What is the best way to evaluate thrombocytopenia in the ICU?

Should we use a systematic approach to evaluate it as fully as possible? Traditionally we're more selective. We formulate an overall clinical impression, then specifically assess for things that are really horrible and require specific action (TTP, HIT).

A small before and after study compared the traditional selective approach with one in which all patients were evaluated as fully as possible:

Methods

Before-and-after study of all patients with thrombocytopenia was used. ‘Before’ group had no intervention. New standard operating procedures for thrombocytopenia management were introduced. In the ‘After’ group, bone marrow aspiration; determination of fibrinogen dosage, prothrombin time, factor V, D-dimers; assay of fibrin monomers, ferritin, triglycerides, lactic acid dehydrogenase, aspartate transaminase, alanine aminotransferase, vitamin B12, folates, reticulocytes, haptoglobin, and bilirubin were performed.

Results

In the Before group (n = 20), the mechanism (central, peripheral, or mixed) was identified in 10 % versus 83% in After group (n = 23) (p less than 0.001) (48% peripheral, 35% mixed). Before intervention, greater than or equal to 1 etiology was identified in 15% versus 95.7% in the After group (p less than  0.001).

Conclusions

Systematic and extensive investigation using routine tests highlights the mechanisms and etiology of thrombocytopenia in most cases.

More patients in the traditional group had normalization of platelet counts than did those who were fully evaluated. Evaluation in the traditional group did not drive any treatment. In the fully evaluated group two patients were given folic acid based on the evaluation and one received corticosteroids and IVIG after a bone marrow finding of hemophagocytosis.