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Acquired thrombocytopenia — Clinical Guidelines

Overview

Acquired thrombocytopenia refers to a decrease in platelet count occurring secondary to various clinical conditions, often seen in critically ill patients, particularly those requiring extracorporeal membrane oxygenation (ECMO) support. This condition can exacerbate bleeding risks and complicate management, especially in settings involving high shear stress and potential von Willebrand factor (VWF) abnormalities. 2 6

Diagnosis

Clinical Presentation: Bleeding manifestations, often associated with underlying conditions like ECMO support.

Laboratory Tests: Complete blood count (CBC) showing thrombocytopenia, peripheral blood smear for platelet morphology.

Special Considerations: Testing for acquired von Willebrand syndrome (AVWS) in ECMO patients, noting challenges in diagnosis due to altered VWF multimers 2 6.

Management

First-Line Treatments: Address underlying cause (e.g., stopping ECMO if feasible, managing DIC).

Platelet Transfusion: Indicated for active bleeding or high-risk procedures 11.

Anticoagulation Management: Careful titration to prevent thrombosis while avoiding excessive bleeding; consider low-dose heparin 8.

Monitoring: Regular platelet counts and coagulation profiles to guide therapy 1 7.

Special Populations

Pediatrics: Higher prevalence of acquired von Willebrand syndrome; tailored diagnostic approaches needed 6.

Comorbidities: Patients with ECMO support may exhibit AVWS, impacting bleeding risk and management strategies 2 6.

Key Recommendations

Diagnose Acquired von Willebrand Syndrome in ECMO Patients: Given the high shear stress leading to VWF abnormalities, consider specific testing for AVWS in ECMO patients to guide bleeding risk assessment 2 6 (Evidence: Moderate).

Use Careful Anticoagulation Strategies: Implement minimal anticoagulation with close monitoring to prevent thrombosis while managing thrombocytopenia 8 (Evidence: Expert opinion).

Evaluate Sedation Practices: Consider the impact of sedation agents on ECMO circuit function; propofol and midazolam have similar effects on oxygenator running time 7 (Evidence: Moderate).

Monitor for Bleeding Complications: Regularly assess for signs of bleeding, especially in patients with disseminated intravascular coagulation (DIC) or those undergoing ECMO 4 (Evidence: Weak).

References

1 Reis T, Ronco C, Soranno DE, Clark W, De Rosa S, Forni LG et al.. Standardization of Nomenclature for the Mechanisms and Materials Utilized for Extracorporeal Blood Purification. Blood purification 2024. link 2 Frere C, Mazzeffi M, Maier CL, Helms J, Steiner ME, Sullenger BA et al.. Acquired von Willebrand syndrome during extracorporeal membrane oxygenation support: a comprehensive review of current evidence: communication from the ISTH SSC on perioperative and critical care thrombosis and hemostasis. Journal of thrombosis and haemostasis : JTH 2024. link 3 Gabarin N, Hack M, Revilla R, Arnold DM, Nazy I. Hematology in the post-COVID era: spotlight on vaccine-induced immune thrombotic thrombocytopenia and a conceptual framework (the 4P's) for anti-PF4 diseases. Expert review of hematology 2024. link 4 Boukobza M, Ehmer C, Baud F, Laissy JP. "Unusual Pattern of Cerebral Microbleeds and Petechial Hemorrhages after Veno-Arterial Extracorporeal Membrane Oxygenation Support. A Report of 2 Cases". Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 2021. link 5 Abulebda K, Hocutt GRNC, Gray BW, Ahmed RA, Slaven JE, Malin S et al.. Development of Validated Checklists to Evaluate Clinical Specialists in Pediatric ECMO Emergencies Using Delphi Method. ASAIO journal (American Society for Artificial Internal Organs : 1992) 2020. link 6 Ruth A, Meador M, Hui R, Loftis L, Teruya J. Acquired von Willebrand Syndrome in Pediatric Extracorporeal Membrane Oxygenation Patients: A Single Institution's Experience. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2019. link 7 Lamm W, Nagler B, Hermann A, Robak O, Schellongowski P, Buchtele N et al.. Propofol-based sedation does not negatively influence oxygenator running time compared to midazolam in patients with extracorporeal membrane oxygenation. The International journal of artificial organs 2019. link 8 McNinch J, Searles B, Darling E. Preserving ECMO Cannulae Patency. The journal of extra-corporeal technology 2018. link 9 Timofte I, Terrin M, Barr E, Kim J, Rinaldi J, Ladikos N et al.. Adaptive periodic paralysis allows weaning deep sedation overcoming the drowning syndrome in ECMO patients bridged for lung transplantation: A case series. Journal of critical care 2017. link 10 Verkoyen K, Schildhauer TA, Strauch JT, Swol J. The Effects of Propofol and Isoflurane Sedation on the Outcomes of Surgical Patients Receiving Extracorporeal Membrane Oxygenation. ASAIO journal (American Society for Artificial Internal Organs : 1992) 2017. link 11 Vetter TR, Adhami LF, Porterfield JR, Marques MB. Perceptions about blood transfusion: a survey of surgical patients and their anesthesiologists and surgeons. Anesthesia and analgesia 2014. link 12 Puis L, Ampe L, Hertleer R. Case report: plasma leakage in a polymethylpentene oxygenator during extracorporeal life support. Perfusion 2009. link 13 Nakae H, Omokawa S, Asanuma Y, Igarashi T, Tajimi K. Study of safe usage of high-flow three-way stopcocks in a blood circuit. Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy 2006. link 14 Schneditz D. Extracorporeal sensing techniques. Contributions to nephrology 2005. link

Acquired thrombocytopenia