J Haematol. 1996;95(1):161–167
  23. Visentin GP, Moghaddam M, Beery SE, McFarland JG, Aster RH. Heparin is not required for detection of antibodies associated with heparin-induced thrombocytopenia/thrombosis. J Lab Clin Med. 2001;138(1):22–31
  24. Gettings EM, Brush KA, Van Cott EM, Hurford WE. Outcome of postoperative critically ill patients with heparin-induced thrombocytopenia: an observational retrospective case-control study. Crit Care. 2006;10(6):R161
  25. Verma AK, Levine M, Shalansky SJ, Carter CJ, Kelton JG. Frequency of heparin-induced thrombocytopenia in critical care patients. Pharmacotherapy. 2003;23:745–753
  26. Lo GK, Sigouin CS, Warkentin TE. What is the potential for overdiagnosis of heparin-induced thrombocytopenia?. Am J Hematol. 2007;82(12):1037–1043
  27. Lee DH, Warkentin TE. Frequency of heparin-induced thrombocytopenia. In:  Warkentin TE,  Greinacher A editor. Heparin-induced thrombocytopenia. 4th ed.. New York: Informa Healthcare USA, Inc; 2007;p. 67–116

☆ Conflict of interest statement: Andreas Greinacher is a consultant for Schering-Plough (Whitehouse Station, NJ, USA) (drug Orgaran); Mitsubishi Pharma (Osaka, Japan) (drug Argatroban); and has received speakers honoraria from Schering-Plough, Mitsubishi Pharma, GlaxoSmithKline (Brentford, Middlesex, USA). Dr Rabbat has acted as a consultant to Pfizer Inc. Dr Crowther has received speaker fees from Bayer (Pittsburgh, PA, USA), Boehringer Ingelheim (Ingelheim am Rhein, Germany), Sanofi-Aventis (Bridgewater, NJ, USA), Pfizer (New York, NY), Leo Laboratories (Copenhagen, Denmark), and Organon (Wyeth); has received unrestricted research funds from Leo Laboratories; and has acted as a consultant for Bayer, Boehringer Ingelheim, Sanofi Aventis, Pfizer, Leo Laboratories, and Organon (Schering-Plough). Dr Warkentin has acted as a consultant for Genetic Testing Institute (GTI) Inc (Waukesha, WI, USA); GlaxoSmithKline; Organon Inc (part of Schering-Plough); and Pfizer Canada. He has received speaking fees from GlaxoSmithKline and Sanofi-Aventis. He has provided paid expert testimony on topic of heparin-induced thrombocytopenia and has received research funding from GTI Inc, GlaxoSmithKline, and Organon Inc (part of Schering-Plough).

PII: S0883-9441(10)00006-7

doi: 10.1016/j.jcrc.2009.12.006

Journal of Critical Care
Volume 25, Issue 2 , Pages 287-293 , June 2010

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