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Niccole Couse

Heparin induced thrombocytopenia (HIT) is a complication of heparin therapy where platelet counts decrease. There are two types: immune-mediated HIT which can be dangerous and cause clots, and non-immune mediated HIT which is self-limited. Symptoms include bleeding or clots. Diagnosis involves platelet count drops and antibody tests. Treatment requires stopping heparin and using alternative anticoagulants to prevent dangerous clots. Nurses monitor patients on heparin closely for signs of HIT and intervene appropriately.

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Heparin Induced Thrombocytopenia By: Niccole Couse University of South Florida College of Nursing
Introduction Baroletti & Goldhaber, 2006 • Heparin Induced Thrombocytopenia is a complication of Heparin therapy that leads to decreased levels of platelets in the blood. • Two types – Immune mediated • DANGEROUS • Rare – Non-Immune mediated • Self limited • Common
Heparin Mechanism of Action • Most common anti-coagulant used in the hospital setting. (Cooney, 2006) • Does not normally affect platelets directly (Baroletti & Goldhaber, 2006) • Binds with anti-thrombin to increase it’s efficacy of inhibiting – Thrombin – Platelet factor Xa – Platelet factor IXa – Platelet factor XIIa (Krishnaswamy, Lincoff & Cannon, 2010)
Normal Heparin Side Effects (Deglin, Vallerand & Sanoski, 2012) • Signs/symptoms of bleeding – Bruising or blackening • Around injection site • On fingers, toes and nipples – Bleeding gums – Nose bleeds – Hematuria – Melena – Hypotension – Decreased H&H
HIT Pathophysiology Cooney, 2006 Immune mediated • Generally presents within 5–14 days of heparin administration • Drop of platelet count by 30- 50% • Requires treatment – can be fatal • Immune response to heparin and platelet factor IX complex – Often leading to thrombosis Non-Immune mediated • Presents within 5 days of heparin administration • Minimal drop in platelet count • Will generally resolve on own – Continued exposure debated • Does not result in bleeding or thrombosis
Incidence Cooney, 2006 • Heparin widely used in hospitalized patients – 1/3 or about 12 million annually • % of patients that will develop HIT – Non-Immune mediated ~ 10% – Immune mediated ~ 5%
Risk Factors Cooney, 2006 • Unfractionated Heparin use – LMW heparin is safer • IV heparin use – Sub Q is safer • Orthopedic, cardiovascular & trauma patients – Cardiovascular patients– more at risk for arterial thrombi – Orthopedic & trauma patients – more at risk for venous thrombi
Complications Cooney, 2006 • HITTS – heparin induced thrombocytopenia thrombotic state – Complication of Immune mediated HIT – Formation of IgG antibody to heparin+PF4 complex > • Activates platelets releasing pro-coagulant rich micro- particles • Lyses platelets
HITTS Cooney, 2006 • Dangerous complication of Immune mediated HIT – 38-76% • Characterized by excessive clotting in the blood. • Clots can travel throughout the body causing harm. – DVT 50% – PE 25% – Limb necrosis 20% – Death – Other target organ damage • Stroke, MI, ARF, etc.
Diagnosis (Baroletti & Goldhaber, 2006) • Drop in platelet count after initiation of Heparin therapy (30-50%) – Presence of HIT • Presence of Heparin + PF IX complex antibody in blood – What type of HIT would this indicate? • Symptoms of clot formation – What complication does this indicate?
Signs and Symptoms (Baroletti & Goldhaber, 2006) • HIT – Drop in platelet count 30-50% • HITTS – Drop in platelet count 30-50% + – Symptoms of DVT • Pain & tenderness of the legs • Sudden swelling • Warm skin • Discoloration of the skin – Symptoms of PE • SOB • Chest pain • Anxiety • Dizziness • Alterations in HR – Symptoms of other target organ damage
Assessment • Be aware! • Closely monitor patients on Heparin therapy – Monitor platelet count • Normal? – Monitor PTT, PT, INR – Monitor for S/S of bleeding and clotting
Treatment (Cooney, 2006) • STOP HEPARIN!! • Begin other approved anticoagulant – Direct thrombin inhibitors • Argatroban & Lepirudin • Block activation of thrombin and do not trigger antibody- mediated reactions • Symptom management • Warfarin can be started after treatment and platelet count reaches minimum of 100,000
Treatments – nursing considerations • Monitor daily INR • Reduce thrombosis – Anti-embolism stockings – Increase activity/exercise • Ambulation – Hydration • Careful observation
Prognosis • Highest mortality rate in Immune-mediated HIT • 6-10% mortality (Ecke & May, 2012) – DVT 50% – PE 25% – Limb necrosis 20% – Death (Cooney, 2006)
Nursing Diagnosis • Risk for – Ineffective tissue perfusion – Ineffective gas exchange – Decreased cardiac output – Acute renal failure – Altered mental status – Etc.
