Diagnosis and Management of Heparin - Induced Thrombocytopenia - Nursing Assignment Help

Assignment Task

Evaluating the Clinical Probability of HIT

In patients with suspected HIT, the ASH guideline panel recommends using the 4Ts score to estimate the probability of HIT rather than a gestalt approach

Laboratory Diagnosis

In patients with a low-probability 4Ts score, the ASH guideline panel recommends against HIT laboratory testing . HIT laboratory testing may be appropriate for patients with a low-probability 4Ts score if there is uncertainty about the 4Ts score (for example, due to missing data).

If there is an intermediate- or high-probability 4Ts score, the ASH guideline panel recommends using an immunoassay . If the immunoassay is positive and a functional assay is available, the ASH guideline panel suggests a functional assay .

Diagnostic and Initial Treatment Algorithm

1 If the patient has an intermediate-probability 4Ts score, has no other indication for therapeutic-intensity anticoagulation, and is judged to be at high risk for bleeding, the panel suggests treatment with a non-heparin anticoagulant at prophylactic intensity rather than therapeutic intensity. If the patient has an intermediate-probability 4Ts score and is not judged to be at high risk for bleeding or has another indication for therapeutic-intensity anticoagulation, the panel suggests treatment with a non-heparin anticoagulant at therapeutic intensity rather than prophylactic intensity. In a patient with a high-probability 4Ts score, the panel recommends treatment with a non-heparin anticoagulant at therapeutic intensity.

For all intermediate/high-probability patients with a positive immunoassay, including those who were receiving prophylactic-intensity treatment with a non-heparin anticoagulant prior to the availability of the immunoassay result, the panel recommends treatment with a non-heparin anticoagulant at therapeutic intensity

In some settings, a functional assay may not be available and decisions may need to be made based on the results of the 4Ts and immunoassay. A functional assay may not be necessary in patients with a high 4Ts score and a strongly positive immunoassay (e.g., an ELISA > 2.0 optical density units).

4 Most patients with a negative functional assay do not have HIT and may be managed accordingly. However, depending on the type of functional assay and the technical expertise of the laboratory, false-negative results are possible. Therefore, a presumptive diagnosis of HIT may be considered for some patients with a negative functional assay, especially if there is a high-probability 4Ts score and a strongly positive immunoassay. This is represented in the figure by a dashed line.

Treatment

n patients with acute HIT complicated by thrombosis (HITT) or acute HIT without thrombosis (isolated HIT), the ASH guideline panel recommends discontinuation of heparin and initiation of a non-heparin anticoagulant . When a non-heparin anticoagulant is being selected, the ASH guideline panel suggests argatroban, bivalirudin, danaparoid, fondaparinux, or a direct oral anticoagulant (DOAC)

Selecting a Non-Heparin Anticoagulant

Choice of agent may be influenced by drug factors (availability, cost, ability to monitor the anticoagulant effect, route of administration, half-life), patient factors (kidney function, liver function, bleeding risk, clinical stability), and experience of the clinician.

TRANSITIONING TO AN ORAL AGENT

In patients with HIT initially treated with a parenteral agent, the ASH guideline panel suggests transitioning to a DOAC rather than warfarin . The ASH guideline panel recommends against initiation of warfarin prior to platelet count recovery . Specific guidance on transitioning from a parenteral agent to an oral agent is detailed in the table:

SCREENING FOR ASYMPTOMATIC DVT AND DURATION OF ANTICOAGULATION

In patients with acute HIT without clinically apparent thrombosis, the ASH guideline panel suggests bilateral lower extremity compression ultrasonography to screen for asymptomatic proximal DVT

If an upper extremity central venous catheter is present, the ASH guideline panel suggests ultrasonography of the limb with the catheter to screen for asymptomatic DVT

In patients with acute HIT without clinically apparent thrombosis and no asymptomatic DVT identified by screening ultrasonography, the ASH guideline panel suggests that anticoagulation be continued, at a minimum, until platelet count recovery (usually a platelet count of ≥150 × 109/L). The ASH guideline panel suggests against continuing treatment for more than three months unless the patient has persisting HIT without platelet count recovery . In patients with HIT complicated by thrombosis and no other indication for anticoagulation, anticoagulation is typically given for 3-6 months.

PLATELET TRANSFUSION

In patients with acute HITT or acute isolated HIT who are at average bleeding risk, the ASH guideline panel suggests against routine platelet transfusion . Platelet transfusion may be an option for patients with active bleeding or at high bleeding risk.

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