High-stakes drug selection for thrombotic microangiopathy, immune thrombocytopenia, tumor lysis and hyperinflammation—where the correct medication is inseparable from plasma exchange, transfusion strategy, dialysis and trigger control.
Treat suspected immune TTP as a time-critical syndrome before ADAMTS13 confirmation.
Use caplacizumab as part of the modern iTTP bundle rather than as a replacement for plasma exchange/immunosuppression.
Use IVIG strategically for rapid platelet rise in ITP and understand product-specific renal/thrombotic risks.
Recognize rasburicase as uric-acid therapy—not a treatment for the potassium/phosphate/dialysis components of TLS.
Use anakinra and corticosteroids only within a defined HLH/MAS phenotype and trigger strategy.
Full TTP diagnostic and plasma-exchange framework.
Integrated TLS monitoring, prevention and dialysis triggers.
The table below is a selection framework. Open the individual monograph for exact dosing, preparation, renal/CRRT/IHD adjustment, interactions and evidence traceability.
ICU role: Anti-vWF nanobody for acquired immune TTP.
Monitor: Platelets, hemolysis, bleeding and ADAMTS13 trajectory.
ICU role: Rapid immunomodulator for severe ITP and standard therapy for selected neurologic autoimmune disease.
Monitor: Platelets/clinical response, creatinine, hemolysis and infusion reactions.
ICU role: Recombinant urate oxidase for TLS hyperuricemia.
Monitor: Uric acid with correct sample handling, K/phosphate/Ca, creatinine and hemolysis/methemoglobin.
ICU role: High-potency glucocorticoid used in several hematologic immune emergencies.
Monitor: CBC trajectory, glucose, infection and clinical bleeding.
ICU role: IV glucocorticoid used in selected severe immune cytopenias or hyperinflammatory states.
Monitor: Glucose, infection, mental status and muscle weakness.
ICU role: IL-1 blockade for selected MAS/secondary-HLH phenotypes.
Monitor: CBC, renal function, ferritin/fibrinogen and organ response.
ICU role: Antifibrinolytic for selected major bleeding syndromes.
Monitor: Bleeding control, thrombosis risk, renal function and seizure risk at high exposure.
ICU role: Concentrated vitamin-K-dependent clotting factors for urgent VKA reversal and selected emergency reversal strategies.
Monitor: Clinical hemostasis, INR when relevant and thrombosis.
| Agent | ICU role | Why I choose it | Why I hesitate | What I monitor |
|---|---|---|---|---|
| Caplacizumab Anti-von Willebrand Factor Nanobody | Anti-vWF nanobody for acquired immune TTP. | ✓ Add to plasma exchange + immunosuppression when iTTP probability is high and bleeding context permits. | ✕ Bleeding risk; does not eliminate the anti-ADAMTS13 autoimmune process. | Platelets, hemolysis, bleeding and ADAMTS13 trajectory. |
| Intravenous Immune Globulin (IVIG) Pooled Human IgG Immunomodulator | Rapid immunomodulator for severe ITP and standard therapy for selected neurologic autoimmune disease. | ✓ Life-threatening ITP bleeding or urgent need for platelet rise; also disease-specific indications such as GBS. | ✕ Thrombosis, hemolysis, AKI, aseptic meningitis and product/infusion differences. | Platelets/clinical response, creatinine, hemolysis and infusion reactions. |
| Rasburicase Recombinant Urate Oxidase | Recombinant urate oxidase for TLS hyperuricemia. | ✓ High-risk or established TLS with significant uric-acid burden when rapid removal is needed. | ✕ Contraindicated in G6PD deficiency; does not treat hyperkalemia/hyperphosphatemia or dialysis indications. | Uric acid with correct sample handling, K/phosphate/Ca, creatinine and hemolysis/methemoglobin. |
| Dexamethasone Long-Acting Synthetic Fluorinated Glucocorticoid (High Anti-Inflammatory Potency) with Negligible Mineralocorticoid Activity | High-potency glucocorticoid used in several hematologic immune emergencies. | ✓ Common first-line corticosteroid option for ITP and part of selected immune/inflammatory protocols. | ✕ Hyperglycemia, infection, psychiatric effects; steroid response does not prove diagnosis. | CBC trajectory, glucose, infection and clinical bleeding. |
| Methylprednisolone Intermediate-Acting Synthetic Glucocorticoid with Minimal Mineralocorticoid Activity | IV glucocorticoid used in selected severe immune cytopenias or hyperinflammatory states. | ✓ When an IV pulse/intermediate-acting steroid is the disease-specific choice. | ✕ Avoid carrying empiric pulses into undifferentiated sepsis without a defined indication. | Glucose, infection, mental status and muscle weakness. |
| Anakinra Interleukin-1 Receptor Antagonist | IL-1 blockade for selected MAS/secondary-HLH phenotypes. | ✓ Specialist-directed hyperinflammation treatment when trigger/severity support it. | ✕ Not a stand-alone treatment for every high ferritin; renal accumulation and infection risk. | CBC, renal function, ferritin/fibrinogen and organ response. |
| Tranexamic Acid Antifibrinolytic / Synthetic Lysine Analog | Antifibrinolytic for selected major bleeding syndromes. | ✓ Use only when the bleeding syndrome and timing have evidence support. | ✕ Not a generic treatment for thrombocytopenia, DIC or all GI bleeding. | Bleeding control, thrombosis risk, renal function and seizure risk at high exposure. |
| 4-Factor Prothrombin Complex Concentrate Hemostatic Agent / Clotting Factor Concentrate | Concentrated vitamin-K-dependent clotting factors for urgent VKA reversal and selected emergency reversal strategies. | ✓ Life-threatening warfarin-associated bleeding with IV vitamin K; selected other indications follow protocol. | ✕ Thromboembolic risk and no benefit from using it to 'normalize' cirrhotic INR without an indication. | Clinical hemostasis, INR when relevant and thrombosis. |
Why: Untreated iTTP can deteriorate rapidly and contemporary therapy targets both vWF microthrombosis and the autoimmune process.