Clinical Example • HPI: Patient 73 year old male admitted to the hospital with a C.C. of shortness of breath. Diagnosed with new onset A.fib and received cardioversion to sync back to NSR. Pateint received a TEE revealing severe mitral valve calcification and regurgitation. He was scheduled for a cath but elected to go home until the surgery due to breathing much better.
Clinical Example • Patient came back early due to SOB and remained hospitalized until the surgery. He received a CAGB X1 and MV replacement. He received Heparin during the surgery. (1st use)
Clinical Example Complications – • 6 days post op he began experiencing increasing SOB – received a CT that identified small bilateral PEs. Also became acutely confused • His platelet level dropped to 94,000 • In the following days he began exhibiting signs of – Acute renal failure (elevated BUN and Creatnine and anuria) – Poor tissue perfusion (R foot: molten toes, cool skin and diminished pulses) – Liver damage (liver function tests diminished)
Relating to the Patient • Pulmonary embolisms • Acute confusion • Arterial embolism in the R leg? • ARF requiring dialysis • Liver function decline
NCLEX style question • TRUE or FALSE? –All patients that develop HIT will experience thrombosis?
NCLEX style question • TRUE or FALSE? –All patients that develop HIT will experience thrombosis? FALSE
NCLEX style question • A patient is started on a Heparin subQ injections daily. You begin to notice bruising around the injection site. You attribute this finding to …. a) HITTS b) Expected side effect of Heparin therapy c) Possible physical abuse d) Allergy to alcohol wipes
NCLEX style question • A patient is started on a Heparin subQ injections daily. You begin to notice bruising around the injection site. You attribute this finding to …. a) HITTS b) Expected side effect of Heparin therapy c) Possible physical abuse d) Allergy to alcohol wipes
Questions?
References • Baroletti, S.A. & Goldhaber, S.Z. (2006) Heparin induced thrombocytopenis. Journal of the American Heart Association. DOI:10.1161/​CIRCULATIONAHA.106.632653 • Cooney, M.F. (2006) Heparin induced thrombocytopenia: Advances in diagnosis and treatment. Critical Care Nurse, 26(6). Retrieved from http://ccn.aacnjournals.org/content/26/6/30.full.pdf+html
References • Deglin, Vallerand & Sanoski (2012) Davis drug guide • Ecke, S. & May, S.K. (2012) Geparin induced thrombocytopenia follow-up. Retrieved from http://emedicine.medscape.com/article/1357846- followup#a2650 • Krishnaswamy, A. Lincoff, M., & Cannon, C.P. (2010) The use and limitations of unfractioned heparin. Critical Pathways in Cardiology 9(1) Retrieved from http://www.automedicsrx.com/publications/The_Use_and_Limit ations_of_Unfractionated_Heparin.pdf

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N.couse case study_hit

  • 1. Heparin Induced Thrombocytopenia By: Niccole Couse University of South Florida College of Nursing
  • 2. Introduction Baroletti & Goldhaber, 2006 • Heparin Induced Thrombocytopenia is a complication of Heparin therapy that leads to decreased levels of platelets in the blood. • Two types – Immune mediated • DANGEROUS • Rare – Non-Immune mediated • Self limited • Common
  • 3. Heparin Mechanism of Action • Most common anti-coagulant used in the hospital setting. (Cooney, 2006) • Does not normally affect platelets directly (Baroletti & Goldhaber, 2006) • Binds with anti-thrombin to increase it’s efficacy of inhibiting – Thrombin – Platelet factor Xa – Platelet factor IXa – Platelet factor XIIa (Krishnaswamy, Lincoff & Cannon, 2010)
  • 4. Normal Heparin Side Effects (Deglin, Vallerand & Sanoski, 2012) • Signs/symptoms of bleeding – Bruising or blackening • Around injection site • On fingers, toes and nipples – Bleeding gums – Nose bleeds – Hematuria – Melena – Hypotension – Decreased H&H
  • 5. HIT Pathophysiology Cooney, 2006 Immune mediated • Generally presents within 5–14 days of heparin administration • Drop of platelet count by 30- 50% • Requires treatment – can be fatal • Immune response to heparin and platelet factor IX complex – Often leading to thrombosis Non-Immune mediated • Presents within 5 days of heparin administration • Minimal drop in platelet count • Will generally resolve on own – Continued exposure debated • Does not result in bleeding or thrombosis
  • 6. Incidence Cooney, 2006 • Heparin widely used in hospitalized patients – 1/3 or about 12 million annually • % of patients that will develop HIT – Non-Immune mediated ~ 10% – Immune mediated ~ 5%
  • 7. Risk Factors Cooney, 2006 • Unfractionated Heparin use – LMW heparin is safer • IV heparin use – Sub Q is safer • Orthopedic, cardiovascular & trauma patients – Cardiovascular patients– more at risk for arterial thrombi – Orthopedic & trauma patients – more at risk for venous thrombi
  • 8. Complications Cooney, 2006 • HITTS – heparin induced thrombocytopenia thrombotic state – Complication of Immune mediated HIT – Formation of IgG antibody to heparin+PF4 complex > • Activates platelets releasing pro-coagulant rich micro- particles • Lyses platelets
  • 9. HITTS Cooney, 2006 • Dangerous complication of Immune mediated HIT – 38-76% • Characterized by excessive clotting in the blood. • Clots can travel throughout the body causing harm. – DVT 50% – PE 25% – Limb necrosis 20% – Death – Other target organ damage • Stroke, MI, ARF, etc.
