HIT in CABGs

Are you guys seeing a lot of possible HIT patients now? How are you treating it? Our surgeons were taking a wait and see approach for a lot of these pts we were trending decreasing platelets on. We had one a while back that ended up with a DVT, so we're seeing some of the surgeons get hemotology consults now instead of sitting on the low platelets. It's a hard thing though because surgery cringes whenever hemotology wants to put them on refludan or argatroban so soon after a CAB.

I dont think we're actually seeing 'more' HIT than in the past, however i think that because we're more 'aware' of the issue, we're checking for the antibodies on all our post-cabg thrombocytopenic patients (it's a standing order for about 1/2 of our surgeons). More often than not the thrombocytopenia is pump-related rather than a true HIT. We use argatroban. I'm unfamiliar with refludan.

Very very rarely we use argatroban, I've only used lepirudin maybe once I think or twice. Usually we don't see VERY low PLT, maybe 80's or something, If that's the case we just usually watch the patients, and you know hold the pepcid or whatnots.

I agree Dinith, I don't think it is a question of seeing "more" of HIT, but just recognizing it and be aware it is a possibility. I had an interesting conversation with hematology a few weeks back on the theories of treatment with HIT. We were discussing the testing, which at my facility is a send out and doesn't come back for almost a week. He said a lot the patients will have false positives shortly after surgery anyway, so he will base the decision to aggressively treat or not based on how the patient looks clinically, and repeat the lab work for the antibodies in 2 weeks, which will often then be negative. You kind of the play the wait and see game.

Looking at the platelet count, he trends it to see if they slowly do start to come up, and watches to make sure they have good circulation and no signs of clots, but he said regardless of the platelet count recovering the patient is at a huge risk for DVT/PE for a couple of months after surgery if they do have HIT. It's a catch 22 and kind of scary when you think about it. If we think they may have it, just wait around and watch, come to find out they really do have and throw a clot 2 weeks post op, that's bad. At the same time, you really don't want half the CAB population on refludan post op when they probably don't have it.

We've seen more of a push for refludan in treatment over the last 6 months I'd say. While argatroban is better for renal patients, a few of the hemotolgy guys don't like because they say they're patients never do well on it, and end up dying anyway. In the back of my mind, I was thinking the cases where it's happened it's usually a train wreck patient with every organ failing anyway, so I don't think the argatrban was the major culprit. But, I guess their experience from what they see is better patient outcomes with the refludan.

We also stop the pepcid in low platelet folks, and start them on protonix.

Just curious if you don't mind Dinith, what type of ICU do you work in? I always enjoy reading your posts. You're very knowledgeable on cardiac issues. How long have you been a nurse?

Very very rarely we use argatroban, I've only used lepirudin maybe once I think or twice. Usually we don't see VERY low PLT, maybe 80's or something, If that's the case we just usually watch the patients, and you know hold the pepcid or whatnots.

We used to be the same way. Lately though we've had a lot of chronic pts with platelets in the 50's.

Ok I was just wondering what the reason is for holding the pepcid and switching to protonix.

Ok I was just wondering what the reason is for holding the pepcid and switching to protonix.

Prior to iv-protonix came around, patients used to get iv-tagamet for stress-ulcer prophylaxis. Before we had the test for HIT antibodies, most surgeons would blame a post-op thrombocytopenia on the tagamet (a rare, but serious complication of giving it iv). Because tagamet, zantac, and pepcid are all basically same class/drug, the docs are probably switching to protonix (in a 'different'/newer class ppi) as thrombocytopenia isnt as likely. Especially in patients whose HIT is negative, but platelets remain low. Also, i dont know if iv-pepcid is as likely to induce a thrombocytopenia as iv-tagamet, but because they're so similar i'm assuming it may???

Not commonly done in Australia, although we are testing and treating it a lot more frequently in VAD patients (argatroban, bivalirudin)

yes pepcid is a big culprit of inducing thrombocytopenia.

yes pepcid is a big culprit of inducing thrombocytopenia.

Our docs hate Pepcid. They say "it is like ****ing in the wind". However, we had a shortage of IV Protonix for a while.

Oldiebutgoodie