Contents
Guidelines For Management Of HIT
Pre-Test Probability Scoring For HIT
The 4T Score
TOTAL SCORE
- < 3 = low probability of HIT
- 4-5 = intermediate probability of HIT
- > 6 = high probability of HIT
Category | 2 points | 1 point | 0 points |
---|---|---|---|
Thrombocytopenia | Platelet count fall > 50% AND platelet nadir > 20 × 109 L−1 | Platelet count fall 30-50% AND platelet nadir 10-19 × 109 L−1 | Platelet count fall < 30% OR platelet nadir < 10 × 109 L−1 |
Timing of platelet count fall | Clear onset between days 5 and 10 OR within 1 day of re-exposure after prior exposure within 30 days | Consistent with days 5–10 fall, but not clear (e.g. missing platelet counts) OR onset after day 10 OR within 1 day of re-exposure after prior exposure 30–100 days ago | Platelet count fall < 4 days AND no heparin exposure within the last 100 days |
Thrombosis or other sequelae | New thrombosis (confirmed) OR skin necrosis at heparin injection sites OR acute systemic reaction after intravenous heparin bolus | Progressive or recurrent thrombosis OR non-necrotizing (erythematous) skin lesions OR suspected thrombosis (not proven) | None |
Other causes for thrombocytopenia | None apparent | Possible | Definite |
Score for HIT in Cardiopulmonary Bypass
TOTAL SCORE
- < 2 = low probability of HIT
- > 2 = high probability of HIT
Variables | Clinical Scenario | Points |
---|---|---|
Platelet count time course | Pattern A ((Platelet count begins to recover after CPB, but then begins to fall again > 4 days after CPB) | 2 |
Pattern B (Thrombocytopenia occurs immediately after CPB and persists for > 4 days without recovery) | 1 | |
Time from CPB to index date | > 5 days | 2 |
< 5 days | 0 | |
CBP duration | < 118 minutes | 1 |
> 118 minutes | 0 |
HIT Expert Probability (HEP) Score
NOTE: This scoring has not been prospectively validated and is not yet recommended for clinical use. Nevertheless, it offers another option for guiding clinical decision-making.
In the initial validation study (referenced above) the following screening cut-offs for total HEP Score were modeled for sensitivity and specificity:
- > 2 = positive for HIT
- < 2 = negative for HIT
(Sensitivity 1.00 [0.56 – 1.00], Specificity 0.60 [0.45 – 0.75])
- > 5 = positive for HIT
- < 5 = negative for HIT
(Sensitivity 0.86 [0.42 – 0.99], Specificity 0.88 [0.74-0.96])
Clinical feature | Presentation | Score |
---|---|---|
Magnitude of fall in platelet count (measured from peak to nadir since heparin exposure) | < 30% | -1 |
30-50% | +1 | |
> 50% | +3 | |
Timing of fall in platelet count | For patients in whom typical onset HIT is suspected: | |
Fall begins < 4 days after heparin exposure | -2 | |
Fall begins 4 days after heparin exposure | +2 | |
Fall begins 5-10 days after heparin exposure | +3 | |
Fall begins 11-14 days after heparin exposure | +2 | |
Fall begins > 14 days after heparin exposure | -1 | |
For patients with previous heparin exposure in the last 100 days in whom rapid onset HIT is suspected: | ||
Fall begins < 48 hours after heparin exposure | +2 | |
Fall begins > 48 hours after heparin exposure | -1 | |
Nadir platelet count | < 20 × 109 L−1 | -2 |
> 20 × 109 L−1 | +2 | |
Thrombosis (select no more than one) |
For patients in whom typical onset HIT is suspected: | |
New VTE or ATE > 4 days after heparin exposure | +3 | |
Progression of pre-existing VTE/ATE while receiving heparin | +2 | |
For patients with previous heparin exposure in the last 100 days in whom rapid onset HIT is suspected: | ||
New VTE or ATE after heparin exposure | +3 | |
Progression of pre-existing VTE /ATE while receiving heparin | +2 | |
Skin necrosis | Skin necrosis at subcutaneous heparin injection sites | +3 |
Acute systemic reaction | Acute systemic reaction after intravenous heparin bolus | +2 |
Bleeding | Presence of bleeding, petechiae, or extensive bruising | -1 |
Other causes of thrombocytopenia (select all that apply) | Presence of a chronic thrombocytopenic disorder | -1 |
Newly initiated non-heparin med known to cause thrombocytopenia | -2 | |
Severe infection | -2 | |
Severe DIC (fibrinogen < 100 mg/dL and D-dimer > 5 mcg/ml)Indwelling intra-arterial device (IABP, VAD, ECMO) | -2 | |
Cardiopulmonary bypass within previous 96 hrs | -1 | |
No other apparent cause | +3 | |
VTE=venous thromboembolism; ATE=arterial thromboembolism; DIC=disseminated intravascular coagulation |
Guidelines for the Use of Bivalirudin in HIT
Please use the following for the initial dose of bivalirudin in heparin-induced thrombocytopenia (HIT):
Creatinine Clearance (CrCl) | T 1/2 | Recommended initial infusion rate (based on total body weight) |
>60 ml/min | 25 minutes | 0.15 mg/kg/hr |
30-60 ml/min | 34 minutes | 0.08 mg/kg/hr |
<30 ml/min | 57 minutes | 0.05 mg/kg/hr |
Dialysis-dependent patients (off dialysis) | 3-5 hours | 0.05 mg/kg/hr* |
Dialysis-dependent patients (on dialysis) | (25% clearance by HD filters) | 0.05 mg/kg/hr* |
*UPDATE 8/2020 – Changes to Bivalirudin Initial Dosing: based on a review of internal data as well as the most recent literature, patients receiving renal replacement therapy are now recommended to start bivalirudin at a rate of 0.05 mg/kg/hr (previously 0.02 mg/kg/hr).
Guidelines For The Use Of Argatroban In HIT
Please see the attached document. Note that argatroban is a NONFORMULARY drug at UW Medicine. Bivalirudin is the preferred agent.
Monitoring Direct Thrombin Inhibitors – DTI Assay
At UWMC, bivalirudin is monitored using the Direct Thrombin Inhibitor (DTI) assay (Plasma-Diluted Thrombin Time).
Used instead of aPTT to monitor injectable DTI therapy. Preferred over aPTT due to better sensitivity, and is not affected by antiphospholipid antibodies. Cost, turn-around time and 24/7 availability at UWMC are similar to aPTT.
- Therapeutic range for DTIs administered by continuous infusion
- For argatroban: 60-100 seconds
- For bivalirudin: 60-90 seconds
- For lepirudin: 90-160 seconds
- Test order code: DTI
- Specimen collection: 3mL or 5mL blue top