  • 10. Diagnosis (Baroletti & Goldhaber, 2006) • Drop in platelet count after initiation of Heparin therapy (30-50%) – Presence of HIT • Presence of Heparin + PF IX complex antibody in blood – What type of HIT would this indicate? • Symptoms of clot formation – What complication does this indicate?
  • 11. Signs and Symptoms (Baroletti & Goldhaber, 2006) • HIT – Drop in platelet count 30-50% • HITTS – Drop in platelet count 30-50% + – Symptoms of DVT • Pain & tenderness of the legs • Sudden swelling • Warm skin • Discoloration of the skin – Symptoms of PE • SOB • Chest pain • Anxiety • Dizziness • Alterations in HR – Symptoms of other target organ damage
  • 12. Assessment • Be aware! • Closely monitor patients on Heparin therapy – Monitor platelet count • Normal? – Monitor PTT, PT, INR – Monitor for S/S of bleeding and clotting
  • 13. Treatment (Cooney, 2006) • STOP HEPARIN!! • Begin other approved anticoagulant – Direct thrombin inhibitors • Argatroban & Lepirudin • Block activation of thrombin and do not trigger antibody- mediated reactions • Symptom management • Warfarin can be started after treatment and platelet count reaches minimum of 100,000
  • 14. Treatments – nursing considerations • Monitor daily INR • Reduce thrombosis – Anti-embolism stockings – Increase activity/exercise • Ambulation – Hydration • Careful observation
  • 15. Prognosis • Highest mortality rate in Immune-mediated HIT • 6-10% mortality (Ecke & May, 2012) – DVT 50% – PE 25% – Limb necrosis 20% – Death (Cooney, 2006)
  • 16. Nursing Diagnosis • Risk for – Ineffective tissue perfusion – Ineffective gas exchange – Decreased cardiac output – Acute renal failure – Altered mental status – Etc.
  • 17. Clinical Example • HPI: Patient 73 year old male admitted to the hospital with a C.C. of shortness of breath. Diagnosed with new onset A.fib and received cardioversion to sync back to NSR. Pateint received a TEE revealing severe mitral valve calcification and regurgitation. He was scheduled for a cath but elected to go home until the surgery due to breathing much better.
  • 18. Clinical Example • Patient came back early due to SOB and remained hospitalized until the surgery. He received a CAGB X1 and MV replacement. He received Heparin during the surgery. (1st use)
  • 19. Clinical Example Complications – • 6 days post op he began experiencing increasing SOB – received a CT that identified small bilateral PEs. Also became acutely confused • His platelet level dropped to 94,000 • In the following days he began exhibiting signs of – Acute renal failure (elevated BUN and Creatnine and anuria) – Poor tissue perfusion (R foot: molten toes, cool skin and diminished pulses) – Liver damage (liver function tests diminished)
  • 20. Relating to the Patient • Pulmonary embolisms • Acute confusion • Arterial embolism in the R leg? • ARF requiring dialysis • Liver function decline
  • 21. NCLEX style question • TRUE or FALSE? –All patients that develop HIT will experience thrombosis?
  • 22. NCLEX style question • TRUE or FALSE? –All patients that develop HIT will experience thrombosis? FALSE
  • 23. NCLEX style question • A patient is started on a Heparin subQ injections daily. You begin to notice bruising around the injection site. You attribute this finding to …. a) HITTS b) Expected side effect of Heparin therapy c) Possible physical abuse d) Allergy to alcohol wipes
  • 24. NCLEX style question • A patient is started on a Heparin subQ injections daily. You begin to notice bruising around the injection site. You attribute this finding to …. a) HITTS b) Expected side effect of Heparin therapy c) Possible physical abuse d) Allergy to alcohol wipes
  • 26. References • Baroletti, S.A. & Goldhaber, S.Z. (2006) Heparin induced thrombocytopenis. Journal of the American Heart Association. DOI:10.1161/​CIRCULATIONAHA.106.632653 • Cooney, M.F. (2006) Heparin induced thrombocytopenia: Advances in diagnosis and treatment. Critical Care Nurse, 26(6). Retrieved from http://ccn.aacnjournals.org/content/26/6/30.full.pdf+html
  • 27. References • Deglin, Vallerand & Sanoski (2012) Davis drug guide • Ecke, S. & May, S.K. (2012) Geparin induced thrombocytopenia follow-up. Retrieved from http://emedicine.medscape.com/article/1357846- followup#a2650 • Krishnaswamy, A. Lincoff, M., & Cannon, C.P. (2010) The use and limitations of unfractioned heparin. Critical Pathways in Cardiology 9(1) Retrieved from http://www.automedicsrx.com/publications/The_Use_and_Limit ations_of_Unfractionated_Heparin.pdf