Heparin-induced Thrombocytopenia (HIT) Type II (Nursing)

by Rhonda Lawes, PhD, RN

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    00:01 Let's talk about -- a big problem with heparin.

    00:04 It's heparin-induced thrombocytopenia.

    00:07 Now, we've got a great diagram for you there in your downloadable notes.

    00:11 That really goes into 4 really important steps.

    00:15 However, remember, we've talked about real estate in your brain.

    00:18 I'm not expecting you to remember that in detail.

    00:22 It's just there if you want some background information, and some of us just learn better when we have that much background information.

    00:28 It is not the focus.

    00:29 I just want you to remember, for sure, that people on heparin can suffer from heparin-induced thrombocytopenia.

    00:39 So what does that mean? Well, penia is in your blood, cyto means cell, and thrombo -- that is low platelets, but look what happens here in this problem.

    00:51 HIT, what we call it, type II is a very rare, but potentially fatal immune-mediated adverse drug reaction to heparin.

    00:59 Okay, I said that way too quickly.

    01:02 I want to slow down the tape and make sure you get that.

    01:06 Heparin-induced thrombocytopenia or HIT type II.

    01:11 It's rare, but when it happens to your patient, you will never forget it because they can actually die from this.

    01:19 It's an immune-mediated adverse drug reaction to heparin.

    01:23 So some people who receive heparin develop HIT.

    01:27 Post-op patients have a higher risk of developing HIT, so put that on your radar.

    01:31 That's worth you remembering.

    01:33 Someone who's had surgery and receives heparin is at an increased risk to develop this rare adverse drug reaction.

    01:41 You want to watch your patients' platelet count consistently.

    01:45 Why? Because thrombocytopenia is a low platelet count.

    01:49 So that's part of routine lab work, keep an eye on that, particularly if your patient is on heparin.

    01:55 A very low platelet count, we're talking about thrombocytopenia, can start within about 5-10 days of a patient beginning heparin therapy.

    02:04 So they've had surgery, they've been on heparin 5-10 days, this would be the window of time and when it might start.

    02:11 Now, this is the weirdness that happens in HIT, that these abnormal antibodies and they develop that attack the heparin platelet protein complexes.

    02:20 Okay, that is not a good thing.

    02:23 Antibodies are part of me.

    02:25 They're developed to attack things that I don't want, but heparin platelet protein complexes are good things, particularly after surgery.

    02:34 But this leads to platelet activation and major clots forming.

    02:40 So think about that.

    02:41 You're on heparin, but now we're going to have heparin-induced thrombocytopenia.

    02:46 Now we've got this weird platelet activation, and I have clots everywhere.

    02:51 This is a dramatic thing to see in your patients.

    02:55 I had 1 patient, especially was a patient who had just delivered a child.

    02:58 It's extremely traumatic to watch this patient walk through this.

    03:04 So the patients treated with low-molecular-weight heparin have a relatively lower risk to develop this.

    03:10 So, it's got about 76% in the probability of developing HIT compared to patients who have unfractionated heparin.

    03:17 So that's another reason that using the low-molecular-weight heparin give us a better result and it's a little safer.

    03:25 So, as nurse Natalie says, and I completely agree with her, look at that last point.

    03:30 Your job as a nurse is to watch that patient's platelet count consistently, even closer when they are on unfractionated heparin.

    03:39 But remember, there are some patients, lower risk, that might even develop this with low-molecular-weight heparin.

    03:45 Okay, so we've established that the biggest complications with HIT are clots, okay? Not bleeding, our problem is clots.

    03:53 So make sure you circle that "clots." You have that solid in your brain that that's the problem with HIT type II.

    04:00 So venous clots are what you primarily see.

    04:03 May also be arterial, but venous is usually what we see most.

    04:07 So let's talk about examples of venous clots.

    04:09 Deep vein thrombosis, like the one I likely had in my leg.

    04:13 Pulmonary embolism, which can often be a DVT that travels up to your lungs, pulmonary embolism.

