Heparin

annie.rn · May 14, 2015

Heparin can effect platelets. There is a phenomenon known as HIT or Heparin Induced Thrombocytopenia. I was taught to hold heparin for platelets less than 150,000. Also, any dramatic reduction in platelet count from one day to the next might be worth a chat w/ the MD prior to administration. You definitely did the right thing by holding it.

As for Hgb, I don't think there is a correlation unless of course the heparin has caused the patient to bleed from somewhere. In that case, the Hgb could drop from blood loss.

Karou · May 19, 2015

I would have held it and called the doctor, yes. Most of our doctors write a standing order when they order heparin that says to hold for platelets less than 150k. If they don't then I would hold and call to notify the MD.

dream'n, BSN, RN · May 23, 2015

A patient with a platelet level of 75 is at higher risk of bleeding and the heparin is used as a prophylactic to prevent blood clots. Does a patient with low platelets (generally) need further blood thinning to prevent clots? No, they do not. Also as this is a chemotherapy patient they could be in their Nadir period where their counts can drop significantly between lab draws, so by the time the heparin is due their platelets could be even much lower than 75. Definitely hold the prophylactic heparin.

SierraBravo · Jun 5, 2015

I would ask the provider to add a hold parameter to the order. For example, hold if platelets

jessRN465 · Jun 27, 2015

At our facility YES! Always hold heparin/lovenox if platelets are less than 100 (and call MD), and hold if hgb is 8.0 or less (ESPECIALLY if that is trending down from previous lab draws and call MD).

BUT if the patient has anemia or sickle cell and an HGB that stays consistent at 8.0 or below, it's usually given.. Situation depending.

jessRN465 · Jun 27, 2015

And it's not that heparin affects hgb.. But if a patients hgb is trending down and below 8.0.. It could possibly be a bleed.. Which heparin would make worse.

This was Atleast how I understood the rationale..

MunoRN, RN · Jun 27, 2015

It sounds counterintuitive, but thrombocytopenia does not actually reduce the risk of DVT or other thrombus formation. And in cancer patients it's not at all unusual for there to be both a hypercoagulable state and thrombocytopenia at the same time, so low platelet counts shouldn't really be ever considered a replacement for thrombus prophylaxis.

SierraBravo · Jul 1, 2015

It sounds counterintuitive, but thrombocytopenia does not actually reduce the risk of DVT or other thrombus formation. And in cancer patients it's not at all unusual for there to be both a hypercoagulable state and thrombocytopenia at the same time, so low platelet counts shouldn't really be ever considered a replacement for thrombus prophylaxis.

Sepsis causes microclots in the circulation regardless of your platelet count. In cancer patients the reason for an increased incidence of clots is secondary to the cancer itself (it inherently activates the clotting cascade), an oncology patient has likely gotten chemotherapy (which causes inflammation and thus increases the propensity of clot formation), and obviously immobility being in the hospital.

Simonesays, BSN, RN · Jul 3, 2015

As other posters have said above, a patient undergoing chemo for cancer is at an increased risk of thrombus formation. It is up to the heme team/onc team/provider to develop a plan of care that includes prophylactic anticoagulant dosing parameters. Definitely communicate this issue to your team and get them to address it. As others have said, heparin won't directly affect a pt's hgb but I would want to question and understand why my pt's hgb was low. (New issue or chronic? An issue of bleeding somewhere or an issue of impaired production?) This would help to guide my nursing care for this patient. I would also want to apply the same logic to a low plt count.

One other thing to consider: is heparin is the best prophylactic anticoagulant or this patient? We tend to give our surgical-oncology patients with heme issues low-molecular weight heparin but it depends on the patient's renal function, etc. If you have a ward pharmacist, I would discuss the issue with them too.

JustKeepSmiling, ADN, BSN, RN · Jul 3, 2015

Great thread! Hot topic too with focus on core measures.

I always fear HIT with a platelet trend down. As far as I know LMWH is not as big of a threat in that regard.

nycsurg · Jul 3, 2015

Someone going through chemo is at very high risk for dvt. Unless the hgb of 8 is an acute change, the heparin should be given. With platelets of 75 HIT is a possibility, but it is far far more likely to be related to the chemo.

On a somewhat related note - do not hold subq heparin for surgery