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
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