    04:20 Skin necrosis, myocardial infarction, or even venous gangrene.

    04:25 So, these are examples of where you can have these clots spread.

    04:30 Now, you already knew DVT and pulmonary embolism, but clots can also break off and go into little tiny micro vascular.

    04:38 So that's where you might see the skin necrosis.

    04:41 Myocardial infarction, that's, again, a clot in the blood supply to your heart, or venous gangrene.

    04:48 That means the clot's there in your veins and it can be like a shower of clots going everywhere.

    04:55 You'll start to see the patient really experienced tissue death, that's what gangrene is going to be, caused from those clots because you just don't have an adequate blood supply.

    05:06 Okay, we've talked about this test a little bit in other videos, but I want to kind of dig down a little deeper; heparin anti-Xa level blood test.

    05:16 This is lab work that you'll do and it indirectly measures the activity of heparin.

    05:21 Remember, that's one of the medications we're talking about.

    05:23 So a heparin anti-Xa level indirectly measures the activity of heparin, that its ability to inhibit the activation of factor X or Xa.

    05:33 So this test is another test in our toolkit that we can use with heparin.

    05:38 We often use it with unfractionated heparin, but you can also use it with low-molecular-weight heparin, so it's a newer test for us.

    05:46 So make sure you familiarize yourself with the name of it, and just that it gives us an indication of the activity of heparin.

    05:52 Now, let me share some of the normal values with you.

    05:55 These are therapeutic levels.

    05:57 Now, there's a difference between normal and therapeutic.

    06:01 When we're talking about a therapeutic level, that means this level should be a little different than what it would be in a body that was not receiving this medication.

    06:10 So, for a patient receiving unfractionated heparin, here's an example of what a therapeutic level would be.

    06:16 Now, I know in nursing school, sometimes students get really frustrated, because it seems like every textbook has a different level and a different range.

    06:25 I understand that, and that's actually true.

    06:28 But you're going to experience that in real life.

    06:30 Every lab has a little bit different normal reference range or therapeutic range.

    06:35 Expect that.

    06:36 It's okay.

    06:37 Every lab will tell you what their normal levels are, and you can just compare your patient values with that.

    06:43 For nursing school, that's something you'll need to negotiate with your faculty to know what level they're accepting.

    06:48 But in real life, whatever lab the work is drawn at, you will see the normals posted right with the results.

    06:55 Okay, so back to our example results.

    06:58 Unfractionated heparin was at the top.

    07:00 You see the level for it, low-molecular-weight heparin.

    07:03 You notice there's a little difference for those.

    07:05 Now, low-molecular-weight heparin, if they have it twice daily, there's 1 range.

    07:10 If they have it once daily, there's a different range just to give you an idea.

    07:15 So, what I'm asking is that you not memorize these, you just know that they're out there and know that the values that are therapeutic will be different based on the medication.

    07:26 And you see I've 1 more medication at the end, but keep in mind, I'm not asking you to memorize these values.

    07:33 I'm asking you to be aware that this helps us understand the activity of heparin, and there are ranges out there that tell us when this particular medication is in a therapeutic range.

    07:43 That's the biggest takeaway points on these slides.

    About the Lecture

    The lecture Heparin-induced Thrombocytopenia (HIT) Type II (Nursing) by Rhonda Lawes, PhD, RN is from the course Cardiovascular Medications (Nursing).

    Included Quiz Questions

    1. 5–10
    2. 1–3
    3. 3–5
    4. 2–8
    1. Venous gangrene
    2. Skin necrosis
    3. Pulmonary embolism
    4. Myocardial infarction
    5. Aneurysm rupture
    1. Factor X
    2. Factor V
    3. Factor VIII
    4. Factor II
    1. Medication
    2. Lab protocols
    3. Dosing
    4. Personal choice
    5. Client's diet

    Author of lecture Heparin-induced Thrombocytopenia (HIT) Type II (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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