Jos P J Wester | PubMed Health

PubMed2007

A rare disease.

Thrombocytopenia is a common finding in critically ill patients. Heparin-induced thrombocytopenia is an infrequent cause of a low platelet count. Intensivists should use the diagnostic classification system developed by the International Society on Thrombosis and Haemostasis to diagnose heparin-induced thrombocytopenia. The clinical relevance of the presence of anti-heparin/platelet factor 4 complex autoantibodies in the absence of clinical heparin-induced thrombocytopenia remains unknown.

Critical Illness↗

PubMed2004

Thrombosis and hemorrhage in heparin-induced thrombocytopenia in seriously ill patients.

OBJECTIVE: Heparin-induced thrombocytopenia (HIT) is the most common form of drug-induced immune-mediated thrombocytopenia. HIT may be aggravated by life-threatening arterial and venous thrombosis and, to a lesser extent, hemorrhagic complications. We investigated the incidence of thromboembolic and hemorrhagic complications in critically ill patients with the multiple organ dysfunction syndrome and HIT. DESIGN: Case-control study. SETTING: A 33-bed general intensive care unit in a university-affiliated teaching hospital. PATIENTS: Twenty consecutive patients with laboratory-proven HIT compared with 20 contemporary, consecutive patients without HIT. INTERVENTIONS: Unfractionated heparin or low-molecular-weight heparin were replaced by danaparoid sodium in patients with HIT. MEASUREMENTS AND RESULTS: Heparin-induced thrombocytopenia was proven by a positive platelet aggregation test. The HIT group consisted of 14 males and 6 females aged 65.2+/-10.8 years (mean +/- standard deviation) with APACHE II scores of 26.7+/-5.4. Thrombocytopenia less than 100 x 10(9)/l developed within 6.4+/-7.0 days. In 12 patients thrombocytopenia resolved after discontinuation of unfractionated heparin in 8.8+/-6.4 days. Arterial and venous thromboembolic complications occurred more frequently in HIT patients than in non-HIT patients (10/20 (50%) versus 0/20 (0%); chi-square p<0.001). Hemorrhagic complications also occurred more frequently in HIT patients than in non-HIT patients (17/20 (85%) versus 7/20 (35%); chi-square p=0.001). CONCLUSION: In critically ill patients with HIT, the incidence of thromboembolic complications and hemorrhagic complications was remarkably high.

Adult↗

PubMed2003

Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication.

STUDY OBJECTIVES: To assess short-term and long-term complications of bronchoscopy-guided, percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) and to report a complication of PDT that has not been described previously. DESIGN: Prospective survey. SETTING: University teaching hospital. PATIENTS: Two hundred eleven critically ill patients in our ICU. INTERVENTIONS: PDT was performed in 174 patients, under bronchoscopic guidance in most cases. ST was performed in 40 patients. RESULTS: No procedure-related fatalities occurred during PDT or ST. The incidence of significant complications (eg, procedure-related transfusion of fresh-frozen plasma, RBCs, or platelets, malpositioning or kinking of the tracheal cannula, deterioration of respiratory parameters lasting for > 36 h following the procedure, or stomal infection) in patients undergoing PDT was 4.0% overall and 3.0% when bronchoscopic guidance was used. No cases of paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis occurred in patients undergoing PDT. We attribute this low rate of complications to procedural and organizational factors such as bronchoscopic guidance, performance by or supervision of all PDTs by physicians with extensive experience in this procedure, and airway management by physicians who were well-versed in (difficult) airway management. In addition, an ear-nose-throat surgeon participated in the procedure in case conversion of the procedure to an ST should become necessary. We observed a complication that, to our knowledge, has not been reported previously. Five patients developed intermittent respiratory difficulties 2 to 21 days (mean, 8 days) after undergoing PDT. The cause turned out to be the periodic obstruction of the tracheal cannula by hematoma and the swelling of the posterior tracheal wall, which had been caused by intermittent pressure and chafing of the cannula on the tracheal wall. In between the episodes of obstruction, the cannula was open and functioning normally, which made the diagnosis difficult to establish. CONCLUSIONS: Bronchoscopy-assisted PDT is a safe and effective procedure when performed by a team of experienced physicians under controlled circumstances. The intermittent obstruction of the cannula caused by swelling and irritation of the posterior tracheal wall should be considered in patients who develop unexplained paroxysmal respiratory problems some time after undergoing PDT or ST.

Bronchoscopy↗