The Monitoring of Heparin Induced Thrombocytopenia Following Orthopaedic Surgery

An audit and international survey

Benedict Rogers Sam Simmonds Meeting

2nd May 2008

Low-molecular-weight heparins
widely used Clexane (enoxaparin sodium) Fragmin (dalteparin sodium) Innohep (tinzaparin sodium) prevention of DVT and PE orthopaedic & general surgery patients

Anastasios K. Lilikakis, Theodoros Papapolychroniou, Georgios Macheras and Emmanuel Michelinakis J Bone Joint Surg Am. 2006;88:634-638.

Case 1
46 yr, DDH Total Hip Replacement Clexane 40 mg od Headache & motor disturbance day 6
Platelet count (103 per mm3 )

Pre-Op Post-Op Day 6 Day 10

250 180 126 35

Case 1
CT Day 11 Bilateral parasagittal haemorrhages Died day 11

Case 2
47 yr, DDH, Total Hip Replacement Clexane 40 mg Fit & well, no previous heparin Discharged on s/c clexane & readmitted day 13 Headache and abnormal left arm sensation

Day 13 MRI , platelet 70 High signal intensity involving the left thalamus ? thrombosis

Day 22 MRI, platelet 40 Large bilateral haematomas Discharged quadriplegic

Heparin-induced thrombocytopenia (HIT)

HIT commonest drug-induced thrombocytopenia Complicating 1-4% of exposures to standard & LMW heparin. Immune (IgG) mediated, (ie non-dose related) High thrombotic morbidity (30-50%) & mortality (10-15%) due to platelet activation and DIC.

Pathoaetiology
Heparin forms a complex with platelet factor 4 (PF4) which is released from platelets by platelet activation.

The antibody-heparin-PF4 immune complex binds to the Fc receptor on the surface of the platelet leading to activation of the platelet.

Why important ?
Bleeding post-joint replacement Operative site Epidural Intrahepatic Retroperitoneal Gastrointestinal Intra-cerebral

Guidelines on Management of Heparin-Induced thrombocytopenia

British Society for Haematology

Haemostasis & Thrombosis Task Force Keeling et al
BJH, May 2006 133, 259-269,

Study Aim
To audit the monitoring of heparin induced thrombocytopenia in patients receiving LMWH following orthopaedic surgery

Audit Loop
Risk of Heparin-induced Thrombocytopenia (HIT) identified Initial survey of 56 patients to assess monitoring of platelet count in post-op orthopaedic patients

Repeat survey 53 patients to assess implementation of BSH guidelines

Dissemination and implementation of BSH guidelines

Comparison of initial survey to BSH published guidelines

Initial Survey
56 Patients Receiving LMWH > 4 days post-op

8 patients Medically unwell or on warfarin

48 patients Well post-op

2 patients FBC after 4 days

46 patients No FBC after 4 days

2/48 (4.1%) of at risk patients had platelet counts monitored

Audit Loop
Risk of Heparin-induced Thrombocytopenia (HIT) identified Initial survey of 56 patients to assess monitoring of platelet count in post-op orthopaedic patients

Repeat survey 53 patients to assess implementation of BSH guidelines

Dissemination and implementation of BSH guidelines

Comparison of initial survey to BSH published guidelines

Guidelines on Monitoring of Heparin-Induced Thrombocytopenia

Keeling et al BJH, May 2006, 133, 259-269

1.

All patients receiving heparin (of any sort) should have a platelet count on day of starting treatment All surgical patients receiving LMWH, platelet counts should be performed every 2-4 days from days 4 - 14

2.

Guidelines on Management of Heparin-Induced Thrombocytopenia

Keeling et al BJH, May 2006, 133, 259-269

If platelet count falls by 50%+ or below normal lab limits And/or patients develops thrombosis or skin allergy consider HIT, stop LMWH & inform haematologist

Audit Loop
Risk of Heparin-induced Thrombocytopenia (HIT) identified Initial survey of 56 patients to assess monitoring of platelet count in post-op orthopaedic patients

Repeat survey 53 patients to assess implementation of BSH guidelines

Dissemination and implementation of BSH guidelines

Comparison of initial survey to BSH published guidelines

Audit Loop

Risk of Heparin-induced Thrombocytopenia (HIT) identified

Repeat survey 53 patients to assess implementation of BSH guidelines

Initial survey of 56 patients to assess monitoring of platelet count in post-op orthopaedic patients

Dissemination and implementation of BSH guidelines

Comparison of initial survey to BSH published guidelines

Secondary Survey
53 Patients Receiving LMWH > 4 days post-op

13 Patients Medically unwell or on warfarin

40 patients Well post-op

23 patients FBC after 4 days

17 patients No FBC after 4 days

23/40 (57.5%) of at risk patients had platelet counts monitored

Pe entage of at sk pat ents on to ed fo hepa n ndu ed th o bo topen a

60 50 Perce a e 40 30 20 10 0 P a Su e Se onda Su e

P < 0.05

Post-Op Platelet Count

Secondary Survey
12 10

Number of atients

23 patients correctly monitored 11 plt 50 - 75 % pre-op 2 plt < 50 % pre - op

8 6 4 2 0 > 75% 50 - 75 %

< 50 %

ercentage of pre-operative platelet count

Survey
Aware of BSH HIT guidelines Canada / Australia UK District General Hospital Teaching Hospital General Practitioner N/A 1/25 1/6 0/22 Monitor platelet count for pts on LMWH 2/12 0/25 0/6 0/22

Conclusion
Poor awareness of HIT monitoring Simple audit improved monitoring (4% to 57%)

Conclusion
Incidence : 1 % of patients on LMWH DGH orthopaedic dept : 10 cases per year (assuming up to 1000 patients per year with LMWH) This study identified 2 cases non-symptomatic HIT

Conclusion
Published case reports Published guidelines If LMWH used HIT should be monitored Medicolegal implications
All surgical patients receiving LMWH, platelet counts should be performed every 2-4 days from days 4 14 If platelet count falls by 50%+ or below normal lab limits And/or patients develops thrombosis or skin allergy consider HIT, stop LMWH inform haematologist

Thank You
Acknowledgements Mr Rosson, Andrew Cowie, Jason Fleming & Chris Alcock The Royal Surrey County Hospital, Guildford, England.