Why: A rapid platelet rise and immediate hemostatic support are required.
Why: Rasburicase treats uric acid; lethal electrolyte and renal complications need separate management.
Why: Ferritin is nonspecific in critical illness.
Recognition becomes selection, then organ-failure adjustment, competing physiology and senior-level prioritization.
Platelets 5 ×10⁹/L, mucosal bleeding, no MAHA or DIC pattern.
Use corticosteroid therapy and add IVIG when a rapid platelet rise is needed; confirm this is truly ITP and not TTP/HIT/DIC.
High-grade lymphoma, uric acid already high before chemotherapy, kidney function worsening.
Rasburicase is preferred when rapid reduction of existing uric acid is needed, provided G6PD deficiency is excluded; continue full TLS monitoring and renal/electrolyte management.
MAHA, platelets 18, confusion, creatinine 130 μmol/L, normal coagulation tests.
Treat probable iTTP now. Plasma exchange and immune therapy should not wait for ADAMTS13; caplacizumab is part of contemporary treatment when appropriate.
After high-dose IVIG, hemoglobin falls and bilirubin/LDH rise without bleeding.
Consider IVIG-associated hemolysis, obtain hemolysis testing and review product/dose/risk factors rather than assuming occult hemorrhage.
AML induction: K 6.8, phosphate 2.8, calcium low, uric acid falling after rasburicase, worsening pulmonary edema and oliguria.
Treat hyperkalemia immediately and involve nephrology for urgent RRT because ongoing electrolyte/volume indications persist despite successful uric-acid lowering.
Targeted anti-vWF therapy for acquired immune TTP used with plasma exchange and immunosuppression. It rapidly reduces platelet-consuming microthrombosis but increases bleeding risk and does not eradicate the anti-ADAMTS13 autoimm…
Pooled IgG used across several ICU immune emergencies, including rapid platelet increase in ITP and standard treatment of Guillain–Barré syndrome. Dose and product selection are indication-specific and must account for thrombosis…
Rapid uric-acid lowering therapy for high-risk or established tumor lysis syndrome. It converts uric acid to allantoin and is contraindicated in G6PD deficiency because severe hemolysis/methemoglobinemia can occur.
Potent long-acting glucocorticoid with negligible mineralocorticoid activity. It is used for selected indications including adjunctive acute bacterial meningitis when given before/with initial antibiotics, symptomatic vasogenic t…
Potent parenteral glucocorticoid with ~5× the anti-inflammatory potency of hydrocortisone and minimal mineralocorticoid action — cornerstone therapy for severe asthma and COPD exacerbations, and non-resolving fibroproliferative A…
IL-1 receptor antagonist used off-label in selected severe hyperinflammatory syndromes such as macrophage activation syndrome/secondary HLH. ICU dosing is syndrome- and organ-function-specific and should be specialist directed ra…
Synthetic lysine analog that competitively blocks plasminogen lysine-binding sites, inhibiting plasmin formation and fibrin clot degradation, reducing mortality in bleeding trauma (CRASH-2) and postpartum hemorrhage (WOMAN) when …
Lyophilized concentrate of vitamin K-dependent coagulation factors used for urgent reversal of vitamin K antagonist anticoagulation in adults with major bleeding or urgent surgery/invasive procedures; it rapidly replaces deficien…
This Masterclass teaches selection and reasoning. Exact dosing, concentration, infusion preparation, renal/hepatic/RRT adjustment and monitoring must be checked in the linked medication monograph and the institution's current formulary/protocol. Local resistance patterns and regulatory drug availability can change faster than a static teaching page.