L HIT and Its Complications Are Inevitable Unpredictable and Cannot Be Prevented

LMWHs have a number of advantages over UFH, one being the lower risk of inducing HIT by one order of magnitude (Martel et al., 2005). Fondaparinux (like

LMWH) also has a low risk of causing significant antibody formation, and in addition (unlike LMWH) does not cross-react with pathogenic HIT antibodies: thus, fondaparinux should have an even lower—perhaps negligible—risk of causing HIT (Warkentin et al., 2005). In my opinion, either LMWH or fondaparinux should be preferred to UFH in the great majority of situations where anticoagulation is indicated, outside of the cardiovascular operating room, cardiac catheterization lab, hemodialysis unit, and, perhaps, renally impaired or high bleeding risk critical care patients. Such a change in practice has the potential to diminish greatly both HIT incidence and sequelae. Short-sighted administrators cannot be allowed to "save money" by divorcing pharmacy acquisition costs for UFH from the institution's costs of monitoring for, treating, and defending lawsuits arising from HIT. The last bastion of UFH use is likely to be cardiac surgery employing extracorporeal circulation, because of the established experience with heparin, including reliable intraoperative monitoring and its rapid reversibility with protamine, although even here potentially safer alternative anticoagulants are being studied (see Chapter 19). Furthermore, appropriate monitoring of platelet counts in patients at risk for HIT, followed by appropriate action when thrombocytopenia occurs, is likely to reduce the thromboembolic catastrophes that might otherwise occur; this is likely to be advanced by "systems-based" approaches (see Chapter 3).

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